“. . . according to the Yoga Sutra (3.1), the term [Bandha] refers to the ‘binding’ of consciousness to a particular object or locus (desha), which is the very essence of concentration.”
Georg Feuerstein



Friday, November 15, 2013

Preventing Yoga Injuries vs Preventing Yoga, Part I: The Hip Labrum

I’m thinking the ancients were onto something. Meaning this (possibly) 5,000 year old art that so many of us enjoy practicing and teaching. I’m talking about the tradition of Hatha yoga. The one that includes putting our bodies into poses like Uttanasana, Dandasana, Padmasana (Full Lotus), Sirsasana (Headstand) etc. Now, part of that practice involves poses that take some of our joints to the extremes of their range of motion (from a western medical perspective). Indeed, many of the benefits of Hatha yoga derive from moving our joints (carefully) within their range of motion.

Obviously, we want to avoid injuries when practicing yoga. One way to do that is to eliminate a bunch of the asanas on the grounds that they’re “too dangerous”. That approach also eliminates the benefits of those poses. Or, we can practice mindfully, using modifications where appropriate and working in a progressive manner towards the classical asanas that are appropriate for each of us individually. Knowledge of the body combined with awareness of mechanisms of injury aids in this process.

In medicine, we look for ways to eliminate the risks of a given activity, not the activity itself. To illustrate my point, check out this quote from one of the scientific articles that studied the effect of extreme hip motion in professional ballerinas:

These results do not mean that the dancers should stop executing these movements, but rather they should limit them in frequency during dancing class.”2

Wow. Think I’m down with that.

You mean we don’t have to toss out Developpe Devant, Developpe a la Seconde, Grand Ecart Facial and Grand Ecart Latéral and create a new "gentler ballet"? Of course not. Because it would be kind of boring to watch a ballet that consisted of folks sitting on a stage, waving their arms around (to say nothing of the dangers to the rotator cuff). Similarly, Hatha yoga wouldn’t have its beneficial effects without, you know, the poses of Hatha yoga.

So, with this in mind, let’s review the structure of the hip, paying particular attention to the labrum.

As a general consideration, mobility and stability of the joints are determined by three factors. First, there is the shape of the bone at the joint; for example a ball and socket vs a hinge. Next there are the soft tissue stabilizers such as the ligaments, capsule, labrum or meniscus. Finally, there are the muscular stabilizers that surround a given articulation. A related subject is the concept of joint congruency. This refers the fit of opposing joint surfaces. High joint congruence means there is more surface area in contact; low joint congruence decreases the contact area.

A central tenet of rehabilitation and injury prevention relates to strengthening the muscular stabilizers of the joints. This aids to enhance congruency of the articular surfaces while at the same time providing dynamic support for the soft tissue stabilizers such as the ligaments, labrum and menisci. For example, in sports that put the soft tissue and bones at risk, we integrate training that improves proprioception and strengthens the muscles surrounding the joints.

Hip joint cross-section showing articular surface and acetabular labrum.

Let’s begin by looking at the acetabular labrum. This is a fibrocartilaginous ring-like structure that encircles the outer edge of the socket of the hip joint. Like the meniscus of the knee and the labrum of the shoulder, the hip labrum deepens the joint and contributes to its stability, while aiding in pressure distribution along the articular cartilage. It also acts as a type of seal that helps to retain the synovial fluid within the joint itself, thus allowing for some of the load on the joint to be borne by fluid pressurization, while at the same time helping with joint lubrication.

1-hip joint and labrum, 2-acetabular cartilage, labrum and ligamentum teres, 3-capsule lining showing synovium.

The labrum is relatively avascular, with blood vessels entering near the peripheral edge where it attaches to the bone and cartilage, and penetrating about one third of the way into the structure. This limits its ability to heal. Tears of the labrum are associated with hip osteoarthritis. Figures 1 and 2 illustrate the hip labrum from the outside of the joint and the acetabulum with the femur removed.

The hip is a synovial joint. These types of joints are surrounded by a capsule, which is lined by a synovial membrane (synovium) which faces the joint cavity. The synovium contains two primary cell types. The first are called fibroblasts and they secrete synovial fluid. This fluid lubricates the joint surfaces, reduces friction during movement and acts as a shock absorber through fluid pressurization. It also carries oxygen and nutrients to the articular cartilage and removes carbon dioxide. The other cell type lining the synovium is a macrophage cell; this cell removes debris or other unwanted material from the joint space. Activities that maintain joint range of motion aid in circulating the synovial fluid and bringing unwanted material into contact with the macrophages. Figure 3 (above) illustrates the joint capsule with the synovium for the hip.

1-iliofemoral ligament, 2-hip capsule, 3-pubofemoral ligament, 4-ischiofemoral ligament, 5-iliofemoral ligament.

On the outside surface of the hip capsule are the ligaments. The iliofemoral ligament runs from the anterior inferior iliac spine (AIIS) to the front and lateral part of the top of the greater trochanter of the femur. The iliofemoral ligament is the strongest ligament in the body. It functions to resist extension and external rotation of the hip and helps to prevent the pelvis from tilting backwards during standing. It also stabilizes the pelvis during the stance phase of walking, thus assisting the hip abductors. The pubofemoral ligament runs from the pubis to the neck of the femur; it prevents hyperextension and hyperabduction of the hip. The ischiofemoral ligament runs from the ischium in a spiral manner to the femoral neck. This ligament tightens in hip extension and becomes loose during flexion. The image above illustrates the hip ligaments.

Finally, there are the muscular stabilizers of the hip. I’m not going to discuss the specific actions of the individual muscles in this post. What I want to illustrate is the positions of the muscles around the joint. For example, look at the psoas and the rectus femoris muscles and how they provide an anterior support to the hip. The images below illustrate the muscular stabilizers of the hip joint.

1-iliopsoas, 2-pectineus, 3-rectus femoris, 4-sartorius, 5-gluteus medius,
6-tensor fascia lata, 7-piriformis, 8-external rotators, 9-quadratus femoris.

1-gluteus maximus, 2-tensor fascia lata, 3-adductor brevis, 4-adductor longus, 5-adductor magnus, 6-semimembranosus, 7-semitendinosus, 8-biceps femoris.

Take your time going over this material, and use the great images Chris produced to help you understand the hip joint. Stay tuned for Part II of the series, where we’ll go over some of the latest scientific research being conducted on the hip joint (research for which all of us in yoga should be extremely grateful, btw).

As always, if you have pain in your hips (from any activity), be sure to consult a health care professional who is trained and qualified to diagnose and treat such conditions.

Namaste'

Ray and Chris

References:

1. Reid DC. Prevention of hip and knee injuries in ballet dancers.” Sports Med. 1988 Nov;6(5):295-307

2. Charbonnier C, Kolo FC, Duthon VB, Magnenat-Thalmann N, Becker CD, Hoffmeyer P, Menetrey J. “Assessment of congruence and impingement of the hip joint in professional ballet dancers: a motion capture study.Am J Sports Med. 2011 Mar;39(3):557-66.

3. Gilles B, Christophe FK, Magnenat-Thalmann N, Becker CD, Duc SR, Menetrey J, Hoffmeyer P. “MRI-based assessment of hip joint translations.J Biomech. 2009 Jun 19;42(9):1201-5.

4. Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD, Griffin LY, Kirkendall DT, Garrett W Jr. Effectiveness of aneuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-yearfollow-up.Am J Sports Med. 2005 Jul;33(7):1003-10.

23 comments:

  1. I'm doing a hip workshop this weekend and I am so thankful for your post!

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    1. Where is your workshop ? Would you please write me Info on my @ address: brankayoga@aol.com. After last year fall and hip injure I'm still copping with some difficulties and coming back in my previous condition to do my full yoga program is challenge. Thank you, Branka

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  2. Great post as always. I really appreciate the images!

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  3. As usual, your posts are excellent and meet a great need in the yoga world. I am a yoga teacher and have spurs on both the femur and the hip and probable damage to the labrum, some pain, a slight limp and significant limited flexion in lunges and Apanasana. Can you address rehabilitation?
    I do a normal range of yoga poses, Iyengar-style, Supta Padangustasana with the two straps and a series of physio exercises to strengthen abduction and adduction.

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  4. Eager for Part II as I am a yoga practitioner and teacher, and am in the process of recovering from a recent hip surgery to repair a torn labrum (among other things).

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    1. Hi Kathy, I also have a tear in labrum, but no surgery,maybe because I have arthritis in hip, they say. I have injections in hip, 2 so far, one more in Dec. Never had any issues, till I lifted heavy weight over and over. Dr says when injections no longer help, I'll need replacement. I also am a yoga teacher, and must be very careful in lunges ect. I want to heal myself through poses done for strength ect.,this Bandha site is awesome. Good Luck! Brenda Crain

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    2. As part of your recovery,be especially careful to work on both hips equally, to minimize potential misalignment or pain in the hip or lower back. I had a torn labrum and acetabular carpet delamination repaired 3 yrs ago and required a few acupuncture and chiropractic sessions to successfully eliminate back and hip pain associated with hip misalignment. I have since been practicing yoga for 2 years now and find that standing poses have successfully kept me pain free and mobile. I am now I'm in training to be an instructor.

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  5. Thank you so much for your wonderful posts. I am making it my mission to teach yoga and teach others to teach yoga in a more anatomically correct manner. Your posts help me with that mission. I'll join you for training or a seminar one of these days.

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  6. In the paragraph on ligaments you say"anterior inferior iliac spine (ASIS)", I think the abbreviation should be AIIF, no?

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    1. AIIS, thanks for the heads up, Janet--fixed it. Best~Ray

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  7. Great post. However most yoga teachers are not doctors or bodyworkers and their knowledge of the human body is very limited. I am a yoga teacher and bodyworker and have been just waiting for this explosion of issues to happen. The criticism is towards the low level education yoga gives to it's teachers, especially if you encourage out of shape or over-zealot people to engage in acrobatics.

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  8. Thank you for your great posts, they all are very useful!
    The books look amazing too, can I found them in french or not?

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  9. Thank you so much! I really took my time with this post...we are driving out of town for the holiday and my goal to read your blog, take my time, and digest. By the way you/this "Bandha Yoga" is brilliance.

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  10. I just met a young woman (22) who is having her 2nd labral tear repair in 3 years - she is an AVID runner and refuses to give it up. Concerning the early statement about not having to give up everything but do it less, do you think it applies here? I encouraged her to consider other sports! and definitely to check out yoga, which she has never tried.

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  11. great information for me after enduring a hip strain during a deep twisting Iyengar yoga class a week ago. Normally very flexible, I have had extreme tightness and pain since the practice.
    The strain occurred in the iliopsoas and piriformis muscles, and required some painful therapy. Although I'm aware of proper form/ alignment and body awareness during my practice, this sight will be extra helpful to prevent future possible strains, thanks!

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  12. Great post as always!
    Do you know what makes the popping sound in the hip, usually during trikonasana? And does it ever stop?
    thank you! :)

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