( Dr. Garner is a PT, yoga instructor and hip patient. Her story of hip recovery and love of yoga is something that I have connected with and has encouraged my hope through this recovery). One of the reasons behind the Hopeful Hippies website/blog is to provide additional resources to patients with FAI and similar hip problems. Dr. Garner has kindly given permission to post this on the Hopeful Hippies Blog. Enjoy! Thank you, Dr. Garner!)
By: Dr. Ginger Garner
The scientific landscape of what we know about the hip joint has vastly changed in the last 10-15 years, especially in the last five, which means there is quite a bit we can do to achieve happy hips. Medical innovation has led to improvements in noninvasive and invasive diagnostic technology and surgical techniques, all of which have greatly changed the outlook of those living with pelvic and/or hip pain.
Hip Replacement Prevention with Yoga
This positive progress directly helps folks whose hips are structurally “unique” or different than the rest of the population, and is a welcome evolution for all those in the medical profession. Why? Because now a substantial number of people who before had no hope other than a hip replacement, can avoid a lifetime of hip pain and even prevent a hip replacement, through early orthopaedic intervention, including physical therapy.
What has not changed is the way we prescribe and use movement for fitness, including yoga. People with different hip structure and/or other congenital, developmental, or acquired anomalies require a different approach to movement and fitness and are at high risk for permanent damage to the hip if their exercise regimens do not consider or modify activities according to their individual hip morphology.
The need for modification is even greater in activities that are repetitive and/or emphasize end range of motion. This includes practices like gymnastics, yoga posture practice, or martial arts. The vast majority of yoga postures are biased toward hip flexion, abduction, and external rotation. This means yoga postures, as they historically stand and are currently taught, are inherently imbalanced. Unless this changes and modifications are made to accommodate all types of hip joints, yoga injuries will be on the rise in the orthopaedic realm. I have seen (and treated) many yoga injuries in the hip and pelvic area that could have been prevented.
Dominant Movements of Yoga Postural Practices:
Hip flexion – Think Knee to Chest (Apanasana) Child’s Pose (Balasana), and the front leg in Triangle Pose (Trikonasana), for example.
Hip abduction – Think Wide Angle Forward Standing Bend (Prasarita Padottanasana), Half Moon (Ardha Chandrasana), and the bent leg position on Head to Knee Pose (Janu Sirsasana)
Hip external rotation – Think the front leg on Warrior II (Virabhadrasana II), the airborne leg in Tree Pose (Vrksasana), and Wide Angle Forward Seated Bend (Upavista Konasana), for example.
Poses which combine all three movements, known as FABER for short, and which increases the vulnerability of the at-risk hip include postures like Cobblers Pose (Badhha Konasana), the front leg on Warrior II (Virabhadrasana II), and the front leg on Triangle Pose (Trikonasana), for example.
Three Golden Rules to Follow for Happy Hips in Yoga Practice (or Any End-range Repetitive Activity):
1. Practice Moderation (and change your nomenclature).
The phrase “Hip Openers” is overused, tired and worn out, and frankly, it is potentially making your hip tired and worn out too. There are two different viewpoints typically taken about the hip, the hip as mobile or the hip as stable. However, the hip does not exist in such a binary vacuum. It is capable of being resilient, responsive, and stable in yoga posture practice. This means that yoga is not just about mobility or “hip opening.” Read more in my post on YogaUOnline, Hip Openers in Yoga? Please Let’s Stop the Madness.
The hip is capable of a finite range of motion, and even then, there is a significant portion of the population who will not be able to structurally achieve that range of motion. This means that “hip opening” could, in those cases, cause more harm than good, unless you know the morphological and structural makeup of the hip joint and surrounding soft tissue.
Hip safeguard: Knowing the limitations and potential of your hip joint requires a physical examination by a licensed health care professional. For the average person, an evaluation is probably not necessary. But if you have ever had any low back, pelvic, groin, or hip pain, or if you are a competitive athlete, I strongly recommend getting a thorough physical examination by an orthopaedic surgeon or physical therapist.
Why an orthopedist or physiotherapist? Because in research that tested healthcare professionals’ knowledge of orthopaedics, including family practice MD’s, FNP’s, PA’s, PT’s, and orthopaedic surgeons and their PA’s, two health care professionals knew more than any other medical professionals about orthopaedics. Those two professions were physical therapy and orthopaedic surgery.
The best advice here is to find a skilled physical therapist who listens to your story, your needs, and cares about your aches and pains, and see them at least once a year for an annual orthopaedic and neuromuscular checkup. They can make sure you are on the right track to prevent and treat injury and not just your hip, but all your orthopaedic aches and pains.
Orthopaedic surgeons are an enormously valuable resource when you need surgery, but your strongest relationship, and the provider who will get to know your body and it’s needs best, is a physical therapist. They can spend a full hour with you, and in some cases even more, to prescribe your “best fit” plan for injury prevention and rehabilitation, as well as fitness and wellness.
2. Change Up Your Yoga Routine.
Don’t practice the same vinyasa, or sequence of postures, over and over. And over. And over.
So you visit your local studio and love it, but the teacher instructs the same dozen or so postures, in the same order, or thereabouts every. single. time. Not only is this approach rather predictably boring, but it is also ineffective and a bit like Chinese water torture for your joints and soft tissues. Your nervous system and muscles will quickly learn the routine and will not continue to develop and respond, which will inevitably lead to 1 or 2 things: 1) Overuse injury from repeated stress, what is also called Repetitive Stress Syndrome (RSS), and/or 2) Flagging fitness progress, or what’s known as a good old fitness plateau.
If you have ever been stuck and can’t seem to make any more progress with strength, endurance, or weight loss, you can thank this phenomenon for that. This means teachers that use repetitive sequences, year in, year out, will likely stunt your physical progress and increase your risk of injury. Our bodies are meant to cross train, interspersed with periods of active rest. This means your fitness plan should change at least quarterly, and for women, on a week-to-week basis.
Hip safeguard: As a physical therapist and athletic trainer, I’ve trained all types of folks – from weekend warriors to high-level university and elite athletes using these guidelines – the same guidelines that Olypmic athletes use. The common denominator here for optimizing your health – whether or not you are a high-level athlete – is CHANGE.
There are many different buzzwords for changing up your routine, periodization being one of them. But the take-home message is no yoga routine, vinyasa, or sequence can remain the same if you want to prevent injury and maximize your fitness potential.
3. Be Kind to Your Body.
Read: Don’t vomit on your yoga mat. The National Institutes of Health report that more than 2 of 3 adults are overweight or obese. 85% of Americans believe obesity is an epidemic, and the children who are alive today are the first generation that is not expected to live as long as their parents. Childhood obesity has more than tripled since 1980, and when it comes to orthopaedic health, over 80% of Americans will at some point experience low back pain.
When you look at most exercise programs, the National Academy of Sports Medicine confirms that they do not universally account for functional movement-based safe ranges of motion, concentric, eccentric, and isometric training at varying tempos, challenging the body’s ability to stabilize or balance itself, or challenging the cardio-respiratory system in an integrated way.
Yoga, although having the potential to achieve all of the previous goals for comprehensive fitness and more, also often fails to meet these training requisites. General classes target the “healthy” public, but with the majority of Americans being overweight and in pain at some point in their lives, there is a GREAT need for yoga to be individualized for personal needs. Yoga “sequences” or cookie cutter recipes for the masses not only won’t work (I wish it were so easy to treat pain and injury), but they are unrealistic and insensitive to the person’s individual story and needs.
Hip safeguard: One precept that can serve all yoga enthusiasts well is adopting the baseline focus of stability first and mobility second. Not just physical stability, although incredibly important, but psycho-social-spiritual-intellectual stability.
Using a panca maya or koshic model, stability should be a primary focus for any yoga class and should, in almost every case, always come before flexibility as a focus. Doing this fosters safety in classes, especially when there is a very good chance of someone being in pain either next to you or, if you are a yoga teacher, in your class. If you had to put elements of fitness in order, the basic orthopaedic building blocks that I learned 25 years ago as an athletic trainer earning my bachelor’s degree in sports medicine still apply. I recommend for achieving global stability look like this:
then strength training
Endurance, and finally
Power = strength + endurance, and has many important substrates that must be met in order to achieve. Neuromuscular patterning and efficiency, as well as the ability to sustain a movement for an extended time, are some of those variables.
How would this look in a yoga class or session? First, hold the poses longer and take double the time to transition in and out of the pose. Anyone can throw her or himself on the floor and roll around, and that’s what happens in the name of yoga in many classes today. It takes control to move slowly and deliberately, paying attention to the finer aspects of the joint position and soft tissue. In my practice, I evaluate all of this through what I call a Vector Analysis, something I teach in my lectures, use with patients, and write about extensively.
The take-home message is here: Don’t vomit on your yoga mat. Figuratively speaking, what I mean is don’t move so quickly through posture, especially sequences, that you miss all chances for development of stability, strength, endurance, and neuromotor patterning and efficiency.
Slow down, move mindfully, and feel. Yoga classes, at least in the US, can be notorious for allowing, or even encouraging students to “vomit on their yoga mat.” Watching early footage of yoga teaching reveals this type of teaching “philosophy,” and is also something I’ve seen countless times in attending yoga workshops, conferences, and classes. And what is the goal? To move as quickly as possible to either keep up with your teacher’s pace and demonstrations? Or to compete with your neighbor or yourself?
This kind of “teaching” and thinking is damaging to both yoga philosophy and physical practice, and has no place on the yoga mat today. Fortunately, there are also many yoga professionals who do understand that “vomiting on your yoga mat” is not a good idea.
Bonus Yoga Tip!
Ditch the lengthy, repetitive asymmetrical vinyasas/sequences. These typically focus on, you guessed it, “hip openers,” and give no regard for those who will not achieve full flexion, abduction, and/or external rotation, or FABER. This position is almost unanimously practiced in yoga, and is a high-risk maneuver for anyone with hip instability, joint hypermobility syndrome, Ehlers-Danlos syndrome, or known or undiagnosed hip dysplasia.
Particularly, it is the asymmetrical nature of a seemingly endless number of postures strung together without consideration for hip morphology that can exacerbate any existing hip, low back, sacral, iliac, and/or pelvic pain or even create a problem where one didn’t previously exist. The nature of how and why this happens is more complex, and includes variables like distinguishing between unloaded versus loaded hip movements, the mechanics of hip limitations, pelvic girdle or nerve contributions, and intra-articular (inside the joint) versus extra-articular (outside the joint) variables.
That is a topic we will dive into in future posts. For now, consider how these 3 Golden Rules of Happy Hips can evolve and safeguard your practice since “Hip Opening” should no longer be considered a holy grail of yoga posture practice.
Ginger is a longtime physical therapist, athletic trainer, and professional yoga therapist. She received her Doctor of Physical Therapy from The University of North Carolina at Chapel Hill and is the founder and executive director of Professional Yoga Therapy Institute, an international post-graduate program for licensed medical professionals, which celebrates its 16th anniversary in 2016. Ginger serves as a consultant to, and adjunct faculty for, medical schools in the US and Canada who use her yoga curriculum and methodology. She is a faculty instructor at Herman and Wallace Pelvic Rehabilitation Institute and Medbridge Education. Ginger maintains an international teaching and lecture schedule.