The perils of poses: Yoga-related injuries
Yoga is becoming increasingly popular with students looking to improve strength, flexibility, balance, and well being. But those who do too much, too soon are at risk for injury.
| The Truth Behind Yoga, Daniel Grove’s Blog |
“A study of imaging observations by Canadian radiologists found that of 23 musculoskeletal yoga injuries identified in the database of a large tertiary care center, 34.8% were tendinous lesions, which in the lower extremity included Achilles partial-thickness tears (13%, 3/23) and peroneus brevis partial-thickness tears (4.3%, 1/23). A further 34.8% of all events were fibrocartilaginous injuries, and in the lower extremity included medial meniscus tears (8.7%, 2/23) and acetabular labrum tears (8.7%, 2/23). [1]
By Emily Delzell, Lower Extremity Review April 2015
Raza Awan, MD, hadn’t been practicing yoga long when he found himself in a class with a fairly advanced group of students. The instructor brought the students to the middle of the room to move into a handstand pose (in Sanskrit, adho mukha vrksasana, or downward facing tree pose). The sports medcine physician said he thought he’d be more comfortable using the wall for support, but the instructor said he looked strong. Rising into an unsteady handstand (his first), he toppled over (despite an assist from the instructor) and broke his big toe.
He was using yoga to rehabilitate from injuries unrelated to the practice, as well as investigating its potential as a tool for his patients.
“About a decade ago, I started seriously looking at utilizing yoga to enhance rehabilitation outcomes in my patients and began bringing yoga practitioners into the sports clinic to becomes part of our rehabilitation team,” said Awan, a physiatrist and medical director of Synergy Sports Medicine & Rehabilitation in Toronto, Canada. “Ultimately, I wanted to ensure that if I was recommending yoga to my patients, I knew both the risks and benefits of yoga practice.”
As yoga gained popularity, he also started to notice more yoga-related injuries presenting in his clinic. The literature revealed little data on the injuries (and published data are still sparse) so Awan began tracking injuries in his patients to analyze patterns, identify high-risk poses, and improve clinical outcomes. Eventually, he began leading injury prevention workshops for teachers, studio owners, and students.
Traumatic injuries like the one Awan experienced aren’t the most common type of yoga-related injury, but his story does illustrate an important risk factor for all types of yoga injuries: an instructor who pushes students too far, too quickly. This high-risk pushing can be physical as well as mental.
“Injuries can be caused by too vigorous hands-on adjustments from teachers who may not be knowledgeable about the individual limits of their students’ bodies,” said Ann Wendel, PT, ATC, CMTPT, an American Physical Therapy Association spokesperson, Thai yoga therapist, and owner of Prana Physical Therapy in the Washington, DC, area.
Hands-on adjustments by yoga teachers are common, but not always benign.
“One of my clients who came to me to rehabilitate from a yoga injury got it during a retreat,” said Wendel. “She was in wide-angle seated forward bend pose [upavistha konasana] and the teacher leaned heavily into her back to force her forward, deeper into the pose—she heard a pop, and ended up with hamstring and low back strains.”
Most of the yoga-related injuries Awan has cataloged are from overuse.
“Performing the same poses over and over again over time can lead to repetitive strain and predispose to musculoskeletal injuries and conditions. In many cases the symptoms come on insidiously, and the patients may not make a causal link between the injury and yoga practice,” he said.
| Chasing a shape: ego and injury |
The biggest risk factors for getting hurt doing yoga aren’t pre-existing medical conditions or old injuries, but the students themselves, who often risk injury to reach full extensions in poses, or asanas, their bodies aren’t ready for (and may never be ready for), as well as teachers, who may lack adequate training, may be instructing classes too large for close supervision, or who introduce an attitude of competition—including competing against oneself —into classes.
“Ego and not listening to your body are big risk factors for yoga injuries,” said Cristina González, a yoga teacher from Toronto who describes her practice as “rooted in the Ashtanga system with a healthy dose of Iyengar sensibilities.” Ashtanga yoga is a vigorous form of yoga with a specific sequence of poses (power and Vinyasa yoga are often variants of this type). Iyengar yoga emphasizes precise alignment in the pursuit of poses as well as the use of modifications, including straps, blocks, and other props, to achieve correct biomechanics and minimize the risk of injury.
“I injured myself quite a bit in yoga in my initial years of practice,” said González, who said she strained her hamstrings, hip, and injured her shoulder severely. “I was chasing a shape rather than an action. I’m pretty typical in some ways of the hypermobile person—I enjoy the sensation of stretching, and I wasn’t balancing it with proper muscular engagement.”
Awan agreed that in his experience hypermobile people are at higher risk for yoga injuries than people with more average range of motion.
“These patients may be drawn to yoga because they possess the range of motion to perform many common poses well, but hypermobility can be a particular risk factor for injury as the patients may not have good proprioception and may push too far into poses, which can cause damage to soft tissue structures over time,” Awan said. “Hypermobile patients may also lack the muscle strength and endurance to support a pose well, contributing to injury.”
Those with limited range of motion are at risk, as well.
“Hip and knee injuries can occur when people are trying to push their bodies into a pose,” Wendel said. “For example, forcing yourself into lotus pose [padmasana, Figure 3] can result in injury to the meniscus. There are real bony constraints in the hip, but the knee is much more flexible, so people may try to crank on the knee to get into that position, and that’s commonly how people tear their meniscus [in yoga].”
Meniscus injury is a documented risk of yoga. Chinese researchers reported in a 2012 study that women aged 20 to 49 years who practiced yoga (they didn’t specify type or specific poses) at least one hour a day were at higher risk of meniscus injury than that conferred by jogging, badminton, or climbing hills, and that risk increased with longer duration of practice.2
Wendel noted that, practicing in the Washington, DC area, she sees a lot of “Type A personalities.”
“They want to push, push, push and work out intensely, and when they take the mentality of pushing and competing and getting in a really vigorous workout into a yoga class, that’s when injuries are likely to occur,” she said.
A 2012 Australian survey, which included 2353 yoga practitioners who answered questions about practice-related injuries sustained in the previous year noted that the respondents commonly blamed themselves for injury, citing reasons that included “pushing it too far,” not warming up, and being “ego-driven.”3
Also potentially problematic are large classes in which it’s impossible for teachers to see how every student is interpreting his or her cues.
“I often attend large group classes out of curiosity and for inspiration, and sometimes I’ll look around the room and think, ‘Isn’t it interesting how many interpretations there are of that cue.’ Some of the language can get pretty esoteric, and I can see why they’ve interpreted it that way, but often it’s not good for the body,” González said.
She began working as a yoga instructor 11 years ago teaching large group classes, moved to small groups of four people or fewer, and now teaches mainly one on one.
“I did this because, over time, I decided it was safer for my students,” said González, who has taken Awan’s yoga injury prevention workshops.
Continue reading in Lower Extremity Review
| References |
Musculoskeletal injuries related to yoga: imaging observations, Le Corroller T, Vertinsky AT, Hargunani R, Khashoggi K, Munk PL, Ouellette HA. AJR Am J Roentgenol. 2012 Aug;199(2):413-8. doi: 10.2214/ajr.11.7440. Full text
