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.

Man Bites Downward-Facing Dog: Dr. Timothy McCall Takes On William Broad of The New York Times

by Nina

Could yoga make you fat (especially if you're a woman)? Does it cause hundreds of strokes per year? Sex you up so much you'll engage in unethical behavior? Did the entire discipline start out as a sex cult? If you read The New York Times you might think so. As much as I've often disagreed with him, up until now I've been diplomatic in my responses to William Broad's writings about yoga in Times and in his book The Science of Yoga. But after his recent article in which he asserted that "yoga is remarkably dangerous — for men," I felt it was time to speak up. —Dr. Timothy McCall

In his new paper “Man Bites Downward-Facing Dog,” Yoga for Healthy Aging blogger and Medical Editor for Yoga Journal Magazine, Dr. Timothy McCall responds to William Broad’s ongoing sensationalistic claims about yoga. In his post on our blog Is Yoga Really Dangerous for Men?, Timothy addressed Broad’s most recent claim that yoga is “remarkably dangerous” for men. In this new paper, he goes further and responds to other over the top claims that Broad has made previously, such as that yoga can make you fat or that the entire discipline started out as a sex cult. He also makes it clear that he is not denying that yoga injuries are a problem; and he acknowledges that he is not in disagreement with all of William Broad's assertions.

Mugsy, the Yoga Dog by Nina Zolotow

Timothy's article is on his web site, in  PDF format rather than on a web page. So if you want to read it, you’ll need to download it and view it with Adobe Acrobat. To get your copy of the paper, you can either use the link in the previous paragraph or go to Timothy's web site www.drmccall.com. I highly recommend that you go ahead and download the paper. Then feel free to pass it on to your friends. We really want to get the word out!

Is Yoga Really Dangerous for Men? Dr. Timothy McCall's Response to William Broad

by Timothy

Science reporter William Broad, who a year ago woke the proverbial sleeping (downward facing) dog of the yoga world with his NY Times Magazine article How Yoga Can Wreck Your Body, is back at it. This time he's claiming—based on a review of injury statistics—that men are at much greater risk of serious injury from yoga (see Wounded Warrior Pose). The claim may or may not be true, but I don’t think you can really tell from the data he presents. I plan on writing more about this topic in my next email newsletter, but wanted to respond to Nina's query for the blog today.

Man in Unwounded Warrior 3 Pose by Nina Zolotow

As Broad makes clear in his book, The Science of Yoga (from which the first Times yoga article was excerpted), the subject of his inquiry is the physical practice of yoga as found in most classes. He’s not talking about meditation, chanting, selfless service or spiritual development. Even so, styles of asana practice, different teachers and classes vary enormously. It’s my feeling that Broad's failure to account for these differences could entirely explain his findings.

Back when I was taking a lot of classes of different styles (which I'm not doing anymore, so if things have changed I’d love to get feedback from readers), I found that in the more meditative and restorative classes, I was often one of the only males in the room. But in some of the more vigorous and acrobatic classes, the gender split was closer to even. Thus, men having a higher incidence of yoga injuries could simply be a reflection of their favoring the kinds of classes where injuries seem more common, and not actually reflect any greater vulnerability to injury.

It is also my experience (and that of most yoga teachers I’ve spoken with) that people who are more flexible are generally at greater risk of injury, particularly for injuries like hamstring muscle tears, and overstretching of the ligaments. It varies from person to person obviously, but on average men are much stiffer than women, and seemingly less prone to these types of injuries.

Many yoga injuries—again based on my experience, since we lack data—happen when people are trying too hard to achieve a particular result. Your foot won’t go into Lotus pose, for example, so you pull a little harder to get it into position, and in the process tear ligaments in your knee. But before that happens, the body almost always gives warning signs, such as pain or strained breathing. If you decide to ignore them and power your way through, problems may result. Both men and women can do this, but if I had to guess I’d say men are more likely to, so in this way may be at higher risk.

William Broad loves to create controversy. Beyond claiming that yoga can wreck your body, he has also written that yoga can make you fat, and that the entire practice started out as a sex cult (neither of which is true). Statistically speaking, if Broad’s analysis is correct (and given the methodological problems in how he did his analysis—see Is Yoga Really Dangerous for Men? Dr. Ram Rao Weighs In—I don't think we can know), men may indeed be at higher risk of injuries when practicing asana, but this may miss a larger truth. My guess is that if a man practices less demanding forms of yoga, or any style of yoga in a less aggressive and more mindful way, that his risk probably isn’t any greater than that of a woman, and may even be less. Uh oh, there’s a potential future headline for Mr. Broad: Women at Greater Risk of Yoga Injuries! You heard it here first….

Is Yoga Really Dangerous for Men? Dr. Ram Rao Weighs In

by Ram

Recently William Broad, author of The Science of Yoga, wrote an article in the New York Times Wounded Warrior Pose, which claimed that yoga is “remarkably dangerous” for men. While this article is a must read for folks who practice yoga asanas (practitioners, teachers in training or students), there are several important issues mentioned in the article that needs to be properly understood and clarified.

Happy, Healthy Warrior Pose

Let’s start by clarifying for the benefit of practitioners and non-practitioners: the main reference throughout the article is to yoga asanas and not yoga per se. While this seem trivial, it is very important because one can resort to other yoga activities like dharana (focus), dhyana (meditation), pranayama (regulated breathing) and sustain very minimal if no injuries. Also, yoga is not a competitive sport; for more on this kindly refer to BKS Iyengar’s book Light on Yoga.

While it may seem that the practice of yoga asana is largely a feminine pursuit, such gender inequalities exist in several other sports and training programs. We do not see a mainstream ladies equivalent of American football, the zumba and pilates classes in the gym that I go to is dominated by females and it is mostly men that are busy working out their “ceps and packs” in the weight lift arena. Uncoordinated or improper movements can put an individual at risk and subsequent injury in any sport or training program. The same is true for yoga asanas, which require coordinated movements of several areas/parts of the body.

William Broad acquired medical data, performed a non-scientific partial analysis and concluded that gender differences in yoga injuries exist and men are at most risk for these types of injuries. To me it seems that the differences could be explained at least in part by differences in the amount of training and asana practice.

Retrospective training/sport injury studies have to be normalized (a suitable denominator has to be factored in). Typically, total exposure time in hours or months or years have to be factored in to draw a reasonable conclusion. In a retrospective 12-month scientific study reported by a group in Finland and published in the 2009 issue of Journal of Sports Science and Medicine, the authors concluded that after combining all reported acute injuries sustained by cross-country skiers, swimmers, long-distance runners and soccer players, no significant difference was observed in such injuries when calculated per 1000 exposure hours.

Similarly, another study comparing sports injuries in men and women that was reported by a group of family practitioners from Kaiser Permanente found no statistically significant gender difference for injuries per 100 participant-years (Sallis et al; Int J Sports Med. 2001 Aug;22(6):420-3. Comparing sports injuries in men and women).

If proper scientific standards were applied to Broad’s yoga analysis, it would mean factoring in the mean exposure hours of yoga asanas performed. Based on the above studies my gut feeling is that no gender differences would similarly be found in injuries sustained from yoga asanas.

So do not be put off by Broad’s article! Remember yoga philosophy, which includes asana practice as well, does not discriminate between estrogen and testosterone. The major component of the practice is about “letting go” of the ego, including your body image, and finding your true self. So focus on yourself and your personal practice. And focus less on a “macho” body and more on achieving stability, mobility and encouraging integration—gently coaxing all the muscles that are tight from sports and weight training to move and work together. Pay close attention to connections—between one part of the body and another, between thought and action and between breath and movement. Moving with this awareness helps in reducing risks from any serious injuries.