Knee Injuries in Yoga: When Are Your Knees Most at Risk?

From our yoga survey project: Yogis report on lotus and knee injuries in yoga

In this current series of posts from our survey project we focus on the most common types of injuries reported. In this post, we take a look specifically at knee injuries in yoga. We explore some potential reasons for why we might be seeing the results that we are. But remember that our survey also indicates that the injury rate of yoga practitioners is NOT especially high compared to many other activities. Refer back to our post summarizing the negative experiences of practitioners for those details.

However, it is still important to examine the injuries that are happening. And it’s especially important to look at the specific contexts in which they’re happening. This is the information that we can use to go forward in the modern yoga experiment. We can improve what so many practitioners are already experiencing as a positive experience, for the better. In order to get more specific about where injuries occurred in the body, we include additional statistical information describing the relationships we report. We also did some consolidation of our data.

Statistics review

Below are a few reminders about the statistics we calculated to help you understand what we report from our survey project. Remember that statistical analysis, in the most general sense, is a method of calculating the likelihood of one particular outcome in a situation, given a specific set of circumstances. We include the information: n=some number, to tell you how many people answered the question we report on. Survey participants were not required to answer every question, so the sample size for each question varies.

Statistical significance

Remember also 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. If the p-value is less than 0.05, then there is a less than 5% probability that the variables are unrelated. Or, you could say there is a more than 95% probability that the variables are related. When there is more than a 95% probability that the variables are related, then we consider the relationship between the variables to be statistically significant.

Effect size

We also report the “effect size” of the relationship between the two variables. Effect size describes the strength of the association between the two related variables. For example, we might say that two related variables have a weak, moderate, or strong relationship to one another. This is noted as Cramer’s V=some number. We say there is:

• a small association when Cramer’s V is between 0.1 and 0.2
• a moderate association when Cramer’s V is between 0.3 and 0.4
• a strong association when Cramer’s V is equal to 0.5 or greater.

Data consolidation

The question we asked respondents about where in the body their injury occurred, allowed them to select multiple areas in the body. We consolidated this data so that we could make direct comparisons. We put the responses of respondents who marked more than one body area into their own category, “multiple areas”. Similarly, we consolidated data about what style of yoga respondents reported they were practicing when injured. We grouped those who marked more than one style into their own category, “multiple styles”.

When we analyzed the data, knees were the body area most commonly injured by our survey respondents. (Also see our previous article on the negative experiences of practice. Of those respondents who experienced one or more injuries during the lifetime of their practice, 21% reported knee injuries in yoga. Remember, this is NOT 21% of all respondents; this is 21% of those respondents who have reported an injury.

Anatomy: Why are our knees so prone to injury?

We outlined the anatomical reasons why the knee joint is potentially tenuous in some situations in our article on injuries in adjustments. Remember that the knee joint is in the middle of a kinematic chain of joints. It is primarily a hinge joint. That is, it to moves primarily forward and backward in flexion and extension. But, when the knee is flexed 10 degrees or more it can do rotation internally (about 10 degrees) and externally (about 35 degrees). It’s often because of those anatomical functions of the knee joint that it gets into trouble.

If there is tension at either the hip joint above the knee or the ankle joint below the knee, then that tension can transfer force into the knee joint. Add in some rotation to the mix and pressure can be put on the knees in ways that can cause knee pain and potentially injury. When the knee is both closed and rotated it is potentially at its most vulnerable.

Relationship of knee injury in yoga to lotus injury

We found a strong association between reporting a knee injury in yoga generally, and reporting an injury in a version of half-lotus or lotus pose (padmasana) specifically (p<.0001; Cramer’s V=0.51). Notice in the table of top ten poses where respondents reported a knee injury in yoga, eight of the ten postures include a half-lotus or lotus. Of those who reported a knee injury in yoga, 42% reported that their knee injury occurred in a pose including a half-lotus or lotus position. Of those who reported getting injured in a pose including a half-lotus or lotus position, 81% reported that it was their knee that they injured.

When are knee injuries in yoga occurring?

We found a small association between knee injuries in yoga (n=1377; p=.0034; Cramer’s V=0.10) and stage of the pose that the practitioner was in, as well as between lotus injuries (n=1388; p<.0001; Cramer’s V=0.15) and stage of the posture. Knee injuries in yoga were just as likely to occur when entering a posture (37%) as when holding a posture (38%). Knee injuries were more likely than other types of injuries to occur when entering a posture. Similarly, injuries in postures with a half-lotus or lotus were actually more likely to occur when entering the posture (47%) than when holding the posture (36%).

We also found a small association between the version of the pose (either a modified version or full expression of the pose) and lotus injuries specifically (n=1382; p<.0001; Cramer’s V=0.13). Of those who reported an injury in a posture including a lotus, 87% were doing the full expression of the pose when they were injured. There was no relationship between version of the pose that a practitioner was doing and knee injuries in yoga in general.

In the case of each of these relationships, the effect size was small, indicating that while there is a relationship, it is not a particularly strong one.

There were also a number of contextual situations that had no relationship to reporting a knee injury or an injury in lotus. This means that respondents were just as likely to have one type of experience as another for each of these variables. For example, respondents were equally likely to have experienced knee injuries in yoga that built up over time as one that happened all of a sudden with no warning.

These factors had no relationship to knee or lotus injury:

• Built up over time vs. Happened all of a sudden
• Saw a doctor about the injury
• Length of recovery time
• Were or weren’t being adjusted during the injury
• Self-reported consistency of practice
• Aware of injury right away vs. aware of injury later
• Pressure from a teacher
• Time of year of practice
• Temperature of the room

Gender and knee injuries in yoga

From our previous survey post on gender and yoga experience, remember we saw that:

“We did find a small relationship between gender and reporting a knee injury (p<.0001; Cramer’s V=0.15). Men were more likely than women to have reported a knee injury from yoga. Of total practitioners who had experienced an injury, 37% of men and 20% of women reported a knee injury. Specifically, knee injuries were likely to have occurred in a posture that included half-lotus or lotus. Again there was a small difference in experience by gender (p<.0001; Cramer’s V=0.15). Of total practitioners who had experienced an injury, 22% of men and 10% of women reported an injury in a posture including a half-lotus or lotus.”

An interesting question that comes up when I look at this discrepancy by gender, is, “why are men hurting their knees more often in general and in lotus specifically?” Is it related to gender differences in pelvic anatomy? Is it related to men being encouraged to play sports more often and from an earlier age? Could this contribute to more men coming to yoga practice with “tight hips”? Is it attitudes in practice? Are there more men practicing aggressively or not listening to signals from their body to stop? Is it something else? Is it all of the above?

These are all interesting questions and not ones that I have any answers to. I’d love to hear from you in the comments.

Style of practice and knee injuries in yoga

Knee injuries in yoga were common among many styles of practice that practitioners reported. The highest percentages of knee injuries per total injuries experienced for a particular style of practice were among those who reported practicing yin / restorative yoga and Ashtanga vinyasa yoga.

We were surprised that percent of knee injuries in yoga was so high in yin/restorative style practice. However, the sample size of respondents that practiced only yin/restorative was small, only nine respondents. So this could just be an artifact of the sample size. It could also be that practitioners who chose to only practice yin/restorative styles were already experiencing knee issues. And perhaps they chose yin/restorative for that reason.

Style of practice when injured in lotus or half-lotus

We found a moderate association between style of practice when injured and those who had reported an injury in a variation of a lotus or half-lotus pose (n=1412, p<.0001; Cramer’s V=0.24).

Those who experienced an injury and practiced Ashtanga vinyasa yoga when injured were more likely to report that their injury was in a posture with a lotus or half-lotus than those who practiced other styles. About 18% of the total injuries reported by Ashtanga practitioners occurred in a posture including some variation of lotus or half-lotus. Injuries in postures with a lotus or half-lotus made up 9% or less of the types of injuries reported by all other styles of practice.

Food for thought

So why so many half-lotus, lotus poses, and variations of lotus poses in yoga? And why especially in the Ashtanga vinyasa practice? AND what to do? Half-lotus, lotus poses, and variations of lotus poses can be a catch-22.

I’ve been writing about the knee and lotus for years now. Although I’m not surprised by the data that we gathered, it is nice to have data to back up my observations. As an Ashtanga teacher for nearly 20 years now, there are three postures that I do make students prepare for. The top of the list is lotus and its related postures. The preparation is all about the hips. Although most people believe the primary series of Ashtanga is all about forward bending, I would beg to differ.

Focus on the hips

Sure, you can make it all about the forward bending. But in my mind, it’s really all about opening the hips in a more general way. Ashtangis should not be doing whatever it takes to do the forward bend. They should also not avoid the leg that has changed shape just in order to get deeper into the forward bend in postures that do right side followed by the left side. I would suggest that the side that has changed shape, meaning been bent in some fashion, is the PRIMARY focus of the asana. The straight leg is the secondary focus. If you’re interested you can see my most common sequence for the opening the hips in my online Lotus Workshop.

The pelvis is the center of our functional movement. Our center of gravity is found there. And the movement that is most fundamental, walking, is directed from there. The common patterns that we often adopt, sitting in a car, sitting at a computer, sitting again on the couch, can encourage excess tension in the front part of the body. And specifically, those patterns can shorten the muscles that flex the hip joints.

Hip tightness from sports

The most common types of sports can also create an imbalance in the musculature around the pelvis through the repetitive movements that are a part of each individual sport. They often have running in common, which requires muscles all around the hip joint to become tight to support the pattern of running. When the balance is off between the muscle agonists and antagonists, we can experience a rippling effect of aches, pains, and restrictions in movement. Those ripples can go down toward the knee. They can also go up toward the lower back.

Open the hips for lotus

One aspect of all of the postures that include a half-lotus, lotus, or some variation, is that they require the hip to be open enough already when you put those legs into lotus and its variations. That is particularly true in external rotation of the hip joint. We do often find that doing a posture naturally opens the tissues that need to open to grow into the full expression of the pose. And this is true of lotus as well. But, the knee is one of THE most commonly injured joints in the general population (not isolated to yoga). So, this is the exact reason I often direct people to spend more time focusing on opening their hips first. We can then acquire the flexibility in the hips to do lotus without generating stress in the knee.

The catch-22 is, of course, that often the muscles we want to stretch in postures that include a half-lotus or lotus are so tight that we can’t get into the postures. So, what to do? Here I think we have an opportunity to take the modern yoga experiment and advance it by learning from our experience.

Understanding that it’s a process

We should recognize that the yoga asana sequences that include a number of variations on lotus came out of a culture (India) where sitting on the floor and squatting were a regular part of everyday movements. If we are a different culture with different kinds of daily movements, then we are starting our work from a different place. This doesn’t change the potential value of stretching the muscles around the hips to achieve more balance around the pelvis. What it may mean is that our steps toward lotus-type postures will be different. They be slower. And they may include more intermediate stages on our way. It may also mean that a full expression of some lotus-type postures is not ideal for everyone all the time.

Each practitioner is an individual

These results definitely highlight the importance of seeing the student who is actually in front of you when you teach. How do the muscles around that person’s pelvis allow or restrict movement? How are their knees? Have they experienced knee pain? Have they had surgeries? What is their activity history? Do they run, bike, or play soccer? Then, can you identify the intentions within a particular posture and help someone work with those intentions in a way that is appropriate for where they are right now?

Here’s how some of our respondents described their knee injuries in yoga practice:

“During urdhva padmasana there was a cracking sound in my knee and terrible pain. It took 6 months to totally recover.”

“the right knee outside made a sound – snap”

“Working on tight hips and working towards lotus I have encountered knee pain”

“Knee pain when first starting.”

“Every time I went to class we started with Virasana supported or Baddha konasana unsupported but as my hips were very tight my poor knees suffered.”

“Niggly pain in inner knee that increased over time despite modification. Turned out to be medial meniscus tear on both sides.”

“My knee popped in Marichyasana B, became swollen and sore for a few weeks”

“Pulled my leg into padmasana rather than glide it in finishing sequence of shoulder stand variation – knee popped and got a bucket handle méniscal year but it was accumulative with playing tennis and tight hips”

“It’s unknown how this [knee] injury developed. I suspect improper alignment combined with repetitive stress.”

“Week long intensive mysore, right knee gradually became more painful in ardha baddha padmottanasana and ardha baddha paschimottanasana, increase in pain gradually over a few weeks, took 6mo + to heal”

“Marichyasana D. Pushed in tore meniscus”

“I have tight hips but tried to jam my legs into lotus.”

“Coming out of Janu Sirsasana C, (10 years ago) I wasn’t paying attention and flicked my leg out of the position to straighten the knee and there was a noise and some pain. I was young and flexible and didn’t really pay enough attention about how I came out of seated postures. This was a big lesson and I changed how I entered and exited with much more awareness ever since. An unfortunate good lesson. ;-)”

“Grade1 tear in lateral collateral ligament during maksikanagasana (dragonfly)”

“Holding pigeon while feeling knee pain and not knowing to come out of it.”

“I was trying to do eka pada sirsasana on my own in a very hot room and think I overstretched a muscle in my tight close to the knee.”

“Meniscus snapped in lotus”

“Pushing L knee too far in Janu C.”

“medial collateral ligament damage and general strain/pain for some time, i was encouraged/insisted upon by teacher to thread arms through legs for Garbha Pindasana. It was possible, but unnecessary and avoided, triggered injury.. Also a consequence of cumulative creep, due to intensive 6 days per week practice over a month intensive course..
Hips were relatively open, but deep hip flexion for this pose with arms threaded too strong. Injury resulted in difficulty walking, and long rehabilitation.”

“Eka pada sirsasana, prior to the injury I was feeling tightness on my lateral lower leg. My ITB band was also tight. While attempting to put my leg behind head, i heard a sounds like a cracking twig. It took me 1 weeks to get back to practice, 2 months of modified practice and 6 months to get back to normal practice”

“I tore a ligament from groin to knee left leg doing the splits after a Bikram class”

“lateral meniscus strain in ardha baddha padmottanasana”

“Both knees developed sharp pain during ardha baddha paschimottanasana during a hot yoga class and I have been dealing with related problems ever since.”

“Not listening to my teacher & pushing into lotus”

“I felt pain in my both knees, especially after doing marichyasanas. Also my knees felt hyperflexed, sometimes I felt a lot of pain even in a downward facing dog and it was very painful to walk normally some hours after my morning practice so I was forced to take breaks for a week or so…”

“L Knee—- Loud popping in closing sequence, coming out of lotus”

“Janu D too much rotation in the knee, when my hip wasn’t open enough – however after a couple of years of being mindful and working on opening my hips the knee is fine”

“overambitious at this time i tried to get into the half lotus seat (right leg) while my hip wasn’t ready for it.”

“Knee pain associated with lotus positions/flexed right knee.”

“I forced myself into the lotus position”

“Transitions on knees from table top to gate and poor instructions tonight going into lotus exacerbated meniscus tears!”

“Hips were not enough open, didn’t have good technique and rush my body to open in lotus or half lotus positions”

“I have tight hips and over years of not really understanding the anatomy of the hip and knee pushed my knees to do things they should not have done considering my tight hips”

“It was a couple of days after a very demanding workshop, my body was tired from an intense week. I wasn’t paying attention and forced my right leg into lotus at the end of my practice. The pain was immediately there and I had to adjust my practice for several month.”

“I have broken my meniscus, not when doing my practice. I think both doing and wanting opening my hips to much in my practice….and a rotated pelvis…can be one of the reasons that it was injured…”

“it was during a longer period, at the very beginning ,trying to do lotus and ignoring pain”

“I was not listening to my body… ego took over, and I pushed too far trying to accomplish lotus pose.”

“My knees often become sore and painful in Warrior Series.”