Tuesday, August 4, 2015

Knee Injuries in Yoga, by Catherine Followell


Knee Injuries in Yoga: 
A look at potential issues of the knee and post-injury knee joint rehabilitation   

Catherine Followell
Yoga Alliance Registered 200 Hour Course
June 6, 2015

Introduction

In the mainstream, yoga has been practiced for years as a restorative and beneficial series of poses that get the body moving.   The combination of weight bearing, muscle flexing and muscle contracting postures help to develop a healthy physical body.  Although understood as beneficial, as with any physical activity, if practiced without focus and understanding of the postures and one’s own body, physical yoga practice can result in injury of various parts of the body. As supported by this research paper, one of the most susceptible parts of the body for injury is the knees.  

Understanding the knee joint

The knee is a complex joint of the body that we rely on to bear most of the weight of the body.  The knee consists of bones, tendons, and ligaments. All of these aspects of the knee help stabilize it to bend and straighten front to back, and keep it from bending side to side. Understanding the knee and how it’s built is the first step in understanding how our actions in the asanas of yoga affect it.
The large upper leg bone (femur) and one of the two lower leg bones (larger tibia) are connected at the knee joint. The knee cap (patella) is a shield-like bone at the front of the knee. The patella slides smoothly along a groove between the femur and tibia when the leg is bends and extends. Connective tissue called the joint capsule is the place where the larger tibia bone, femur, and patella intersect in a sleeve-like casing. The joint capsule is reinforced with a number of ligaments that connect everything. Inside the sleeve, fluid is contained which keeps space between the bones so when the bones shift past one another, there is no bone to bone friction. The ends of the bones are coated with cartilage that acts as a cushion. Lastly, the thicker cushions on the top of the tibia are called menisci.

Degenerative issues in the knee which contribute to injuries

As we age, the action of walking, running, and other activities can take a toll on the knees. Some even struggle with the knees from an early age, being predisposed to issues even before life has a chance to take its toll.  Some common knee issues include:
o   Osteoarthritis – The cartilage in the knee begins to wear away. Rheumatoid arthritis is another arthritis that occurs in the knee and begins with inflammation and then cartilage is destroyed.
o   Patellar Subluxation – The knee cap miss-tracks from its groove between the femur and tibia. Many times this can occur due to uneven strength in the vastus medialis and vastus lateralis (inner and outer quadriceps muscles).
o   Tendinitis Inflammation of the tendon due to overuse.
o   Osgood-Schlatter DiseaseOsgood-Schlatter disease is caused by stress or tension on part of the growth area of the upper shin bone. Osgood-Schlatter Disease causes swelling in the knee upper shin bone. This occurs when the tendon tears away from the bone and a piece of bone goes with it. Young people are susceptible to this while playing sports that require running and jumping.
o   Illiotibial (IT) Band Syndrome – Occurs when the tendon rubs over the outer bone of the knee causing swelling. This can occur due to overuse.
o   Osteochondritis Osteochondritis can occur when there is a lack of blood going to part of the bone under the surface of a joint. The bone and cartilage gradually loosen resulting in pain. Cartilage may break off and cause sharp pain, weakness, and locking in the joint.
o   PlicaOccurs when bands of tissue in the knee swell from overuse or a previous injury.
o   Chondromalacia – Occurs when cartilage of the knee cap softens which can be caused by injury, overuse, muscle weakness, or misalignment.
It is very important to have aches, pains, or other discomfort medically diagnosed before beginning or continuing a yoga practice. Take caution with yoga asana practice when there is an existing weakness or previous injury such as those listed above or any others. It is necessary to make any instructor aware of the issue so the proper precautions can be taken and modifications to the practice can be made to accommodate the practitioner.

Common yoga injuries to the knee by the numbers

Lack of understanding of the body and the asana are a major cause of injuries to the knee in yoga.  7,369 yoga injuries were recorded from visits to doctor’s offices, clinics and emergency rooms in 2010, an increase from 5,500 in 2007 (U.S. Consumer Product Safety Commission). A number of these were knee related.
According to the U.S. Consumer Product Safety Commission, “Nearly 4,500 people ended up in the emergency room after yoga injuries in 2006, slightly fewer than the year before but still up 18 percent since 2004.” Included in the most common of recorded yoga injuries includes torn cartilage in the knee.
Along with misunderstanding on the student’s part, instructional cues given to students by teachers can also cause injury. Although it is becoming more widely understood that proper alignment in yoga poses varies by the body of the student, many styles of yoga still stress that there is only one way to align, which can cause wearing and tearing of muscles and joints, including the knee.  It is ultimately up to the student to listen to what their body is telling them, and to not push themselves over the limit of stress to injury.

Asanas which can contribute to knee injuries

There are a number of asanas, such as in the following lists of poses below (via Yoga Journal) that require a lot of the knees and should be practiced with caution.
·         Extreme flexion of the knee joint can weaken the joint if not performed properly, and it is theorized that these can eventually lead to injury, either during practice or regular daily activity.
o   Child’s Pose
o   Hero’s pose
o   Noose Pose
o   Reclining Hero’s Pose

·         Hyperextension in straight leg poses has also been linked to degenerating cartilage in the knee. It is important to know how the asanas listed, as well as related poses affect the body, and know how to prevent degeneration of the joint.
o   Head to knee forward bend
o   Gate Pose
o   Lord of the Dance Pose
o   Extended Triangle Pose
o   Pyramid Pose

·       Poses like Padmasana are damaging to the knee if the proper alignment is not intact from hip to toes. Padmasana, for example, requires the student to fully rotate the ball of the femur bone in the hip joint 145 degrees. If the hips are tights, students will rely on forcing the knee down to bring the foot to the opposite hip crease. Knees are not designed to twist this way, and the result is a pinching of the inner knee and over exposure of the outer knee. Similar rotation is required of poses such as:
o   Happy Baby Pose
o   Easy Pose
o   Bound Angle Pose
o   One-legged King Pigeon Pose
o   Reclining Bound Angle Pose
o   Lion Pose
o   Fire Log Pose

How to strengthen knee after injury occurs

What should be done after an injury occurs? Whether it’s a torn meniscus, tearing of a ligament, a dislocation caused by the practice, or normal daily activity care should be taken with the injured knee.
Straight leg asanas should be practiced by those recovering from a knee injury before attempting asanas that require flexion. Trikonasana and Padangusthasana are poses that require flexion of the muscles around the knee which will help strengthen and stabilize the leg. When practicing asanas like Virabhadrasana A and Utthita Parvakonasana, be sure that the knee is pointing in the same direction as the middle toe of the bent leg; this will help protect the soft tissue of the inner knee.
If an injury has taken place, it is equally as important to take care of the entire body as it is to nurse the injury back to health. Over compensation in other areas of the body can make one more susceptible to injury.  Introduce activity into daily life slowly. Depending on the injury, physical therapy may be recommended. If so, diligent practice of the exercises is necessary to keep both legs in good condition and building even strength within the body.

Asanas which benefit strength and flexibility of the knee

There are many physician assigned rehabilitation techniques of all varieties to recover from knee injuries. Yoga asana practice can serve as a great way to strengthen the injured knee and keep the rest of the body strong and resilient. It is also a great method to be able to see slow progress and overall results in the mobility and relief from the injury.
If practicing yoga asana for rehabilitation, full range of motion (when the joint is ready) is healthy for knees, with proper alignment. For example, Surya Namaskar A and B and Balasana can be helpful for knee joint cartilage. Poses that work to strengthen all the muscles around the knee joint, including the quadriceps, hamstrings, adductors and IT band will help align the bones of the knee. Examples of the poses would be standing poses with straight legs such as Parvottanasana and Trikonasana. Squeezing a block between the thighs for poses in which the legs are parallel, in poses such as Utkatasana and Tadasana, can help to strengthen the inner muscles of the thighs (vastus medialis) as those muscles tend to be weaker. Bent knee standing poses, like those mentioned above with the thigh parallel to the ground are great inner thigh strengtheners as well.
Other options to strengthen the muscles around the knee include isometric extensions, as recommended by Doug Keller. With legs extended and together, engage the inner quadriceps muscle and hold for 10 seconds. Repeat this exercise two times. Other physical therapy exercises for the knee include wall sits and bridge pose, but consulting with a physician will provide the best exercises for rehabilitating the specific injury.

Conclusion
Whether someone is new to the practice of yoga or has been practicing for years, it is important to be educated about the body, and most importantly to have an understanding of one’s own body. With that information, a safe practice or recovery from injury during the course of a practice or otherwise, will be sure to be a great one.

 References
Apt, M. (12 Jan. 2010). How to Help Heal a Knee Injury. Yoga Journal. Web. 6 Apr. 2015. .
Cole, R. (8 Aug. 2007). Protect the Knees in Lotus and Related Postures. Yoga Journal. Web. 6 Apr. 2015.
Editor, YJ. (22 Aug. 2013).  The Bee's Knees. Yoga Journal. Web. 6 Apr. 2015. .
Keller, D. (25 Sept. 2013). Yoga Therapy for Your Knees. Yoga International. Web. 28 May 2015.
Knee Injury Contraindications. Yoga Journal. Web. 6 Apr. 2015. .
McDowell, D. (28 Aug. 2007). Weak in the Knees? Yoga Journal. Web. 6 Apr. 2015. .
(1 July 2010). What Are Knee Problems? Fast Facts: An Easy-to-Read Series of Publication for the Public. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Web. 27 Apr. 2015.
Wolffe-Perrine, J. (15 July 2008).  Bad Karma: When Yoga Harms Instead of Heals. NBC News. Web. 6 Apr. 2015.


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