Monday, May 7, 2012

Yoga Shouldn't Hurt Part I: The Inner Knee

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Avoid injuries on the mat with this practical guide to caring for your knees, hamstrings, and sacrum ~ by Roger Cole

If you practice yoga, no doubt you're aware of its health benefits. But like any physical activity, it's not completely risk free. If you've been practicing for long, you or someone you know has probably pulled a hamstring, tweaked a sacrum, or experienced some injury while on the mat. Close to 9,000 Americans received medical treatment for yoga-related injuries in 2004 and 2005, according to the U.S. Consumer Product Safety Commission. Still, there are only two yoga injuries reported for every 10,000 times it is practiced, according to American Sports Data.

Injuries can be great teachers. They invite you to uncover your yoga demons—misalignments or overzealous attempts to force your way into poses—and make corrections. But it's smart to learn proper technique, especially when it comes to your inner knees, hamstring tendons, and sacroiliac joints. These parts are vulnerable to damage and take time to mend. But if you understand what causes trauma to these areas, it's easy to adjust your practice to avoid or help heal injuries.

Inner Knee

The Road to Injury
Have you always found it difficult to get into Padmasana (Lotus Pose) and felt tempted to force your legs into the position to join your serene-looking classmates for meditation? If you are thinking of traveling down this road, please reconsider. You may have discovered that rather than leading you to the blissful land of the Lotus, pushing yourself in this way dead-ends with a sickening "pop" in the knee, followed by years of pain and limited mobility.

When you hurt your inner knee doing yoga, it's usually because you've tried to force a leg into Padmasana or one of its variations. Sometimes the injury occurs after one or both legs are already in Lotus position and you attempt a pose that adds a back-bending movement, such as Matsyasana (Fish Pose), or a forward-bending movement, such as Ardha Baddha Padma Paschimottanasana (Half-Bound Lotus Seated Forward Bend).

To understand how Lotus can hurt your knee, visualize lifting your right foot up and placing it atop your left thigh. To get into this pose safely, your thigh will have to rotate outward about 115 degrees. For many of us, though, the thigh cannot turn out that much, either because of its bone structure or because tight muscles and ligaments inhibit its movement. If your thigh stops rotating but you keep lifting the shin and foot, you'll bend the knee joint sideways, which will pinch the inner-knee bones together—the upper inner end of the shin-bone pressing against the lower inner end of the thighbone. Between these bones lies the medial meniscus, which is a protective rim of cartilage that pads the knee joint and guides its movement. When you lift your foot, you are using your same-side shinbone as a long lever. If the thighbone doesn't rotate enough, you'll apply tremendous pinching pressure to the meniscus—as if your shinbone and thighbone were a giant pair of pliers. Forcing this lift even moderately can do serious damage. Similarly, if you are in Lotus and your top knee is not on the floor, pushing that knee downward can apply enormous damaging force to the meniscus.
Prevent and Prepare
To prevent this injury, the first rule is to never force your legs into any Lotus variations—either by pulling the foot strongly upward, pushing the knee downward, or thrusting your body forward or backward. Don't let your yoga teacher push or pull you into any of these poses either. Janu Sirsasana (Head-of-the-Knee Pose) and Baddha Konasana (Bound Angle Pose) can cause similar (though usually less severe) pinching of the inner knee, so practice them cautiously, too. Stop going deeper and back off if you feel pressure or pain in the knee. The structures that need to loosen up in these poses are all located around the hip area, so that's where you should feel stretching or releasing sensations as you go deeper.

The safest way to practice Padmasana and related poses is to strongly rotate your thigh outward at the hip and not go deeper into the pose when you reach the limit of your outward rotation. This means that you'll have to stop lifting your foot when your thigh stops rotating, so you may not get your foot on the opposite thigh. (Remember the upside: happy, functional, pain-free knees.) You can use your hands or a strap to help rotate your thighbone outward. Whether using your hands, a strap, or a cloth, if your knee ends up dangling in midair, support it with a folded blanket so you do not inadvertently force it downward as you turn the thigh outward.
The Path to Healing
If you have the misfortune of hurting your inner knee in Padmasana or a related pose, the first thing to do is leave it alone. You need to rest, ice, elevate, and compress it for a few days to reduce swelling and inflammation. If the injury seems serious, seek medical attention. It's a good idea to reintroduce knee range of motion as early as you can by gently flexing and extending the knee to the extent possible. A yoga program for recovery needs to be individualized to your needs and supervised by a qualified instructor. But the general pattern is to promote alignment and strength with basic standing poses, such as Trikonasana (Triangle Pose) and Virabhadrasana II (Warrior Pose II). If necessary, support your body with a chair to take weight off the knee. In addition, increase range of motion by doing Virasana (Hero Pose) with the pelvis supported on a prop, and eventually reintroduce outward rotating movements like Baddha Konasana (and perhaps Padmasana) using a rolled cloth behind the inner knee.
Padmasana (Lotus Pose), preparation Set up blankets to support your pelvis and right knee. Sit in Dandasana (Staff Pose) with both legs extended. Bend one knee and place a washcloth behind it. Keeping the knee firmly bent, grip the end of the cloth in one hand and pull toward your body and out to the side to open the inner knee and rotate the thighbone outward. Continue this rotation as you lift your heel with your other hand and place your foot high atop the opposite thigh, near the hip if possible. Note: Discontinue if you experience knee discomfort.
Virasana (Hero Pose), modification Avoid pain in your knees by elevating your pelvis as high as is necessary with folded blankets. Align your heels directly under your outer hips (this is less stressful for the knees than the standard alignment of having your heels outside of your hips). Keep your knees slightly apart, with your thighbones parallel. Place your feet in line with your shins. Sit for several minutes daily. Gradually lower the props over a period of weeks or months.
Roger Cole, PhD, has practiced yoga since 1975 and taught since 1980. He is a certified Iyengar Yoga teacher trained at the Iyengar Yoga Institutes in San Francisco and Pune, India. He teaches at Yoga Del Mar in Del Mar, California. For more information, visit http://www.rogercoleyoga.com.
 

4 comments:

Kristin said...

Sara,

I would have thought the potential for injury to the knee in Padmasana would be greater in the outer knee, given that is where the "pressure" is (so to speak) of the the knee bones trying to twist outward in a non-conventional movement.

Since the knee joint is designed to technically move back and forth in a linear/straigh fashion, in Padmasana, the bowing out action would stress the outer tendons and ligaments more so than the innter.

And I have found that this is true for variations on Pigeon: Reclined (thread the needle pose) - people push on the knee to try and open the hip)

Standing - people pull up on the foot, thus pushing the knee joint out, to try and open the hip

Traditional - people put pressure on the knee trying to either relieve pressure on the hip or to deepen the stretch.

Thoughts?

Sara said...

Hi Kristin - Thanks for writing. I totally hear what you are saying and I agree that overstretching the outer knee cannot be good either.

What is odd to me is that people report that they do not have any sensation of stretching in the hip (even when they are deeply in a pose like thread the needle) so they push on their own knee to get to some kind of sensation. Of course I say "Keep your foot flexed to protect the knee" and "don't push your knee away" but this doesn't always stop folks from doing it.

In addition, this pushing action often misaligns the pelvis on the spine. This is a concern to me as well.

As far as the inner knee vs. outer knee, what it seems like the article is saying is that the pinching of the meniscus on the inner knee is the main problem when using your own leg as a lever to get more deeply into the pose. Here's what Mr. Cole says:

"If your thigh stops rotating but you keep lifting the shin and foot, you'll bend the knee joint sideways, which will pinch the inner-knee bones together—the upper inner end of the shin-bone pressing against the lower inner end of the thighbone. Between these bones lies the medial meniscus, which is a protective rim of cartilage that pads the knee joint and guides its movement. When you lift your foot, you are using your same-side shinbone as a long lever. If the thighbone doesn't rotate enough, you'll apply tremendous pinching pressure to the meniscus—as if your shinbone and thighbone were a giant pair of pliers. Forcing this lift even moderately can do serious damage. Similarly, if you are in Lotus and your top knee is not on the floor, pushing that knee downward can apply enormous damaging force to the meniscus."

I don't feel like I know enough about anatomy to comment on which damage is worse. But I do know enough to say that if we are shoving our bodies around to "get somewhere" in yoga, we are probably pushing too hard.

Thoughts?

Kristin said...

Sara,

Ah! Yes! Totally makes sense: "for every action there is an equal and opposite reaction" kind of thing.
If you are torqueing the knee out to get into Padmasana, naturally the knee will pinch on the inside. Neither action is desirable.

In a workshop I was at this weekend we focused on the hip joint itself (where the femur meets the pelvis) and the “deep 6” muscles that define the glutes, but that to move into certain postures, it is absolutely necessary to engage the external rotation of the knee (away from the body) to protect the joint, in addition to flexing the foot.

But people WANT to FEEL that hip stretch - they are listening to the hip and not the knee. Then later wonder why their knees are so achy. Our hips have an incredible range of motion, our knees, not so much. And our knees bear the brunt of our activities.

Agreed, especially from a power yoga/vinyasa yoga POV: “If we are shoving our bodies around to "get somewhere" in yoga, we ARE pushing too hard.” You are not present in the pose.

Sara said...

Sounds like a great workshop. I'm sure both you and your students will benefit from your deeper learning.