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.

What Your Yoga Teacher Really Wants to Know

by Baxter

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.

Beans, Beans, and More Beans (from Wikimedia)

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.

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!

What is an advanced yoga practice?

by Nina

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.

Year-Old Snow and New Snow by Philip Amdal

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 yesterday in his post on wrist care (see "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.

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.

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.