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Forward bends and hamstring injury: What’s going on?
You’ll remember from our survey post on negative experiences in yoga, that rate of injury reported in our survey was actually lower than a number of other physical activities. However, among those who did report an injury in yoga, there were some situations where injury was more common. These areas seem worthy of a conversation in the yoga community. The first of these topics we’ll delve into is forward bends and hamstring injury.
Forward bends make up many of the fundamental asanas for most styles of yoga asana practice, whether we’re thinking of a flowing vinyasa style practice or a more static restorative style practice. Forward bends are often seen as “safe”. It’s the direction of action in which most of our daily tasks take place. It’s familiar and can seem less mysterious than backbending or twisting for example. However, in reality, there can be a lot going on when we bend forward.
We didn’t list areas as specific as individual muscles, like “hamstring”, as body areas to select as a choice in our survey questions regarding injury. However, respondents had the option to describe, in an open ended question, what happened in their injury. From this information we learned of the significant number of hamstring injuries. (We also weren’t terribly surprised based on the amount of searching happening on this site related to sit bone pain). Survey participants also had a opportunity to list, as a response to an open ended question, what posture they were doing when they were injured. Forward bends showed up again and again. Forward bends were also at the top of the list of poses practitioners were doing when they experienced an injury while being adjusted.
It’s important to point out, before we get too far into the numbers, that it is certainly possible to injure or feel pain in other places besides the hamstrings while in forward bending postures. Likewise, it is definitely possible to injury the hamstrings doing postures other than forward bends. However, we did find that there was a strong relationship (p<.0001) between reporting an injury in a forward bending posture and reporting pain or injury to the hamstrings. Those that did not report being injured in a forward bend were also less likely to have reported a hamstring injury. Since they do have a relationship, we’ll discuss our findings related to both the forward bends and hamstring injury.
Numbers and statistics for forward bends and hamstring injury
Remember from previous posts that you’ll see within the text, this symbol: p=some number. This value, referred to as the “p-value”, is the probability that variables in the survey are unrelated; the lower the p-value, the stronger the relationship.
From our negative experiences summary post, you’ll remember that hips (including hamstrings) was fourth in the list of body areas most frequently injured among survey participants. A little less than 10% of respondents who reported experiencing one injury, reported hips (including hamstrings) as an area where they had experienced a physical injury. (Other common areas in the body where practitioners reported getting injured included: knees (21.0%), shoulders (19.0%), and low back (19.4%); and don’t worry, we’ll discuss those areas too in later posts).
When we evaluated data from the open-ended question that asked practitioners to describe their injury, we learned that almost a quarter (23%) of survey respondents who reported an injury during their practice lifetime had injured their hamstrings! Sixteen percent of survey respondents who reported an injury during their practice lifetime said they were injured doing a forward bending posture.
You might remember from the survey post on adjustments, that four of the 11 most common poses where respondents reported being injured in an adjustment were forward bending postures (seated forward bend (9%), Upavistha konasana (5%), Prasarita padottanasana C (4%), utthita hasta padangusthasana (2%). You could add those percentages up to get 20% of survey respondents who reported an injury while being adjusted were injured while being adjusted in a forward bending posture.
We found no relationship between reporting an injury in a forward bending posture and age, gender, self-reported level of practice, and the number of years of practice.
Similarly, we found no relationship between reporting an injury to the hamstring and age, gender, self-reported level of practice, and the number of years of practice.
Likewise, we found no relationship between style of yoga practice and reporting an injury in a forward bending posture or reporting a hamstring injury.
If you want to learn a process for working with injuries you should definitely check out the online injury workshop. It teaches you a process of how to assess, modify, and work with injuries.
Hamstring injuries and sports
Hamstring injuries don’t just show up in yoga. In fact, the sports literature suggests that hamstring injury is the most common muscle injury across sports (Edouard et al., 2016; Liu et al., 2012)! Hamstring injuries in other sports and activities almost always occurred when hip flexion and knee extension were maximized simultaneously (Fournier-Farley et al., 2016; Lempainen et al., 2015; Askling et al., 2008).
There are two ways that injuries occurred when getting to this point of significant hip flexion simultaneously with significant knee extension. One way was with a rapid, sudden movement as in running. A second way was with a slower, but more extreme reach, in both flexion of the hip and extension of the knee (Askling et al., 2007; Askling et al., 2006). This second description of injury mechanism is a pretty accurate description of how we might move into a forward bending yoga posture.
Researchers also reported that injury was more likely to occur when the hamstring was in eccentric contraction (Beltran et al., 2012; Liu et al., 2012). This is the kind of contraction that’s occurring in the hamstrings when we are moving into a standing forward bend. It’s also the kind of contraction that we could experience in the hamstrings if we were being adjusted in a seated forward bend and resisted or pushed back against the person adjusting.
All of this suggests that the hamstring’s attachment can be a tenuous place in the body. It is worthwhile for us to pay close attention to how we’re getting into forward bends, how we’re transitioning out of forward bends, and what we’re feeling while we’re in the poses.
So what is it about those hamstrings?
You might remember from our previous muscle of the month post, that the hamstrings are actually three separate muscles: biceps femoris, semitendinosus, and semimembranosus. All three hamstrings share a proximal (upper) attachment point on the ischial tuberosities, or sits bones. This attachment point is a place where otherwise large muscles taper off to small tendinous connections to the bone. It’s possible for us to put considerable pressure onto these somewhat tenuous attachments.
It’s also important to take notice of obvious imbalances in each side of the pelvis because that can contribute pressure onto one or both of the hamstrings. That may look like one sit-bone higher than another in a forward bend or downward facing dog. You may even notice a difference in the hand placement in a posture like down dog. You might be surprised to find this pattern connected to a pelvic imbalance.
If there is a pelvic imbalance it can indicate an already tighter hamstring than is ideal. Alternatively, it could mean that a hamstring is longer, and therefore already under more stress than we would ideally like to have. I have seen both of these over the years and either could result in hamstring trouble in a forward bend. This subject by itself could be a post.
So what does this mean?
What might we do differently as yoga teachers regarding how we’re asking others to forward bend? What about as practitioners? What is our intention with forward bending? What about adjusting forward bends?
As teachers, we’re holding the space and making the suggestions to students about directions for their practice that we think will serve them. We have a responsibility to recognize where students are in the life of their practice and to share clear intentions when we suggest a change to the patterns we observe. The ultimate “yoga” pose, of course, is not the farthest forward bend; it is the one in which we can maintain a balance between effort and ease. It’s the one in which we can breathe steadily with sustained concentration. That might mean that there is a time and place in practice when the emphasis in a pose shifts from “can you go further?” to “how steady is your breathing?” and “how stable is your concentration?” As students, we can ask ourselves these questions as we practice. What is my intention when working in this pose? What do I feel?
As a teacher, when we do go in to adjust or assist a student in forward bending, what is our intention?
Beginners don’t necessarily know their bodies well. They may not know where their “end” is or that their “end” moves around from day to day. Expecting them to always know when to speak up if they’re having a “tight” day and need to back off from some depth in forward bending is probably too much to expect. What’s the hurry anyway? Do we as teachers need to squash everyone as far as they can go in every forward bend? Where are we trying to get to? If our intention is to set a long-term pattern of length in hamstrings, then wouldn’t enough pressure to make the intention clear be sufficient to create change over time? Are we as teachers feeling and sensing each time we adjust a forward bend, so that we are taking notice of any resistance from the student?
And what about those students with the already long hamstrings, the hypermobile, bendy students? Just because they can go further, should they? At the point where the pelvis has rotated anteriorly so much that the sit bones seem to be facing the ceiling, the pressure in the hamstrings is likely no longer even and throughout the muscle belly. At that point, when I’m working with students with bendy body types, they sometimes report some amount of irritation at the sit bone attachment of the hamstrings. This is not building a functional long-term pattern in the hamstrings. With these students, I actually want to suggest a long-term pattern of grounding through the sit bones (if the forward bend is a seated version) or encouraging a bit of posterior tilt in the pelvis.
Here we share in students own words their experiences with forward bends and hamstring injury:
“Injury to the hamstrings, happened as a result of repetitive strong adjustment during seated forward folds.”
“Subluxed SI joint while working deep in a forward bend in a technique picked up in YJ conference Ansuara workshop.”
“Pulled hamstring attachment, was aggravated by my practice.”
“Hamstring pull when being physically assisted in prasarita padottanasana C”
“In a Hatha class we were being taught Upavistha Konasana as the 2nd or 3rd posture without having done any sun salutations. I felt my left hamstring tear as we folded”
“Pulled hamstrings by going into seated poses too deeply. My teacher applied too much pressure during the hands-on adjustment because I’m relatively flexible.”
“Bad adjustment- too forceful in a forward bend and the hamstring popped and was strained for years and consequently led to the torsion of that knee which required surgery years later due to a torn medial meniscus.”
“The exaggerated (or therapeutic as it was called) application of the inner spiral caused damage to right hamstring attachment to IT bone. The teacher was motivating and moved by the beauty of the practice, she could not have foreseen, the body is tough and fragile, sometimes we try new stuff and nothing happens or something really cool does….”
“A muscle / many small muscles stretched right next to sitting bone in an asana. It didn’t feel to stretch at all at the time of the happening, and I had done the asana many times with no problems. It was most unpredictable and as such, unavoidable.”
“Strained left hamstring. Over stretching in a forward bend.”
“Pulled hamstring – was practicing with a cover teacher and she pushed me a bit too far in utthita hasta padangusthasana pulled the hamstring attachment at the top of my left leg/buttock. That specific injury healed however I think is probably connected to an injury I have now on that side around my lower back/hip and hamstring which is currently undiagnosed.”
“Hamstring tear during triangle pose”
“Hamstring injury doing Hanumanasana, not in a class situation just showing off !!”
“I tore a hamstring tendon while practicing King Dancer pose. However I have since realised that that pose was probably “the straw that broke the camel’s back” as once it had happened and I learned about it, I realised that I had been practicing forward folds etc with incorrect alignment for my level of flexibility.”
“I was adjusted into a seated forward fold. I have a discrepancy in length of my legs (2cm shorter on right). The teacher pushed me too far and I damaged the attachment of hamstring on the right. Struggled to walk for a few days and it took a long time before my practice became comfortable again.”
“My alignment wasn’t attentive, I wasn’t “ready” in the posture (Upavistha Konasana) when my teacher came and gave my assistance (he pushed me into the forward movement “head to the floor”).”
“pulled right hamstring in forward fold”
“my hamstring ripped of during upavistha konasana”
“(not exactly hips – it was a hamstring pull. The teacher was pressing down on my back to increase the stretch. I heard and felt the snap. It took many many months to recover.”
“I entered carelessly into a Prasarita Padottanasana and hurt my hamstring. Music that I liked was playing outside the shala.”
“It was in my hamstring from getting too deep in forward fold when my body was not quite ready.”
“ After backbending, assistant leaned on me in forward bend with full weight of her body. No problem until I finished and was getting into car..”
“teacher pushed me down in a forward fold(paschimottanasana) far too strongly for the state of my hamstrings.consequently tearing and lower back issues-and the hamstrings have taken years to come good-and even now i really have to watch it-in fact i used to run prior to this injury and there is no way i can do this anymore”
“I pulled my hamstring on my left side in standing separate leg head to knee.”
“Sit bone/hamstring attachment pain highlighted by asana practice but caused by a misaligned pelvis”
“In my early days of ashtanga practice… Trying too hard to do paschimottanasana”
“constant pain in the right sitting “bone”. Caused by forward bending in 1st series without enough (or any) moola bandha and too little activeness in legs. Didn’t come at once, but over a longer period of time.‘
“I was feeling very open and good in a led primary and pulled on my heal during uptavisa and pulled a hamstring attachment”
“I didn’t warn up enough for the splits, and I tore my hamstring attachment.”
“I’ve gone for hips but it was hamstring tendon was requested to demonstrate posture (toe stand) in class when reluctant to do so as has had strong massage earlier, hamstring ripped – grade two on exit from posture”
“it was a 50 hours Yin yoga teacher training , the studio was not heated that day (it was a cold winter day) we did seated forward folds with long hold, without warming up (they never do in Yin) I told the teacher I experienced pain in my lower back en she told the hole group (of uber flexible young girls ( I am 65)that in older women the fascia in de lower back becomes stiff . She demonstrated how an old woman walks ( this was not how I walked prior to this incident, but after I did for sure)”
“Fascia tear left hamstring during advanced workshop, in parivrtta janu sirsasana, I was not adjusted physically, but the teacher encouraged deep practice. This later lead to SI-joint pain (i have scoliosis and leg length difference to begin with)”
“hamstring / adductor injury. accumulated effect with increasing pain over time.”
“i snapped my hamstring during a transition from one asana to another”
“A yoga teacher smashed my face into my knees during paschimottanasana and pulled my sits bones, causing me a whole lot of pain for the next two years.”
“Very strong adjustments (being pushed much further forward quite forcefully) in forward bends both seated and standing started to create an ache at both sit bones. At first this was only felt during the adjustments and then during the postures even when not adjusted and then the ache felt even when not doing yoga. This got worse until I stopped doing forward bends. Eventually a scan showed ischial bursitis .”
“Soreness/tenderness around the area where hamstrings attach to the hip bones (on one side). Developed over 6 months (?) of hot power yoga. I was not practicing at home at all during this time, only taking classes.”
“Repetitive forward folds during a power class training situation led to hamstring & piriformis pull. There was no tearing, but I’m still mindful of these areas.”
“At an early morning Mysore practice at the shala I attempted to “fall” into a wide-leg forward bend from Supta Konasana (Ashtanga Primary). I felt a twang in my hamstring at the time but next day it developed into pain that lasted a year. I had been doing 4-times-a-week Mysore for about 6 months when this happened. Strangely (or not!) it was a day my teacher was not present in the room, so in essence we were doing self-practice as a group of students.”
“Torn hamstring while moving from bound side angle to bound triangle”
“sacroiliac strain in forward bends – has recurred whenever I’ve been encouraged to go forward with a “flat back””
“my own fault. not concentrating, it was cold. I tore my hamstring”
“I have an ongoing issue (pain) in my lower back on the right side (almost more pelvis than lower back: alongside the tailbone) that occasionally flares up during yoga. It seems to be caused by doing forward bends and other poses stretching the lower back; I have extra tightness all along my back on the right side, from foot to calf to hamstring and into the lower back. I don’t know if it is a bad enough problem to call an “injury” or just strain on the muscle/fascia that flares up sometimes.”
“It was the hamstring attachment to my pelvis. Has been chronic for 2-3 years. I managed it when I practiced regularly, but coming back to practice after having a baby it has been quite difficult.”
“hamstrings. I was trying too much, not listening to my body.”
“Hamstring injury from not concentrating properly and falling out of dancers pose in early years of practice – Bikram yoga”
“I was adjusted cold in revolved triangle in a yoga workshop and tore my hamstring.”
“I joined an Iyengar 90 min class and half way through a continuous series of forward folds I felt my back protest. Despite attempting to release it by gently bending backwards, it simply had had enough. As a result i came out sore, and feeling stiff. Definitely my back could not cope with the balance of asanas offered that day (mostly many versions of Downward dog and lots of versions of seated forward folds)”
“Strained/minor hamstring tear – caused by repetitive passive stretching of hamstrings. “Death by a thousand cuts” – had minor pains in ligaments near ischial tuberosities, progressed to straining middle left hamstring”
Askling, C.M., M. Tengvar, T. Saartok, and A. Thorstensson. 2008. Proximal hamstring strains of stretching type in different sports. The American Journal of Sports Medicine. 36(9):1799-1804.
Askling, C.M., M. Tengvar, T. Saartok, and A. Thorstensson. 2007. Acute first-time hamstring strains during slow-speed stretching. The American Journal of Sports Medicine. 35(10):1716-1724.
Askling, C., T. Saartok, and A. Thorstensson. 2006. Type of acute hamstring strain affects flexibility, strength, and time to return to pre-injury level. British Journal of Sports Medicine. 40:40-44.
Beltran, L., V. Ghazikhanian, M. Padron, and J. Beltran. 2012. The proximal hamstring muscle-tendon-bone unit: a review of the normal anatomy, biomechanics, and pathophysiology. European Journal of Radiology. 81(12):3772-3779.
Edouard, P., P. Branco, and J-M. Alonso. 2016. Muscle injury is the principal injury type and hamstring muscle injury is the first injury diagnosed during top-level international athletics championships between 2007 and 2015. British Journal of Sports Medicine. 50:619-630.
Fournier-Farley, C., M. Lamontagne, P. Gendron, and D.H. Gagnon. 2016. Determinants of return to play after the nonoperative management of hamstring injuries in athletes: a systematic review. The American Journal of Sports Medicine. 44(8):2166-2172.
Lempainen, L., I.J. Banke, K. Johansson, P.U. Brucker, J. Sarimo, S. Orava, and A.B. Imhoff. 2015. Clinical principles in the management of hamstring injuries. Knee Surgery Sports Traumatology Arthroscopy. 23:2449-2456.
Liu, H., W.E. Garrett, C.T. Moorman, and B. Yu. 2012. Injury rate, mechanism, and risk factors of hamstring strain in sports: a review of the literature. Journal of Sport and Health Science. 1:92-101.
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David explains why the key to lowering into chaturanga is doing two things at once: maintaining an active serratus anterior and relaxing the triceps and deltoids.