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What's happening with low back injuries in yoga?
Reports of back pain in everyday life have become almost ubiquitous. I note in my book, Functional Anatomy of Yoga, that back pain is the second most common reason for a doctor’s visit and the third most common reason for surgery. It’s maybe not a surprise then, that we see low back injuries in yoga showing up. Back pain, in comparison to pain elsewhere in the body, can be particularly elusive. It’s often hard for people to pin down where the pain is exactly and even harder to source where it’s coming from. Certainly, in yoga, we don’t want to add to or cause any back pain in ourselves or in our students.
In this article, we’ll continue our series of posts that focus on the most common types of injuries reported in our survey project by taking a look at lower back pain. Where is it showing up in yoga? What poses are often involved in low back injuries in yoga, and in what practice contexts are they more likely to show up?
Below are a few reminders about the statistics we’re calculating to help you understand what we’re reporting 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’re reporting on. Survey participants were not required to answer every question, so the sample size for each question varies.
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. We would then say there is a statistically significant relationship between the two variables.
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, and a strong association when Cramer’s V is equal to 0.5 or greater.
Let’s see what respondents said.
Remember that, in order to get more specific about where injuries were occurring in the body, we also did some consolidation of our data. The question that we asked respondents about where in the body their injury had occurred allowed for multiple areas in the body to be selected. We consolidated this data so that we could make direct comparisons by putting the responses of those participants who did mark more than one body area, into their own category, “multiple areas”. We similarly consolidated data about what style of yoga respondents reported that they were practicing at the time of their injury. Those who marked more than one style were grouped in their own category “multiple styles”.
The low back was the second most common body area where respondents reported an injury in yoga practice.
While the lower back was second among body areas most injured in yoga asana, it was not associated with any one posture or type of posture. There were three general categories of poses where respondents reported injuring their lower back: 1) backbends, 2) forward bends, and 3) twists. Although these categories don’t include every pose where respondents reported a back injury, a majority of poses where practitioners reported a low back injury fit into these three categories, with backbends and forward bends as the top two categories and twists making up a smaller third category.
Backbending, forward bending, and low back injuries in yoga
We found a moderate association between low back injury in yoga and reporting an injury specifically in a backbending pose (n=1414; p<.0001; Cramer’s V=0.22). Sixty percent of those who reported an injury in a backbending posture also reported that that injury occurred in their low back. There was also a small association between low back injury in yoga and reporting an injury specifically in a forward bend (n=1415; p=.0017; Cramer’s V=.09). Thirty-three percent of those who reported an injury in a forward bend said that that injury occurred in their low back.
So, from an anatomical perspective, why might our survey respondents be reporting low back injury in yoga, specifically in these three categories of postures: backbends, forward bends, and twists? There are a number of muscles and other structures that contribute to maintaining the balance between forward, backward, side to side, and rotational movements at the lumbar spine. What’s important to keep in mind is that this balance is directly impacted by the balance of structures above and below the lumbar spine itself. In particular, the movements of the pelvis can impact what’s felt in the lumbar area of the back.
Anatomy: Why might our low back be prone to injury?
The general description “lower back pain” is exactly that, general and non-specific. Even the location “lower back” is hard to pin down, as people may include everything from the gluteals to the thoracic spine in their description of “lower back”. Pain in and around the sacrum, including pain at the SI joint, is often included under the “lower back pain” umbrella as well. For the purposes of this post, let’s take a look at two areas: the lumbar spine and the sacroiliac joint.
Backbending and forward bending
The vertebrae of each of the three sections of the back (cervical, thoracic and lumbar) are constructed a bit differently to allow for the different main movement types that happen in each area of the spine. The lumbar spine typically includes five vertebrae above the sacrum. The lumbar vertebrae link to one another between the discs as well as at what are commonly called the facet joints. Those facets joints are aligned parallel to the midline of the body. This alignment allows for the movements of flexion and extension at the lumbar spine with great ease. If forward or backward movement is restricted either above or below the lumbar spine, more force is often directed into the more mobile lumbar spine.
The large umbrella of lower back pain can be coming not only from a large area but also from varying depths and types of tissues. Sometimes back pain is from disc problems, other times the vertebrae have shifted out of place. Ligamentous structures could be damaged. Most superficially we can find that certain muscular patterns of tension can create or add to problems through this area.
For instance, in backbending it’s possible for tight hip flexors to restrict the movement of the pelvis and in that way create a feeling of compression in the lower back as you move into a backbend. Tight gluteals (not necessarily just contracting, but generally overly tight) can also contribute to restricting the movement of the pelvis and potentially reduce space in the low back. Over-doing deep backbending even in very “bendy people” can contribute to low back compression. That compression can be at different depths as well. Vertebrae can be shifted out of place or muscles can spasm or go into contraction. This can happen either as a result of pushing too far on your own or reaching too far with the assistance of a teacher.
In forward bending it’s possible for tight hip extensors, like the hamstrings, to pull the pelvis into excessive posterior tilt. This can set people up to flex their spine more deeply than intended. There is some association between flexion of the spine and disc herniations. If you have herniations you should, in fact, avoid deep flexion of the spine. In addition, with additional force the muscles in the lower back can be injured by being overstretched in this same situation.
Even in very “bendy people” long, open hamstrings and hypermobile joints can allow the pelvis and spine to move more easily to their detriment. Over-doing forward bending then has the potential to cause pain and/or injury in the low back whether the practitioner is on the tighter side or especially bendy.
The lumbar spine allows for a lot of movement in the forward and backward direction, but not so much in the twisting or rotation action. When we try to twist at the lumbar spine, the facet joints on the vertebrae bump into each other fairly quickly. If twisting is restricted either above, in our thoracic spine, or below, by keeping the pelvis fixed in place, then more force can be directed into the lumbar spine and even into the sacroiliac joints below that.
If we follow the lumbar spine down the body, we come to the sacrum. The sacrum is what we often speak of as a triangular-shaped bone (although it’s really five bones fused together) below the lumbar section of the spine. The pain that comes up around the sacrum tends to be at the joints where the sacrum is connected to other bones. Probably the one that receives the most attention is the sacroiliac joint, where the sacrum is connected to the ilium on each side of the pelvis.
As each side of the pelvis can move to some small degree independently of the other side, tension or imbalance in one side of the pelvis can direct more force into joints on the other side of the pelvis. The sacroiliac joint is one of the joints where either the tension from imbalance or that extra force from an imbalance might be felt. Students in my classes and workshops most commonly report SI joint pain coming up when they are in poses that approach the end of range of motion in backbends, forward bends and twists.
What’s also important to keep in mind is the relationship of the pelvis to the lumbar spine. Consider that the hip joints, the SI joints, and the lumbar spine work as a functional chain of joints.
Movement of the pelvis at the hip joints can impact movement and the amount of force directed into the SI joints and the lumbar spine.
Practice context: When are low back injuries in yoga occurring?
In our survey, we found a small association between low back injuries in yoga and stage of the posture that the practitioner was in. Respondents were more likely to report that their low back injury occurred while holding a posture, rather than entering or exiting a posture, compared with all other types of injuries (n=1319; p=0.00672; Cramer’s V=0.09).
We also found a small association between low back injuries in yoga and recovery time. Practitioners reported that their low back injuries had a shorter recovery time than injuries in other areas of the body (n=1396; p<.0001; Cramer’s V=0.16), with the highest percentage of low back injuries healing in 6 weeks or less.
There was a small association between low back injuries in yoga and re-injury. Survey respondents were more likely to report re-injuring their low back than other areas of the body (n=1403; p<.0001; Cramer’s V=0.15). More than half (51%) of those who reported a low back injury also reported re-injuring their low back. Of those who reported injuries of other areas of the body, 33% reported re-injuring the same area.
Style of practice when low back injuries in yoga occurred
Low back injuries were very common among many styles of yoga asana. The highest percentages of low back injuries per total injuries experienced for a particular style of practice, were among those who reported practicing Sivananda yoga, Iyengar yoga, and Bikram/hot yoga.
Most practice contexts that respondents were asked about had no relationship to reporting a low back injury. 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 a low back injury that built up over time as one that happened all of a sudden with no warning.
There was NO relationship between these factors and reporting low back injuries in yoga:
- built up over time vs. happened right away
- respondent saw a doctor about the injury
- type of class situation that injury occurred in
- self-reported consistency of practice
- version of the posture (modified, full expression, etc.)
- aware of the injury right away vs. later
- pressure from a teacher influencing the injury
- temperature of the room
- time of year of practice
- gender of practitioner
Common situations for low back injuries in yoga
Our results, and the direct quotes of practitioners that you can read below, suggest that there are some common situations in which increased likelihood of low back pain and injury in yoga practice are experienced. These are not the only situations of course, but they are worth pointing out as situations to be aware of.
Not balancing the acquisition of strength with increases in flexibility (especially when working on forward bends, backbends and twists)
Quotes from practitioners describe that experience:
- “Lower back, SI joint pain and instability. Caused by too much flexibility and not enough strength, trying to go for the ‘look’ of poses rather than doing them properly. Particularly twists and backbends.”
- “Not so much injury as soreness due to being more flexible than strong.”
- “It happened within the first year of practice. I had very little core strength and am ‘flexible’ by nature. The injury happened with extreme forward bending that affected the sacro-iliac area.”
SI joint issues coming up in twists, forward bending and backbending
These may be due to a number of causes, including but certainly not limited to: postural imbalances from other activities or genetic predisposition, pregnancy, previous accidents/injuries.
Quotes from practitioners describe that experience:
- “SI joint dysfunction.”
- “SI joint inflammations in forward folds.”
- “Overdid it with an already-dicey low back. SI pain triggered by back bends and asymmetrical postures not done well.”
- “Many years ago …subluxation in SI joint doing revolved triangle.”
Over-doing the “bending” part of poses
This was more commonly reported in forward bends and backbends, particularly in already bendy students. Over-stretching includes students pushing themselves too far as well as being over-adjusted by teachers. Based on detailed descriptions of lower back injuries written by respondents, approximately 11% of low back injuries occurred when practitioners either pushed themselves or were pushed too far in forward bends and an additional 12% of low back injuries occurred when practitioners either pushed themselves or were pushed too far in backbends.
Quotes from practitioners describe over-doing forward bends:
- “Being pushed in the back in a seated forward fold.”
- “Too deep in forward bending.”
- “Pushing too hard in an intense forward bend resulted in an injury/strain that resulted in sciatica.”
- “Stretching too much in forward bend.”
Quotes from practitioners describe over-doing backbends:
- “Pushed into backbends.”
- “Overworking kapotasana and low back blew 3 discs out. Maybe it was kapo. Maybe it was a car accident. Maybe it was life. But it was probably 20 breaths in kapo.”
- “Backbending adjustment – too strong.”
- “Over-doing backbending.”
- “Hyperextended during backbend.”
As teachers it is worth taking a look at where we might be over-adjusting our students. We have a responsibility to be checking in with students so we’re aware of how assists and adjustments are feeling to them. We also need to keep in mind the overall picture of their practice as we suggest postures with more extreme ranges of motion. If we’re asking someone to do deep forward or backbending, do they have the ability yet to support that flexibility with strength and awareness?
These are important considerations as we strive to reduce pain and injury in yoga practice.
Here are some additional descriptions of how respondents experienced low back injuries in yoga practice:
“Back muscle pain just above one side of my pelvis. It got worse overtime. The Dr. says, I must be over doing it in yoga, but I doubt she knows for sure.”
“Moving into triangle, my hip and low back gave way. I was not grounding through my feet and I was not supporting my low back.”
“My sacrum shifted on one side causing pain after doing supta kurmasana during my daily practice.”
“I was doing prasarita padottanasana and felt pain afterwards in the right hand side of my lower back.”
“I felt a pop around the sacrum while trying to get into supta kurmasana.”
“The teacher instructed us to lift leg up to down dog split and then bend the knee allowing the foot to drop towards the opposite shoulder, and she pulled my leg up higher than it should have been with the twist, ended up really hurting my lower back and sacrum. As a teacher, I knew this was not a ‘real’ pose (it was a flow class), but gave it a go (not the best judgement on my part). I now don’t ever do this pose when it’s offered, I just stay in down dog breathing.”
“Lower Back Pain d.t. Inflamed disc.”
“Pulled muscle, lower back, during a seated forward bend.”
“Not sure how it happened, but my back ‘went out’ the day after a yoga class, such that I couldn’t move for a day and had difficulty for days afterward.”
“Teacher adjusted my hip at a Parivitta trikonasana pose and I heard a click sound and could not move and was in severe bad pain for a week.”
“I didn’t know better, bad alignment in lower back when backbending and not well adjusted/corrected on that wrong alignment.”
“I over-work my body doing yoga and pilates and I have scoliosis. I have injured my lower back doing ashtanga but only because I was very tired and I wasn’t careful.”
“Backbending… with an SI joint instability.”
“Herniated disk L4-L5 forcing my way into Visvamitrasana.”
“Decided to try an anusara class with a well known teacher. She had asked us to do chaturanga in a way I had never been instructed. She had a student demo it, then she came around to the rest of the students to help us do it ‘correctly’. She was trying to move my body in a way that it did not want to go. I am not sure it was her inexperience or the method, but I hobbled out of the studio w/tremendous back pain. I’ve always had a sensitive lower back and this method just aggravated it more.”
“I had herniated disk in L4-5 area, probably due to hypermobile lumbar spine combined with a teacher who didn’t care about alignment issues.”
“I was doing drop backs with [my teacher] and she gave me a very strong adjustment. She took me too deep and I had back pain for three months afterwards.”
“Lumbar disks herniation due to improper forward bending techniques as well as backbending crunching lower back.”
“I had finished first series, and was practising some postures from the second series. I had an unpleasant feeling in my lower back, but I didn’t say anything or stopped. I had injured my lower back muscles, on the right side of my body. I had to stay in bed for almost 2 weeks. After that I visited a doctor only to discover that I had a disc bulge between L5-S1.”
“It was after coming out of Uthita Hasta Padangustasana.”
“I was doing a twist while weight bearing in an adjustments class before I started practicing Ashtanga.”
“Too much kapotasana…”
“As a beginner I took a class at the gym. It was a vinyasa class. There were not modifications given for vinyasa. I was trying my best to keep up with the class. I strained my lower back. Looking back, I should have been focusing on my breath. I needed to go slower, or take a child’s pose. This teacher offered none of that. 5 years later I still have lingering issues with my lower back.”
“I was in up dog and the teacher made a major adjustment and pushed my back up. My muscle spasmed. That was four years ago and I’m still in pain, if affects my quality of life.”
“Left lower back pain after upward facing dog.”
“Overstretched back muscles.”
“Pain as a result of teacher adjusting me in kapotasana.”
“The teacher corrected my posture quite forcefully although I said I am not able to twist more which resulted in pain in my lower back, probably a stuck nerve. It was hard to walk for a couple of weeks and I had to avoid exercise as it hurt so much.”
“Overuse of lower back in backbending postures.”
“Turned too far in a seated twist, I think the hand position was wrong and the encouragement to use the other hand to ‘pull myself round’.”
“Gradual onset of lower back pain after several weeks of consistent practice, while working toward deepening expression of poses, specifically twists. Back pain started to manifest earlier in each daily practice.”
“I have also had problems with my lower back because of the backward bending.”
“In the end when doing paschimottanasana as a counterpose to urdhva dhanurasana, I was assisted and hurt my lower back, which healed with rest and time.”
“My back locked during a forward fold.”
“I was doing kapotasana and getting into the pose, trying to reach the ankle right away, I kind of twisted my spine.”
“In my early days of ashtanga practice… Trying too hard to do paschimottinasana.”
“Sacroiliac injury. Upper facing dogs became unbearable.”
“Adjustment in Supta Kurmasana (lower back injury).”
“SI joints too loose as a result of pushing too hard in repeated seated forward folds.”
“I was trying to square the pelvis forward when in trikonasana.”
“Backbending and catching ankles.”
“Sharp pain during forward folds.”
“My practice progressed into a deeper kurmasana and supta kurmasana. I went with depth of the hips farther and farther without first building strength into my new space of flexibility. I think I had over stretched for a period of a month and bent over one day and my sacral space froze. I could not move. I experienced pain and tweaks for over 2 months as I recovered.”
“Lower back injury caused by cobra.”
“Teacher lay on my back in paschimottanasana.”
“Back bend threw my back out.”
“W/o warming up repetitions of a twisting pose.”
“Overtwisting, hands-on assist in marichyasana D.”
“Sacroiliac strain in forward bends – has recurred whenever I’ve been encouraged to go forward with a ‘flat back’.”
“Kapotasana – lower back pain/injury.”
“Over reaching in uttanasana in a hot room before I was warmed up. I knew I’d hurt myself instantly but the really excruciating SI pain didn’t hit until I had to get in the car after class and was stuck in traffic for 90 minutes. At the end of my trip I couldn’t get out of my car.”
“SI joint pinching nerve coming out of triangle pose especially.”
“Assisted forward bend… too far.”
“Bikram pose, standing head to knee.”
“Trying to square the pelvis in standing poses.”
“Overworked fragile lower spine. Encouraged to overstretch.”
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David summarizes research which evaluates physical effort needed to do common standing yoga postures and how that effort compares to walking.