Does Ashtanga Yoga Hurt Your Knees?

 The Ashtanga Primary series contains a number of poses in which the hips are externally rotated with the knee or knees in maximum flexion. (Examples include: lotus, lotus variations, janu sirsasana variations — including janu sirsansana C, which externally rotates the shin bone on the femur), one pose in which the knee is fully bent, and the practitioner sits to the inside of the heel (Triang Mukha Eka Pada Paschimottonasana). It has a very low ratio of other poses (to these) that would balance the actions of the hips and encourage hip stability (a crucial component to knee health).

[style note: Ashtanga may also be spelled “Astanga” – both are acceptable]

I’ve heard from and worked with a number of physical therapy (physiotherapy) patients who suffered MCL, LCL or other knee injuries that began in their Ashtanga practice. Usually this was from a Mysore-style practice, sometimes from teacher adjustments. I’ve also fielded many email inquiries from students about Ashtanga and knee pain.

Most recently, the topic of knee pain in Ashtanga came up in the Yoga for Hypermobility Facebook group that I run:

“I’ve taught Astanga to quite a number of people with cruciate replacements, and they’ve all been able to practise with modifications.

I’ve also damaged a meniscus while being adjusted in an astanga practice when I was young. It wasn’t a strong adjustment.” – Jess Glenny, yoga teacher in the UK

“I have always been bendy-flexy but never put my joint pain and other factors together as hyper-mobility until I started practicing Ashtanga yoga. Not knowing my boundaries, I tore my hamstring where it attaches to the hip, have had considerable alternating knee pain (from locking my knees out too much), and hamstring soreness. ” – Kristin F., yoga teacher

Pattern recognition such as the two patterns noted above, begs the question: is Ashtanga bad for the knees?

Deep Inquiry

The question is not “Is Ashtanga bad”, because it isn’t.

Yoga Anatomy Academy takes the perspective that there is no right or wrong yoga practice or methodology. What WE are curious about is how various yoga disciplines serve us as practitioners, or perhaps don’t, particularly on the physical level. We are also curious about how we can create a culture that is more dedicated to satya (truthfulness), than adhering to a perception of tradition or singular (external) guru in yoga asana.

“This is such a complex issue I could write a book about it. There are so may ‘it depends’ in the equation: how dogmatic the practice is, whether it’s Mysore-style, the kind of relationship between student and teacher, how aware the student is of what different sensations denote in their body… There is definitely a lot of room for modification.” – Jess Glenny

History shows that asana was not practiced remotely close to the way it is now commonly practiced (at least in the West), until around the year 1900. So we take the long perspective when it comes to “tradition”.

We do not believe one method is 100% good nor bad. We do believe in deep inquiry.

Deep Inquiry means allowing all questions about our practice to surface at all times. It’s a powerful discovery of satya, Sanskrit for truthfulness, which — Kali-like — may slash through comfortable routine.

To step into the flames, what is it about Ashtanga yoga that works? …and what, perhaps, doesn’t work well?

Although I want to get specific on the knee-hip relationship, I believe these body-part questions cannot be divorced from the broader questions around this practice.

Here’s some of what works (this is not an exhausting list):

Specificity of Training

There’s a concept in athletics known as “specificity of training”.  If I want to be the very best baseball pitcher possible, I need to pitch baseballs again, and again, and again, and again.

Ashtanga yoga, which has 4 progressive (meaning you move from #1 to #2, etc) set sequences (known as series), is a perfect example of specificity of training.

Practitioners (in the Ashtanga Mysore practice) show up, repeat the same sequence (strongly suggested) 6 days a week until they master those poses. Only then do they move on to the next poses or sequence. Repetition creates physical mastery.

Ritual

In a society (I am writing from the perspective of living in the U.S.) that is increasingly devoid of ritual, I believe the ritual of Ashtanga yoga is extraordinarily valuable in yogis lives. Although this subject goes much deeper and broader than we can dive into here at Yoga Anatomy Academy, community and chanting and the comfort of same-ness are potent rooting forces (1st chakra business).

Movement

A commitment to challenging daily exercise is still so very rare in our modern society that Ashtanga yoga, which has this commitment built-in, can be a powerful health boost.

A regular daily or multiple-times a week yoga practice is also much less likely to cause general injury than dropping into yoga classes every other week.

What can go wrong with Ashtanga yoga? (Click here for a valuable perspective on the lack of feminine in linear Warrior-based practice.)

Repetitive Stress Injuries

Watch Dancing with the Stars, or go on a YouTube spiral and you’ll see the human body is capable of infinite movements. Movements don’t necessarily cause harm by themselves.

Specificity of training, as described above, is well and good when you have something to train for. If your asana practice (for any style) is limited to or has multiple repeats of specific poses, ask yourself what are you training for? Why do we really practice yoga? Are we on the mat to train for more yoga asana?

Specificity of training without great intent/ sankalpa, and without the cross training that is mandated for all top performers can simply become Repetitive Stress Injury.

Repetitive stress injury is essentially what it sounds like: pain, inflammation, or loss of physical integrity in a body part that has been overused in a specific range. If it can happen from texting, it can happen from yoga asana.

“Regarding Astanga being a balanced practice, the first series (primary) has a lot of forward folding in it. The vinyasas become the counter pose and are peppered through the practice. But this works solely in the Sagittal plane. Some dedicated and skilled Astanga teachers are increasingly questioning the balance of the series in light of growing scientific knowledge, and encouraging variations, making up their own sequences sometimes.” – Ruth H-C, yoga therapy practitioner, trained in Ashtanga Yoga

Passive Stretch Creates Unstable Range

Stretching passively into any motion — in this case hip external rotation (meaning: using the floor, another body part like the arm or leg for leverage, or a yoga teacher who is pushing the knee down to the floor), WILL cause hip instability.

Hip instability can lead to a cascade of joint changes that include FemeroAcetabular impingement and may lead to the eventual need for hip joint replacements.

Unstable hips also reduce stability at the knee, SI joints and lower back.

Forceful Adjustments are passive stretches.

This is not really its own subject, but I made it a new headline anyway.

Although it’s clearly edited for shock value, this video of Patthabi Jois demonstrates one extreme end of the adjustments that may be performed in Ashtanga yoga : http://vidism.com/video/28686/pattabhi-jois-ashtanga-yoga-adjustments/ (if the previous link stops working, please see http://www.decolonizingyoga.com/pattabhi-jois-yoga-adjustments/).

Forceful yoga adjustments are not limited to one style of yoga, but they are a frequent cause of injury in the yoga world.

“Mindfulness” Isn’t the Only Answer

“I have had three joint wear and tear injuries in the past year (hip, shoulder and elbow), even with being mindful.” – Gloria, 200 hr yoga teacher training student in Ashtanga-inspired program 

There’s a tendency within the yoga world to think that if someone got injured, they messed up, spaced out, or didn’t “Listen to the body”. “Listen to your body” is an instruction that will only take you so far when a teacher (or lineage) is also telling you what to do.

What’s more, when we are warm and moving (stretching in particular) we are flooded with endorphins, which reduce pain signals that might make us back off.

Why Should We Externally Rotate the hips?

Plenty of individuals who sit in chairs don’t have enough external hip rotation to sit comfortably on the floor for more than a few minutes. This includes many people who attend yoga classes.  Working toward improved external rotation of the hips is helpful for many adults to achieve more basic functional positions.

When is the Knee Most Vulnerable?

However…The knee is at its most vulnerable when it is in a position of flexion (bent knee) with external rotation of the hip (front of the thigh moves to the outside) of the hip, with the foot not on the ground.

Examples of this position in yoga asana include: sukasana (easy pose – basic cross-legged seated) padmasana (lotus pose), and eka pada sirsanana (foot behind head pose).

In my opinion, each named style of yoga asana has strengths and weaknesses. 

Generally speaking, one of the vulnerable physical components of Ashtanga yoga (“Mysore” implies a daily morning self-paced Ashtanga practice) is repeated pressure on the lateral (outside) knee since the practice sequence repeats almost daily. As mentioned before, there are benefits to practicing a structured, set sequence daily, but one downside is it sets up the body for repetitive stress syndrome.

This is a massive topic, but I’ll narrow it down as best I can:

If you’ve hurt your knee, only a hands-on physical examination or diagnostic imaging will give you definitive diagnosis, but the lateral collateral ligament (LCL) connects the outer thigh bone to the outer shin bone, and is one of the more vulnerable structures in the Ashtanga primary sequence.

To risk stating the obvious, the knee functions optimally when used like a hinge, bending and straightening without much twisting or side stretching.

Twisting, when the shin bone and femur turn to face different directions relative to the other, can damage the meniscus. The crescent-shaped meniscus (actually menisci – two per knee) fills the gaps between the two bones like a wedge and is most easily torn where it tapers off to a point.

Side stretching of the knee, pulls on the collateral ligaments on the inside (medial aspect) or outside (lateral aspect), possibly creating micro (visible by microscope only, cells pulled apart) or macro tears (damage to the tissue).

Real-life injuries and movement rarely happen in a single plane, meaning there’s often a combo of side stretch, twist and regular old hinging when a knee is injured. Both of the above injuries are notorious for slow healing because of limited or lack of blood flow. This is important since circulation is the main highway system your body uses to transport healing components (white blood cells, etc.).

Time helps, but unfortunately, does not heal all wounds.

A skilled manual physical therapist can help increase the blood flow to the injured zone and lead you to the precise exercises to decrease your symptoms. When a ligament is torn, unless the tears are tiny-tiny, new fibers are laid in the gap, and their effective strength is neither as great, nor is the proximity of the joint as close as with the original structures.

Let’s take a closer look at padmasana. To achieve lotus pose, 99% of practitioners use their arms to finagle the legs into position. When you use muscles outside of the limb itself to achieve that limb’s position, you are in a danger zone. This is passive stretch / leveraging, and your muscles may not engaged in a protective way because they have to be able to give in to the external force.The same can be true when a teacher gives forceful adjustments.Your best option is to strengthen the muscles through their fullest range and do everything you can with the leg muscles themselves before pulling/pushing limbs into position.

Know that there will always be a slight amount of pressure into side bend and twist in the knee in lotus pose period, therefore a danger of injury.

My advice for yogis entering poses with external rotation of the hip and knee bent,and particularly for Ashtangis, would be to bend your knee fully and engage the muscles along the entire length of the leg –- i.e. flex (dorsiflex) your foot with toe spread — before entering a full pose that requires hip external rotation.

For example, if entering into padmasana from dandasana (staff pose),

1^st – engage your toes and the top of your foot back toward your eyes,

2^nd – spread the toes so that the pinky toe starts to separate from the others,

3^rd – bend your knee as deeply as you can

4^th – use the external rotating muscles of your hip (not your hands) to lift the inner ankle as high as you can. Try to place it on the opposite thigh without using arms.

5^th – keep the engagement through the entire leg and make slow, subtle adjustments using the arms as needed. Repeat on the other side.

If you notice any unpleasant sensation – even mild — during entry, hold, or exit of one of these knee flexed / hip external rotation poses, eliminate that pose for at least a few days. If you have a known or suspected knee injury to the meniscus or collateral ligaments, maybe consider eliminating the most dramatically knee flexed/hip externally rotated poses until healed.

“I think it’s important to be aware when talking about astanga vinyasa teaching – or even Mysore teaching – that you’re not talking about one thing. There’s an old school tradition, there’s what comes out of Mysore now, which is very particular and instantly recognisable if you’re a seasoned Astangi, there are people who are teaching in very different ways, with a lot of awareness of the relational nature of yoga and of the dynamics of power. It’s very hard to make any generalisations. Certainly you could use primary series to hammer your knees, especially if you don’t naturally have a lot of lateral rotation. You could also use it to heal them.” – Jess Glenny

There is so much more to say on this subject — I haven’t even touched on how to create more hip stability, or how to cope with underlying hypermobility in Ashtanga. But that will be another day, another post.

Meanwhile, I look forward to reading your comments below, hearing what you would add, and answering any questions you may have. (Since I’m not an Ashtangi, I’m especially interested in the perspective of those of you who are or were practicing Ashtanga yoga regularly). 

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To your health!