Originally published in Elephant Journal Feb 15, 2013

There’s something missing from the debate on yoga injuries: a distinction between acute and overuse injuries.

People naturally associate acute injuries with a single, traumatic event, but mention overuse injuries and they’re not so sure.

That’s because these injuries are more subtle in nature—the result of micro-trauma to the tendons, bones and joints that occurred over periods of time. Overuse injuries are more common in yoga than acute ones, however they don’t sell books or magazine articles quite like strokes, seizures and crippling disabilities do.

Yoga is neither a performance nor a competitive activity, but we may still learn something from the gymnastics field; we have more in common than meets the eye.

As Mark Singleton explains in his book Yoga Body, modern yoga postures do not originate in ancient texts, but in a range of more recent movements and practices including British gymnastics and military training exercises.

Each year more than 86,000 gymnastics-related injuries are treated by medical professionals.

You’d think the majority would be of the acute variety, given the physical toils that gymnastics requires. In fact, severe injuries are rare—the most common ones occur in the ankles, feet, lower back, knees, wrists and hands due to overuse or simple stress. Matthew Matava, MD explains clearly how this happens:

“The human body has a tremendous capacity to adapt to physical stress. We tend to think of “stress” in the context of its negative effect on our emotional wellbeing, but physical stress, which is simply exercise and activity, is beneficial for our bones, muscles, tendons, and ligaments, making them stronger and more functional. The remodeling process involves both the breakdown and buildup of tissue. There is a fine balance between the two, and if breakdown occurs more rapidly than buildup, an overuse injury occurs.”

Overuse injuries are “creeping” ones because of their habit of sneaking up on you unawares.

Before you know it, you’ve lost that fine balance and crossed a threshold that’s fiendishly hard to recover from.

So think twice before labeling any injury as “minor,” since it can often turn into a major one.

Unfortunately this message has yet to penetrate the yoga community, where disproportionate attention is placed on acute injuries. Meanwhile, more and more yoga practitioners are being affected by overuse injuries, which are harder to diagnose.

I’ve seen a marked rise in such injuries in my own physical therapy practice, usually in connection with advanced asana practice.

The typical patient, who may be a teacher or a student, has self-treated their pain for some time before seeking help.

There are always multiple causes, however most patients have either repeatedly pushed themselves too far in an attempt to achieve the “perfect” posture, or have been repeatedly pushed beyond their limits. It’s the gradual, cumulative effect of many small actions—the straw that breaks the camel’s back.

Yoga offers many great health benefits, including the prevention and treatment of injuries, so it’s ironic that we’re seeing injuries caused or exacerbated by yoga.

Although overuse injuries cannot be prevented 100 percent, we can minimize their occurrence by taking simple precautions.

For example, yoga studios, health clubs and spas can do a better job of explaining the different styles of yoga, which can be confusing, so the overzealous novice does not wander into a class that’s too advanced for them.

Under the guidance of teachers, students can learn to listen more attentively (what the Upanishad seers called “shravana”), recognizing the body’s subtle warning signs and risk factors.

Teachers can incorporate more time for stillness and reflection between asanas to give the body a chance to recover before the next series of postures.

If we go too far (push ourselves too hard, or are pushed too hard), we are at risk of ligament, tendon and joint injury, and also possibly nerve irritation. Although the body usually heals itself over the course of a few days, the long term effects from repeated, aggressive movements (e.g. overstretching) can cause chronic pain syndrome.

Here’s a real case from my physical therapy practice:  Last year I worked with a woman in her seventies (we’ll call her Anne) who was in good health but complained of sciatic pain that has been bothering her for years and has progressively gotten worse. During the initial eval I noticed that Anne’s lumbar and sacral ligaments (see picture left) were extremely lax compared to the rest of her body. We spoke at length about her activities and it turned out that over the last 40 years, her primary form of exercise has been walking and Yoga. I examined her Yoga form and noticed that most of the movement with forward bending asanas was coming from her lower back and less so from her hamstrings (the restricted area). Whenever she pulled herself forward to complete a full bend (hands around her feet and knees fully extended) she felt  pain in her sacrum and nerve irritation in the back of her thighs. Her symptoms were caused by aggressive over-stretching to the sacral joints, lumbar spine and the sciatic nerve. 

What helped Anne was to avoid extreme forward flexion and to engage in Yoga and Pilates abdominal and hip strengthening exercises. I instructed her to use the strap instead of her hands, and engage the abdominal musculature. We also focused on pelvic/hip strengthening and balance exercises and modified some of her Yoga postures. Anne  did not have to give up her Yoga practice, but merely learn how to practice differently and allow her body to heal. After a few months all of her symptoms subsided and she presented with more strength in her low back and abdomen. Now she never over-stretches when performing postures, because she knows that “where there’s a zig, there is a zag.”

1. Age

Yoga is a wonderful way to maintain mobility in the joints, but we must be careful not to place excessive tensile load on the connective tissue and damage it. For example, an aggressive assist intended to make a student conform to the textbook lotus position can cause a microtear at the knee joint, i.e. the meniscus.  This can happen at any age, but the risk is greater for people who are older because our connective tissue (muscles, tendons and ligaments) gradually lose collagen over time, making it less elastic and therefore less tolerant of stress. If you start Yoga later in life, you should not go beyond your normal range of motion and perform a forceful posture, otherwise you are at increased risk of musculoskeletal injury.

2.  Genetics (body type)

There’s a lot of truth to the saying, “everybody is different.” Genetic predispositions will make someone a better gymnast or a sprint runner.  Some people are born with a larger bone structure and more muscle bulk, whereas others are more slender and flexible with more elasticity in their tissue and laxity in the joint capsules.  It is fairly easy to spot a person who will excel at Yoga and can perform the more difficult postures more easily.

The shape of our joints is genetically determined. Some people have a shallower joint surface than others. A good example is the hip joint. The hip joint is a ball and socket joint surrounded by many ligaments and small and large muscles.  Someone with a shallower hip socket will have more mobility in the hip joint compared to someone with a deeper socket. In Yoga some people can perform the split without difficulty and some will probably never get there. An aggressive push into a split position can cause severe ligament, tendon and muscular damage to hip joints. The risk is higher for those with deep hip sockets.

3. Prior injury

If you have suffered from multiple ankle sprains or hamstring injuries from school or college sports, then you may have caused tissue damage. Old injuries can be detected in the tissue at the microscopic level. Relating this to Yoga, aggressive stretching or excessive force will only exacerbate the damage.  For example, if the ligaments of the ankle are already lax (due to multiple ankle sprains) then an aggressive stretch to the ankle joint can make those ligaments even more lax and result in swelling and pain. The more you place excessive stress on the already damaged tissue, the more damage will occur. Strengthening the muscles sensibly around the ankle is beneficial, but overstretching the ankle is damaging to the connective tissue. Yoga postures that improve balance (e.g. tree or warrior III) are helpful, whereas a full lotus or any posture that turns the ankle too far in any direction is to be avoided.

4. Occupation

If you sit in front of a computer all day, certain muscles will become fatigued and stretched (e.g. upper back muscles, tendons and ligaments) and some will be shortened (e.g. hamstring). You may have poor postural alignment and may be prone to overstretching the already stretched soft tissue. Without proper guidance and verbal cues, you may be at greater risk for injury.

If you spend much of your work day lifting heavy items you are going to have more muscle bulk in your arms (especially males). In certain postures you are more prone to injury because of muscle hypertrophy (increased muscle size).  A forceful assist can not only damage the muscle/tendon but also the joint capsule.  For example, the shoulder is a very loose joint which primarily relies on ligamentous and muscular support. Overstretching the shoulder capsule increases the risk of shoulder dislocation or subluxation (partial dislocation).

5.  Years of practice/how often you practice

Someone who has had many years of Yoga practice from a young age will be more likely to know the postures well and have attained a degree of flexibility, making easier and more fluid movements, especially if the student has had the benefit of individualized attention from a skilled teacher. Then he or she will have learned the postures and will know their body’s limitations. 

6. Gender

Females are generally more flexible because of hormonal effects. They are even more flexible during their menstrual cycle and during pregnancy. An awareness to specific hormonal changes among women should be considered while practicing Yoga. One is more likely to overstretch ligaments when pregnant or during the menstrual cycle. Limiting excessive movements and avoiding aggressive assists will decrease the risk for injury.