Is Yoga Tearing Labrums?

David Keil Yoga Injuries 11 Comments

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Is yoga tearing labrums? There is no simple answer.

I’m hearing more conversations about labral tears in the yoga world recently. Are the instances of labral tears increasing? Are we just getting more informed about accurately identifying pain and injury within the yoga community? Is it the yoga that is tearing the labrum? These are valid questions, however, the answers to questions like these are difficult to fully uncover. The possible cause of any injury is hard to discern, much less prove without a doubt. As I referenced in a prior article Injuries In Yoga – Framing the Conversation from June of 2014, there are many aspects to the conversation around injuries. These conversations are a good thing because they make us take stock in and question how we are practicing asana.

Let’s start exploring this conversation by learning a little more about what the labrum is and what we mean by a labral tear.

What Is The Labrum?

labrum tears in yogaLet’s start with the basics. The labrum is an additional piece of fibrocartilage and connective tissue around the edge of the socket (acetabulum) that receives the ball (head) of the femur. The two together make up what we call our hip or acetabulofemoral joint.

To keep it as simple as possible, the labrum essentially extends the acetabulum to add stability to the joint (this is the typically accepted theory). It is also associated with managing stress coming into the joint as well as helping to seal the joint. More research is being done to figure out exactly how the labrum functions.

A Labral Tear

The labrum in the hip is similar to the meniscus in the knee joint. It can tear. This can happen over a long period of time or all at once with direct trauma to the joint. The tear can be in the form of a flap. It can also occur as degradation, lesions, or a fraying of the cartilaginous material. The labrum can also peel off the bone making space between itself and the bone.

Like the meniscus, the labrum has a difficult time healing on its own. Blood supply is limited to the majority of the structure with the outer edges typically receiving the most blood supply. This means small tears to the outer edges may heal on their own, but the circumstances of each individual tear dictate whether they will heal or not.

Typical Symptoms

The most common symptom of a labral tear is a “pinching” sensation in the hip joint. Of course, this is not the only reason you may feel pinching in certain postures. Check out my article on Hip Pinching in A Twist. Having said that, the type of pinching I’m referring to with the labrum is not one that is relieved by rubbing your iliacus muscle as I describe in that post. It’s more like a pinching sensation that never seems to go away in the position causing it.

Most commonly the pain and sensation is felt on the inside of the thigh and groin area. Other symptoms include pain that feels like it is “deep” in the joint including sensations in the back of the hip joint. Clicking sounds when you walk or do certain movements in the hip joint are also common symptoms. This is not to say that any one of these symptoms is definitely a tear. Good evaluation by a professional is necessary for any diagnosis.

If you think you may have a tear, go see a doctor. At some point you will need an MRI with contrast to confirm a tear.

Pre-existing Conditions

There are certain pre-existing conditions that make you more likely to end up with a labral tear.

Hip Dysplasia

Hip dysplasia is a condition where the acetabulum (socket) is misshapen. Usually it is larger than it should be which allows the femur to move within the socket more than it should. There are varying degrees of this and if diagnosed as a child, various types of harnesses can be used to stabilize the joint so that the bone formation can continue normally, reducing future problems.

“In a study of patients with mild to moderate hip dysplasia and hip pain, McCarthy and Lee (2002) found that 72% of the 170 hips studied had labral tears, and 93% of these tears were in the anterior region of the labrum.” 

Structural Differences

Any structural differences that create less distance between the femur and acetabulum can make the probability of labral tears higher. This includes a short femoral neck (the area between the head and the shaft) or a condition known as Femoral Acetabular Impingement (FAI). Wikipedia link

There are different types of FAI. The neck of the femur can have a bony growth along it. When there is a bony growth there, it is known as a Cam deformity.

fai

from physiorehab.in

It is also possible to have what is called a Pincer deformity. In this case there is bony deformation on the pelvic side of the joint. It is due to a deeper than normal socket or an abnormal tilt to the socket.

It is also possible to have a mix of the two (the most common). In all cases the femoral neck ends up bumping into the socket quicker. This can by itself reduce the range of motion possible at the joint. It also increases the chance that the labrum gets pinched and torn.

Reduced Acetabular and/or Femoral Anteversion

If the acetabulum is facing backward more than normal you either have what is called reduced anteversion or if pointing backward then it’s called retroversion. You can also have decreased anteversion or retroversion of the femur. This is referring to the line created by the femoral neck relative to the distal (bottom) end of the femur.

Without over-complicating it, with these shapes in your hip joint, you are more likely to have the neck of the femur bumping into the socket more quickly. For instance, in acetabular retroversion, flexion of the hip, along with adduction, bring the femur and the socket into contact pinching the labrum. (Lavigne et al., 2004; Ganz et al., 2003)

labrum cross section

What If You Don’t Have Any of These?

In those that do not have any of these pre-existing conditions, the cause of labral tears varies, but generally includes direct trauma. Activities such as running, cycling, tennis, soccer, hockey, golf, and ballet can be associated with labral tears. It seems reasonable that yoga would be included in the list. Something like dropping into a hanumanasana too quickly could do it.

A wide range of movements may be associated with labral tears but most commonly they include hyperextension of the hip joint, especially when also including external rotation of the joint at the same time. Having said all of that, up to 74.1% of labral tears (Santori and Villar, 2000) are not associated with any known specific event or cause. It is believed that repeated microtraumas over a long period of time might be the culprit.

Personal Interviews

I reached out to a friend of mine who had a labral tear and general hip degradation. She is both a yoga practitioner and a teacher. She ended up with a complete hip replacement. I know what you’re thinking; it was the yoga that did it. After all, she’s a practitioner and a teacher.

When she went to the doctor she was diagnosed with a mild case of hip dysplasia as well as decreased anteversion. One factor alone would have put her at a higher risk; two increases the probability that if she just did moderate activity/exercise of any type, she might have ended up in the same place. There’s no way to know for sure. Did the practice of asana make it happen? Or was it just what she chose to do as her activity?

Because she has been through this herself, she has since worked with a few other practitioners who ended up with labral tears.

Three students that she has worked with were diagnosed with at least one of the pre-existing conditions. Unfortunately I don’t have all of the details of years of practice of asana or other activities prior to or during their yoga practice. On top of that, it’s not a very large sample of students, so there’s only so much we can learn from these particular experiences. It could just be a coincidence that each of them had at least one pre-existing condition.

What should I do with my practice if I have a labral tear?

First and foremost, check with your doctor or PT. My friend suggested that from her experience there are definitely some do’s and don’ts. Keep in mind that they would change depending on where the tear was located, how severe it was, if you have a pre-existing condition described, and which pre-existing condition you have.

Basically, take extreme ranges of motion off the table. In almost all of these situations, even if the students didn’t feel pinch or pain during their practice (by avoiding the pinching feeling completely through modification) and they did backbending, or complete forward bending, they were more likely to feel pain later in the day. That pain was possibly due to inflammation.

So, the simplest answer is to avoid the pinching sensation if you have it. Second, avoid depth of movement in any direction at the hip joint in any posture. In theory you could test certain movements. If you choose to do something like this, do just one movement (and not to an extreme) for a few days and test the outcome. Then test a different one by itself for a few days. This way you can isolate which movements are more likely to be exacerbating the problem for you. Then feed this information back to your physical therapist or orthopedic doctor.

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.

Should I Have Surgery?

This is a discussion that you should have with your doctor. Typically, they will send you to physical therapy first. There are exercises that they can give you that can help strengthen or stabilize the hip joint that may reduce problems.

Conclusion

I would suggest that it is possible that yoga does cause labral tears. For me the question that follows is whether or not it is the sole cause. I’m sure sometimes it is. Is it the “straw that breaks the camel’s back”? Is there a pre-existing condition that has set you up for it? If you didn’t do yoga but instead were a runner, cyclist, football (soccer) player or dancer, would you have ended up with a labral tear anyway?

The question is not whether or not people practicing yoga are tearing their labrum. They are, just as they are in other activities. Is the rate higher in yoga than other activities? I couldn’t find a study specifically about this, although there is plenty of conjecture out there. It may be that asana practice is causing more labral tears by more regularly taking already destabilized or not ideal joint shapes and pushing them to the edge of where they should be going.

More research is needed.

The only way to know if you are more at risk than the person on the mat next to you is to have been diagnosed with one of the pre-existing conditions discussed. Then you would “statistically speaking” be at greater risk.

References:

Ganz R., Parvizi J., Beck M., et al. 2003. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop. 417:112–120.

Lavigne M., Parvizi J., Beck M., et al. 2004. Anterior femoroacetabular impingement, part I: techniques of joint preserving surgery. Clin Orthop. 418:61– 66.

McCarthy J.C. and Lee J.A. 2002. Acetabular dysplasia: a paradigm of arthroscopic examination of chondral injuries. Clin Orthop. 405:122–128.

Santori N. and Villar R.N. 2000. Acetabular labral tears: result of arthroscopic partial limbectomy. Arthroscopy. 16:11–15.

Additional articles: Remember, what works for one person may not work for you. Proceed with caution with anyone’s recommendations, including mine!

http://www.findwholeness.com/blog/body/finding-relief-from-a-labral-tear-when-surgery-is-not-recommended/#comments

https://drbenkim.com/natural-treatment-hip-labral-tear

This article is loaded with great information. It was originally published in 2006. If you’re aware of new studies, especially related to yoga directly, let me know so I can update the information in this post.

http://ptjournal.apta.org/content/86/1/110.full

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This website is simply about delivering yoga anatomy to the yoga community in a simple and understandable way. It has always been about you, the reader, understanding the complexity and diversity of our own humanness as well as our anatomy.

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Comments 11

  1. Thanks for the great article, David. As always your level of detail is appreciated :)! So how timely – I was recently diagnosed with a labral tear in my left hip. Having been pregnant majority of time over the past 2+ years while i maintained my yoga (primary series) practice, I do think asana during a time when I had a lot of relaxin floating around in my system exacerbated what very well may have happened on its own. I ran for years & this same hip was an issue back then when it contributed to some serious knee pain. Who’s to know. I’m doing PT now, but, per recommendation of my orthopedic dr, may elect for arthroscopic surgery in coming months (once nursing little less). For now postures involving deep hip flexion (& having the stability to transition out) are the biggest culprits for pain — so warrior postures, for instance. I miss my practice so much, but I’m nervous to do more damage. And then, if I opt for surgery, what then for post-op practice to not just wind up in the same boat (though pregnancy won’t be a factor again – we are done on that front!)? This fear is part of my “big yoga” now – trying to get through that because of course I want a healthy body to enjoy these kids of mine! Thanks as always for your insights – I need to get back on my mat & start testing the waters, to strengthen my body & mind again, & not be held hostage by this injury.

    1. Post
      Author

      Thanks for sharing Robin. There are plenty of asana that I’m sure you could do after surgery. It’s possible that warrior is only a problem now that there is a tear, but by itself is probably not enough to cause a tear. Just go slowly and follow the advice of your PT and Ortho.

      Good luck…

  2. So, to my understanding, the labrum can tear at any location around the acetabulum, correct? So movements that are contraindicated for one student with a labral tear may not be for another (besides to avoid the extreme ranges).

    1. Post
      Author
  3. Hi David,

    What perfect timing for this article. I have a student who came to me recently because of a Labrum tear of the hip. How? Is questionable, but the chances that it was from yoga is slim. She did other activities and yoga was not on the top of the list.

    With that said, her doctor prescribed PT which she did, but the pain persist especially at night while she sleeps or when she is driving for long periods of time.

    So my question is as yogis what can we do to help facilitate healing?
    At the moment, we are trying to increase strength in the quadriceps, hip flexors and gluteus muscles to stabilize the hip more. Any other recommendation would be helpful?

    Also, I have notice in this particular case difficulty in tilting the pelvis.

    I look forward to any suggestions and November’s workshop on the “Hips”. :-))

    Z

  4. Here is a link to a study revealing that hip/femur bone shape or design or shape is not the cause of FAI syndromes, labral tears etc in elite ballet dancers. It compared hip structure with ballet dancers and the control group who did not do ballet. The study used the splits in combination with forward bending with the dancers. There was no anatomical difference in hip joint structure between the dancers and the control group and the conclusion is that it is changes in tissue from movements or positions that caused the labral tears and osteoarthritis that showed up in the dancers and not hip architecture. None of the dancers felt pain unless they did the pose. However it can take a decade or so until the damage is enough to start the groin pain, clicking, pain walking or going up stairs.
    I think the same or similar body positions are done in yoga so it appears that the flexed hip positions with adduction or abduction and extension at the same time is causing the acetabular damage in yogis and not some kind of anatomical deformity in the joint. Women are in more danger as well since we have more elastin and relaxin and are made to be more ‘open’ in the pelvis for childbirth.
    Many yogis with hip replacements are being told that they had hip bone anatomy that predisposed them to hip joint deterioration. But what is they had not done these extreme yoga poses that put the hip in 180 degrees of flexion ( straight knee forward bends ) ?
    This is a great article David and I feel you have given a balanced approach. Some images of yoga poses that create hip anteversion( forward tilt of pelvis) and retroversion would give an even clearer picture of which body positions may tilt the socket backwards or forwards and down.
    I think you are correct to say that yoga can cause labral tears although of course not the sole cause because we use our body in a variety of ways. However the extreme body positions done by both yogis and ballet dancers would definitely put the hip socket into both anteversion and retroversion far beyond most every day activities. Also yoga poses tend to be static which means more time spent in these positions.

    Here is the link to the study
    http://www.arthroscopyjournal.org/article/S0749-8063(12)01755-0/abstract

    1. Post
      Author

      Hi Michaelle,

      I had a feeling I would be hearing from you on this one. I need to review the full text of the study (not just the abstract) you kindly linked to in order to make any comment about it.

      Best,
      David

    2. Post
      Author

      Hi Michaelle,

      Sorry it has taken me so long to respond to this. Travel schedule.

      Yes, in this study of ballet dancers they did not find that the cause was pre-existing conditions.

      As stated in the study dancers also maintain an externally rotated position throughout dancing which increases the strain on the posterior labrum. “This could explain why their lesions were found it he superior and posterosuperior positions.” (Direct quote from the study.)

      I will concede that excessive overuse of a non deformed joint could also lead to problems. I would suggest that in this case elite dancers are doing movements somewhat explosively, rapidly, and repeatedly. There is certainly more variety of movement in yoga making it harder to determine what exactly is the main cause. That is just a difference to point out with yoga. Being in a position for 30 seconds could be a problem… but we don’t know. Being in it for 15 minutes might be more of a problem. Again, we don’t know.

      You make a larger leap than I would be comfortable making when say that the same or similar positions are done in yoga and IS CAUSING the acetabular damage in yogis. We don’t know that, it might be in some, but is it true of them all? If not, what is the cause?

      You also have to figure that some number ARE having trouble because of the pre-existing deformity and then doing extreme movements that are NOT limited to flexion. Other movements can definitely cause problems. It may very well be true that if these people did not do any extreme movements then they would not have torn labrums. How would they know if they could/should or not. I know that what you’re saying is that no one should be doing these things anyway. But they are, and they want to. Why? Damn good question but hard to answer.

      I must admit, I don’t understand your use of straight knee vs. bent knee forward bends in this comment. In my experience, if you bend your knees, you’ll create deeper flexion at the hip joint. If you have tight hamstrings and you keep your knee straight, you’re less likely to make it to 180 degrees. Am I missing something?

      I would separate pelvic positioning from anteversion and retroversion.

      I will also point out that the study also said that they felt this was a small sample and that more research was needed.

      Thanks for adding to the conversation.

  5. Labrum in facts acts as a cushion and gasket at the femuroacetabulum joint.It maintains the almost vacuum type situation in the socket,that is why dislocation of this joint is almost impossible.
    If there is a tear in the labrum ,the vacuum cannot be broken as the torn fibres are sucked to the inner side of the socket- and the joint remains intact.
    However it causes stiffness in the joint and affects range of motion.How much stiffness? well,how much was the tear?In any case,in some directions the motion becomes rough and pain may be felt because connecting muscles in that direction have to work against the sucked in,torn fibres of the
    labrum.
    The repairs of torn fibre will be eventually done by the body,yet the removal of sucked-in fibre is not possible,neither it will join the main body of labrum in its contour.
    It will therefore go on causing stiffness for the rest of life.So what should be done?
    In first place do not allow the tear to take place- prevention is better than cure.It can be achieved by gradually increasing the range of motion. A sudden increase in range,while moving a body part
    may cause spasm in the muscles involved.
    If at all the tear has taken place,than allow it to heal,by adopting a body position in which the pain reduces and comfort is felt.It will accelerate healing and relax the stressed muscles.if any.
    What about stiffness? Well,most of it will be restored as the stressed muscles get de-stressed.However the impinged fibres(sucked in fibres) still remain on the inner side of head of femur(Between the socket and ball) ,some stiffness shall remain through out the remaining life.

  6. This is a great article, thank you. It has taken me a lot of digging and research to understand my labrum tear. My MRI showed the tear, and my physical therapist – not my doctor – educated me on my anteversion, tibial torsion, and anterior pelvic tilt. Apparently all these things make it difficult for me to utilize side glutes and pelvic floor – now add in an extreme yoga practice = BINGO. So I am pretty sure for me if I was a normal active human being I would have been just fine. But all that extreme external rotation, and relying on flexibility more and stability less, it was bound to happen. My question is – what now? Will I ever be able to do the full expression of extended side angle angle again? Should I continue to try and point my toes straight ahead when tipping them in slightly allows everything to be easier? I do need to figure out the hard limits in my practice. Any practical advice for me moving forward? The tear may get better, but my bony structure is not changing! I am working with a very good PT and have an appointment with a highly recommended hip specialist, but some yogi advice would be super!

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