What does practicing yoga after meniscus surgery look like?
Unfortunately, knee injuries are popular. That’s not limited to yoga, it’s a common problem in the general population as well. The average number of meniscus tears reported each year is about 66 for every 100,000 people. Of those 66 reported tears, 61 people choose to have surgery to address the torn meniscus (Baker et al., 1985; Hede et al., 1990). However, when you look at yoga and its relationship to knee injuries, our own research shows that knee injuries are common in practitioners of yoga.
More specifically, meniscus injuries are also high on the list, particularly for a practitioner who puts their legs and knees more specifically into more vulnerable positions. Those more vulnerable positions are, generally speaking, when the knee is both fully flexed (bent) and when the knee is also rotating (which is a normal movement at the knee). The most obvious posture that requires this is padmasana (lotus posture).
Among those practitioners who do half or full lotus, those that have come to the practice with tighter hips, such as runners and cyclists, have a higher chance of experiencing an injury. The reason for this is that the tighter the hips are, the less movement you have from this large secure joint. As a result, more movement is required at the next joint down the chain of the leg and this leads to increased pressure placed on the knee.
What happened to me
This is a subject that is personal to me. I have had both a meniscus tear as well as meniscus surgery (partial meniscectomy). This was many years ago now and I was practicing yoga at that time. Before I get to the specifics, I always like to put things like this into context.
Before I proceed in my story, please do remember that my experience was specific to me. It seems obvious enough, but there are a number of variables that may dictate what type of procedure and therefore what the outcome may be in your or someone else’s situation, should you have a meniscus tear. Some of those factors include: location of the tear, type of tear, size of tear, as well as what type of surgical intervention, if any, you may have. For instance, small tears on the outside of the meniscus may simply heal on their own. Larger tears near the center of the meniscus may need to be repaired and the knee stabilized for weeks.
My right leg has always been the challenging one. When I was 8, I broke my femur on the right side and that definitely had an impact on how that leg functioned. As it turns out, that femur is longer than the other. That was confirmed by x-ray. However, it might have been long before the break; it’s hard to say whether those two things are connected or not. In my mind, they are somehow connected, along with my right hip being the tighter of my hips. As good as my external rotation is naturally, my right hip was definitely less open.
Take that history and keep it in the mix as I then find myself stuck in a middle seat flying from Los Angeles to Auckland, NZ. I don’t remember getting out of my seat more than once on that trip. My right leg was a little puffier than usual. That’s another thing that tends to happen on my right leg. I don’t remember any pain after that flight, but I do remember not being able to fully straighten my leg.
Skip forward a few days after settling into the time zone and then start adding on some Ashtanga third series postures including most of the foot behind head postures that happen in the first part of that sequence. Putting your foot behind your head can add stress to the knee. During this entire trip, I did not have a moment of popping or pain in my knee until the end of that trip. At that point, the pain was very mild and small on the inside of my knee. I figured it was the kind of pain that would probably go away on its own as I did not feel it all the time or consistently in any particular posture or activity.
Fast forward my way through months of practice and one day, while sitting on the floor, I lifted my leg to bring it into a half lotus and I did hear an audible pop at my knee that did NOT feel normal. I found myself limping a little for the next few days. By the way, this is the classic description of symptoms for a meniscus tear. An audible click or pop followed by a few days of limping. This, of course, doesn’t mean everyone will have the same experience.
At that point, I went to the orthopedic doctor, and based on the description of events, he assumed it was a meniscus tear. I still went for an MRI and confirmed that there was a small tear in the posterior (back) medial (inside) meniscus. This is a location that is notorious for meniscus injuries. Personally, I don’t fear going to the doctor to get more information from their point of view. I don’t have to do what they say, but if I’m going to make an informed decision, I want to have as much information as possible.
I’ll never forget what the doctor said, which was that meniscus surgery was like pulling a tooth. What he meant by that was that it was such a normal everyday thing for him that he did not see it as a big deal. Research backs this up suggesting that this particular kind of meniscus surgery (a partial meniscectomy) is actually the most common surgery that orthopedic surgeons perform (Englund, et al., 2001; Salata et al., 2010).
What I did during the meniscus tear
I decided that I did not want surgery at the time and I would see if it would heal on its own as it was a small tear. During this time I did the following:
- Maintained space in the back of the knee by not completely flexing it
- Maintained as much external rotation of both the upper and lower leg as possible
- Closed the knee more and more over time, while maintaining external rotation at the knee to maintain movement
I mostly used my hands to increase external rotation of the thigh and lower leg, but some people find that using a rolled-up towel to create space in the knee joint, keeping the knee elevated when doing lotus-like postures, or other adaptations can all be useful. For me, I related the knee injury to the tension in the hip and therefore maintained the external rotation there and added to it gently at the knee. I also did my lotus preparations more regularly to keep my hips open.
The pain and inflammation decreased in about a month and then the knee got better and better until the point where I could do full lotus and not feel any pain. There was caution in my movement still, but no pain. Then, about a year after the original injury, doing nothing particularly daring or different, the knee popped again.
This time, I limped for about a day and then the pain mostly subsided. After this, however, my knee started to bother me outside of practice, when going up and down the stairs, after long walks, or after a week of teaching. At some point, I decided to have the surgery and scheduled it about four months out when I knew I would be able to take time off from teaching after the surgery.
I discussed staying awake and not going under anesthesia during the surgery. Of course, there would be a nerve block etc., but in my mind, I wanted to stay awake and see what was in there.
What I did pre-surgery
I basically stopped doing anything that had the potential to cause inflammation in my knee prior to surgery. I backed off of practice, did not fully close my knee and I also did not rotate it. My logic at this point was that I wanted to make sure that the knee was neither irritated or inflamed in any way when they performed the surgery.
Although I did not do things that exacerbated the problem, I did keep moving it and practicing. Typically, those that are healthy going into surgery, have better outcomes. In other words, for most yoga practitioners that maintain a regular practice, we do have healthy tissues that are resilient and therefore, more likely to heal better and recover faster than the average person.
As they were about to give me the anesthetic, I put up my hand and said no. They were in disbelief, and said that the doctor would need to approve it. The doctor came over and although he did remember us discussing it in his office, he wanted to remind me that there was no turning back once I said no. I agreed and declined the anesthetic.
I did this partly because I did not like the idea of the anesthetic in general, and the amount of drugs, etc. Mostly, I did it because I was curious. My anatomical mind wanted to see and know what it looked like in there, what had happened and what could I learn from it to pass on to others in my workshops and writings. I would be the sacrificial lamb! Just kidding, nothing so dramatic. There were a number of reasons that brought me to that decision and to be honest, I was glad I did it.
I was wheeled into the operating room and to my surprise, the nurses were surprised by me being awake. They even asked, “Why are you awake?” “Did the doctor approve this?” Then the doctor walked in. I was given a nerve block on the outside of my knee. To be honest, it’s the only part of the entire procedure that hurt, and it did hurt!
After that, the knee was draped so that I could not see it. But, what they did was fill the knee with a saline solution, both to clear out any floating debris as well as make it easier to see inside. Before I knew it, there was the inside of my knee on a screen at my side. The doctor knew that I teach anatomy, so he started quizzing me. Do you know what that is? I think I passed because there were only so many structures that could be on the inside of my knee.
When the camera made its way to the posterior medial meniscus, the tear was obvious. In my case it wasn’t a flap, which is probably more common. Instead, it looked more like two ends of a frayed rope that were linked together. Next, on-screen came a tiny pair of scissors, which on the screen looked huge. A small snip on one end, a small snip on the other, and the bits of frayed meniscus floated away.
After that, a cauterizing device was used to smooth the edges of the meniscus where it was snipped away. I did feel that part; it was more like a little shock rather than pain per se. That was it. The procedure was essentially finished, so I thought.
As the camera was being removed, the doctor paused and pointed the camera up so we could get a look at the femoral condyles. Those are the large knobby ends that have the cartilage on them that ultimately make contact with the meniscus underneath. This is where the largest surprise came.
The cartilage at the end of the femur looked almost like a golf ball. That is, the clearish cartilage that covers the bone there had dimples in it. Those dimples were the result of the cartilage gliding over the uneven surface of the meniscus tear. For me, this was unexpected. I hadn’t even considered the secondary effects of the cartilage gliding over that uneven surface over the last two years. The doctor’s comment at that moment was that this was something to keep an eye on as the uneven wearing away of cartilage can lead to arthritis in the long-term.
The entire procedure took between ten and fifteen minutes. There was no blood, gore or anything like that. It was two small incisions at the front of the knee, that was it. That doesn’t mean that I took it lightly, it just means it was not what most people have in their mind when they think of surgery.
What I did after surgery
First and foremost, after surgery I did not practice for at least a week. What I did do was elevate and ice the knee quite a bit. During this time, I would also let my leg just hang off the edge of my bed and couch depending on where I was keeping my knee elevated. The weight of the leg created a passive weight that would help the movement long term.
After that week off of practice, I started to practice again. I started off very slowly and did not try to fold my knee too far. To be honest, I could only bend it close to ninety degrees. I later found out that I was way past normal at the seven-day mark when I went to see the doctor. Undoubtedly that was a result of the normal range of motion through which I, and possibly you, take your knee and the rest of your body.
In terms of daily practice, I generally deepened it with particular caution when it came to bending my knee and eventually putting it into lotus again. But lotus was a few months from the time of surgery. That was not because I had pain when trying. It just felt like the right thing to do and I was not really in a hurry. To be honest, there really was no pain after surgery that felt at all related to the pain prior to surgery. At this point it was more like a mental tentativeness, as well as the general swelling and pressure in the knee post-surgery.
Something else I did was assess the ability of my knee to rotate passively. I would sit on my mat, bend my knee to ninety degrees, and then slowly internally and externally rotate my lower leg at the knee joint. This is a normal and natural movement. I know that many people say that you should never rotate your knee. I certainly wouldn’t recommend forcing that movement, but it’s something that your knee is designed to do, both for walking and running as well as pivoting. It is also part of lotus, but NOT the main part which should come from the hip.
Essentially, I did the same general things when practicing post-surgery that I did when it was a meniscus injury:
- I decreased the depth of flexing the knee.
- I generally did not rotate the knee within postures.
- I elevated the knee with a block to reduce pressure coming from the hip.
- I continued to focus on the tension in my hip that I personally feel led to the dynamics that led to the meniscus tear.
- I avoided anything that seemed to cause any type of inflammation during movement or practice.
As mobility, and confidence to be quite honest, continued to grow, I continued to work with the edges of range of motion. I would see what half lotus felt like, but not hold it too long, even though it did not hurt at all.
Within a couple of months, my practice was pretty much happening. I didn’t push the depth of any postures around my knee, but perhaps I would get into it for just a moment and then release postures like half lotus and then see if there were any repercussions from doing that. If there weren’t, I might hold it in there for a little longer the next day.
I let the healing progress at its own speed. If there is one thing you should be learning from your practice, it is dialing in the experience of being in your body. What is the felt-sense experience of being in this moment doing this movement or being in this position?
Should you have surgery?
If you’re reading this far down and are asking yourself or want to ask me this question, it’s understandable. The truth is, I’m not suggesting that you do or do not have surgery. All I can describe is my experience and outcome. That may not have any bearing on your particular situation. With a procedure like this, there are many factors that should go into the decision of whether or not you should have surgery as well as what the most likely outcome will be.
There are a few things that I do often point out to people who ask me this question, however:
- When people think of surgery, they often think of cutting things open and lots of blood. This was not my experience at all. Two or three holes in and around the knee without any real blood as the incisions are small and arthroscopic (sometimes referred to as keyhole surgery).
- Different procedures are used depending on the severity and/or location of the tear. What I had was a small tear in a common place with a high success rate without recurrence. That success typically drops if they try and repair (stitch) the meniscus back together and restrict movement.
- Depending on a number of factors, your meniscus tear may heal on its own or with other non-invasive treatment protocols.
- Your knee will never be the same as it was prior to the meniscus tear whether you have surgery or don’t have surgery. I think this is important for reasonable expectations regardless of whether you have surgery or not.
Unfortunately, meniscus tears are common in the human population for many reasons during a number of activities. There are things you can do to avoid this of course such as making sure your hips are as open and flexible as possible before you do lotus postures. After all, this is probably the main reason the knee gets into trouble in yoga.
Although we should definitely avoid surgeries of any type when possible, it’s up to you to weigh all of the information you have and find a doctor who is willing to discuss the procedure and outcomes they expect.
Englund, M., E.M. Roos, H.P. Roos, L.S. Lohmander. 2001. Patient-relevant outcomes fourteen years after meniscectomy: Influence of type of meniscus tear and size of resection. Rheumatology. 40(6):631-639.
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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.