“Hip Openers” in Yoga? Please, Let's Stop The Madness.

By: 
Dr. Ginger Garner

Yoga is, inarguably, a popular contemplative science. According to Yoga Alliance’s 2016 study, Yoga in America, there are 36.7 million practitioners in the US alone, up from 20.4 million in 2012. A 16 billion dollar industry, yoga is one of the most widely utilized methods of complementary and integrative medicine in America today. In 2008, the editor of Yoga Journal declared “yoga as medicine” as the next great wave. That was right in the middle of the Great Recession, when the last thing on the collective healthcare industry’s mind was yoga.

However, it (yoga and healthcare) has always been on my mind. Reflecting on these statistics and literally a lifetime of practicing yoga and over 20 years of using it in healthcare as a physical therapist, I decided to Google the hip and yoga. What I found was disappointing.  Pages and pages of articles on “hip openers,” and not a single one that emphasizes moderation or anything other than “hip openers” as good for the hip. This is not a good trend. Anything “good” for us must be taken in moderation, so it’s time to put out a plea for moderation in hip practice in yoga.

The Other Thing That’s Surged During Yoga’s Rise

Knowledge. What we know about the hip vastly evolved thanks to the advent of new diagnostic and evaluative technology. Frankly, the new discoveries have become game changers.

Our expanded knowledge of hip anatomy, physiology, and pathophysiology exploded onto the medical scene, providing more information than ever about how to address, preserve, and otherwise attend to the hip joint. Prior to this new age of research, the hip was relegated to a joint worthy of no more than a tendonitis, bursitis, or osteoarthritis diagnosis. A person was simply a hip replacement candidate or not. There was no other option once a hip joint had prematurely degenerated. Now, that has all changed, thanks to technological advances in diagnostic testing and investigation.

Yoga Posture Practice Must Evolve

The world of hip preservation and rehabilitation is a rapidly developing, complex science. However, the world of yoga and knowledge of hip health and safety have yet to join hands. Many of my patients and colleagues have suffered from unnecessary hip injuries, from labral tears, all types of impingement, and compounding secondary diagnoses such as torn hamstrings, sports hernias, gluteal tendinopathy, to pelvic pain, all due to yoga practice. Some suffered injuries in yoga class during a single traumatic injury, and some injuries were drawn out over years of accumulated microinjury to capsuloligamentous, bony, or cartilaginous structures.

Diagnosis of hip labral injuries have vastly increased over the last 10 years, perhaps making hip labral injuries the newest orthopedic diagnosis of the 21st century. This discovery also makes surgical and conservative management of hip labral injury uncharted territory. Conservative therapy includes nonsurgical and post-surgical rehabilitation, and since the average time from injury to diagnosis is 2.5 years, there are many people with hip, pelvic, back, or sacroiliac joint pain that have undiagnosed hip labral tears. All of this means that yoga practice must evolve to better suit (and preserve) the hip joint.

No More “Hip Openers” Please

I should make myself quite clear, however. I am not out to demonize yoga or fear-monger the practice of yoga or how it may wreck a person’s body (to use recently controversial language).

My purpose is two-fold: (1) To clarify “what” and “how” yoga can be a safe, effective form of physical therapy and rehabilitation for the hip and pelvis, and (2) to underscore the areas where yoga posture practice should be evolved to prevent injury. Of course I cannot do that in a single blog post. However, I have many resources, including an ongoing blog, combined with teaching coursework in hip labral rehab and injury prevention, which continue to work to meet these goals. Yoga can and should be a safe practice for anyone to use.

My first request would be that we please strike the phrase “Hip Opener” from our yoga vocabulary. It is not helpful to that many people to think they only need to “stretch out a tight hip,” when in fact, they have bony and structural idiosyncrasies that prevent them from ever moving into certain yoga postures. Sure, soft tissue structures can be inhibiting hip range of motion but rarely is it helpful to put the bony parts of the hip in vulnerable end ranges. We aren’t going to force or bully the tissue to deform under these kind of extreme tensile loads, and 99% of the time, the average person (unless you are an elite athlete) isn’t going to be able to stabilize yoga postures in end ranges of motion. Typically, the capsule, ligaments, and cartilage will bear the load, including the bony structures, and they have a finite shelf life for handling that kind of adverse stress.

Additionally, using the tired phrase “hip opener” suggests pursuit of an end range of motion—moving further, “stretching” deeper, and/or using yoga postures for the sake of increasing hip range of motion and flexibility. This is a dangerous concept to present to the general public and it misrepresents the essence of yoga. Yoga is not about flexibility, stretching, or moving further or deeper into any posture. Yoga is about a way of living, which encourages moderation and mindful movement and thinking. All the “hip opening” in the world is not going to foster enlightenment, especially if the “yoga” that is being practiced is only focused on some kind of orthopedic or fitness end goal.

Yoga is not a Cure-All

My second request would be that we reconsider using the phrase “yoga for ________(fill in the blank with whatever pathophysiology or health problem you want to address).” This phrase pigeonholes yoga as a panacea for anything and everything. Using this phrase inherently marginalizes yoga’s full meaning, divorcing it from its philosophy and real capacity for healing and well-being. Additionally, it can lead people to believe that their yoga teacher can “cure” or address a problem simply through a drop-in yoga class setting, which is misleading and inaccurate. A person with depression or low back pain may be helped by a yoga class, but it is not a panacea or a substitute or comprehensive medical care.

Yoga instructors are not medical professionals, so don’t saddle them with the burden of trying to be one. Only a licensed medical professional, in this case an orthopedic physical therapist or orthopedic surgeon, can properly and thoroughly screen and evaluate hips for structural deformities or problems. Your yoga teacher is not your health care provider, nor is he or she trained or licensed to be one, unless they have separate medical licensing.

Help your yoga teachers do their job well by avoiding end range of motion in any pose. And to yoga teachers: help yourselves tremendously by no longer using the phrase or practicing “hip opening” in classes without additional training in knowing how to screen for red flag hip problems.

To the yoga enthusiast: yoga is far more than a way to treat a problem. Yoga is about prevention of impairment and promotion of health across the lifespan. Yoga is about fostering mindfulness and well-being through all circumstances; and of finding your sense of calm and equanimity, even in chaotic times. Yes, yoga can sometimes “fix” broken things, like hearts and hips; however, if you are seeking yoga as medicine, find a healthcare provider who is well versed in both yoga and medicine. Find A Therapist, a site that specializes in yoga in medicine is one place to start.

Another tip for yoga instructors in safeguarding their students is to not focus on end range of motion (“full” expression of a yoga posture like Virabhadrasana II, Trikonasana, Vajrasana, or Parsvakonasana, for example) in your class. Moderation in all range of motion for the hip, which means avoiding end range in all planes of motion, unless you are a licensed health care professional who has evaluated the hip joint(s), is the safest course of action when instructing yoga. Lastly, yoga teachers, avoid adjustment to anyone’s hip in a pose, which also means not forcing the knee or spine into an end range as well. This will safeguard both you as a yoga teacher and a yoga student.

Another great article from YogaUOnline and special contributor, Charlotte Bell: Yoga for the Bendy - Learning to Back Off.

Study with YogaUOnline and Dr. Loren Fishman and Ellen Saltonstall - Yoga for Joint Health: Keys to Staying Mobile and Agile all Life Long.

Another course from Dr. Loren Fishman and Ellen Saltonstall - Yoga Before and After Hip Replacement.

reprinted with permission from www.gingergarner.com

Dr. Ginger Garner PT, DPT, ATC, PYT    

Ginger is a longtime physical therapist, athletic trainer, and professional yoga therapist. She received her Doctor of Physical Therapy from The University of North Carolina at Chapel Hill and is the founder and executive director of Professional Yoga Therapy Institute, an international post-graduate program for licensed medical professionals, which celebrates its 16th anniversary in 2016. Ginger serves as a consultant to, and adjunct faculty for, medical schools in the US and Canada who use her yoga curriculum and methodology. She is a faculty instructor at Herman and Wallace Pelvic Rehabilitation Institute and Medbridge Education. Ginger maintains an international teaching and lecture schedule.

Ginger’s multimedia platform textbook, Medical Therapeutic Yoga, will be published in the summer of 2016. She is currently pursuing research at UNC on MTBI, PTSD, and yoga methodology. Ginger’s clinical practice, Crystal Coast Integrative Medicine, focuses on pelvic, orthopaedic, and women’s healthcare. Ginger is a mother of three, which drives her advocacy work for partnership-based education, integrated medical care, and egalitarian economics.