Yoga Journal Cover Story - June 2003

"Do more!" the producer urged as I stretched back from my kitchen sink into Ardha Uttanasana (Half Standing Forward Bend). An article I'd written about practicing yoga while cooking had attracted the attention of a national TV show, and now a camera crew crowded into my home to film me doing "Kitchen Yoga." But the simple postures I incorporate into my dinner preparation didn't seem impressive enough. So with a TV camera pointed at my face and hot lights nearly blinding me, I lifted one foot, grabbed my big toe and extended my leg into Utthita Hasta Padangusthasana (Extended Hand-to-Big-Toe Pose) - and felt a sickening pop in my hamstring.

Somehow I finished the session smiling, but the next day I could barely walk Hamstring tears heal slowly, and mine required rest and extensive physical therapy. It took me six months to be able to run again and more than a year to fully extend my leg in Hand-to-Big-Toe Pose. I learned the hard way that there is no place for showing off in yoga. But I am grateful to have recovered completely and consider the experience a small price to pay for the invaluable lessons learned, including respect for the importance of warming-up, proper sequencing and having the right attitude.

Like me, growing numbers of Americans are getting injured doing yoga-an unfortunate trend touted in news stories with headlines like "The Wounded Warrior," in The Washington Post, (April 16, 2002) and "Power Yoga Can Cause Powerful Aches, Pains," in The Los Angeles Times ( December 13, 1998). Often, media reports express surprise that this ancient healing discipline can actually cause harm, especially since many people take up yoga specifically to heal injuries. Yet like any form of physical activity, hatha yoga practice carries risks-especially when people push themselves, or are pushed by teachers, to "achieve" a particular posture, says Leslie Kaminoff, a New York yoga therapist and body worker who regularly treats yogis with both acute and chronic injuries linked to improper practice.

"Some people have such faith in yoga that it overcomes their critical thinking," Kaminoff says. "They think yoga practice-or a yoga teacher-can't hurt them, which isn't true." Yoga injuries range from torn cartilage in the knees to joint problems from overly-aggressive adjustments to sprained necks from "the domino effect" of being knocked over by classmates while doing Sirsasana (Headstand). "Many classes now are so crowded that one person out of control can take out any number of people," says Kaminoff, who treated a client with a neck sprain that occurred when a neighbor fell out of an inversion and knocked her into another yogi. And teaching carries its own hazards, he explains, recalling a teacher who was kicked in the face by a student she was helping, resulting in a chipped tooth, bruised face and blood nose.

Harsh adjustments can be especially risky for flexible people who can be easily pushed deeply into a pose without knowing that an injury may result. To counter this, Kaminoff advises knowing your own areas of strength and weakness and studying consistently with a teacher you know and trust.

While there are no comprehensive statistics on yoga injury, reports about problems continue to grow. For example, physical therapist Jake Kennedy, of Kennedy Brothers Physical Therapy in Boston, says that over the past six months his five clinics have seen a quadrupling of patients with soft-tissue and joint injuries from practicing yoga. "Yoga's become a hot exercise trend with some classes that are really aggressive," Kennedy explains. "It's attracting people who used to be sedentary, and often they do too much and get hurt."

The Roots of Injury

One reason for the growing number of injuries is that record numbers-an estimated 15 million Americans-now practice yoga. With physicians increasingly recommending yoga to patients, more new practitioners are coming to the mat with pre-existing ailments and low fitness levels, which makes them challenging students even for experienced teachers. Yoga's popularity also has spawned a scramble for instructors, resulting in some teachers with inadequate training being hired. Even new graduates from the mushrooming number of reputable teacher training programs often lack experience.

New students and inexperienced teachers are more likely to fall prey to a common problem that is a leading cause of injury--overzealousness, says Edward Modestini who teaches Ashtanga Yoga with his wife, Nicki Doane, at the Maya Yoga Studio in Maui, Hawaii. "The trap is that people are coming from a sincere, inspired place," he says. "But they get excited and push too much, which over-extends their threshold and can be very dangerous." This tendency is linked to the Western mindset "to always want more," Modestini notes. "Without a more balanced approach to practice, he says, injury can occur.

Modestini observes other contributing factors that correlate to yoga's evolution in the West-large classes and the intention of students. Traditionally, students came in search of enlightenment and studied one-on-one with a yoga master. Today, however, "people now come to yoga to lose weight or to get in shape, or to be healthy," he says, adding that burgeoning class size makes it difficult for even the most skillful teacher to connect with every student.

Richard Faulds, a senior Kripalu Yoga teacher, who lives in Greenville, Virginia, echoes Modestini. When you're striving and the mind has an agenda to get somewhere, the body may resist and injury may occur," explains Faulds. In contrast, he says, "true yoga starts with radical self-acceptance. You're fully present with what is, observing the self without judgment. When the body knows that the mind is kind, it will open and release."

Judith Hanson Lasater, PhD., provides yet another perspective on the theme of striving or being overzealous during yoga practice. Injuries can often arise "not from what we do, but from how we do it," says Lasater, a San Francisco Bay-area physical therapist, yoga teacher and author of Living Your Yoga (Rodmell Press, 2000). "If people are greedy and acquisitive in their asana practice, and feel like they're never going to be satisfied until they get that Handstand in the center of the room," that can lead to injury, says Lasater, who notes that teachers' desire for their students to master more difficult poses also can be dangerous. "I train teachers to teach people first and asana second. Instead of thinking about 'How can I force this person's body into this position,' the approach is 'How can this person's body express this pose right now?' Anyone can work on any pose as long as it's modified and broken down into the smallest pieces."

Another problem, says Leslie Bogart, a Viniyoga teacher in Los Angeles, is that "we make our teachers gurus when what we really need to do is use their expertise to learn how to eventually be our own teachers." In addition, she says our sedentary, stressful lifestyle makes us more susceptible to injury. "We go from strollers to chairs to couches, so we've lost core postural muscles that surround the spine," Bogart notes. "People who sit all day have a lot of tension through the neck and shoulders. Then they go to Power Yoga, with lots of repetitions of Chaturanga Dandasana, which can put even more stress on their upper body." A healthier approach, she says, "is to use yoga to balance our lifestyle. If you're the type of person who likes to do everything hard, I'd caution you to be careful of hard yoga classes."

Yet sometimes, despite all best intention and right practice, "injuries just happen," notes Paul Grilley, a yoga instructor in Ashland, Oregon. "It's a physical practice and the physical body is always changing. Most of us have had the experience of going into a posture the way we always do, and -- perhaps depending on the phase of the moon or how we slept last night -- something goes twang. As yogis we try to be sensitive and move slowly and with awareness, but even so the body is malleable and changeable. It's just not humanly possible to prevent all injuries."

The "Kick-Butt Yoga" Factor

Another piece of the injury puzzle surrounds the new area of "fitness yoga," where the 5,000-year-old practice is taught in mirror-and-chrome gyms, and teachers are sometimes aerobics instructors who've attended a weekend yoga workshop. "Couple this inexperience with a population that demands a vigorous, 'kick-butt' type of yoga workout, and you have a situation that definitely warrants more education on the part of consumers and fitness professionals," says Yoga Basics (Henry Holt, 1997) author Mara Carrico, who teaches fitness professionals about yoga in courses accredited by the American Council on Exercise (ACE). "Sometimes it seems that the only thing growing more quickly than the number of yoga classes offered in fitness facilities is the number of injuries sustained by eager participants."

Even some of the best yoga teachers can find it challenging to teach what Carrico calls "health and fitness yoga" since, she says, "people often come and go, so it's not a situation where a teacher can develop a relationship with a student and monitor him or her closely." A teacher's lack of awareness about students can lead to varied problems, says Carrico, who cites an incident where paramedics were summoned because a student's hip replacement was dislodged during a yoga class. For these reasons, she is cautious about teaching certain poses in the health club setting. "I'm adamant that Headstand and Shoulder Stand should NOT be taught in fitness facilities," she says, "unless it's a very small class with a very experienced teacher."

The Weakest Links

To minimize injury risk, "teachers and students need to understand where the body is most likely to get injured in yoga and know how to protect these areas," says Roger Cole, PhD, a scientist and Iyengar yoga teacher in Solana Beach, California. Cole names the lower back, knee and neck as the most prone to injury, followed by the sacroiliac (SI) joint and the origin of the hamstring muscle" (where it joins the sitting bone). Back and SI injuries are often linked to forward bends, he notes, because they put a lot of strain on the disks and ligaments at the base of the spine.

The riskiest postures are any seated, straight-leg forward bends that also include a twist. "To make these postures safer," he says, " tilt from the pelvis as far as you can before the back gets involved, elongate the spine, don't flex it too far, and never force yourself into the pose." But he cautions that "Tilting the pelvis has its own risk. It puts more stretch on the hamstrings, so if you push too hard, you can strain them, especially at the point where they connect to the sitting bones."

To prevent knee injury, Cole emphasizes the importance of not forcing the knees--especially in Padmasana (Lotus Pose)-and instead turning the thighbone outward from the hip joint. "Pulling up on the foot or ankle, or pushing down on the knee in Lotus puts a tremendous crushing force on the cartilage of the inner knee," he says.

The most common posture to cause injury-especially in people over 40--is Shoulderstand, according to Larry Payne, PhD, a Los Angeles yoga teacher and therapist and co-author of Yoga Rx (Broadway Books, 2002). For beginners he suggests Half Shoulderstand, a variation of the full pose where the hands are placed on the lower back to support the weight of the hips, thereby removing most of the weight from the neck. "Half Shoulderstand has most of the benefits without the risks or the necessity of using props." Full Shoulder Stand can be dangerous because of the excess weight many Americans carry, notes Payne, who avoids the pose for anyone who is more than 30 pounds overweight. He offers students a continuum of options, including Viparita Karani (Legs Up the Wall Pose) -with and without bolsters-Happy Baby Pose and Half Shoulderstand. "The attitude of the teacher is very important in avoiding injury," he notes. "Teachers who make the class feel intimidated or wimpy if they need a modification or want to come down out of a pose are asking for trouble."

Roger Cole agrees that the neck is vulnerable and can be injured during Shoulderstand if it is made to bear the body's weight. "The neck has a natural, concave curve in back," he notes. "Shoulderstand bends the neck the opposite way. Practiced too aggressively, it might contribute to problems ranging from bone spurs to disk injury."

This is one reason why in the Iyengar method, blankets are used under the shoulders to reduce the forward bend of the neck in this pose. "With all these cautions some people may be scared away from yoga," notes Cole. "But yoga is too good to miss. Some of its big lessons are to act with awareness, balance, nonaggression and common sense. If people do that, they will enjoy a safe and happy practice."

Insurers Weigh In

Despite the new focus on yoga's risks, hatha practice is one of the safest forms of exercise, says Lewis Maharam, MD, a Manhattan sports medicine specialist and medical director of the New York City Marathon. "I often recommend yoga to my patients, especially runners, who tend to be incredibly tight," he says. "If you see injury in any activity-including yoga-it's often a question of someone trying to do too much, too fast."

Compared with other forms of exercise, yoga generates fewer and less costly insurance claims, says Jeffrey Frick, CEO of the Fitness and Wellness Insurance Program at the Murria & Frick Insurance Agency in Solana Beach, California. "Yoga continues to be one of the fastest growing forms of exercise we insure," notes Frick, whose program specializes in coverage for fitness facilities including health clubs, yoga studios and climbing gyms. The yoga liability program averages about 10 to 12 claims per year, he says, with the average paid claim amount $6,000.

In contrast, the company averages about 200 claims per year from their other fitness programs, with the average paid claim amount $20,000. The program's biggest yoga insurance claim-for more than $200,000 in 1994 - concerned a teacher overstepping ethical boundaries and injuring student. More commonly, Frick notes, "Yoga claimants say the instructor pushed them too hard into positions that caused injury to them." Frick echoes Leslie Kaminoff and Judith Hanson Lasater by saying that, to prevent problems, teachers need to be sensitive to their students' ability to do certain poses. In the fitness industry in general, he says, "Half of claims are customer induced; that is, they come not from our negligence, but from an over-zealous client. The lesson is that instructors should have protected that person from themselves."

Sidebar: Seven Ways to Reduce Your Risk

Yoga students and teachers can reduce the risk of injury by paying attention to the following:

Attitude. "I have observed injury happens less when people have an attitude of devotion, surrender, acceptance and honesty," says Louise Ellis, an Ashtanga yoga teacher in Fayetteville, Arkansas. "Injury is more likely when there is an attitude of competition, greed, insensitivity, hurrying and attachment to the results of the practice. When the ego gets involved wanting results, that's not really yoga--that's exercise."

Alignment. "Yoga is risky because you're asking the body to move into the greatest range of motion possible," notes John Friend, founder of Anusara Yoga. "Without a focus on good alignment, we'll continue to see a lot of injuries."

Previous Injuries. Past injuries, particularly to joints, are vulnerable to re-injury. Teachers should ask new students about injuries, and students should communicate special needs to instructors-before class if they're embarrassed to mention concerns in front of a group.

Danger Signals. "If your breath gets exaggerated or you have to open your mouth to breathe, this can be a sign that you're going past your threshold," says Edward Modestini, who notes that an individual's threshold may vary from day to day depending on diet, sleep, emotions and other factors. Other danger signals, he notes, are "shaking beyond control or if the pose feels as if it's collapsing instead of ascending."

Transitions. "People forget that two-thirds of the practice is going in and coming out of poses with control," says Ana Forrest, a yoga teacher based on Orcas Island, Washington. "These are two places where people often don't pay attention and can tweak old injuries or create new ones."

Individual "Edge". An essential part of practicing yoga is developing the awareness to know when to reach and when to rest. In a mindfulness practice, the act of non-harming self by backing off and resting is true yoga.

Finding a Good Teacher. "What makes a good teacher is their deep respect for their student, not about students getting their palms on the floor," says yoga teacher Judith Hanson Lasater, who advises students to speak up if they have concerns or problems. "Trust your gut. If the teacher isn't willing to create an environment where individual differences are respected, I wouldn't study with them."