Understanding and Preventing Yoga Injuries

Yoga Leaflet 7

Loren M. Fishman, MD, Ellen Saltonstall, RYT, Susan Genis, RYT, ESQ. did a research project in the form of a 22-question survey in 2007. This was send out to 33,000 Yoga teachers, Yoga therapists and clinicians. From the 1,336 responses from 35 countries the most common and the most severe injuries were tabulated and preventative strategies were suggested for these reported Yoga injuries.
The recommendations address the 4 top-stated causes of injury, which are: poor technique and/or alignment, previous injury or condition, excess effort, and inadequate or improper instructions from teachers. These 4 causes are interrelated and addressing any one will often be a gateway to addressing the others.

Preventing Yoga injuries when prior conditions exist.
It is imperative that new students disclose any pre-existing conditions. As these conditions often remain undisclosed, teachers should be proactive in mentioning any contraindications of a pose.

Preventing Neck Injuries.
The cervical spine is the most vulnerable part of the spine because it is the most mobile. The two types of poses in which the most care is needed to protect the neck are backbends and inversions. In back-bending, vertebral compression and nerve impingement occurs when a Yoga student is too aggressive in thrusting the head and neck back in cobra pose, up facing dog pose or the camel. The key instruction and awareness that will protect the neck is to arch the head back only after achieving the maximum possible arch in the thoracic spine. It is also helpful to maintain some muscular tone in the front of the neck. With these protective actions, the arching movement is spread evenly through the vertebral column.
The inverted postures most implicated for neck injuries are the head-stand and the shoulder-stand. In the headstand it is essential for students to understand how the use of arms and shoulders can support body weight. Pressing the arms down and lifting the scapulae elongate the neck evenly when weight-bearing. Without this support from the foundation of the pose, excessive weight on the vertebrae may cause injury.
In shoulder-stand blanket support (or a large foam) may be required to prevent excessive flexion of the neck. When the pose is performed flat without blankets beneath the shoulders, the vertebrae of the neck are forced into 90 degrees of flexion, pinned to the floor by the body's weight. Ligaments, tendons, discs, and muscles connecting these vertebrae are all at risk. With the shoulders and upper arms elevated on folded blankets (or a large foam), less flexion of the neck vertebrae is required and inevitable pressure on this area will be shared by the shoulders. Strengthening and stretching of neck and shoulders are prerequisites before the attempting of inverted postures. Abdominal strength and a vigorous stretch in the legs further reduce collapse of the body weight into the neck.

Preventing Lower-Back Injuries in Forward Bends.
Considerations of the anatomy of the spine, pelvis and legs are relevant here. The risk in most forward bends (standing and seated) is that tightness in the hamstrings will restrict the pelvis from tilting, causing excessive flexion in the lumbar spine rather than flexion of the hips. This excessive lumbar flexion could result in sprains of spinal ligaments or muscles, such as the dorsal and lumbar paraspinal musculature and quadratus lumborum and could also cause disc herniation or osteoporotic wedge fracture. Here, previous injury, excess effort, inadequate instruction and poor technique are a treacherous combination. Students will benefit from the instruction to tilt the pelvis forward toward the legs as a first step to any forward bend, especially one in which gravity will increase the intensity of the pose. Broadening the thighs helps this pelvic tilt, as does bending the knees and extending the thoracic spine away from the pelvis.
Aggressive pulling with the arms in forward bends should be discouraged.
(In a seated forward bend sitting on a foam block can be helpful as it enables the forward tilting of the hips and /or prevents leaning backwards of the lower back).

Preventing Lower Back Injuries in Twists.
Excessive flexion of the lumbar spine is also a risk in seated twists and flexion combined with rotation puts particular force on the spinal discs. Sitting with the hips on a blanket or other support can help the pelvis tilt forward, maintaining the natural arch and length of the lumbar spine, even while one leg folds in toward the chest. In seated twists the teacher should instruct students not to use their arms to force themselves into a more aggressive twist. The use of props for instance in floor twist under the shoulder or knee (or head) is helpful.(Initiate seated-twists from the waist upwards only).

Preventing Lower-Back Injuries in Backbends.
In backbends like camel pose and upward facing dog pose, injury to the lumbar region often occurs because the thoracic spine does not bend, forcing the lumbar spine into overextension. Here an overzealous student may over-contract the lower back, going for the outer shape of the pose without regard to technique or awareness. Exploitation of the flexibility of the lower back is not the intention of such poses. Maintaining steady strength in the legs and the rooting down of the tail bone (and pressing down of the front of the feet) can help stabilise the pose. The lifting needs to happen through the whole upper body. The head, shoulders and chest are curled back (without collapsing in the shoulder). (Knees can be grounded initially and hands press towards the body).

Preventing Injuries in the Shoulders and Wrists
Downward facing dog pose and side plank and all poses requiring weight on the arms and hands have been linked in the survey to injuries of the shoulders, wrists and hands. Poor alignment and over-efforting need to be avoided. The following actions in these postures can reduce injuries; spread the fingers of the hand and press through the whole hand avoiding passive weight-bearing on the wrists. Stabilize the arm(s) by contracting all arm muscles, pulling energetically up away from the floor. Move the upper arm(s) toward the back of the body, using the shoulder-blade muscles of the upper back to position the humeral head toward the back of the shoulder joint. Turn the upper arms laterally as well with the biceps muscle revolving forward. Then expand the chest and lift the weight of the hands as much as possible by recruiting strength in the torso muscles. Initially this can be practiced with a wall or knees on the floor as weight bearing skills develop.

Preventing In juries in the Knees in Standing Poses
The knee is situated between the long bones of the upper and lower leg and shares muscles with both the hip joints and ankle joints. This makes the knee dependent on the alignment and mobility of both the hips and ankles for its safety. Wide-legged standing poses such as the warrior poses put such a demand for stretch on the hip muscles that the safety of the knees can be compromised. Overzealous students may attempt to go deeply into one of these standing poses, even if the force of the pose is being transmitted to the knees rather than to a healthy stretch in the hips. A narrower stance, which puts less demand on the thigh and hip muscles is a safer way to start. The centre of the knee needs to be aligned with the centre of the foot and use of the muscles should be evenly distributed around the joints as to avoid uneven pulls on the knee. (Not locking the knee and keeping the foot centred is indicated).
To prevent injuries in sitting postures such as the hero posture and the one legged pigeon pose, props such as blocks or a folded blanket under the hip will lessen the demand for knee and hip flexibility. People with previous knee injuries or surgeries need to progress carefully to regain range of motion in these poses.

Conclusion
Teachers need to know how to plan a safe Yoga practice for the students at hand giving alternatives where and when needed.
Students and teachers may need some form of assessment or self-assessment in relation to students experience of strength and flexibility in order to remain within their appropriate level or capacity in a class.
Students need to realise that pre-existing conditions will affect their practice. They need to be encouraged to seek help in adapting the practice according to their specific needs. The teacher and the student must both know what constitutes appropriate levels of effort. The teacher must know how to spot overzealousness and alignment risks before injuries occur. (In large classes assistant teachers are helpful to spot faulty practices).

For this survey no attempt was made to pre-screen respondents regarding their anatomical or medical knowledge or to verify the reports of injury. The strengths of the resulting data lie in the number and wide distribution of the people involved and the striking agreement in opinion across many styles of Yoga as to both the causes of injuries and areas of the body most vulnerable. This is only an extract of the whole study, outlining the preventative measures with a few additions between brackets from myself. I thought it might be interesting for those of you who are familiar with these postures to know about this study.
Loren Fishman, who initiated this research is a physiatrist and professor at Columbia College of Physicians and Surgeons. He has been using Yoga in his medical practice for thirty years and studied Yoga with B.K.S. Iyengar in India for a year before he studied medicine. He has co-written many therapeutic Yoga books and is an internationally renowned rehabilitation specialist.
Marjolein Gamble 2013-08-23