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Practicing Yoga Safely: How to Protect Yourself from Hip Injuries
Are people with certain variations in hip structure at higher risk for yoga injuries to the hip? In this interview with YogaUOnline, Dr. Ginger Garner, P.T. and author of Medical Yoga Therapy, talks about why yoga asanas, the way they are commonly practiced, might not be suitable for some people, particularly women who have different pelvic structures. Ginger further discusses how we can spot people at risk for injuries, and what we can learn from science about developing yoga teaching methodology that honors the variations in people’s bodies.
YogaU Online: You are a fervent advocate for promoting greater attention to the prevention of yoga injuries. In your work as a physical therapist, do you see many injuries caused by yoga?
Dr. Ginger Garner: Unfortunately, in my years of work, I have spent more time treating people with yoga injuries than should have been necessary. I’ve seen spinal injuries to the neck, injuries in the hip and injuries in the pelvis. The oath that we take as yoga instructors is to help people and to first do no harm. I want to make sure that this is the case across the yoga community, at whatever level people are choosing to practice.
YogaU Online: One area of injury you particularly focus on in your writing is the hip joint. How has medical science changed our understanding of the hip joint and how does it impact the way we should teach yoga?
Dr. Ginger Garner: Prior to the use of CT scans, and MRA’s of the hip, we didn’t have many options for addressing the hip in a way that could change a person’s longevity. When I went to Physical Therapy school over twenty years ago, the only options were bursitis, tendinitis, or hip replacement.
Today, we have different types of tools available to us to reach the deeper structures of the hip, and the hip itself isn’t the enigma that it once was. I practice women’s health and do internal work as a physical therapist. This allows me access to the pelvis and the hip in a way that wasn’t available before. We can really change hip outcomes, often dramatically and in a short period of time with things like dry needling and other interventions we use in physical therapy to affect the hip. This change in technology allows us to see, visualize, and touch the hip in a way that we couldn’t before. Unfortunately, we are still lagging behind in society about what we’re doing with the hips.
The problem is everyone’s, and doesn’t belong uniquely to the yoga community or the healthcare community. This problem hip injuries plagues us across the board, but because yoga is emphasizing end ranges of motion, we are often in a position to first see hip issues crop up, particularly in women.
YogaU Online: What are some of the statistics we now know about hip injuries?
Dr. Ginger Garner: One statistic that is most concerning to me as an individual, as a yoga practitioner, and as a doctor of physical therapy is that it takes, on average, 2.6 years from a person’s onset of hip pain, to get a diagnosis. I think 2.6 years is a long time, filled with many opportunities to do additional damage.
I’ve had several colleagues as well as patients who had total hip replacements that are now widely thought to be preventable had an early intervention been possible. If we see people early after their pain has started, and then offer our suggestions as to how they can adapt their movements in yoga, golf, and their other activities, then we can prevent early degeneration of the hip.
On average, patients see 4.1 health care providers before they get to the right one. This is an opportunity we have in the yoga community for yoga teachers and yoga therapists in unlicensed fields of practice to say to our students, “I’m concerned about your movement or some of the pain you’ve been having in class. Maybe you should go see a PT.”
An orthopaedist or orthopaedic surgeon is too extreme, as most people aren’t surgical, but a PT can do a lot to help someone avoid surgery and also prevent injury, thus getting them back to a yoga class where they want to be. People don’t have to go through years of pain and outright agony; we can change that in the yoga community with a few pieces of information like knowing the major red flags.
YogaU Online: What are some of the risk factors or predispositions people may have that would result in a hip replacement down the road?
Dr. Ginger Garner: There are many risk factors for hip trouble, including age, and being female. Understanding the internal structure or morphology of the hip is important. The hip has six degrees of freedom; it’s a multi-axial ball and joint. The hip has a capsule that is essential to the integrity of the joint itself. The hip has cartilage, a labrum, which is also essential to the pressurization of the joint. If any of those components are interrupted or if you have pre-existing weaknesses in certain muscle groups and motor patterning, then those could predispose you to injury or cause you to go down the path of having a total hip replacement.
Nutrition is also going to be a risk factor. We don’t think about nutrition as being top of the list but if someone is regularly consuming things that are biomarkers for inflammation for them as an individual, that’s certainly not going to help them. Almost half the time I spend with patients is going over nutritional education, resource utilization, and showing them how they can access healthier eating. The other half is spent looking at their movement, screening it to see what’s going on, and then determining how they need to change their yoga postures accordingly. The internal structure of the joint is going to make a tremendous difference as to how I might advise them to do their Warrior I or II. After I screen someone’s hip, their yoga pose alignment is going to completely change depending on what I saw.
YogaU Online: You once stated, “No yoga posture practice should occur without an initial screen of the hip joints.” That is a very strong statement, could you please elaborate?
Dr. Ginger Garner: I stand by that statement because if we’re not aware of what a new student’s movement capabilities are, then we cannot establish boundaries that will give us a safe zone of movements for them. I want to give people that safety net so they are able to come in and say, “If I stay between point A and point B, then I’m less likely to have an injury.” Being able to screen a hip, even if it’s only observing people as they’re walking in the door, will provide you with information about what their limitations are.
YogaU Online: In your blog you write about your many patients who have suffered from unnecessary hip injuries, labral tears, all types of impingement, compounding secondary diagnoses such as torn hamstrings, hernia, and pelvic pain, all due to yoga practice. Is the common denominator pushing too hard or is it repetitive strain? Is there a safe zone formula that people can use to avoid this vast range of issues?
Dr. Ginger Garner: The wide range of issues is why diagnostics of the hip can be difficult-- specialties need to be branched into multiple fields in order for me to practice as a specialist with the hip. Often, to help with someone with their hip, I also need to be a clinical specialist with pelvic pain, which presents a whole other range of postures. If we look at how we might create a hip safety net for yoga practitioners, we need to look at it from a biopsychosocial perspective where there are certain physical components that should be addressed through a physical screen.
Additionally, there are also intellectual, spiritual, and energetic components that we may think of as the softer, more philosophical side of creating that safety zone for our students. Sometimes, the language that we use in our instruction can lean towards a dominator position of “guru as God,” and the language is authoritarian instead of collaborative. When I’m teaching therapists how to develop their own poetic language, I advise them not to be overly clinical and antiseptic, and not to use aggressive words such as “push” and “pull”; I think yoga teachers need to consider that as well.
YogaU Online: Are you suggesting that yoga teachers change the way they cue asana sequences?
Dr. Ginger Garner: I have written several blog posts asking yoga teachers to recalibrate the language that they are choosing and realize that every word counts- particularly when cuing hip opening. For example, if you tell a student to “press their knee into their chest", what is that going to do to their hip? What if they have an indication of sacroiliac joint dysfunction, or the Sartorius or the IT band is not functioning as it should? Those conditions can be at play with hip impingement as well, and all it takes is for a teacher to say, “press your knee into your chest,” to do that.
I believe that teachers should do away away with some of the current cuing, such as telling students to “push forward” or “if you feel good, then go a step further.” Instead, teachers need to conduct an observational screen of their students so they can cue them to find a healthy limit that is not about flexibility.
YogaU Online: Do you think some of the problems we are seeing with hips are the result of the glorification of being flexible?
Dr. Ginger Garner: Yes, the goal of yoga is not flexibility. When I’m teaching or working with a patient, I try not to say the word “flexibility,” and I rarely use the word “stretch.” I also don’t tell someone they’re “tight”, or that they need to “stretch that out”. This kind of language can have a big effect on the hips.
Upon Googling “hip opener”, I found that nothing in the entire internet was addressing the negative aspects of hip opening, or telling the cautionary tale of what could happen. That is when I decided to become an advocate for adjusting our language to a more non-violent, collaborative language that empowers the yoga practitioner to protect themselves, rather than having a yoga teacher who is seen as a guru, pushing the student into a situation. I believe changing the language could greatly improve our yoga outcomes and mitigate some of the backlash that the yoga community is experiencing because of the prevalence of extreme postures being taught.
YogaU Online: Hip opening sounds like something very desirable, therefore many people want to push a little bit extra to reach that goal of a nice open hip. How do you work with your students and patients and teach them that most people have their own range of motion and flexibility isn’t the goal?
Dr. Ginger Garner: When I’m teaching healthcare providers to use yoga, I use something that I wrote about in my book called a Vector Analysis. The first part of a Vector Analysis is making certain that you’ve identified the optimal kinematics that a person has available to them. If someone comes to a yoga class and they have less than optimal kinematics, or less than optimal structure of the joint that you’re addressing, you will automatically know you’re going to have a more difficult time with the rest of the analysis for them.
The next tool that I use is efficient motor patterning. This means instead of using a muscle’s brute force, thinking about the most optimal or efficient motor patterning possible. For example, imagine someone coming to class who is already experiencing osteoarthritis. As you are layering up challenges for that individual, the last thing we want to do is prescribe, “Do Warrior II like this,” when we don’t know what the structure of their joint is.
We need to work on efficient motor patterning with them. They know they have osteoarthritis, how the progression happened and they’re working on it. They may have some fear of movement because of being pushed in the past, so it’s important to help them regain that trust. Sometimes getting students to be overcome their fear of movement is more challenging than the neuromuscular patterning.
The student that has osteoarthritis knows they’re weak in certain points so we know that their motor patterning is different. We know they have some fear that automatically affects their outcomes. The last thing we look at is how the tissue responds from a fascial and neurovascular perspective; what is the response of the skin and the other soft tissue?
Those are the four parts of a Vector Analysis. When someone comes in the door and I want to teach them Warrior I, I have to look at all of those components and then use language that is partnership-based to collaborate with them. It is not me saying, “I’m the doctor and you have to do what I say.” It’s helping empower them so that they can say, “I’m in charge of my healthcare and I’m in charge of my yoga practice.” I consider it my job to make sure that they don’t need me anymore, that they don’t come back with another injury. That is the essence of what I’m advocating for.
YogaU Online: Yes. For many yoga teachers the lack of self-referral by students is also compounded by the fact that many look to the other students in class as a gauge for what they should be doing. It takes time to help students make the psychological shift that the real teacher is their own body and what it tells them. How do you help students make this shift, particularly when they are in a mixed level class?
Dr. Ginger Garner: One way of helping students make that psychological shift to seeing themselves as their teacher is having them fill out forms before they come into a class. This allows for more information to be consciously shared from the individual to the teacher so they become more aware of what’s going on with their own body.
As a healthcare provider, my intake forms are quite thick. I want to know everything that’s going on with a patient including previous medical history, medications, diagnostic testing, what’s worked in therapy, what hasn’t worked, and what the other risk factors are. And yet, someone can come to yoga class and forget to say they’ve had a cervical fusion, or that they have osteoporosis in the hip. This means we need to get to know our students a little bit more. Doing this requires more investment from a teacher or therapist standpoint, but the end result is that we have more of a relationship with our students, and can make them feel safer and more empowered in their yoga practice.
YogaU Online: We have a course on YogaU with you on this incredibly important topic. Can you tell us what you’re covering and what people can expect?
Dr. Ginger Garner: The course will talk about hip preservation and the surgery called arthroscopy that many people are getting now which is hopefully helping prevent a large number of hip replacements. It’s a massive surgery with far more stringent precautions, and an exponentially longer recovery time, but the outcome is that you don’t have the restrictions or need the revision that a hip replacement requires.
Generally speaking, people can have one hip revision, maybe two in their lifetime, and after that, they’re non-ambulatory- unable to walk anymore. Hip replacement is a short term fix that should happen at the end of life rather than earlier on. At its heart, the course is about hip preservation and a way to recalibrate asanas- asana evolution, as I like to call it.
We will discuss hip functioning and how that affects mind-body health. When someone comes in to our yoga class, we don’t know what their hip morphology or structure is. What can you do as a teacher? What can you do to evolve the yoga postures to make them safe in absence of an MRA or non-contrast CT scan? How can we screen for the hip and self-assess to increase safety for our students? What are some techniques to support preservation of the hip that you may use to create a language and environment of safety? These are some of the questions I answer in the course.
Then, we will go through some guidelines for asana, and really focus on teaching cues. Should you say this, or should you say that? Can we get rid of certain phrases in order to help people to pull back and self-regulate a little better? What kind of boundaries and red flags do we need to look for in yoga instruction to help yoga teachers, yoga therapists, and yoga practitioners be able to refer themselves or someone they know to a specialized physical therapist? In some cases, that PT may refer them on to an orthopaedic surgeon when they do feel like additional testing is actually needed. How many serious injuries could be avoided if yoga teachers knew when to make that referral to a PT?
YogaU Online: It sounds like your course should be mandatory in every single yoga teacher training program in the country.
Dr. Ginger Garner: Yes, I think it’s very important for every yoga teacher to have this information because the hip is our connecting point for the upper and lower quarter; it’s intimately connected to the pelvis where there are very sensitive neurological and vascular structures that need to be protected. I consider the pelvis to be one of the vulnerable structures of human body along with the hands and the feet. These are the body parts to protect, and indeed, I truly wish everyone could take my course on the hip because without the connection of the hip, asanas tend to fall apart.
I also want to give the early yogis a break and not blame them, because these yoga postures were created for young men and boys; they weren’t calibrated for women with completely different pelvic structures. Asanas weren’t created with a knowledge of what a reconstructed pelvis on a non-contrast CT scan looks like; these testing measures weren’t available. So now, it’s time that we add the science to the picture and evolve the asana in a way that is compassionate and sustainable for the future.