Who wouldn’t want a magic formula to ward off injury on the mat or protect our yoga students from harm? That wish for safety, however, may have given rise to a host of misconceptions about yoga injuries. For instance, we may believe we can avoid injury if only we’re sufficiently mindful. Or that if we just move slowly enough, or do a pose perfectly enough, we will never be hurt.
But the factors underlying injury are complex and varied, which limits our ability to make generalizations about injury prevention that will hold true in all cases. Bill Reif, a physical therapist based in Atlanta with forty years’ experience, and the author of The Back Pain Secret, weighs in below on ten common myths about yoga injuries—myths that I wish were true.
Yoga is physical activity that challenges our bodies and moves them in non-habitual ways. While these aspects of practice are largely beneficial, they may at times lead to injuries. By some tallies (such as this study published in the Orthopaedic Journal of Sports Medicine in 2016), the rate of yoga injuries (many of them strains, sprains, and fractures) is on the rise.
Some injuries in which yoga may play a role aren’t easily tallied, however. Reif says that a lot of his yogi patients aren’t sure how they got injured. "Although a sudden injury can occur in yoga class, many injuries are more nebulous. A lot of them are cumulative: They occur over time. Injuries arising from joint instability may only arise after years of hyperextending joints. Common neck or lower back problems (such as a bulging or herniated disc) often occur over a period of months and sometimes years before they cause symptoms of pain and numbness.”
Because many injuries occur so gradually, the line between what is and is not a “yoga injury” is blurry. Some injuries that first make themselves felt in yoga may have arisen from a movement pattern off the mat (that pain I feel in chaturanga may have something to do with my habit of carrying a heavy bag over my malpositioned left shoulder). Conversely, some injuries that make themselves felt in daily life may have arisen from a movement pattern on the mat (that pain I feel when I throw a heavy bag over my left shoulder might have something to do with all those chaturangas I’ve been doing with my shoulders rolling forward). And just as repeatedly lifting heavy boxes with your lower back rounded might contribute to your back pain in yoga class, some of yoga’s more extreme movements may contribute to spinal problems, which you might not notice till you bend over to pick up the laundry basket. “Deep flexion (forward folding) can cause wear on the discs, deep extension (backbending) can cause wear on the facet joints. Both can wear out the ligaments supporting the spine over many years,” says Reif.
If we accept that yoga does occasionally cause or play a role in injuries (which may show up in class, or much later), we can take steps to protect both ourselves and our students during practice. However, because our movements throughout daily life can also play a role in the injuries we experience in class, our awareness and caution off the mat may be valuable in staving off yoga injuries, too.
While careless and inexperienced teachers are certainly more likely to harm their students, even experienced yoga teachers can teach a pose or make an adjustment that leads to injury.
“No teacher can avoid all injuries,” says Reif. “All instructors can do is lower the odds of injury.”
Reif tells us that teachers can help lower the odds of injury by asking about and accommodating a student’s limitations, and “reminding them often that this yoga practice is their journey, and no two bodies share the same musculoskeletal history.” Demonstrating with props and offering the less extreme version of a pose as the rule rather than the exception can help keep students safe. Just as important is to offer adjustments with extreme care, and to instruct transitions slowly and carefully.
As for students, Reif encourages us to inform our instructors of any pre-existing musculoskeletal conditions, and to always remember: “You’re responsible for your body. Honor it, and back off when you feel that something isn’t right.”
While ambitious, inexperienced students may be more likely to get injured, experienced practitioners can also get hurt, as many of us undoubtedly know.
“As with any conditioned athlete, the chance of injury for a more experienced practitioner is greatly reduced as compared with a newbie,” says Reif. But he also emphasizes that even the most experienced practitioners may find that their bodies become new to them, and newly vulnerable, as they change in various ways.
For example, “During pregnancy, an experienced student or teacher may be unaware that as her tissues and ligaments become lax due to hormonal changes, laying off asymmetric strain to the sacroiliac joint might be advisable.” Muscular fatigue from an intense month of yoga training can also make an experienced yoga practitioner susceptible to injury, according to Reif.
Despite experience, the effects of aging can also make us vulnerable to injury. In that 2016 study published in the Orthopaedic Journal of Sports Medicine, those over 65 had triple the overall injury rate. Were all of the injured new to yoga and overly ambitious, or were some of them experienced practitioners whose bodies responded differently to familiar poses? Reif says: “An older student with osteoporosis who’s practiced for decades may not be aware that the increasing brittleness of her bones means she should lay off poses that require extreme ranges of motion, like forward folds and deep backbends.” He adds that loss of muscle mass as we age can also make experienced practitioners more susceptible to injury, as can the increased likelihood of pre-existing injuries or conditions (see myth five for more on this).
Reif recommends that students remain continually aware of the changes happening in their own bodies, even the smaller day-to-day changes, and that teachers encourage this awareness: “Your practice must be a dynamic experience, meaning one day—or one year—you might do the more challenging version of the pose, and another you won’t. Each time you come to the mat your experience may vary. Give your body permission to say ‘maybe next time’ or ‘this is enough.’”
While listening closely to signals from our own body is an excellent idea, Reif points out that warning signs aren’t always easily interpretable, especially for beginners. “New students don’t always know if the sensation they are feeling is a ‘normal’ feeling. It’s not immediately clear if that pull on the hamstrings, tingle in the toes, or ‘pop’ in the hip signals a good release or an injury-in-the making.” According to Reif, these sensations and sounds sometimes signal the latter.
While listening closely to signals from our own body is an excellent idea, Reif points out that warning signs aren’t always easily interpretable, especially for beginners.
But some warning signs might be hard for even experienced practitioners to parse. While some wobbling in a single-leg balance pose is fine and part of the process of gaining strength and control, according to Reif, drastic wobbling could be a warning sign of torsion (twisting) to the ankle or knee, and injuries to the patella (kneecap), meniscus (knee cartilage), or the ligaments of knee and ankle—or it may even warn of an impending fall. “If your standing-leg knee or ankle starts to wobble severely, this would be equivalent to a dashboard warning light in your car—in other words, ‘pull over.’ If you can’t stop or minimize the wobble by focusing on a drishti (a focal point), it’s a good idea to return both feet to the ground.”
Furthermore, Reif tells us, “Not all injuries are instantly perceptible. Often lower back pain is delayed minutes to hours after the movement that caused it, and some diagnoses like cervical and lumbosacral pain are cumulative and not noted at the time of the strain.” In other words, it’s possible not only that we don’t feel pain in the moments preceding an injury, but also that we don’t immediately feel the injury itself.
Reif recommends that students back out of a pose when they feel pain, but also when they feel any numbness or tingling. It’s important that teachers give students permission to come out of a pose whenever needed.
Certainly we should strive to practice every pose in optimal alignment. Yet “Injuries don’t always mean a student did something improperly,” Reif says.
He elaborates: “A minority of injuries happen because of a misalignment in a single pose in a yoga class. It’s far more common that someone has a prior injury or unknown underlying problem, such as a mild disc bulge in the neck or back, that led to the pain that happens to show up in that pose.” According to Reif, that pain may show up even if the student is doing the pose “right.”
A mild injury may not make itself felt, or may be felt only as a distant ache or pain, until “physiologic capacity is breached,” says Reif, or until that vulnerable tissue or bone is pushed to its limit.
“If a yogi had a rotator cuff tear he didn’t know about”—a distinct possibility, particularly for older students, as up to 50 percent of the general population over 50 (and 80 percent of the general population over 80!) have asymptomatic rotator cuff tears—“he might not notice this until he performs thread the needle [threading one arm under the opposite shoulder from a hands-and-knees position] for the first time.” That does not mean he is doing the pose improperly—he’s simply putting pressure on a vulnerable place in his body, making the preexisting injury perceptible for the first time.
Sudden pain in yoga class may also indicate the "last straw," where a pose damages an already-vulnerable tissue or bone, notwithstanding the good alignment of the student. “If you are dealing with a shoulder issue like a rotator cuff strain or minor tear, a posture like thread the needle can escalate the damage even if a student is doing it ‘right,’” says Reif. “Or if a student has osteoporosis”—not unlikely, since 55 percent of those over 50 in the U.S. are estimated to have either osteoporosis or low bone mass—“a ‘sudden’—collapse of a bone may come about if she bends the torso too far, no matter how good her alignment is as she folds.”
To avoid exacerbating an underlying injury or condition in yoga class (regardless of excellence in execution), Reif recommends that students get persistent low-grade aches checked out before they develop into serious problems. “Addressing minor injuries early means less healing time and prevents the cumulative breakdown to irreversible damage,” says Reif. He suggests that we seek diagnoses for incipient conditions—for instance, that older women have their bone density checked, since osteoporosis may necessitate changes in their practice.
This was a view propounded in my teacher training, and one I could easily add to this list of things I mis-learned in yoga school.
Reif points out two flaws in this reasoning: Resistance isn’t always a signal of trouble, nor is non-resistance a clear signal that all is well. In fact, pressing on or manipulating that extremely flexible student who doesn’t resist at all may be more dangerous than pressing the student who is on the stiffer side. “Added pressure in a hypermobile student may cause her joints to exceed the physiologically normal range of mobility, causing instability and pain,” Reif says.
Reif uses pulling a student’s hips back and up in downward facing dog as an example. “Resistance here would be expected in a less flexible, larger man who lacks an anterior (forward) pelvic tilt and a lordotic (inward) lumbar curve, and might help lengthen his rounded lower back, as well as give him a clue as to which direction his pelvis should move.” It’s in fact the student who doesn’t resist who shouldn’t be receiving this pressure, which may increase the mobility of joints that are already hypermobile. “In an extremely flexible student there won't be any resistance to this well-intended assist. In this case, the pressure would not be appropriate. It might exaggerate the student’s forward tilt, and create excessive lumbar lordosis.”
Reif advises that teachers use extreme caution when adjusting flexible bodies—perhaps giving adjustments to arrest the depth to which they go in a pose, rather than adjustments that aim to take them deep into their end range. Since for these flexible students it’s vital to stabilize joints that are already hypermobile, using verbal cues that encourage strengthening actions in less extreme versions of a posture can be more beneficial than adjustments aimed at increasing flexibility.
Facilitative adjustments that ask a student to “lift” or "press into the teacher’s hand” (often meant to conjure more muscle engagement) are in many cases safer than adjustments that push or pull on a student. “The student perceives the inner effects of the action whereas the instructor cannot,” Reif says. “However, if you facilitate a student who is misaligned, you may be asking them to perform a muscle contraction in a compromised position. Applying force outside of correct alignment can lead to injury,” says Reif.
That injurious force can be external—that is, it can come from the teacher—or it can be internal, coming from the student’s own body. A student can certainly hurt her own shoulder in triangle, for instance, if pressing her top hand into the teacher’s palm while her shoulder is rolled forward.
To bring a student’s bones onto the proper track before you ask her to send force through them, Reif recommends that teachers try verbal cues (for instance, if a student’s shoulders are rolling forward, instruct her to move her shoulders up and back, and press her shoulder blades against her back); offer demonstrations (showing optimal shoulder placement in your own body); and make use of props such as the wall that help a student to perceive where her shoulders are in space (“Bring your shoulder back to the wall”). Then ask the student to push or press.
It would be nice to be able to say with certainty, “No one’s ever gotten hurt in my class,” or even “Only one person has ever been hurt in my class.” But, in truth, a yoga teacher may not be aware of every injury her students experience—for the simple reason that her students don’t tell her.
In my own case, I was silent after having received an injurious adjustment—partly because I didn’t want my teacher to feel bad or in any way criticized (after a class that was excellent in all ways except for that pain in my left buttock). But as Reif points out in myth number four, many injuries don’t make themselves felt immediately, and I wasn’t entirely sure if I was in fact hurt. Though I’d felt a sudden, sharp pain when the teacher pressed my hips in single pigeon, what I felt by the end of class was only a vague heat. Only days later did I understand that I was injured.
Like me, students may be hesitant to voice problems, either to protect a teacher’s feelings or because they’re unsure of their injuries. They may also vote with their feet, and simply not return to that class. In either case, the teacher is left in the dark.
Reif stresses the importance of letting our teachers know about our injuries. “If you report your injury to your teacher you can both explore what happened, and perhaps keep it from recurring,” says Reif. Teachers can keep the channels of communication open by asking students, “How does/did that feel?” They should avoid any implicit defensiveness, or any critique of the student’s performance, making it clear that they want to know if something does not feel right, and meeting any confession of injury with openness. (“Thanks for letting me know. I’m so sorry that happened. Let’s keep a close eye on that.”)
Reif values gradual movement. “My single biggest complaint in yoga class is when an instructor does not allow enough time for everyone to get into a pose. I cringe, thinking someone is going to get hurt,” he says.
However, Reif admits that in and of itself, moving slowly is no panacea. “If a movement is poorly executed, even moving slowly can do damage,” says Reif. If an injury is caused by the off-track movement of a bone (for instance, if your right knee does not tend to track toward the center right foot), moving slowly does not guarantee that your right knee will automatically track toward the middle of your right foot. What moving slowly does do is offer more time to notice and make a correction to the position of your knee.
Reif recommends that students and teachers move slowly and be continually mindful of alignment through each pose and each transition.
It may be—minor injuries can heal completely, according to Reif—but it may not be. The place in our bodies that was injured or vulnerable in the past is very likely vulnerable in the present.
“Every active adult, yoga teachers included, typically has an ‘Achilles heel,’ a vulnerable area of their body in which there’s pain, crepitus (noise), or restrictions in mobility, strength, or coordination,” says Reif. “This could be the result of an old fracture, trauma, arthritic history, a childhood or athletic injury.”
For a variety of reasons, that spot may get injured again. First of all, "Scar tissue is not as pliable, so it’s likely to be reinjured,” says Reif. Secondly, even if the injury has healed completely, the disrupted movement pattern or less-than-optimal alignment that played a role in the injury may remain. (Your right knee may have healed, but your right knee may still not be pointing toward the middle of your foot.) Thirdly, you may get less feedback from that place. “It’s common for us to have less proprioceptive awareness in a limb that was previously injured—that is, we might not be able to feel where it is without looking at it,” says Reif. This means that warning signs like pain or tingling might not be as pronounced.
That vulnerable area—whether or not it’s emanating clear warning signs—is one we need to keep paying attention to in every yoga class. “For example, if you sprain the same ankle multiple times, that’s the ‘weak link’ that you’ve got to stay aware of, especially when you are putting weight on your foot in a balance pose, or a one-legged downward facing dog. If you have history of sacroiliac pain or hypermobility, you may always need to be cautious going into asymmetrical poses.”
In addition to maintaining our awareness of our own vulnerable areas, Reif encourages us to let our instructors know about prior injuries (in addition to current injuries), particularly if the past trauma was repeated or severe. That way, teachers can help us look out for that area, or at least avoid placing extra pressure on it, and perhaps also advise us in modifying or even avoiding certain poses.
Many of the suggestions mentioned above—staying aware of abnormal sensations, moving gradually, maintaining awareness of our own alignment as well as our pre-existing conditions and limitations, and clear communication between students and teachers—are invaluable in minimizing risks. However, they are by no means foolproof.
“There’s no magic formula for injury prevention, in yoga class or in life,” concludes Reif. He does not, however, see this as a reason to avoid yoga. After all, “There’s a calculated risk to everything we do.”
Reif often encourages his patients to take yoga class, since studies affirm its power to enhance our strength, flexibility, cardiovascular fitness, addiction recovery, stress reduction, mood, pain relief, and general sense of well-being. He also values its role in recovery from certain kinds of injury: “Rhythmical, symmetrical movement such as yoga flows or poses that are repeated on both sides can help patients relearn a normal pattern. For instance, yoga can help a patient who’s been favoring one leg to walk with even weight distribution,” Reif says.
And if you are injured in yoga class? That RICE acronym you may have learned from your coach or yoga teacher is no myth. According to Reif, RICE (rest, ice, compression, elevation) is still good advice, despite some controversy of late around “rest” and “ice.” “The main change in this philosophy,” he says, “is that we now understand that ‘rest’ doesn’t mean total immobilization for weeks. Depending on the severity of the injury, it means ceasing activity that places demands on that area for somewhere between 24 and 48 hours following the trauma. For example, if your sprained ankle is accompanied by severe pain, swelling, and black-and-blue discoloration, rest it for 48 hours; but if the sprain is mild, you may well resume moving that ankle during the very first day.” Reif explains that the rest period is important to allow clots to form without disruption. As for the ice, while it does not help with healing, Reif clarifies, “It has a numbing effect on pain. Ice should be applied directly to the injury for about ten minutes every four hours for the first day or two after injury.” Additionally, compressive wraps and elevation both work to prevent swelling. “If swelling isn’t prevented,” says Reif, “it can prolong rehabilitation.” After one or two days of RICE, and once the swelling and pain have lessened, he recommends a gradual return to activity. (And of course, seek out medical attention if you are injured. Specific recommendations may vary depending on your injury.)
When practicing or teaching yoga, it is important to remain aware that even with our safeguards, the truth is there will always be some potential for injury. Accepting this requires equanimity in the face of uncertainty, acceptance of the limits of our control over the world, and a brave embrace of the imperfect along with the perfect. Fortunately, these are skills yoga can help us to learn.