by Shari
The latest New York Times article from William Broad Women’s Flexibility is a Liability (in Yoga) sparked a conversation between Nina and me, both whom are long-term yoga practitioners who have grappled with orthopedic injuries. Broad states that he has recently learned that women are at higher risk of hip injuries in a yoga class because of their inherent flexibility compared to men. He quotes a single yoga teacher, Michaelle Edwards, saying that “women’s elasticity became a liability when extreme bends resulted in serious wear and tear on their hips. Over time the chronic stress could develop into agonizing pain and, in some cases, the need for urgent hip repairs.” He also says of arthritis researchers:
The investigators found that extreme leg motions could cause the hip bones to repeatedly strike each other, leading over time to damaged cartilage, inflammation, pain and crippling arthritis. They called it Femoroacetabular Impingement — or F.A.I., in medical shorthand. The name spoke to a recurrence in which the neck of the thigh bone (the femur) swung so close to the hip socket (the acetabulum) that it repeatedly struck the socket’s protruding rim.
I personally can’t stand sensationalism of any type and particularly sensationalism of the fear and scare tactics kind. When I first saw this article, I groaned inwardly. But I then proceeded to read it carefully, including the related links, and then went on to do some additional research of my own. After all that, my response is: maybe.
First of all, I, as a long-term yoga practitioner, am not sure what exactly he means. We all can be overly flexible in some areas of our bodies and conversely overly tight in other areas of our bodies. The biomechanical model of structure and function is a beautiful yin and yang interplay between forces that influence our bodies, and yes, can ultimately change our structure and function. Some changes may not be as beneficial as others so we need to be consciously selective and astute to observe what changes occur with function.
I also think, as in the past, Broad is careless in his citations of his evidence and is vague about these ER records of hip injuries. However, he does cite some orthopedists and one international study that do substantiate his observation that women who put their hips into extreme ranges of motion can injure their hips. Well, this is blatantly obvious to anyone who may be neurologically intact. When a joint is taken into an extreme position there is a pain response recognized by the central nervous system that warns the person to back off. Of course, if we choose to ignore the pain response, then is it the yoga that is causing the injury or is it the person who is foolishly not listening to the feedback their body is providing?
I also think that to address William Broad’s assertion that women are more flexible than men, we need a better working definition of (biomechanical) flexibility:
Flexibility is the range of motion in a joint or group of joints, or, the ability to move joints effectively. Flexibility is related to muscle strength. Flexibility is also the ability to move through a full range of motion.
Flexibility is a conscious movement that has an intricate feedback mechanism between the muscles and the nerves innervating the muscles and the joints and the central nervous system. There are significant protective mechanisms that prevent the individual from overstretching if they PAY ATTENTION to the sensation of pain rather than ignoring it.
So are women “inherently” more flexible than men? Well, it depends who you ask. But all sports attract a body type, and if yoga is considered a “sport” then there is a body type that is drawn to yoga. We all like to do things that are “easy” and for some flexible bodies yoga is “easy.” The rub here is that this isn’t “yoga” but athleticism masquerading as yoga!
So now let us look at his assertion that yoga is the root cause of “femoracetabular impingement”. The literature that I read, including one of his references, states that the subjective symptoms are deep anterior groin pain with associated intermittent catching and locking of the hip joint. In addition, there is a significant decrease in hip internal rotation. The morphology is that there is a breakdown of the hip labrum (how the head of the femur is connected into the cup of the pelvic acetabulum) and the articular surfaces of the femur and acetabulum. There is a structural change in how the head of the femur is sitting and facing, and movement of the hip will continue to tear the tissue structures with a loosening of the integrity of the hip joint. The problem is that a lot of individuals who have this condition are pain free, asymptomatic and don’t know they have it. The concern is that this condition may be a precursor to developing hip arthritis down the road. There are four types of femoracetabular impingement and one type is more common in women and one type more common in men!
Another article that I read stated that the condition is caused by internal rotation of the hip while in 90 degrees of hip flexion. Yes, this can be Uttanasana (Standing Forward Bend)! So is the problem the combination of these two movements? I don’t know, but does that mean you need to stop doing Uttanasana? I don’t think so unless it is causing pain. And, yes, there are some pretty extreme hip positions in yoga which only some of could do when we were younger (maybe can still do them now) but the bottom line is that we need to practice with intention and attention to form, function and our own bodies’ abilities and not soldier on through the pain. Yoga, as we have mentioned time and time again, can be physically and mentally challenging, but is not supposed to hurt. So don’t be scared off again by a sensational journalist who claims he is a yogi.
In a future post I would like to present some of the inherent differences between male and female pelvis and hips that might also help to put into perspective the allegation of the differences between men and women.
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Perfect. My primary problem in yoga class is my "hyper flexibility", long muscles, loose large joints and the ability to with ease, go into the most extreme poses. I need to be very very careful and have over the last 6 years injured myself several times. Clearly I need to spend more time on developing stregnth…Having said that, nothing can keep me away from class. Yoga is my opening up and finding serenity every week.
I think what might be being overlooked here is that there are individuals who actually have genetic defects in their connective tissues that cause their ligaments to be lax and allow them to be overly flexible with ease AND often without experiencing the same type of pain (which would be an indicator to stop) when one is exceeding the normal joint ROM. Many of these women (though men are equally affected but less symptomatic due to testosterone) may actually have a disorder called Ehlers-Danlos Syndrome (EDS), or even just "Benign Joint Hypermobility Syndrome" (joint hypermobility with little pain), both of which inherently predispose affected individuals to joint/ligament micro-trauma and laxity.
Often individuals will mistakenly be given a diagnosis of Fibromyalgia (due to doctors not having EDS on their "radar") – and some even take up Yoga as part of its management. In these cases (if they had been correctly diagnosed), Yoga would be contraindicated for the reasons you discuss: predispositions to joint injuries. People with these conditions need to be very careful about the time of physical activity they participate in. Gentle Pilates is generally thought to be OK, as well as low-impact, close-chained exercises. Yoga should only be done in these individuals after they have received a comprehensive assessment and individualized routine, tailored to their body's capabilities.
My point is illustrated perfectly actually by the "Anonymous" poster above me – the "hyper-flexibility", "loose large joints", "ability to go into the most extreme poses with ease", and "several" recurrent injuries due to yoga…all hallmarks of an increasingly recognized, yet frequently misdiagnosed/undiagnosed disorder of faulty connective tissue.