Getting Clearer on Yoga and the Risk of Injury (Rerun)

by Baxter

A Clear Day on Mount Tamalpais by Brad Gibson

If you have not had a chance to read Nina’s Monday post (see Not All Yoga Poses Are Created Equal) about the New York Times article How Yoga Can Wreck Your Body, please do, because she articulates some very important points to consider as you digest all this hype coming from William Broad, a New York Times writer. In addition, you’ll find my take on this issue on Yoga Journal’s blog, where I am an occasional guest blogger (see here).

Before getting into recommendations for modifying specific poses to reduce the risk of injury, I’d like to step back today and look at what we know about key areas of the body that are at risk of injury from an unbalanced asana practice. What do I mean by an unbalanced practice? In my view an unbalanced practice is one where you are doing one or more of the following:

• Practicing at an incorrect level of difficulty for your present level of expertise 
• Doing the same poses over and over, increasing your risk of repetitive stress injuries
• Attending classes with an inexperienced teacher unfamiliar with guiding students who have special vulnerabilities or who is aggressive with adjustments
• Attending a class or pursuing a home practice that has an overly competitive quality to it

Well, you get my drift. One of the few studies that has tried to get a handle on this topic of yoga-related injuries was published in 2009 in the International Journal of Yoga Therapy by Loren Fishman, MD, et al (see here). He and his colleagues surveyed 33,000 yoga practitioners from around the world, got back 1336 responses, and compiled the results. In descending order, the areas of the body most affected were as follows, with the number of times reported in parenthesis beside it: neck or cervical spine (674), shoulder, including rotator cuff (661), low back, including sacrum, SI joint, sciatica (644), knee (597), wrist (414), back or spine - any area (392), hamstring (332), hip (112), leg - including ankle and foot (64), and groin (52). There were other areas also mentioned, but at much lower frequency, including elbows, headaches and nausea.

What does this mean for you and me?  Should we be overwhelmed and fearful? Probably not. Remember, only four percent of the surveys sent out were returned, so we still have a relatively small sample of folks here. What we can say is that, just as Nina pointed out Monday, any physical endeavor has some inherent risk of injury to it. However, if we keep returning to the essential quality of mindfulness and honesty in our practice, we can go a long way in minimizing the risks of injury. I can honestly admit that I have injured myself on several occasions, once from inattention in class, once from being in over my head in an advanced class I was not ready for, and once when my ego decided I should do an advanced pose that my hamstring had other ideas about. But I have also had several injuries, yoga related and not, that improved and healed through mindful and attentive practice of yoga asana.

In my next post, I’ll look at Fishman’s number one area of injury, the wrists, with some ideas and recommendations on how to approach poses that are more risky for us ordinary humans! Until then, keep on practicing.

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Sudden Acute Traumatic Injury

by Shelly Prosko

“Hey I did it! Look everyone, I’m doing it!” was what I remember thinking when I was Double Dutch skipping at our recent family Christmas function.  I was feeling confident, smiling and showing off my superb skills at age 41. Even though I hadn’t skipped in 25 years, I could still keep up with the kids because I take such good care of myself—I’m fit, agile, do yoga for healthy aging, meditate, eat healthy, create joy, educate and inspire others to do the same. Life is good. I’m so perfectly healthy. Then I remember a sudden intense “hit” to the back of my lower calf at my Achilles tendon that accompanied a loud pop. I went down in excruciating pain—and shock. I was looking around to see what steel object had hit me at such supersonic speed. But I couldn’t find anything. My cousin said, “Nothing hit you, you just went down.” It was then that I knew from experience as a physical therapist that I had completely ruptured my Achilles tendon. This is an example of an acute unexpected orthopedic traumatic injury. I have treated several of these types of injuries over my career, but when you are the patient, it’s a completely different ball game.

Shari’s post on Acute Orthopedic Injuries defines what an acute orthopedic injury is and how it is managed. Today I’d like to discuss the process that you may go through after sustaining an unexpected traumatic injury and how yoga can help you through the process. This is based on my experience in treating these injuries over the past 15 years in an outpatient orthopedic setting, as well as my recent personal experience.

Immediately after my injury, I was in shock for about an hour after. I was also in denial, and not thinking clearly. I didn’t even go to ER that night. Intellectually I “knew” the treatment protocol and prognosis, but for some reason, I wasn’t relating it to my own situation. This makes me realize how important it is to have support and allow people to help you when you are going through trauma. I wasn’t in a balanced mental or emotional state, and I certainly wasn’t equipped to be making important decisions. However, it’s in this state, that we are asked to make a decision: Do you want to treat this surgically or take the conservative, non-operative approach?

The benefits of my regular yoga and meditation practice were becoming evident as I embraced the truth of the situation, surrendered and became completely present in the moment. The combination of increased mental clarity and wonderful support from family and friends led me to finally go to the ER the next morning.

I was informed that the recent literature shows that there is not much difference in the long-term outcome between surgical vs. non-operative approaches and that they don’t commonly do surgical repairs to the Achilles anymore. I would be placed in a plaster cast for two weeks, then transfer to a boot cast for six to eight more weeks after that. The surgeon said, “Okay?” I replied “Okay.” Then he left the room and started working on making my cast. I don’t remember asking many questions. Typically, I would ask many! But I was not my usual self. I was still overwhelmed with emotion: fear, anger, guilt and sense of loss. Everything was just happening so fast. I remember hearing similar stories from patients. I would guess many people go through this type of experience.

Over the next week, the question lingered: Should I get surgery or not? There are so many factors to consider when you are deciding whether or not to undergo surgery. For the first several days, I was using vijnanamaya kosha (intellect, wisdom) to aid my decision: researching evidence-based results online, reviewing my own anecdotal evidence from clinical experience, analyzing other PT’s opinions, having discussions with family members and spending time in self reflection. These methods certainly played a huge role in my decision. We must use our mind as a tool to process all the information, so that we make an “informed” decision. But as many of you know, when you have a difficult decision to make, and you’ve analyzed it over and over again from all angles, sometimes your mind is no longer of service to you. You just need to make the decision, and, as Shari said, “make the right choice for me.”

I want to share the role that meditation can play in making decisions. Simply observing all thoughts and emotions without trying to “fix” or “decide” for a few minutes each day helped me in my decision.  I found that connecting to that space where my true self lies—without expecting or looking for an answer to my dilemma—was very beneficial to creating a clear mind. Often times the answer comes effortlessly after this (although it’s not wise going into the meditation expecting the answer because then you have defeated the intention of the meditation practice in the first place).

A yoga therapist/PT friend recommended that I try accessing pranamayakosha (energetic body) to help with the decision, an approach you might want to try for yourself. He recommended that I visualize each scenario in detail, and simply watch how my breath responds. I also brought awareness to how each scenario physically felt in my body. It was astounding to see the difference between the two scenarios. In the end, I opted to stay with the conservative approach to treatment and I can say that I finally feel at peace with my decision.

But it’s not over. I was told that rehab would not START for another eight weeks. As a physical therapist and yoga therapist, I intuitively know that there are SO many other areas and issues that can be addressed immediately post injury, even if we cannot touch or move the injured body part.
Allow me to briefly outline how I’ve been able to immediately use yoga for rehabilitation of this acute traumatic orthopedic injury. Keep in mind that yoga is not simply asana practice. “Yoga” means to “yoke” or unite body, mind, breath and spirit. In yoga, we can address all five kosha layers to optimize healing:

Annamayakosha (physical body):

• Asana practice involving non-injured body parts will help me maintain overall physical conditioning, to prevent overuse injuries of areas being overworked due to abnormal mobility patterns and to improve overall feelings of well-being. My practice includes Cat/Cow pose, Thread the Needle hip opener, One-Legged Downward-Facing Dog pose, One-Legged Plank pose, Happy Baby pose, and modified standing poses with a chair and bolster (Warrior II, Extended Side Angle pose Resolved Extended Side Angle pose, Reverse Warrior pose, Eagle pose arms, Cobra pose, Supported Side Twist with bolster, and Legs Up the Wall pose. Here’s the first in a series of videos that show my practice (you can find the rest here on my youtube channel):

Vijnanamayakosha (intellectual/wisdom):

• Injury Education. I researched recent literature about my injury. 
• Meditation methods for pain and anxiety control. I’m using a variety of focused mantra meditations and mental/visual imagery via a body scan.

Pranamayakosha (energetic):

• Breathing methods to address pain and/or anxiety. I’m using belly breath, nadi shodana, and bee’s breath.
• Focused meditation on breath.  Simply watching/observing without trying to change pattern has been one of my most powerful tools for finding peace during times of intense crying and frustration.

Manomayakosha (mental/emotional):

• Resources and support for grief/loss (injuries resulting in any form of loss are traumatic regardless of ‘severity’). What is working for me includes conversations with trusted family and friends and readings from “Untethered Soul,” including this interpretation of Yoga Sutra 2.16: “Painful effects that are likely to occur should be anticipated and avoided.” (See here for more info.) 
• Meditation. I’m practicing observing and watching emotions without trying to change them, but knowing they are “not me.”

Anandamayakosha (spiritual):

• For me, spirituality is connection to that space within that is true self, therefore connecting us to nature and all living beings. Injuries commonly cause a reduction of participation in normal social activities, resulting in feelings of isolation, loss and even depression. Connecting to ourselves, to others and to nature (even a daily brief outdoor meditation) can help us continue to feel this deep connection to spirit, which I believe is essential in any healing process.

I will continue to address all five koshas over the next eight weeks of waiting for “official rehab” to begin. Of course, this outline is unique to my current situation and it obviously does not serve as medical advice for your injury. However, I hope this sheds some light on how you could use yoga to help promote your healing in similar ways, even after an acute unexpected orthopedic injury!

Disclaimer: This article is not meant to diagnose, treat or act as medical advice. Please consult your health care provider for clearance and guidance before following or participating in these activities. 

Shelly Prosko is a Licensed Physical Therapist, Professional Yoga Therapist and a Certified Pilates Instructor. She received her Physical Therapy degree at the University of Saskatchewan, Canada in 1998, her Yoga Therapist training through Professional Yoga Therapy Studies in North Carolina and her Pilates certification through Professional Health and Fitness Institute in Maryland. Currently, Shelly resides in Sylvan Lake, AB and travels across Canada and the United States offering specialty Physio-Yoga Therapy workshops, yoga classes, private PhysioYoga sessions, lecturing at University and College programs, instructing at Yoga Teacher Trainings and actively promoting the integration of medical therapeutic yoga into our current healthcare system. She believes that bridging the gap between Western and Eastern healthcare philosophies is essential in order to achieve optimal health. Her treatments are individually based and are a unique blend of both approaches. Please visit www.physioyoga.ca for more details and information.

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Acute Orthopedic Injuries

by Shari

In my role as a physical therapist and yoga instructor, I see lots of clients and yoga students who have experienced both acute and chronic orthopedic injuries. In western medicine, an injury is considered acute rather than chronic when it is less than three months old from onset. In general, an acute injury is an injury that occurred as a result of a traumatic event, including:

• Muscle pulls
• Ligament sprains
• Fractures
• Dislocations
• Contusions (bruises)

Signs of an acute injury generally include one or more of the following:

• sudden, severe pain
• swelling, often with the inability to place weight on a limb
• extreme tenderness on palpation of limb or other body part
• inability to move a joint through full range of motion,
• extreme limb weakness, visible dislocation or breakage of a bone

In general, there are two types of acute injuries: an unexpected acute injury and a cumulative trauma. An unexpected acute injury is one that is sudden and immediate, for example, the result of a skiing accident or a fall. My friend Shelly Prosko, who will write a post for us in the near future, experienced an unexpected acute injury when she was Double Dutch skipping and ruptured her Achilles tendon. On the other hand, a cumulative trauma is one that has been building up for a long time, possibly due to micro-injuries to a specific, vulnerable area until a final “last straw” movement causes the injury. This was the case with my right knee medial meniscal tear, which happened during a yoga class when I was doing the same pose I had been practicing for many years.

After you experience either type of acute injury, you have a dilemma: do you seek immediate medical advice or practice the “wait and see” method? Obviously if you think you may broken a bone, have a concussion, are bleeding profusely or are in excruciating pain, you should go to the emergency room. Otherwise, if the injury seems minor, you can take a 48-hour wait and see approach. During this 48-hour assessment period, you can practice R.I.C.E first aid:

REST: The first 24-48 hours after the injury is considered a critical treatment period, and you should curtail your activities. Gradually use the injured extremity as much as you can tolerate, but try to avoid any activities that cause pain. Often using a splint, sling, or crutches is necessary to adequately rest the injured body part.

ICE:
 For the first 48 hours post injury, ice the sprain or strain 20 minutes at a time, every 3-4 hours. The ice pack can be a bag of frozen vegetables (such as peas or corn), allowing you to be able to re-use the bag. Another popular treatment method is to fill paper cups with water then freeze the cup. Use the frozen cube like an ice cream cone, peeling away paper as the ice melts. Do not ice a sprain or strain for more than 20 minutes at a time! You will not be helping heal the injury any faster, and you can cause damage to the tissues!

COMPRESS: Use compression when elevating a sprain or strain in early treatment. Using an Ace bandage, wrap the area overlapping the elastic wrap by one-half of the width of the wrap. The wrap should be snug, but should not cut off circulation to the extremity. So, if your fingers or toes become cold, blue, or tingle, re-wrap!

ELEVATE: Keep your sprain or strain elevated, higher than your heart if possible, to reduce swelling. Elevate at night by placing pillows under your arm or leg.

One of the most wonderful positions for reducing swelling (edema reduction) is Legs up the Wall pose (Viparita Karani). And you can even do this pose in bed if your bed is next to a wall and you have the agility to position yourself into the pose. If this isn’t possible, you can try using two bolsters propped up against a chair instead of a wall, especially if you have someone to place the bolsters for you. However, in acute trauma, this pose may NOT comfortable so short bouts might be more beneficial than longer periods of time.

Another spectacular pose for edema reduction is Chair Shoulderstand (see Judith Lasater's Favorite Poses), which you can do in a more passive position with your legs perpendicular or in more active position with your legs upright. The more passive pose is to rest your legs against the chair back, which requires less physical work and allows more relaxation (although this creates more of a backbend).

As you practice your R.I.C.E, keep assessing your pain levels. Sometimes the severity of an injury isn’t apparent immediately but if the pain worsens as the hours progress, this is a good indicator to seek medical care.

Ok, so your 48 hours have passed and you have religiously been practicing R.I.C.E. but you are no better, but no worse. At this point it is time to go to a medical doctor and learn as much as possible about the different possible treatments for your injury and then go through a careful decision process. And yoga can help you through all this.

In my situation with my right knee medial meniscal tear, I waited over six weeks of my own “conservative care” approach before the grim reality hit that things weren’t getting better. I didn’t follow my advice of getting medical help after 48 hours because I thought I could just heal my knee with a lot of RICE and restorative inverted poses. It did slowly get better over the six weeks but I reached a plateau in regaining movement and decreasing edema, and finally acknowledged I needed to be evaluated and diagnosed by a physician. (And frankly, I do have “white coat syndrome” and found it is easier hide my head in the sand and not acknowledge that my injury was more serious than I thought. There was no actual injury so I kept hoping it would get better. Sometimes we ALL practice avoidance!)

I then entered into the traditional medical model (see Fizzy Yoga!) and began non-surgical medical interventions. Along the way, I realized that I needed to add other C.A.M. (complementary alternative medical) approaches to my other endeavors. I realized that I needed to address all five koshas and sought out other medical practitioners that I trusted to aid me in my healing not just by addressing the physical injury but also by preparing me for the question that I had been avoiding: was I going to opt for surgical repair of my meniscal tear?

I meditated on the reason I wanted surgery and what would I gain from it. I had never in my 58 years had ANY surgical interventions, so even to contemplate surgery was a huge question for me to come to grips with. Many people told me to “just have the surgery, it is no big deal,” while others told me horror stories about failed meniscal surgeries and a NY Times article on why knee arthroscopy doesn’t work. But the surgeon who I consulted for this procedure was spectacular. He told me point blank that the decision was mine, but that I couldn’t be on the fence about it. I needed to believe it was the right choice for me. He even went as far to tell me that I could cancel in the surgical suite before anesthesia if I wanted to. His words changed the power dynamics and allowed me the space to meditate on my own fears and come to terms with them. He would do his job, but I had to do mine also.

Yoga helped me through the surgical process in many ways. Pre-op as I was waiting to be brought into the surgical suite, I was in a "comfy" type room with a recliner chair. I lay in that chair, covered myself with the blankets and practiced Ujaii breathing to calm myself. Also, I tried to clear my mind of all doubts and fears by just counting and following my breath. That practice helped immensely, and I was surprised on how low my blood pressure was when they took it before taking me into the operating suite. Just before the anesthesia was administered, I also tried to follow my breath as the lights literally went out. Post op in the recovery area again some Ujaii breathing helped to center me.

Once home, pranayama was helpful in quelling the anxiety and pain from the procedure. I didn't really start yoga asana practice till 24 hours post procedure. Starting with using my breath as I worked through my range of motion exercises and tried to be "kind” to my knee. Yoga is intimately connected to my current recovery. I really can't separate it out from my activities—everything I do now is with mindful attention to my knee and how it will respond to a new activity or asana position. Learning to GO SLOW is my current practice because when I don't, boy oh boy, does my knee balloon up! My knee is my teacher now and the rest of my body is the student—a different place to be for sure.

So, now it is two weeks post-op recovery. I have learned how to ask for help, which for me is really challenging. I have also learned that I need to still the little voice in the back of my mind that criticizes or is unhappy that I still can’t do something that I “should be able to do.” On the other hand, I’ve found it quite amazing how my knee has taught me how to experience asana differently. Yes, before I had to modify, modify, modify, but now the experience of gratitude is present. I ENJOY pranayama now and am practicing it more regularly. Also, I feel embraced by Chair Shoulderstand when I practice it. It is hard to describe but as soon as I am up in the pose I feel like I am getting a “big hug” that encompasses my entire being. The words don’t quite communicate the feeling of prana in my body!

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Friday Q&A: Is Women's Flexibility a Liability in Yoga? Baxter's Response to William Broad

The Flexible Melina Meza!

Q: So, Baxter, what do you think of William Broad’s latest claim that women’s flexibility is a liability in yoga?

A: Firstly, I want to thank Shari for her level-headed look at New York Times science writer and author of The Science of Yoga William Broad’s most recent assertion that women who do yoga are at great risk of injury due to their flexibility (see Women's Flexibility is a Liability in Yoga).  Thanks, as always, Shari, for your practical experience as a physical therapist and a long-time yoga practitioner and yoga teacher. I think your insights will go a long way in helping clarify articles like these that may have an unstated agenda that colors and lessens their credibility. I’d also direct some of you to this balanced response by yoga teacher Paul Grilley to the article as well. As always, William Broad’s articles do get us thinking and talking about yoga. 

But if I read Broad’s most recent article and his latest assault on yoga accurately, am I to understand correctly that both men’s tightness and women’s flexibility are liabilities in yoga? So is yoga now safe only for animals and children? I have always encouraged men to try yoga because they seem to hold so much tightness in their bodies. And women often master the more challenging poses in yoga from a seemingly more inherent flexibility. But I also have plenty of incredibly flexible male students and an equally large number of stiff and inflexible women in my classes. 

As a yoga teacher and also a student of yoga for several decades, I find most teachers today are cautionary to their students to be mindful of the feedback their bodies give them as they approach more physically challenging yoga poses. And yet, as if to throw one more barb of accusation at yoga and its teachers, the author offers this final warning: Unfortunately, yoga teachers too often encourage students to “push through the pain.” 

With all the supposed statistics the writer offers in the article, none are offered with this statement, and I am not certain where this impression comes from. I know that this can happen in some classes and styles of yoga, but this generalization, I believe, does not represent the overall state of yoga teaching in the US today.

And the tone used by the author implies that he has uncovered some hidden or unknown risk to yoga practitioners, and, more pointedly, women, that some of them could be at risk of hip injuries or impingements. As far back as 2009, the International Journal of Yoga Therapy published an article by Elaine Goodall "Preventing and Healing Injuries in Yoga: Acetabular Labral Tears.” In her detailed article, Ms. Goodall notes that gymnasts and dancers may have a predisposition for these kinds of injuries as well as some in yoga. So much for breaking news! 

One of my difficulties with the statistics—if they can be called statistics—that are offered in the New York Times article to back up the assertion that women are at a significant risk of hip injuries of a very specific kind is statements like this:

“Each year, he (Dr. Kelly) said, roughly 50 to 75 of his patients who danced or did yoga underwent operations. Most, he noted, were women.” 

The author goes to the effort of interviewing a surgeon, getting a guesstimate from said doctor, and never follows up with: how many were yoga related and how many dance related, and how many were a combination (as many yoga students, men and women, danced when younger)? And how many were men? What meaningful conclusions can a yoga teacher make from such superficial exploration?

In addition, the author points to a 2008 study done in Switzerland that looks at the kind of unique arthritis/traumatic changes to the hip called Femoral Acetabular Impingement, or FAI. However, he fails to mention that the women in that study had unusual hip anatomy, considered abnormal, though subtly so. The authors of the study go on to say, “The focus of the new concept (the theory on what underlies FAI) addressed those remaining cases of hip OA (osteoarthritis) in which the deformity (FAI) was considered mild, slight or even, in the eyes of casual observers, nonexistent.” 

So women and men who develop this impingement injury to the hip (prior to starting yoga) already had an anatomical reason that movements in the hip joint could lead to injury. Interesting. Developmental abnormalities that usually arose prior to adulthood were present in most cases. And this kind of FAI occurs in men and women, not women alone. Only once does this study mention that the pincer-type of injury is to women with underlying anatomically abnormal hips. And that these women often participate in “yoga and aerobics.” The authors don’t say the yoga caused the problem. As Paul Grilley so astutely points out, correlation does not mean causation! In fact, yoga is never mentioned again in the fairly lengthy article, and not at all in the final wrap up discussion that usually highlights the facts they find most compelling. They also don’t give statistics that clearly outline what percentage of women, with hip pain that requires surgery, have this kind of injury (FAI). So, again, the practical applicability for us in-the-trenches teachers is very unclear.

And statements like this are just mystifying: “I found that hundreds of orthopedic surgeons in the Mediterranean region heard a conference presentation in 2010 that linked F.A.I. to middle-aged women who do yoga.” If this was true, why does he not cite the study or the “presentation”? What was the presentation based on? Who made the presentation? Was there any study to back up these assertions?

And quotes like this: “Michael J. Taunton, an orthopedic surgeon at the Mayo Clinic, told me that he first learned of the danger a half decade ago and now annually performs 10 to 15 hip replacements on people who do yoga. About 90 percent, he added, are women.” This again does not help me much, as I don’t know how many hip surgeries this doctor does each year (about 20-30 a month, I would guess), so this may represent a small percentage of his annual surgeries, but the way it is presented seems really worrisome, if not epidemic, if you don’t have all the facts.

I have been teaching about the risks and benefits of yoga to future yoga teachers now for over 10 years. Some sort of classroom instruction on the topic is included in many 200-hour beginning level teacher trainings. So, from my personal experience and perspective, the yoga community is aware of potential dangers of certain aspects of the physical practices of asana and is better defining and sharing that information with each passing day.

Despite the author’s initial statements on the wonderful potentials of yoga in the first paragraph, little that follows in his article supports this assertion. I reminded myself that the final chapter of The Science of Yoga does give some insight into the author’s feelings and motivations regarding yoga:

“Yoga can grow up or remain an infant—a dangerous infant with a thing for handguns.” 

And a bit later in the epilogue, when discussing his concerns for the commercialization of yoga, he seems to pushing for huge government oversight of yoga with the following:

“Imagine if Big Pharma had no Food and Drug Administration and other regulatory agencies looking over its shoulder. The marketing of fake diseases and bogus cures…would be much worse.” 

And in the time since the release of his book, the three articles Mr. Broad has published have only dealt with potential negative aspects of yoga: the two on the dangers of yoga to men and women and one on the sexual scandals of yoga teachers.

How about a story from this self described yoga practitioner on the benefits of yoga next next time instead of sensationalist fearmongering?

—Baxter

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Is Women's Flexibility a Liability in Yoga? Shari's Response to William Broad

by Shari

The latest New York Times article from William Broad Women’s Flexibility is a Liability (in Yoga) sparked a conversation between Nina and me, both whom are long-term yoga practitioners who have grappled with orthopedic injuries. Broad states that he has recently learned that women are at higher risk of hip injuries in a yoga class because of their inherent flexibility compared to men. He quotes a single yoga teacher, Michaelle Edwards, saying that “women’s elasticity became a liability when extreme bends resulted in serious wear and tear on their hips. Over time the chronic stress could develop into agonizing pain and, in some cases, the need for urgent hip repairs.” He also says of arthritis researchers:

The investigators found that extreme leg motions could cause the hip bones to repeatedly strike each other, leading over time to damaged cartilage, inflammation, pain and crippling arthritis. They called it Femoroacetabular Impingement — or F.A.I., in medical shorthand. The name spoke to a recurrence in which the neck of the thigh bone (the femur) swung so close to the hip socket (the acetabulum) that it repeatedly struck the socket’s protruding rim.

I personally can’t stand sensationalism of any type and particularly sensationalism of the fear and scare tactics kind. When I first saw this article, I groaned inwardly. But I then proceeded to read it carefully, including the related links, and then went on to do some additional research of my own. After all that, my response is: maybe.

First of all, I, as a long-term yoga practitioner, am not sure what exactly he means. We all can be overly flexible in some areas of our bodies and conversely overly tight in other areas of our bodies. The biomechanical model of structure and function is a beautiful yin and yang interplay between forces that influence our bodies, and yes, can ultimately change our structure and function. Some changes may not be as beneficial as others so we need to be consciously selective and astute to observe what changes occur with function.

I also think, as in the past, Broad is careless in his citations of his evidence and is vague about these ER records of hip injuries. However, he does cite some orthopedists and one international study that do substantiate his observation that women who put their hips into extreme ranges of motion can injure their hips. Well, this is blatantly obvious to anyone who may be neurologically intact. When a joint is taken into an extreme position there is a pain response recognized by the central nervous system that warns the person to back off. Of course, if we choose to ignore the pain response, then is it the yoga that is causing the injury or is it the person who is foolishly not listening to the feedback their body is providing?

I also think that to address William Broad’s assertion that women are more flexible than men, we need a better working definition of (biomechanical) flexibility:

Flexibility is the range of motion in a joint or group of joints, or, the ability to move joints effectively. Flexibility is related to muscle strength. Flexibility is also the ability to move through a full range of motion.

Flexibility is a conscious movement that has an intricate feedback mechanism between the muscles and the nerves innervating the muscles and the joints and the central nervous system. There are significant protective mechanisms that prevent the individual from overstretching if they PAY ATTENTION to the sensation of pain rather than ignoring it.

So are women “inherently” more flexible than men? Well, it depends who you ask. But all sports attract a body type, and if yoga is considered a “sport” then there is a body type that is drawn to yoga. We all like to do things that are “easy” and for some flexible bodies yoga is “easy.” The rub here is that this isn’t “yoga” but athleticism masquerading as yoga!

So now let us look at his assertion that yoga is the root cause of “femoracetabular impingement”. The literature that I read, including one of his references, states that the subjective symptoms are deep anterior groin pain with associated intermittent catching and locking of the hip joint. In addition, there is a significant decrease in hip internal rotation. The morphology is that there is a breakdown of the hip labrum (how the head of the femur is connected into the cup of the pelvic acetabulum) and the articular surfaces of the femur and acetabulum. There is a structural change in how the head of the femur is sitting and facing, and movement of the hip will continue to tear the tissue structures with a loosening of the integrity of the hip joint. The problem is that a lot of individuals who have this condition are pain free, asymptomatic and don’t know they have it. The concern is that this condition may be a precursor to developing hip arthritis down the road. There are four types of femoracetabular impingement and one type is more common in women and one type more common in men!

Another article that I read stated that the condition is caused by internal rotation of the hip while in 90 degrees of hip flexion. Yes, this can be Uttanasana (Standing Forward Bend)! So is the problem the combination of these two movements? I don’t know, but does that mean you need to stop doing Uttanasana? I don’t think so unless it is causing pain. And, yes, there are some pretty extreme hip positions in yoga which only some of could do when we were younger (maybe can still do them now) but the bottom line is that we need to practice with intention and attention to form, function and our own bodies' abilities and not soldier on through the pain. Yoga, as we have mentioned time and time again, can be physically and mentally challenging, but is not supposed to hurt. So don’t be scared off again by a sensational journalist who claims he is a yogi.

In a future post I would like to present some of the inherent differences between male and female pelvis and hips that might also help to put into perspective the allegation of the differences between men and women.

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What Your Yoga Teacher Really Wants to Know

by Baxter

Beans, Beans, and More Beans (from Wikimedia)

You may recall one or more of us suggesting that one way to keep yourself safe as you are learning yoga, or dealing with an illness or injury, is to advocate for yourself when you are in class. But what exactly do we mean when we ask you to do this? Another way of thinking about this is that you should take responsibility for your own well-being when you head into any public class by telling your teacher before the class about any problems you may be experiencing.

Before I address what you should be sharing with your instructor, I want to tell you why you should do so. First off, any teacher worth their salt (which used to be very valuable a century or so ago!) or who is operating with genuine compassion and concern for his or her student actually wants to know what is going on with you.  Especially if you are dealing with illness or injury! And don’t think your experienced teacher is fooled for a moment when you are asked if you have any injuries or health conditions they should know about and you reply “Not really.” My next question is always, “So what is that I should not really know about?” This question is usually received with a smile, and sometimes I even become privy to what is going on with my student. Yes, we really want to know! Hopefully this argument alone will be enough for those of you feeling reluctant about sharing, for whatever reason, to go ahead and spill the beans.

But what if you’re unsure about whether or not the problem you have is one that your teacher should know about? Now it just so happens that in preparing for a workshop I am giving to teachers next weekend, I came up with a list of conditions that we really want to know about, before, not after class!  Telling me you are twelve weeks pregnant at the end of class doesn’t serve either one of us (or the three of us, in this case!).
 
Some other urgent or significant things to report are the following:

• can’t stand and balance well on two feet
• can’t get up and down from the floor without assistance
• dizziness
• advanced pregnancy or history of miscarriage in previous pregnancy and no yoga experience.
• acute recovery from stroke or heart attack
• communicable diseases

With such symptoms or conditions, you might be advised that a one-on-one setting would be safer and more appropriate at this time. 

And here is a list of common areas of injury and other situations that we also really want you to tell us about:

• plantar fasciitis
• acute ankle sprains
• acute knee strain and beyond
• acute hip pain
• hamstring strains or tears
• sacroiliac joint issues
• lower back pain
• inguinal hernia
• acute shoulder strains
• acute neck pain
• recent motor vehicle accident
• carpal tunnel syndrome and other wrist and hand pain
• broken bones, splits, or braces
• missing or limited functioning limbs
• severe scoliosis
• post surgery (even small wounds, such as skin tears, can be problematic)

(This list is not done is not in order of importance, as they are all important to share with your instructor.)

There are also some conditions that affect stamina that we would like for you to let us know about:

• hypertension
• stroke
• fatigue due to illness
• headache, nausea, dizziness
• respiratory illness such as asthma and emphysema
• fibromyalgia
• diabetes (type 1, and type 2 if newly diagnosed or poorly controlled)

Finally, some conditions might be more appropriately addressed in a gentle class or even a restorative yoga class, so if we know what is happening with you, we can guide you to resources you might have a hard time finding on your own, such as specialty classes or an especially talented instructor for what is going on with you. A few conditions that might fall into this category would be:

• chronic fatigue syndrome
• active multiple sclerosis
• post chemotherapy
• severe rheumatoid arthritis
• Lyme disease

Now that I’ve—hopefully—convinced you of the importance of informing your teacher of any problems you may be experiencing and let you know the kinds of conditions we want to know about, how should you approach him or her? If you want to talk to your teacher in person, it is probably a good idea for you come a few minutes early to class to have adequate time to give your teacher a good synopsis of what is going on. Or, you can use email prior to coming to the class. I often have had students send me an email to check in with me about the appropriateness of my class for their level of experience or their present condition. This is a good way in our modern era to get the information you need to feel more comfortable attending class as well as to keep your teacher informed. But really, in any and all of these cases, it takes you stepping up and sharing what is happening with you, so your teacher has the best chance of providing an appropriate and beneficial experience for you in class.

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Healing from an Injury

by Baxter

It seems that no matter where we develop an injury, it has a profound effect on the way our entire body functions in everyday life. I myself injured my left rotator cuff many years ago while participating regularly in rock climbing. And although I gradually recovered most of my function in that arm, after giving up climbing and taking up yoga, it is still stiff every time I do my first Down Dog!

And just this past weekend, after doing some home improvement projects which had me doing movement patterns that where not routine for me, I woke up Monday morning with right should pain when taking my arm forward and up or out to the side and up.  I immediately modified my usual yoga practice and limited those particular movements, while essentially working around the painful movements in order to allow what ever is aggravated to quiet down. My underlying assumption is that I have strained my right deltoid muscle, the lateral band of fibers. However, if the pain and limitation persists, I will consider a thorough evaluation by an orthopedist.

For any of you who have a yoga injury, I’d recommend following the same advice I gave myself. If you have not already done so, I recommend having your injury looked at by a physician or other qualified health care provider to more clearly identify what is really going on in the muscle or joint.

I would also encourage you to seek the assistance of a local yoga teacher with lots of experience working with your particular issues. In addition, you may have to consider a longer-term modification of how you approach your yoga. You can certainly continue to practice many yoga asana to keep other parts of the body strong and flexible, while using the injured part of in a more neutral way. But this might mean not doing certain poses at all, if they continue to cause pain and provoke inflammation of your injured area. I know that this can be very challenging for many of us, but you may not heal without such a modified approach and a re-framing of your goals with your yoga practice. I have given up running, soccer, and climbing due to the negative effects these sports were having on my body and my desire to avoid uncertain surgeries. At first, I was disappointed and a bit saddened at the prospect of not doing these things that I had previously enjoyed. However, I came to find equal satisfaction with the new activities I explored, including biking, hiking and yoga. And boy, is my shoulder happy about my decisions!

Lonely Rock by Brad Gibson

Finally, I feel compelled to remind our readers that our yoga practice is not static, nor is it designed to keep us in the exact state of physical condition we had at age 25 as we age. It can help us age gracefully, maintaining some strength, balance and openness on the physical plane. But the yoga practice has at its core this paradox of acceptance and change. When I was training in India, they used to chuckle at our American obsession with youth. There, the individual’s yoga practice would gradually change over time, becoming less about physical asana practice and more about breath and meditation, not because you cannot do physical poses, but because you are more capable of diving into the subtle practices as you mature and age, which are felt to be much richer and rewarding than mere asana. I am sure we will discuss this particular aspect of yoga again in the future. For now, all the best on your healing journeys!

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What is an Advanced Yoga Practice?

by Nina

Year-Old Snow and New Snow by Philip Amdal

A number of years ago, I encouraged a close friend of mine, M, to join me in taking Rodney Yee’s advanced class. Even though she had a muscular, athletic, and stiff body that made doing super bendy poses difficult, if not impossible, I knew that she understood how to take care of herself in class, that she would adapt the poses for her particular body type and keep herself safe, so I wasn’t worried about the class being too hard for her. She was interested, however, she expressed some concerns about not being “advanced” enough for the class. I decided to discuss the matter with our teacher himself, feeling fairly sure of what he was going to say. But what he told me when I asked him if she was “advanced” not only took me by surprise but has stuck with me all these years, transforming my thinking about the asana practice in general. What he said was this:

“Of course she’s advanced enough. M does yoga more mindfully than any student I’ve ever seen.”

And here I’d been thinking that being advanced meant being capable of doing difficult poses, like 10 minute headstands or extreme backbends, at some level or another! But doing yoga “mindfully”—now, here was goal we could pursue for our lifetimes and no matter our level of physical capacity was, we would always have the the ability to go deeper and deeper into the practice.

I’m thinking about this today because I’m helping a new friend of mine adapt her practice to allow her to heal from an ongoing injury. It’s taken her a long time to even be ready to temporarily give up certain poses and ways of practicing, because she felt such regrets about excluding poses from her practice that she used to be able to do with such great enjoyment. 

But as Baxter mentioned in his post on Wristful Wrists: How to Keep Your Wrists Safe, sometimes rest is the best way to heal from an injury. So being willing to adopt mindfulness as a goal in the practice rather than achievement is a necessary element in being able to heal from an injury.

People who are aging may find themselves in a similar position, not necessarily due to injury but simply due to the physical changes that come along with aging. To be honest, I used to have what I sometimes call a “semi-fancy” yoga practice. But in the last few years, I developed arthritis in my right hip that makes it impossible to do seated poses that involve a lot of external rotation. Lotus and half lotus are now impossible for me, and seated forward bends and twists that require certain leg positions are painful and difficult. And I now need props in many of the standing poses now. Still there is no question I consider my practice more advanced these days than it was in the years when I regularly took the East Bay’s most “advanced” yoga class.

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Getting Clearer on Yoga and the Risk of Injury

by Baxter

If you have not had a chance to read Nina’s Monday post (see here) about the New York Times article “How Yoga Can Wreck Your Body,” please do, because she articulates some very important points to consider as you digest all this hype coming from William Broad, a New York Times writer. In addition, you’ll find my take on this issue on Yoga Journal’s blog, where I am an occasional guest blogger (see here).

Before getting into recommendations for modifying specific poses to reduce the risk of injury, I’d like to step back today, and look at what we know about key areas of the body that are at risk of injury from an unbalanced asana practice. What do I mean by an unbalanced practice? In my view an unbalanced practice is one where you are doing one or more of the following:

• Practicing at an incorrect level of difficulty for your present level of expertise 
• Doing the same poses over and over, increasing your risk of repetitive stress injuries
• Attending classes with an inexperienced teacher unfamiliar with guiding students who have special vulnerabilities or who is aggressive with adjustments
• Attending a class or pursuing a home practice that has an overly competitive quality to it

Well, you get my drift. One of the few studies that has tried to get a handle on this topic of yoga-related injuries was published in 2009 in the International Journal of Yoga Therapy by Loren Fishman, MD, et al (see here). He and his colleagues surveyed 33,000 yoga practitioners from around the world, got back 1336 responses, and compiled the results. In descending order, the areas of the body most affected were as follows, with the number of times reported in parenthesis beside it: neck or cervical spine (674), shoulder, including rotator cuff (661), low back, including sacrum, SI joint, sciatica (644), knee (597), wrist (414), back or spine, any area (392), hamstring (332), hip (112), leg, including ankle and foot (64), and groin (52). There were other areas also mentioned, but at much lower frequency, including elbows, headaches and nausea.

A Clear Day on Mount Tamalpais by Brad Gibson

What does this mean for you and me?  Should we be overwhelmed and fearful? Probably not. Remember, only four percent of the surveys sent out were returned, so we still have a relatively small sample of folks here. What we can say is that, just as Nina pointed out Monday, any physical endeavor has some inherent risk of injury to it. However, if we keep returning to the essential quality of mindfulness and honesty in our practice, we can go a long way in minimizing the risks of injury. I can honestly admit that I have injured myself on several occasions, once from inattention in class, once from being in over my head in an advanced class I was not ready for, and once when my ego decided I should do an advanced pose that my hamstring had other ideas about. But I have also had several injuries, yoga related and not, that improved and healed through mindful and attentive practice of yoga asana.

In my next post, I’ll look at Fishman’s number one area of injury, the wrists, with some ideas and recommendations on how to approach poses that are more risky for us ordinary humans! Until then, keep on practicing.

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Not All Yoga Poses Are Created Equal

by Nina

If you haven’t read it already, you might want to check out the article “How Yoga Can Wreck Your Body” in the Sunday New York Times Magazine (see here). So were Baxter and I—we’ve both read it—shocked and surprised to read that yoga can cause serious injuries? Well, not exactly. As teachers and long-time practitioners, we’ve both seen our share of injuries and had them ourselves, too. And for some time, I’ve been talking about wanting to write an article or post called “Not All Yoga Poses Are Created Equal” that would differentiate between relatively safe poses that can be done frequently by most people and other poses that should probably be done less often due to their tendency to provoke injury. (Think about it: you’re probably not going to hurt yourself doing Savasana unless you’re practicing near a bookshelf during an earthquake or something, however, poses that combine external rotation of the leg with a forward bend, such as One-Legged Seated Forward Bend aka Janu Sirsasana and maybe even Triangle and Extended Side Angle poses, if done too frequently really do have the potential to cause some pretty yucky injuries).

Forward bend with external rotation of bent leg

To be honest, there are a couple of myths in the yoga world that are currently in the process of being exposed. The first is that the poses have evolved over thousands of years and are therefore “perfect.” In fact, if you read books like Yoga Body: The Origins of Modern Posture Practice by Mark Singleton or The Yoga Tradition of the Mysore Palace by N.E. Sjoman, you’ll learn that most of the poses we do in modern-day classes were developed during the early twentieth century. Of course the modern yogis who developed the poses (including Krishnamacharya and B.K.S. Iyengar) were geniuses, but they were also, like us, only human.

The second myth is that if you do a pose “properly” with the “correct alignment” it is always perfectly safe. And, conversely, that if you injure yourself, you must be doing something “wrong.” As you can see in the NY Times article, scientific research is backing up what many of us have already understood intuitively: that while there while there are certain robust individuals who seem to be able to do extreme forms of yoga without serious problems, that’s not really possible for the rest of us. For example, the Ashtanga Primary series is notoriously hard on the knee joints and Sun Salutations that include Chaturganga Dandasana (Pushup pose) are equally hard on vulnerable shoulder joints.

But does all that mean we should stop doing yoga?

Just yesterday a good friend of mine showed me her hand, which was still swollen and black and blue after a fall she took when she was walking her dog. And when I was in the software industry, a significant number of people I worked with seriously injured their wrists sitting at their desks, typing. My point is obvious; almost any physical activity you take up has the potential to cause injury. And we all need to continue being active. So for our practice of yoga, as in our other activities, it’s really of matter of combining knowledge with common sense. I’ve asked Baxter to work on a post where he specifically lists the poses that you should approach with caution, but in the meantime, here are some common sense guidelines:

• Don’t do a pose that hurts
• Don’t do the same poses or the same types of poses over and over (repetitive stress injuries are not limited to typists, cashiers, and factory workers)
• Come out of a pose early if you need to
• Use props as needed to help prevent overstretching or strain
• Find a yoga teacher who has had a long, thorough training and experience teaching people of your same age and condition
• Tell your teacher about any injuries you may have or any relevant health conditions

You may have noticed that for every pose we feature on our blog (and these are generally very safe and accessible poses), we provide a list of cautions. These are based our current best knowledge, but if you have any concerns of your own that we haven’t mentioned, follow your common sense and listen to your body.

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