WAWADIA Update #5 /// “First Do No Harm”: an M.D. on Asana-Related Injuries

Doctors and yoga teachers have the same first principle: Do No Harm. If we do things blindly, and if we don’t mine data, we won’t fulfill that principle. — Dr. Raza Awan

 

What I love about listening to Dr. Awan talk about yoga injuries is that he has all the relaxation of someone with no conflict of interest. He’s the medical director for Synergy Sports Medicine in Toronto, so he can show up for an intense yoga injuries discussion forum on a Thursday night, drop some data-bombs, and go back to work on Friday morning like nothing happened. Meanwhile, the rest of us yoga teachers wake up wondering what we should do next.

I can say this: he inspires to me move forward as if I have nothing personally at stake in this difficult discussion. But I do. How do I report to the yoga world I’m so invested in, to which I owe my livelihood, and that I spent over a decade teaching in, that several basic staples of asana practice might be definitively unsafe?

In an incisive comment to my last post, Adam Grossi criticized my rejection of “faith” in yoga discourse as being both reductive and dismissive of the “possibility that the practice is operating on us in a great many ways, while we may only be consciously aware of a few of them.”

So I’ll eat some crow here: I find myself moving forward on the faith that we’re all practicing enough to be able to take an honest look at what the tissue specialists are saying about how much we forward-fold, how much we practice, how repetitively we practice, and whether there are whole swaths of the population that do not need the enhanced flexibility that asana privileges while they paradoxically serve as the body models for the entire culture.

Here’s Awan’s presentation from the 5/29 “What Are We Actually Doing in Asana” gathering at 80 Gladstone. I’ll recount his key points below, interweaving some of my own commentary, in red italics. Please note that I am not commenting as a medical professional, but as a long-term student and teacher.

 

The Intro:

  • Awan has been teaching yoga injury prevention since 2011. He got into it because he’d been sending patients to yoga classes for movement rehabilitation, but soon discovered that they were coming back to him with new injuries. This put him in violation of the Hippocratic Oath: “First do no harm”, which he’d assumed was also a foundational idea in yoga, vis a vis the principal of ahimsa. From there, he embarked upon his present project: to help yoga fulfill its therapeutic promise, in which he strongly believes.
  • He describes wanting to approach Diane Bruni, his yoga teacher at the time, to discuss his research into yoga injuries. At first he felt intimidated, knowing that he was going to be asking some very challenging questions about a practice to which she’d dedicated her life. But he found her to be receptive.
  • Diane explains that several years prior to this meeting, she wouldn’t have been open to Raza’s ideas and questions. But since having recovered from a severe hip injury herself, she wanted answers as well.
  • Caveat: the rate of injury among yoga practitioners is not higher than for those engaged in any other sporting activity. For instance, 70% of runners are injured every season, and the percentage is higher for basketball players. Nonetheless, if people are attracted to yoga to improve their health and well-being, a preventable injury that sidetracks them from their goals doesn’t help anyone. Also — many physicians who recommend yoga to their patients are under the impression that yoga is a gentle exercise that would be appropriate for older or overweight patients.
  • This lack of awareness amongst physicians of how rigorous asana practice can be may be a direct result of the success of yoga marketing in projecting an air of relaxing holism. Some forms of practice harmonize with this description, but many do not.
  • The first patterns Awan noticed were repetitive stress injuries resulting from common movements and postures within the ashtanga-vinyasa category of practice. He began wondering whether if some general injury mechanisms were identified, the injuries themselves could be reduced through better education of teachers and teacher-trainers.
  • The data in this presentation is culled from 75 case studies of yoga injuries, which is a pretty good sample, and will be more instructive than what we see in the scant research that’s been done so far.
  • Here I think it’s important to note the obvious fact that Awan is reporting on patients who were willing to come to a biomedical practitioner and presenting a yoga injury. I have no statistics to support me here (and wouldn’t know how to generate them), but I imagine that this sample overlooks a large yoga demographic that is unwilling to see a biomedical specialist except in dire circumstances. In my many years in yoga culture I’ve known scores of colleagues who would exhaust every method of complementary and alternative medicine before entering a medical clinic. I was once of this mindset as well. My point is that his sample may be representative of the types of injuries that occur, but it likely also consists of that small proportion of injured yogis who would be willing to appeal to him as their primary support. There’s nothing wrong with practitioners using CAM to aid in the healing process, or in using nothing at all as the injury heals itself. The problem is merely that the CAM network is less disciplined in case study recording and collation, and often has no access to the most definitive diagnostic techniques of conventional medicine, such as advanced imaging. Injuries that heal on their own, of course, cannot be counted.

 

The data:

  • The sample consists of 70% women, 30% men: not surprising.
  • Average age: 40
  • It’s worth noting here that injuries are likely occurring more frequently in the approach to middle age. While this is not surprising in itself, it makes me wonder about the impact of the majority of asana teachers today being under 35.
  • Most commonly affected body part: lumbar spine, 40% of the sample. Disc herniations, disc bulges, sciatica. Many resulting from over-application of forward folding. Awan notes that lower back injuries “take months and months” to heal.
  • Awan had assumed that these lower back injuries would mainly occur in men with tighter hamstring muscles who would be forced into stronger spinal flexion. But women classified as “hypermobile” were most prone to lumbar injuries. He discovered that these practitioners had often been encouraged by instructors to push into and beyond the end-range of their motion.
  • 20% of the sample featured knee injuries involving torn cartilage, most taking 6-8 weeks to heal.
  • 15%: shoulder injuries, most common in women doing arm-balance poses.
  • 10%: neck injuries from headstand and shoulderstand.
  • Of the sample, 20% of injuries were sustained by yoga teachers. Awan remarks that coaches for basketball, volleyball etc. should know the mechanisms of injury for their sports and should know the proper techniques for avoiding them.
  • I believe this is not representative, because my sense is that many yoga teachers are even more resistant to biomedical care than average yoga practitioners. Many teachers are quite invested in the idea that yoga practice will heal the injuries that come from practicing yoga.
  • The fact that 20% of his sample are yoga teachers leads him to infer that a main mechanism of injury is overuse. 
  • Awan refers to Diane Bruni’s report of having practiced for 3 hours daily, six or seven days per week — which is not unusual for many dedicated teachers — and notes that if she’d done any other intense physical activity like running or playing basketball for that amount of time every day, she would be injured as well. Overuse is compounded by repetition, using the same muscle groups and actions, day in and day out.
  • See Kathryn Bruni-Young’s comment on this narrowness of focus.
  • 45% of injuries featured an increase of yoga practice as an onset condition.
  • 25% of injuries came from beginning teacher training.
  • 3% of injuries came from from harsh adjustments.
  • This last statistic does not jibe with my interview research of 60+ practitioners so far. I believe that the rate of injury occurring through adjustment is much higher, and possibly underreported because of fears of interpersonal or even legal conflict.
  • Awan recounts, somewhat disbelievingly, the story of a hypermobile patient who was injured when a teacher stood on her back with both feet.
  • I think the good Doctor is perhaps unaware of the ample video footage of several of the founders and central teachers of MPY doing exactly the same thing.
  • 40% of injuries were sustained by those who were practicing 3x per week or more.
  • Poses most likely to cause injury: forward bending in either standing or seated positions. Featured in 40% of recorded cases. This is an essential movement in several postural vocabularies.
  • 10% of injuries were incurred through backbends.
  • 10% of injuries were incurred through rotations.
  • 7% of injuries were incurred through arm balancing.
  • Typical high-risk postures: pigeon, headstand, arm balances, arm binds, lotus, warrior one, crow, shoulderstand.
  • Awan recounts an outlier story of a thin male practitioner who lost control of his wrist and hand after performing an arm bind that compressed his radial nerve. Awan says that he’s beginning to see other nerve injuries that come from poses that apply prolonged pressure.
  • In his training sessions for YTT programmes, Awan has been working with his colleague Riki Richter to present the injury mechanisms behind certain poses and then teach safer biomechanics approaches.
  • Awan acknowledges that class size is a factor in preventing teachers from clearly addressing each instance of risky behaviour.
  • He wonders aloud whether headstand and shoulderstand should ever be taught in level one classes.
  • He wonders aloud whether hypermobile and non-hypermobile students should be in the same classes at all. Classes for the hypermobile could focus primarily on strength training, and not put them at risk in by encouraging end-to-range-and-beyond stretching.
  • He wonders aloud whether any fixed set of asanas can be healthful, and whether a series should be changed for those who practice 2 or more times per week.
  • He finishes with a reiteration that despite all of these data, he still believes that yoga asana is a very helpful practice, but that it would benefit from dialogue with the medical community.

 

Addendum:

I’ll write more about this in an upcoming post, and much later in the eventual book, but I wanted to briefly address two issues that have come up in relation to this general discourse on injuries. One commenter on a Facebook thread had this to say about the notes that I delivered on 5/29:

Yet another voice encouraging personal responsibility in asana practice. Most of this video describes individuals who have ignored what their own bodies are telling them, yielding responsibility to some half-baked advice from a yoga instructor or a yoga philosophy taken out of context. The examples he cites seem to come from those who confuse a physical asana practice focused on ever-increasing levels of flexibility, with yoga.

Setting aside the implicit victim-blaming here, as well as the willingness to decide who is and isn’t doing “yoga”, this is a misinterpretation of my position. Personal responsibility is always important, but the research so far is actually calling for much more than that. The injuries cited were provoked by a number of factors, only one of which involved the goal of increasing flexibility. Other factors include the poor biomechanics training of the instructor, invasive/assertive attitudes in adjustments, and a general pressure to “go deeper”.

Even more problematic is the fact that many injured yogis have actually been listening to their bodies, but have either sublimated or rationalized pain according to prior training or present encouragement. (Or they might also have compromised nociception.) It’s becoming clear that instructors who think that telling a student to “listen to their body” is adequate for preventing injury are simply wrong. Our neurology and psychology have too many built-in workarounds for pain for this to be sufficient advice. Confusingly, some of these very workarounds can be inflated by appeals to philosophy, etc. I think the bottom line is that teachers must learn to listen to their student’s bodies along with them. Less than this can involve blaming the student. It’s helpful to remember that medical professionals do not rest on invoking personal responsibility alone. As Dr. Awan pointed out later that evening that his governing body — the Ontario College of Physicians and Surgeons — levies severe penalties for malpractice.

The second and related issue was raised by a participant during the evening, and it’s familiar to me from dozens of previous conversations. It basically asks: Aren’t all of these injuries arising out of an ignorance of the non-asana aspects of yoga practice? Aren’t we getting injured because we’re uninterested in the ethics, attitudes, breath sensitivity and meditation practices of yoga?

I think the short answer is that practicing “non-violence” or “mindfulness” is not enough to protect people from injuring themselves. Moral and psychological principles do not translate into tissue-knowledge. There are thousands of practitioners who are extremely serious about the 8 limbs — lifelong vegans and meditators, for example — who have still been injured in asana practice, because their biomechanics training is insufficient. In the meditation world, there are countless examples of practitioners who injure themselves by meditating on non-violence! Practicing with these ideals in mind is doubtlessly helpful, but it will not stand in for qualified training.

Finally, we must consider the argument from some practitioners — as expressed in this recent post from David Garrigues — that asana in and of itself encapsulates all other modes of practice. This belief is resonant with centuries-old haṭhayoga notions that physical practices should precede the intellectual consideration of morality, etc., lest immature or disembodied understandings contribute to the psychic pressures that suppress the flow of kuṇḍalinī. (For more on this, see Swami Muktibodhananda’s commentary to the HYP.) It’s an argument that would seem to make it even more important that asana be practiced in as safe and nurturing way as possible.

Between those who say that MPY has lost its way because it doesn’t adhere to ancient philosophy, and those who say that asana done properly contains its ancient philosophy, the need for improved biomechanics education and more informed pedagogy clearly remains.

 

44 Comments

  • Thanks for another enlightening post. I hope that all yoga teachers read and consider these explorations on a subject that is so vital to practice. I agree with all your points. Your post has given me a lot to digest. Here’s one—among many—that immediately stands out:

    ” It’s becoming clear that instructors who think that telling a student to “listen to their body” is adequate for preventing injury are simply wrong. Our neurology and psychology have too many built-in workarounds for pain for this to be sufficient advice. ”

    The reasons you cite—sublimated or rationalized pain or compromised nociception—are certainly a part of it. The other issue is that some ,tissues such as cartilage, are not enervated. We do not feel pain in our hip joints, for example, until the cartilage is worn down or the labrum is compromised. Listening to your body is important, but it’s not enough. It is the responsibility of the teacher to understand biomechanics and, as you write, the quickie trainings that churn out 200-hour teachers cannot provide adequate training.

  • I really appreciate this message. As a budding researcher and someone who deeply reveres and respects the scientific process, I feel the need to point something out: The evidence presented here is anecdotal, and therefore we cannot draw causal conclusions. In an effort to facilitate right knowledge we must be careful to make the distinction between experimental inquiry and ‘me-search’. He presents the information as though he and/or the sports-medicine doc have discovered a causal link, and this presentation creates just as dangerous an illusion as the notion that all yoga is healing.

    • Sarah — thanks for your excellent feedback. I’m not claiming here or anywhere or anywhere else I hope that the data moves beyond the anecdotal. Dr. Awan is reporting from what patients from 75 case studies have presented. It’s not a controlled study, but Awan believes it’s a good starting point for further epidemiological research. In my own work I’ve stated several times that my data is gathered from self-selected informants. So any tips you might have about how I can make the contours and limitations of this project clearer — I’d love to hear them!

  • In my perspective, the main reason for the high rate of running injuries is over-striding. Most of the statistic on running injuries started over the last 40 years, with the invention of the cushioned shoe, and the running boom. The rate of injury has not changed since. Coaching, training methods, running shoes have improved. Running is not seen as a skill and the heavy cushioned shoes along without correct bio-mechanics has encouraged the runner to heel strike in front of the body, working against gravity. The common believe the longer the stride the better. Where all the tall elite runners? ( most of the fastest runners in the world are under 6 feet tall) In reality, sticking your feet out in front of your body, is like putting on the brakes. As a long tome running skills coach and yoga teacher, over-striding and over-stretching is the main issue. Pulling yourself apart is not going to bring you back together. In both yoga and running we actually move from the center of our bodies when done properly. As a yoga teacher, yoga safety has to be our number one priority to our students. We need to stop and re-think this silly notion that more is better. What is the benefit of trying to pull ourselves apart at the seams?

  • Matthew-

    I am following these posts with avid interest. Several notions discussed above and in previous posts are vital and important acknowledgment of what can and does happen in yoga asana classes.

    For example, while I agree with David Garrigues that asana practice can encapsulate all other modes of yoga practice (this is my particular position), it is vital to also understand that asana practice is still a physical discipline.

    It is not immune to or beyond many very well understood physical principles, — for example of adaptation, of overuse, of over-reaching, of the importance of cautiously increasing volume or intensity, etc, etc.

    The cross-discipline conversation, which I see you initiating here, is one means of working to improve our understanding.

    It’s also important to remember that you are likely to present with a fairly large selection bias (as you mentioned, self-selected interview responses).

    As such it is statistically very, very tricky to infer generalizations about the larger asana population (i.e. your comments on your conclusion that injuries occur towards middle age, or even the rate of injuries through adjustments. Not that your intimations are not true, it’s just that your data can not support these inferences.)

    I look forward to future articles (and also the book with M. Stone!)

    j

    • Thanks for the helpful feedback, Jason. I have to be sharper with adding caveats in future posts. I can’t do much about the selection bias at this point except to tie the qualitative data together in such a way as I believe will resonate with the highest number of practitioners. The proof will be in the pudding, if it’s to be found…

  • Since most yogis do not seek medial attention when injured and because yoga is not regulated, do we really have any reliable statistics on how many injuries are occurring? The fact that yoga injuries are happening at all is a huge red flag we cannot ignore. Yoga is considered a healing practice and so not unlike physical therapy, people should not be getting injured doing asana.
    Many yoga injuries are cumulative as a result of the breaking down of the necessary tensional forces in the body in performing yoga poses that flex and compromise the integrity of the spinal column and hip joint. It comes as no surprise to me that the majority of the injuries are in the lumbar sacral region. Forward bends with the knees straight from sitting or standing break all the rules of human biomechanics. As any back doctor will emphasize , bend the knees and not the spinal column.
    We frown upon people slouching in chairs with the sacral/lumbar region flattened and compressed. So why is it OK to bend forward with both knees straight reversing the lumbar sacral region and the entire spinal column in extreme flexion? Is there a right way to do forward bends? Humans age by going forward and so I always wonder why this emphasis to bend forward in yoga? How is it really affecting the body? Massive compressional forces measured in hundreds of pounds are generated in these forward bends.

    People do not realize that the ligament forces that stabilize the hip and knee joint are getting loosened by this repetition of forward bends. This is why the more flexible people get injured more frequently according to the study. They are loosing the necessary ligament stabilization forces needed for shock absorption and joint positioning for natural functional movement. Men with strong gluteals cannot bend forward with their knees straight. Women, with looser ligaments needed for birthing can oftentimes bend over with straight knees. What is the outcome? Many get a flat looking butt, collapsed sacral platform and joints that are so loose that some wind up needing hip replacements.
    As Charlotte mentions, we do not have nerve innervation in the ligaments and cartilages to signal us with pain when listening to our body. Longer is not better for the ligaments. I was injured over twenty years ago and begin to create YogAlign which has a focus on correcting postural misalignments by strengthening the body in upright alignment.
    “Anityasuciduhkhanatmasu nityasucisukhatmakhyatiravidya” (What at one time feels good or appears to be of help can turn out to be a problem; what we consider to be useful may in time prove to be harmful.) from the yoga sutras

    • I agree with your concerns. The “more is better” philosophy, especially when applied to flexibility, is not healthy. Ligaments are meant to limit joint mobility. Loosening our ligaments only destabilizes our joints and causes muscles to have to tighten to stabilize, which is not their function. I’m currently dealing with gluteal spasms because the ligaments attached to my sacrum are so loose that my sacrum is rotated in my SI joint.

      I hope people take Matthew’s investigation seriously and begin to move toward a more balanced, physiologically sound practice.

  • “I have no statistics to support me here (and wouldn’t know how to generate them), but I imagine that this sample overlooks a large yoga demographic that is unwilling to see a biomedical specialist except in dire circumstances. In my many years in yoga culture I’ve known scores of colleagues who would exhaust every method of complementary and alternative medicine before entering a medical clinic.”

    I would suspect this demographic would be even greater in the US, where many yoga teachers have poor (if any) health insurance.

    • I think so. In the previous video I describe the experience of a practitioner who continued to practice injured under the influence of her practice culture, but also under the pressure of not having insurance.

  • I find Dr. Awan’s report of spinal injuries and injuries related to forward bending to be very compelling because it squares with what I would expect based on the biomechanics of the pose.

    Katy Bowman does a great job explaining the problems and potential solutions with this pose here: http://www.katysays.com/forward-bend-modified/.

    My issues with yoga have always been rooted in the fact that it has sprung from tradition and not from a scientific background. Now that I have had some minimal training in biomechanics and alignment, I simply cannot practice yoga anymore without major modification. Which, in a way, proves your second point. Because, before, I was absolutely tuned in to my body and trying to honor it. But, once I learned more about how the mechanics of my body worked, I couldn’t allow myself to enter poses that I knew were (at best) not doing me any good and (at worst) potentially harmful.

    This is an important, valid dialogue that you are engaged in and please know that you have an audience for it despite pushback you may experience.

  • Loving your posts and happy to jump in!

    Yoga teacher trainings would do us all a service to focus on teaching students how and what they are feeling (physically) before a practice, in any given posture, and afterwards, rather than on the ‘proper way to do a pose’. Then, what a gift of sensitivity/mindfulness that is to take off the mat.

    These concepts are more common now than when I began teaching in 2001, but I am grateful to Paul Grilley who taught me how to recognize the difference between the compression (of tissues or joint structures) and tension (stretching of tissues/traction in joint structures). With this knowledge we can teach students where we should expect sensation in a given posture for a given desired result. With an understanding of how and how far ‘joints can open’ or ‘muscles can stretch’ in any given body, teachers can tailor postures, alignment sequences, timings, based on the effects they are trying to illicit. The experience of the student is individual, and alignment and effort for that student individualized. Understanding the difference in sensation between stretching or elongating tissue, and squeezing, pinching, torquing tissue can do much to help teachers direct students away from ‘going too deep’ in a pose and the nerve impingements and inflammation that go with repetitively asking joints to ‘open’.

    I think we have all experienced pains that we were not certain what to do with. It takes experience (wisdom) to first notice pain, experiment with the practice to see if we can understand/heal/resolve pain, and then determine whether to get outside help. The teacher’s job is to lend her experience/wisdom to help the student determine the right course of action. Letting go of goal oriented practice and embracing experiential practice is key and should be taught in Teacher Trainings.

    We have to remember that the physical fitness aspect of yoga is a fairly new phenomenon (19th century) and that the physical austerities of the ascetics of tradition inherited a culture of physical sacrifice as a way towards an end that most of us are not even seeking: Enlightenment in the form of Detachment from everything that matters to us. I think most of us are seeking something else instead: Increased health and vitality, and a sense of connection to others and the world around us as a way towards a brighter quality of life.

    On your comment about the doctor’s experience with Yoga teachers…I’m not surprised so many are teachers. Yoga Teachers are everywhere…whether they’re teaching or not. This is the not-so-small subset of ‘advanced’ practitioner that supports the livelihood of so many yoga centers in the form of teacher trainings. This is a large demographic of students who attend the most physically rigorous classes in any community.

    At the risk of sounding cynical, in many communities many teachers are not extreme yogis with regard to lifestyle (strictly rejecting western medicine and adhering to holistic alternatives), but rather extremely athletic young people taking extremely athletic asana classes (mostly for exercise) from charismatic teachers who are inspiring and who push students to their physical limits, and thus a group catharsis resolving in a fantastic Savasana. As women (primary demographic) head towards 40 (I’m 41) ‘working’ injuries that have been a part of a practitioners practice for some time become harder and harder to ignore/manage, joint tissue begins to shrink and dry up, hormones change with pregnancy/childbirth/menopause, and these women go to doctors because other things aren’t working.

  • How does looking for the edge of compression or joint opening contribute to people finding “Increased health and vitality, and a sense of connection to others and the world around us as a way towards a brighter quality of life”?
    Charlotte Bell and myself have been trying to explain, there is no nerve innervation in the ligament and connective tissues that would signal us with pain.

    It is of course highly important that yogis pay attention to what they are feeling by cultivating the kinesthetic proprioception sense. Many yogis are trying to performing poses rather than paying attention to how their joints naturally function and what the possible outcome may be of performing these asana actions and positions. As Charlotte says, she wish she had known to avoid poses that have led to the joint instabilities she has now. Collagen bonds break down in the connective tissue and these longer ligaments do not provide stabilization forces needed to keep joints functioning. These muscle connective tissue structures are continuous in the body and cannot really be isolated in function. Do you use just parts of your body in any action when upright and moving? How does isolating parts contribute to the big global anatomy picture?

    Since flexible people are injured more frequently according to the study, how is it that we should even explore how far a joint can open? Flexibility is over-rated and glamorized in yoga with people pushing joints far past normal ranges of motion to do the pose. How is this related to the deep principles of yoga and ahimsa and finding the middle path?

    Most flexy bendy people need joint stabilization not joint opening. Stabilization requires using muscular force rather than hanging from your ligaments as in pose practices such as down dog with the chest pushed to the floor. The question is how does this extreme range of motion contribute to real life function. Anyone?

    The fact that women get most of the approximately half a million hip joint surgeries a year is the proof of the liabilities of flexibility. Hip surgeries for yoga practitioners and teachers is not uncommon either. What if the practice of yoga asana stabilized and strengthened the hip joint instead of opening it?

    http://www.nytimes.com/2013/11/03/sunday-review/womens-flexibility-is-a-liability-in-yoga.html?_r=0

    • Hi Michael, Couldn’t agree with you more on every point. Teaching students to understand the difference between compression and tension and where we might expect to feel sensations in a given pose in a given joint is just one of any number of ways we can pay attention to our experience of practicing asana. When the shoulders hurt behind the shoulder, deep in the join, or radiating pain is felt around the shoulders and down an arm from pressing the chest towards the floor in DD that’s not the sensation of the ‘shoulders opening’ as many students believe and so continue to press. And jamming into that compression 30 times during a class is going to cause pain, not just during the pose, but after. Like you said, rather that joint needs stability.

      What I was suggesting is that, among other contributing factors, there is a no pain no gain attitude towards asana that is leftover from the ascetics starving, piercing, isolating, etc.. themselves in the name of enlightenment. We don’t need to carry that heritage on in our modern asana practices…going deeper and deeper into poses regardless of the feedback from our bodies, insisting on severe and unusual feats of pretzeling and balancing on structures not designed to bear the weight of the rest of us (like wrists and necks). Instead, we are opting for health and vitality. So with health and vitality as a goal the experience of practicing asana should be providing us that in body and mind, without sacrificing those joints/tissues in the name of this ideal/identity. If a joint needs stability we should be able feel it, our trained teacher see it, and the result should be that we figure out how to engage the muscle groups that stabilize. For the ‘tighties’ the exact same yoga posture will be an extremely different experience.

      One question might be, ‘what are all the different ways this joint can move, and if I move/support/stretch it this way for a while, does it leave me feeling stronger, more agile, and later relaxed? Or does it leave me in pain?

      Matthew mentioned the concept of ‘nociception’, and that listening to ones own experience is not enough, as we have so many built in mechanisms to override our recognition of pain. Isn’t that the journey…unveiling/unraveling our own understanding of ourselves and others through experience and sensitivity, ideally with a knowledgeable and helpful guide at our side.

      • Valerie, I appreciate your response and totally agree with you that the no pain no gain attitude left over from the ascetics has no place in modern asana practice. Most yogis agree that we should never push too far and listen to the body. However the lack of nerve innervation in the connective tissues leaves us blind to damage that is occurring from repetitive stress of the sacral/lumbar ligaments when doing a pose like seated or standing forward bends with straight knees.
        How does bending forward with the knees straight help our real life functions? Are we causing more harm than good?
        How are we able to know if a pose is safe? Is the spine in its natural curves? Can we take a full deep breath? Many yoga poses are akin to putting the body in a cage and twisting it. What is the benefit of pushing space from our body and strengthening the flexor forces to bend forward? People have weak back extensors from sitting in chairs and also people age by going forward so why are we obsessed with stretching forward and cranking on our back body in yoga?
        Stretching as many people understand it is a myth. One cannot pull on a muscle and change its tension because the nervous system runs the software of how our body does millions of complex actions. This happens globally as no part ever moves in isolation.
        If you pull on your joints, the ligament tissue which is continuous with the muscles has collage bonds which will break down. Having longer ligaments is not healthy and doing passive stretches which do not engage muscles to engage a joint weakens the structure of the shock absorbing stabilization forces of our joints. Weak muscles and loose joints are a recipe for disaster.

        Our spine has a lumbar and cervical curve which provides shock absorption when moving. Flexing the spinal column and pulling the chest toward the knees removes the curves and weakens the collagen bonding forces that keep us upright. The body is not made of parts. Linear right angled muscle isolationist yoga asana practice does not contribute to real life natural anatomical function. We need to think globally and that includes our body.

  • Yet another great post, thank you! I read your blog but don’t generally comment. However, as a yoga practitioner who got injured form too much forward bending (primary series daily) and not enough biomechanical knowledge – neither I nor my teachers knew enough back then – I’ve felt strongly about these issues for a long time!

    It’s wonderful to have such a well-researched article to point people towards. I wonder what the incidence of SIJ injury might have been, or did he include that with the lumbar issues?

  • I totally support Dr. Awan in his quest to keep yogi’s safe. It’s completely unexceptable to EVER be injured in a yoga class. If you are injured in a yoga class, it’s very important to bring it to the studio’s attention, tell the teacher you were injured from so that they can correct their approach to that pose. I am sure they would understand their mistake and make sure it never happened again. The teacher should be learning from the student too, observing the individual at all times. I alway’s encourage my students to talk to me, I am completely approachable and available before or after class. I am very happy to say I have never had anyone ever report and injury to me in 20 years, I am shocked that people are getting injured with all our developed knowledge of the Western body and Yoga. I believe I have a lot to offer on this topic of “Keeping students absolutely safe at all time’s.”
    I am sure I have bruised an ego, unintentionally of course.
    Teaching yoga is not Rocket Science. It’s a privilledge and a joy to help people feel great!

    • Thanks for chiming in, Brooke. Many of my interview subjects describe being too intimidated to approach teachers regarding injuries sustained in class — even if they were caused by adjustments. I imagine that in 20 years you’ve seen a lot of students, and I’m wondering if you think its reasonable to assume that some people have been injured in your classes, and that, despite your approachability, they’ve simply not told you?

      • In regards to both your and Brookes comments. How do we know what happens when a student leaves? I belive a lot of the people who get hurt in yoga just slumps out of the door and we never knew what happened. These could include people we have been teaching for a long time who has accumulated injuries through the practice. Also i belive a lot of yogis attributes their problems to other things in their life than yoga. Movement practice of any kind hurts people from time to time, and there are no movements that are safe for everyone to perform. Of course limiting the risk of injury should be one of our primary concerns.

  • Have you people never heard of T. Krishnamacharya? Seriously, this man and his son TKV Desikachar taught the correct principles for teaching Asana for over 50 years. They repeatedly explained to all who would listen that ALL asana taught to ANYONE over the age of 20 should be one on one, highly individualized and should always use slow deep ujayi breathing as a gauge for what was and was not appropriate. Instead, the entire western Yoga world worshipped at the feet of two students who only studied with Krishnamachaya for a couple of years, and this was when they themselves were young men. With their extremely limited understanding of Asana, they continued to every single person what they were taught: young boy, group class, alignment centered (Iyengar) or athletic vinyasa (Patabhi Jois) Asana

    Now you Asana jockeys suddenly seem surprised or outraged at the number of injuries in modern Asana practice (as distinct from the complete somatic, relational Psychology of Yoga as outlined in the Yoga Sutras).

    Open your eyes and admit that for thirty years now, you’ve been mislead, miseducated and mistreated by teachers who themselves were never exposed to the larger context of Yoga as presented by Patanjali (which contains only three Sutras on Asana, illustrating its relative (un)importance and limitations as a transformative tool).

    I would laugh at the cosmic irony of these current ‘revelations’ on the dangers of Asana if it weren’t so genuinely tragic that Yoga, a transformative, holistic healing art has been the cause of so much suffering on so many levels.

    So wake up, read Heart of Yoga, choose one teacher firmly rooted in the lineage of T. Krisnamacharya (there’s a few of us around) learn the correct purpose and practice of Asana, as well as it’s true place in the big picture of Yoga philosophy and stop doing so much sahasrara mula bandha. Have a nice day.

    • I really admire the passion and commitment hidden within the victim-blaming and partisan vitriol of this comment.

      Have you seen David Gordon White’s new “biography” of the Yoga Sutras? You might be interested in the penultimate chapter, in which very thin threads of fact are drawn out of the mythological web that has cocooned Krishnamacharya’s legacy from inquiry. We can begin with the fact that 3 of the 4 authorized biographies of the man (recording his interactions with his students and children) are written by the Desikachars, who change their stories year by year. Leaving aside the geographical impossibility of visiting R. Brahmacari in Tibet (or Nepal) in the shifting timeframes given, it’s perhaps most important to note how the stories change around the centrality of the Sutras’ influence on Krishnamacharya’s life and teaching.

      There might be good reason for you to question the “parampara” validity of the asana regimes that have come to be associated with Pune and Mysore. But there’s equally good reason to question the basis and assess the potential psychological damage of hagiography, or believing that the Yoga Sutras present a “complete somatic, relational psychology”, or indeed that they were ever chanted, Vedic sloka-style, prior to the 1970s, despite the claims of TKV.

      Pot, meet kettle. Everyone tells a story, but nobody has the truth.

    • It is tragic that the supposedly healing practice of yoga is now injuring so many people and causing suffering on so many levels. If we let go of the forceful linear aspects of asana, there would not be the injuries that we see now.
      Nature builds in spirals, curves and and circles. Human design, like all of all organic nature, contains no straight lines or right angles. I often wonder why people think forcing their spine and hips into right angle positions or straight lines will benefit the natural curving shape of the spine and torso or the spring of the knee and foot.
      The sacral platform injuries are revealing that bending forward with the knees straight loosens the ligament tension of this most important shock absorbing platform, weakens the gluteals and enlists the psoas group primarily as flexors. There is a huge compressional force on the hip socket as well which may explain the labral tears occurring in many yoga practitioners. ( The labral is the connective tissue that keeps the head of the femur rooted in the acetabulum.)

      • As a yoga instructor, my path has included bulging discs and a sore hip. I have listened to my body and through adjustments have been able to continue to practice and to heal myself. When I found Yogalign it was the first time I had actually seen many of the adjustments I was using and teaching in printed form. So recently when I visited Kauai, I made it a point to see Michelle and to participate in one of her classes. I didn’t tell her I was a teacher because in that format I was simply a student. I really enjoyed her class and the emphasis that she places on the breath moving the body. I thought I had always used my breath (I’ve been practicing for almost 15 years) but because of the added resistance/release-based movements she had us perform, I found a new, deeper way of using the breath to facilitate a shift in the central nervous system all the way down into the fascia. It was amazing. You do great work Michaelle. Keep it up. Our paths are somewhat parallel in that I have been working to heal my own injuries and have learned deeply through the process and what I teach is not always welcome or the most popular approach with cookie-cut scripts and money hungry studio owners. But, I march on and am inspired by your work. I also believe that in order for yoga to survive and continue to develop health on so many levels, we have to be able to fold in approaches that help the budding yogi keep him/herself safe from injuries. Anyways, just some thought and thank you, again! V. Herron, Yogawakened.com

  • Thank you! How wonderful. Matthew you always address the issues I feel are swept under the mat so to speak. It’s refreshing to feel that as in a yoga practice, nothing is swept to the side it is all part of the journey, the learning the growth. Even that which seems ‘negative’ or scary is welcomed into the process. Injury is a scary issue for many yoga teachers and this article makes it clear that this is something not to be ignored.

  • Godfrey Devereux’s form of dynamic yoga addresses exactly this problem. Through his years of constant inquiry, study and meditation, he has adapted the asanas for beginners and instructors alike. He centers the practice on constant observation and sensitivity, so there is virtually no possibility of injury, while retaining the essence and and benefit of the strict postural forms. People interested in continuing yoga injury free would find much of interest in his books, though the best is to learn from teachers formed in his school of dynamic yoga. It was a life changer for me, as dramatic as that sounds. I am in my mid-fifties, and have grown more in 3 years of these classes that in all my youth of classes that pushed and demanded from the outside. And never one day of pain. It is worth looking into!

    • Thanks for the great comment, Frores. I’d like to interview Godfrey for this project, and will reach out to him separately. But can I ask you as a student: what’s your understanding of “the essence and and benefit of the strict postural forms”? By whom are the essences and benefits described? Where does this particular vocabulary of “strict postural forms” come from? It sounds like you’re describing a rational and mindful approach to something “classical” or well-established, and I’m wondering what that is.

      • Hello mremski, in reply to your questions, first of all I am definitely a student and can not claim any expert opinion of anything. The vocabulary is mine, not Godfrey’s, as I was relating my own (limited but evolving) experience. I have suffered through teachers who, with the best of intentions, have insisted on the strict forms of asanas of whatever school of yoga they were a part of, fairly disregarding the physical make-úp and situation of the student. I had minor but recurring injuries from following the teacher’s instructions too closely when my body was trying to tell me something else.

        Godfrey’s approach is to, as I see it, distill the asana to its essence in the cleanest physical form that the body can manage. By essence I mean that the energy flows freely within the body in the way the asana is constructed. There is no tension of a body trying to get into a shape. The body and mind work together to open from the inside, not push and pull from the outside. The “benefits” I spoke of were the all the “benefits” (I’m not sure if that is the best word) that each asana was made for. The body becomes open, grounded, and strong, as the mind becomes ever more sensitive in observation. There comes a point where the line between posture practice and meditation becomes very fine indeed.

        I hope this answers what you were wondering. Please ask me again if it isn’t!

  • I am really enjoying this series and can’t wait for the final book. Thank you! I’m a trainee yoga teacher and wondered if you could recommend any good anatomy courses? I travel a lot so an online course would be best. Many thanks.

    • Victoria, check out Katy Bowman, Susi Hately, Leslie Kaminoff or Jill Miller (or other Yoga Tuneup teacher). I have learned loads from all of them about anatomy, biomechanics and helping students to find their safe range of movement.

      Matthew, Thanks for this great series and wonderful discussions. Keep up the great work!

  • Hello mremski, thank you for this article which i found very interesting and comforting.
    I just would like to share my very short experience with ashtanga; sorry in advance for my English but this is not my first language.

    I started with ashtanga at the beginning of march: i never had yoga before but about 6 years of pilates training (withouth any issues at all).

    I definitely like ashtanga and i must be what Awan calls a “hypermobile” since everybody kept asking “where did you practice before”?

    Mid March: an issue with a shoulder that did not prevent me from practicing and was healed in a week.

    End of March: while on ardha baddha padma paschimottanasana, I felt a “crack” behind my left knee. I could not walk for two days and could not go lotus for the rest of the month. I thought i was stupid for having wrongly used my leg.

    Early April: my right leg, with no apparent reason, started hurting as the other one did… first doubts but I went on

    Second half of May: my lower back started hurting. Stopped for one week, tried again and the result was even worse.

    The teacher said I should have kept practicing because yoga reinforces the back (!!!).

    In this case I finally decided to listen to the underestimated messages my body was sending and gave up. My chiropractor, who I did not see since more than 3 years, said I have L3-4-5 discs and sciatic nerves inflammated.

    A side effect, which I connected only now to the practice, is that i spent three months feeling always tired and more tired, so much that even a routinary housekeeping hour required intermediate breaks. I felt my muscles as if they were “loose”, inconsistent. And just felt ok during practice.

    I am full of question marks: am I not fit for ashtanga? Is the practice wrong? Is the teacher wrong?
    Why can’t I skip or modify the asana’s that I can’t perform properly rather than trying to do them wrong?
    And why have i been looked at as a creep when i stated that I would not practice if my lower spine was hurting in order not to create further damages?

    End result is that I am waiting to feel better to go back to pilates, although I still have a slice of my hearth on ashtanga.

  • My knee was damaged and injured over 25 years ago doing ardha padma uttanasana. At that point, I stopped all practice and begin to create a more natural way to get connected to my body and breath.
    Yoga poses have been heavily influenced by Westernized exercises and there is overwhelming evidence that many are based on military drills, gymnastics, and contortionist routines. You can blindly follow or listen to the intelligence of your body which is saying NO to the pain you are experiencing. > You say you are hyper mobile which puts you in more danger since you are loosening ligaments and destabilizing your joints by doing things like bending over with your knees straight and doing half lotus while you bend forward or twist.
    I have created a program called YogAlign that has an emphasis on getting naturally aligned though breathing techniques that create lift and expansion while the asana is based on joint stabilization rather than the stretching of parts. The overemphasis of forward bending in Astanga creates many issues including a loosening of the ligament tension necessary for upright posture. People age by going forward and so why this emphasis to push the body forward in yoga asana? Many are led to believe that have to suffer to feel good.

    • I’m really confused. A lot of kinesiologists say you should never bend your knees in forward bends as it puts undue stress on the spine musclses (rather than using the might of the hamstrings). There seems to be a lot of conflicting info.

      • Victoria , stress to the spinal column happens when knees are kept straight in forward bends. why? Because bending the knees allows the gluteals and hamstrings to engage supporting the torso. Keeping the knees straight when leaning forward causes the spinal column to flex with hundreds of pounds of pressure. Diane’s weak gluteals are no surprise when we consider thousands of forward bends with straight knees and disengaged gluteals. Try to walk without bending your knees. Not very comfortable and awkward? There appears to be no benefit in stretching forward with knees straight as there is a serious torque on the sacral platform, weakening of the butt and reversal of the lower lumbar curve.

  • Well – actually bending the knees slightly in standing postures has a lot of benefits. I can’t imagine how it would put undue stress on the spine muscles. Bending with legs straight can be dangerous unless practitioner can consciously choose to bend from hips and from the spine. Oftentimes practitioners just bend from the weakest part of the spine (the part that bends easily) creating compressional forces that can cause damage to the spine. It’s good to learn to bend actively from the spine, create space between each vertebra instead of compressing space between one or two of them.

    Bending with knees slightly bent allows to work on the strength of the muscles. When you straighten knees you usually lock the knee which causes some slight external rotation. Besides most of the people, especially from Iyenfar yoga style keep on pulling their kneecaps so hard (at least the ones that I’ve encountered) that they risk to overextend them which can lead to may other imbalances in the hip joint and throught the hip joint in the spine.

    When the muscles of the knee can be controlled and used to stabilise the knee, the hip can be me more safely manipulated and postures such as comfortable sitting on the floor become more accessible with less risk of knee or lower back pain. But it requires a lot of conscious effort. I would say that for most people the best way to bend forward would be with knees bent and only when they feel comfortable try to straighten them.

    Besides the best way to protect the knee (any joint actually) is to co-activate (not forcefully) all of the muscles surrounding it. So for example in the weight bearing standing positions done with the knee extended it would be good to a) pull up the kneecaps (in order to activate knee extensors, it’s enough to use 20 – 25 % of the force), b)try to bend the knee with knee caps still pulled up and/or press into the front of the foot (activate
    knee flexors).

  • I think the main point being missed here is the lack of true knowledge in yoga instructors coming to the scene. With yoga growing so rapidly in the world, so many studios/individuals are looking at teacher trainings as a way to make lots of money. In turn, the teacher’s teacher may not have enough knowledge to train these up and coming teachers. It’s a domino effect. It shows when you go to a class and there is little to no physical cues from the teacher as to where certain body parts should be, how certain parts of the body should feel, modifications for those with inquiries, etc. Myself being a yoga teacher, I take pride in those things. I am always looking for more information on anatomy to make sure my students are safe. They come to class to get personal instruction. If they wanted to do class along side the instructor with no cues, they could just stay home and do a video, and save lots of money. It’s our job as teachers to be there to heal our students with our knowledge, not make them afraid to return.

  • I think it’s important that we move forward from considering asana practice to be yoga practice. The practice of asanas is a small portion of the practice, but in the western world and increasingly promoted by western popularity even in India many people think of yoga as asana. Asana practice is a preparation for meditation…the meditation of life as well as actually sitting for long periods. From my experience in the Hatha world most people’s practice ends at the end of the physical process and includes trying to constantly be more flexible, more physically strong, closer to the physical ideal of yoga magazines and uber flexible people, etc. In this case, the entire yoga is being missed. The mindfulness is out the door. Injury happens when we are not mindful, not present, not respectful and aware of our bodies and not practicing ahimsa (non-violence) toward ourselves. When we rush to a class be cause we HAVE TO GO or we believe that simply PUSHING HARDER in our asana practice is going to improve our experience…we’re missing the practice all together and it’s become another workout. Exercise is beneficial, yoga is about connecting every part of the finite experience of you with the infinite experience of the universe as best you can. I feel that the more we move toward a true practice, the less injuries will be a part of the experience. Injuries are not the fault of the practice, but lessons for the practitioner. I personally found a place in Kundalini Yoga that I felt was more complete and whole, but I still have to remind myself to be mindful of where I’m at every time I practice so that this becomes the habit.

  • Interesting points. I never realised that forward bends were so problematic. I own a hot vinyasa yoga studio in Barcelona and I haven’t come across injuries from forward bends but hand balancing, shoulder stand and back bends yes. I am one of those over flexible people that shouldn’t do too much yoga and need to do muscle strengthening so I have a cronic problem with my shoulder. I agree on several points about the overly flexible needing to do other sports. I am actually from Toronto myself so I will have to look you up sometime I am back in Canada.

    namaste
    heather

  • Thanks for reposting this mremski.

    Good stuff here.
    I’m grateful to you for calling out Robert Birnberg on his rude’ish comment, which was some sanctimonious…. (having known Robert, and studied in the TKV/Whitwell/Kaustaub world I feel I can say this outloud here).

    –I’m surprised that Robert B. would behave with this ‘attitude’, as I’ve known him to admire your work mremski (hmm well, or at least USE your work ,to blog himself up…

    While I understand the frustration Robert displays, I am comforted by the reality and ‘difference’ of the ‘Indian’ body –vs– the Western body.
    —- We are different animals, and that’s the truth.
    Some of us have –not– been sitting on our haunches since we were tiny kids.
    Then there is the Houdini gene the Chinese enjoy. No problem folding themselves into circus contraptions.

    That some of us are hyper mobile (some just in the upper torso, others top and bottom…)
    That some of us are ‘stiffies’.

    Well, absolutely different classes for different people. The Dr. has that right!

    Robert: One on One? Is a luxury few can ENDURE, let alone afford.
    I’ve been ripped off in this kind of ‘format’, and even –abused– in this setting.
    Nothing wrong with Group Classes, smallish, and when the teacher is knowing the students to some degree.
    — Sanctioned by your lineage,Robert, by the by.

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