Should Yogis Worry About hips & knees that click & pop?

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When you lower down into squat pose (malasana) in yoga, do your knees make a popping sound? When you lift your leg toward your chest, does your hip sometimes make a clicking or “snapping” noise? What do joint sounds like this mean? Are they dangerous?

As of late, many yoga teachers seem to have taken a fearful turn with regard to joint noises. We often hear the claim that sounds emanating from joints are an indication of a significant dysfunction in the body such as weakness, instability, or tightness. We are cautioned that we should take immediate action to remedy these dysfunctions, or else we will face negative consequences such as joint degeneration and eventual joint replacement surgery in the future.

Now we all want our joints to stay healthy and move well for us as long as possible. This is a major focus of the yoga and movement classes that I offer, so I’m always interested in any information about the body that can help me guide my students toward increased joint health and longevity.

However, it turns out that the scientific literature on joint noise such as knee popping and hip snapping is clear. If you experience a joint noise that is accompanied by pain, swelling, or an acute injury, you should see a medical professional to have the joint evaluated. However, if your joint noise is pain-free and asymptomatic (which the vast majority of bodily joint noises are), there is no reason for concern.

  A very helpful graphic by Matthew Dancigers, Doctor of Physical Therapy, that I saw on  his Instagram feed .

A very helpful graphic by Matthew Dancigers, Doctor of Physical Therapy, that I saw on his Instagram feed.

DEMYSTIFYING JOINT NOISES

Joint noises are actually a normal, natural by-product of movement. The catch-all medical term for all of the interesting sounds that joints can emanate is crepitus. Examples of joint crepitus include clicking, popping, snapping, clunking, and more. The exact mechanism for the noise we hear when a joint clicks or pops is still not known, but some common explanations include anatomical structures coming into contact with each other, and the formation or collapse of air bubbles within joint cavities [Ref], [Ref].

Joint crepitus is more prevalent and obvious to hear in some bodies and than in others, but despite the fearful messages that we commonly hear about them in the yoga world, these noises on their own (i.e. unaccompanied by pain, swelling, or injury) are simply a normal physiological phenomenon that are nothing to be concerned about.

 

A CLOSER LOOK AT KNEES

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It’s common for people’s knees to click and pop when they flex and extend them - thus those knee pops we often hear when students lower into their squat (malasana) poses in yoga class. Many people believe that these noises are a sign that their knee joints are “wearing away”, that their bodies are prematurely aging, or that they have arthritis. But did you know that in a cohort of 250 subjects with normal, pain-free knees, 99% of them had knees that made noise? [Ref]. This is how prevalent, normal, and benign knee noises are. Yes, some arthritic knees can have joint crepitus - but so do most healthy knees. No definitive link between joint noise and joint pathology has been demonstrated by research [Ref].

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In fact, in this same study I mentioned above, the remarkable suggestion is made that knees that make noise are actually healthier than knees that do not. I’ll give you a moment to pause and absorb this thought, because it is the complete opposite of the cautions we usually hear. Knees that make noise might be healthier than knees that don’t. It’s true!

Without going too far into the details, the basic idea is that there is one type of knee sound that specifically happens in joints that are mobile and well-lubricated. As a knee becomes arthritic and starts to lose mobility, this type of crepitus actually decreases. So when this sound is absent, it can be a sign of an unhealthy joint with arthritis and decreased joint lubrication - not the other way around!

Therefore despite popular thought, noisy knees are normal and very common. And rather than being associated with joint degeneration and dysfunction, research suggests that knee crepitus is actually associated with healthy knees!

 

A CLOSER LOOK AT THE HIPS

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Hips that click, pop, and snap when they move are another joint noise we are often taught to worry about in the yoga world. This noise is commonly the result of either the psoas tendon moving across a bony prominence on the front of the pelvis, or the iliotibial band moving over the greater trochanter of the femur.

Although this type of hip noise is often claimed by yoga teachers to mean that one has a dysfunctional, unstable, or problematic hip that should be addressed, the scientific literature actually points to the same conclusion I mentioned in the beginning of this piece: if a snapping, popping, hip is accompanied by pain, seeing a medical professional is certainly advised. (The issue is generally resolved through conservative treatment, which is great!) But if the hip noise is pain-free and asymptomatic (as most hip noises are), there is nothing to be concerned about. Here are a few quotes I pulled from the scientific literature on this topic:

“When pain is not present [with snapping hip], treatment is not warranted” [Snapping Hip Syndrome (Musick 2017)].

“[Snapping hip is] a common asymptomatic condition which may occur in up to 10% of the general population” [Endoscopic Release of Internal Snapping Hip: A Literature Review (Via et al 2016)].

And my personal favorite: “Snapping caused by the iliopsoas tendon… is a common incidental observation that often requires little treatment on the part of the clinician other than assurance to the patient that this finding is not a harbinger of future problems” [Evaluation and Management of the Snapping Iliopsoas Tendon (Byrd 2006)].

This serves as further evidence that audible joint noises are normal, and are not a necessarily a sign of dysfunction in the body.

 

THE MOST CLASSIC EXAMPLE: KNUCKLE CRACKING

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Perhaps knee and hip noises don’t warrant concern if they are pain-free, but what about the sounds associated with knuckle cracking? We are probably all familiar with the caution that cracking your knuckles will give you arthritis later on in life. But it turns out that this warning is unsubstantiated as well.

We knew this as far back as 1975, when a study conducted found no correlation between knuckle-cracking and arthritis. A quote from this paper reads: “The data fail to support evidence that knuckle cracking leads to degenerative changes in the metacarpal phalangeal joints in old age. The chief morbid consequence of knuckle cracking would appear to be its annoying effect on the observer.” [Ref]

Additionally, a more recent study on knuckle cracking from 1990 looked at 300 subjects and compared those who did and did not habitually crack their knuckles. It found that “there was no increased preponderance of arthritis of the hand in either group” [Ref].

 

WORRY AND FEAR-AVOIDANCE OF BENIGN BODY NOISES

As we can see, the evidence about joint noises is clear: if they’re accompanied by pain, swelling, or injury, you should see a medical professional for an evaluation. But if they are asymptomatic and pain-free, there is no need to worry about them.

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In reality, the human body is not a perfectly silent organism. Our insides naturally make noises due to normal physiological processes. Think about the sounds we sometimes hear when we are digesting our food, or the sound of our heartbeat when we’re exercising. Joint noises are simply another form of sound that can be a by-product of movement.

Rather than encouraging worry and catastrophizing, we should see asymptomatic joint noises as a normal part of healthy movement. When we teach people that certain movements and joint sounds are inherently worrisome, this can encourage fear-avoidance behavior and a reduction in movement, which have their own negative consequences and can ironically contribute to pain.

As physiotherapist Clare Robertson writes in her excellent paper titled Joint Crepitus - Are We Failing Our Patients?:

“To accurately inform and reduce anxiety is likely to empower patients and reduce their risk of catastrophizing... It is well documented that there is a clear link between catastrophizing and long-term poor outcome within musculoskeletal medicine.” [Ref]

 

P.S. If you find the topic of joint crepitus interesting, you might enjoy this short video from Physiotutors, a source for evidence-based physiotherapy education:

 

The Psoas & the Idea of "Special" Muscles in the Body

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I highlighted the psoas in this quote graphic because we’ve probably all heard the claim that many people’s psoai (that’s technically the plural of psoas heheh) are “dysfunctional”, “imbalanced”, “tight”, or some other similarly kind of scary word.

But the psoas isn’t the only muscle we’re often taught to pathologize: the upper traps, piriformis, QL, and glutes (just to name a few) are all special muscles that we commonly hear labelled as problematic or having “issues”.

But the thing is that *none* of these muscles are more special or prone to issues than any of our other 600 muscles.

In fact, our brain doesn’t even know “muscles” - it only knows *motor units* (this is a whole topic I cover thoroughly in my Keeping Your Yoga Teaching Current online course, btw!)

And to top it all off, our muscles don’t create pain - our nervous system does! (Also covered in my course)

All of which is to say that the less we pathologize our innocent, well-meaning psoas & other special muscles, and the more we learn about pain science, the more evidence-based we’ll be in our approach to the body & movement.

Yay for the specialness of *all* of our 600 muscles!

5 Things We Didn't Learn About the SI Joint in Yoga Teacher Training

Today I'd like to offer 5 insights about the SI joint (or sacroiliac joint) that we don't tend to learn about in yoga teacher training, but which definitely have implications for how we teach and practice yoga. Also included are multiple scientific references for each point. I invite you to read these points with an open mind and a willingness to possibly question your own biases (because I know I have had to question my own many times as I continue to study and learn about the body!)

 

 

Insight #1: The SI joint is a strong, resilient structure that is supported by thick layers of some of the strongest ligaments and muscles in the body. [Ref, Ref, Ref]


Although the SI joints are some of the strongest joints in the body, we often receive the impression from our yoga teacher trainings that they are actually quite fragile structures that are vulnerable to injury and instability from the slightest misalignments in yoga. For example, we are sometimes taught that if we hold our pelvis "square" when we twist in poses like twisting triangle (parivrtta trikonasana), we can "tweak" our SI joints by pulling them out of alignment, and we should therefore instead always be mindful to let our pelvis turn slightly in the direction we are twisting in these poses. Another example is that we are often instructed in backbends like bridge pose (setu bandha sarvangasana) and locust pose (shalabhasana) to relax our glutes (or to at least soften them somewhat) because if we contract them too hard, this could injure our SI joints.

One reason we tend to believe that our SI joints are vulnerable to damage in yoga is that we generally learn about SI joint anatomy by looking at a skeleton model or a drawing like this one here:

 
 

When we see the bones by themselves like this, we can certainly get the impression that the sacrum can "slide around" relative to the pelvis easily, resulting in an SI joint that can be pulled "out of place" or "strained" due to small misalignments in yoga poses.

However, what we rarely see after learning about the bony anatomy of the SI joint's structure is an image like this, which depicts all of the extremely resilient, tough ligaments that surround and support the SI joints from all sides, holding them firmly in place:

  The ligaments that support the SI joint include the anterior sacroiliac ligament, interosseus sacroiliac ligament, sacrotuberous ligament, posterior sacroiliac ligament, and sacrospinous ligament.

The ligaments that support the SI joint include the anterior sacroiliac ligament, interosseus sacroiliac ligament, sacrotuberous ligament, posterior sacroiliac ligament, and sacrospinous ligament.

 

A rarely-cited fact is that the ligaments of the SI joint include some of the strongest ligaments in the human body! [Ref]

If after seeing an image of the SI joint's ligamentous support, we were then shown an image like this one below, which depicts all of the thick musculature and fascia on top of all of those ligaments on top of the SI joints (including the powerful gluteus maximus, the largest muscle in the human body), we might have reason to be more confident and less fearful about this naturally strong, sturdy area of our body:

 
 

 

While our SI joint can certainly be injured and we can absolutely experience pain there (more on this in #4), it would take much more force to injure a healthy SI joint than the relatively low loads involved in a yoga practice.

 

Insight # 2: The SI joints are inherently stable by design, not inherently vulnerable. [RefRef, Ref]

The SI joints serve to transfer the load of the upper body to the lower body, as well as to distribute forces moving up the body from below. Therefore, stability is built into their very design so that these forces can be transferred efficiently through the pelvis.

In fact, the SI joints are so inherently stable that there is only the tiniest amount of movement available at these joints. While some sources state that the amount of motion available at the SI joint is a barely-perceptible 2-4 millimeters, other sources actually state that there is in fact no movement available at these joints at all.

 

Insight #3: Even if the SI joints could "slip out of place" easily, we don't have a reliable way to assess this in someone's body. [Ref, RefRef, Ref, Ref]

SI joint movement is so minute and difficult to identify with either manual palpation or radiographic imaging that none of the tests traditionally done to assess the SI joint have been shown to be reliable. Without an accurate method for testing the position and movement of an SI joint, how can we definitively know that someone's SI joint is "out of place", "misaligned", or "unstable" in the first place?

 

Insight #4: SI joint pain is certainly a common experience among yogis and non-yogis alike, but SI joint pain does not necessarily mean that there is an SI joint injury. [Ref]

  His left hand would actually be a bit lower if this were truly SI joint pain. (I couldn't find a photo that showed the right spot - they all seem to feature general low back pain instead!)

His left hand would actually be a bit lower if this were truly SI joint pain. (I couldn't find a photo that showed the right spot - they all seem to feature general low back pain instead!)

Thankfully, insights from modern pain science are beginning to become more widely known in the yoga world, but if this topic is new to you, consider taking a look at the introduction to pain science article that I wrote for Yoga International a couple of years ago. It turns out that despite what we have traditionally been taught, pain and tissue damage often do not correlate on a 1:1 basis - especially when pain is experienced in a more persistent or chronic way. Pain is actually a much more complex, multi-factorial phenomenon than simply "I have tissue damage and therefore that is what is creating my pain."

As an example, if someone has SI joint pain and they have experienced a recent blunt force trauma to their pelvis region (think from a car accident or a major fall of some sort), then their pain is very likely due to an actual SI joint injury. Once this injury has healed, this pain should subside. In fact, my husband and I suspect that his SI joint may have been injured many years ago in yoga by a strong adjustment he received. His yoga teacher forcefully pulled both of his legs behind his head in a pose called dwipada sirsasana and he felt a searing pain at his left SI joint in that moment. Thankfully the injury healed, but this type of forceful, deep adjustment seems like it was enough to cause injury to his SI joint (or at least a strong protective output of pain in the area).

But in contrast to those examples of short-term pain associated with acute injury, when someone's SI joint pain is more long-term or chronic in nature (chronic pain is sometimes defined as pain lasting longer than 3 months), it's less likely that this pain is connected to a specific injury or damage to the area, and more likely that the person's nervous system is instead sensitive around that spot. Nervous system sensitivity and an output of pain can be the result of many different factors aside from actual tissue damage. Other influences include emotions, past experiences, stress levels, beliefs - and particularly beliefs about one's body. In fact, the more that someone believes that their SI joints are fragile and vulnerable, the more likely their nervous system is to perceive threat in that area and to output pain there. And conversely, the more someone learns that their SI joints are strong, inherently stable structures well-supported by some of the most durable ligaments and muscles of the body, the less likely their nervous system will be to perceive threat and output pain in this area. [Ref, Ref]

 

Insight #5: Warnings about protecting the SI joint in yoga are often unnecessary.

As we have seen, the SI joints are held stable by a ligamentous and musculature support structure that is strong and resilient - and the joints themselves have only a tiny amount of movement available (if any) in the first place. With this in mind, whether or not we hold our pelvis square when we twist in yoga is probably not a likely mechanism for SI joint injury either way, given the relatively low loads involved in the pose. And whether or not we squeeze our glutes in backbends in yoga is also unlikely to be a mechanism for SI joint injury; in fact, contrary to the common cautions in yoga, contracting our glutes in backbends has actually been shown to have a positive stabilizing effect on the SI joints. [Ref, Ref]

Additionally, it's common these days to hear warnings about "overstretching" the ligaments of the SI joints in yoga poses, leading to SI joint instability and pain. (I myself used to offer such cautions too - the idea just seems to make sense!) We are learning, however, that this is not actually how ligaments respond to stretching. During a stretch, a ligament lengthens temporarily, but then it returns to its resting length afterward (sometimes after a short recovery period.) Despite popular warnings, passive stretching has not been shown to lengthen and destabilize ligaments and joints. I have personally changed my perspective on this issue due to insights from newer research and teachings from my yoga biomechanics mentor Jules Mitchell.

(For more reading on the fascinating topic of stretching, ligaments, and joint instability with lots of research references cited, I encourage you to read this recent blog post by Greg Lehman, a researcher and clinician whose work I have followed and admired for quite some time now. But fair warning: this post is long and is really territory for the more serious body geeks among us. You can always jump right to "Questionable Assertion #3", which specifically addresses these topics and might offer some new, interesting information for you to ponder.)

 

IN CONCLUSION...

In summary, SI joint pain is common among yogis and non-yogis alike and there are many factors that can contribute to it, including physical, psychological, and social ones. How we align our body in yoga is probably not a mechanism for SI joint injury, though (strong, forceful adjustments by yoga teachers excepted!) Rather than worrying too much about alignment for SI joint protection, a more effective means to injury-prevention is to simply strengthen and condition the muscles and connective tissue that support the SI joint, so that their capacity to handle load increases.

Thank you for reading these 5 points with an open mind, and I hope to see you on the mat virtually or in person in the near future!

**Related: Keeping Your Yoga Teaching Current Online Training

Top 5 Movement Science Insights For Yoga Teachers

These are 5 of the most eye-opening insights I have learned from anatomy, physiology, kinesiology, and pain science that have given me a much different perspective on the body than the one I learned through my yoga studies alone. I hope you find these ideas interesting and inspiring for your own yoga practice and teaching!

Each of these insights is simply my best offer at a summary and takeaway for yoga teachers who might not have the time or interest to study these issues thoroughly on their own. There are volumes more to be read about each of these points from primary and secondary sources, so feel free to investigate the links and references I've included below, or to do your own research on these topics to help you come to your own conclusions.

If you're interested in how one might embody these Top 5 insights in their yoga teaching, consider trying some classes in my online class library, which is a great resource of practices from myself and other wonderful science-minded yoga teachers I admire.

Please read the insights below with a willingness to question your own biases and an openness to incorporate critical thinking into your approach to yoga and movement. Without further ado, here are my Top 5 Movement Science Insights For Yoga Teachers!

 

 

MOVEMENT SCIENCE INSIGHT #1: STRETCHING & STRENGTHENING ARE NOT OPPOSITES

One of the core rules we tend to learn in our yoga teacher trainings is that after we've "worked" or “strengthened” a muscle or muscle group, we should then stretch the area to lengthen it back out and restore "balance". The reasoning behind this rule is usually that when a muscle "works" or "contracts", it is shortening. Therefore to avoid leaving your muscle in an excessively shortened state, you should balance it out by "lengthening" or "stretching" it after you've worked it.

This idea would make sense if muscles did only shorten when they contract. But shortening while contracting is actually only one part of the physiological equation - muscles work just as often as they lengthen too. Picture your hamstrings and the way they lengthen while they're working to control your swan dive into uttanasana (standing forward fold) in yoga. When a muscle works as it lengthens, this is called an "eccentric contraction", and we move this way all the time in our normal human movements. [Ref]

Because muscles can and do actually contract through all of their ranges (short, long, somewhere in between, etc.), it is clear that the physiological opposite of a muscle contraction is not a stretch. With this in mind, it might be time to re-think our classic "strengthen it, then stretch it" rule!

 

MOVEMENT SCIENCE INSIGHT #2: NO YOGA POSES ARE INHERENTLY "BAD" OR "GOOD"

Last year I wrote a blog post called Are Some Movements Inherently Bad? which basically suggested that no movements are inherently “bad”, and the only truly bad movement is one for which your individual body is not prepared or conditioned. But the inverse of this insight is also true. While no movement is inherently bad, no movement is inherently good, either. There is a trend in the yoga world toward teaching yoga poses and other movements like “corrective exercises” that are thought of as "better", more "functional", or "healthier" for the body. But the reality is that movements don't have inherent value (i.e. "better for you", "worse for you", etc.) outside of the specific context of who is practicing the movement and with what goal in mind.

We honor the complexity of the human body and its relationship to movement when we avoid valuing certain yoga poses and movements as inherently better, more functional, or worse than other yoga poses and movements. Context and individualized goals are the main determinants of what makes a movement “good”, “bad”, “functional”, or “dysfunctional”.

 

MOVEMENT SCIENCE INSIGHT #3: ALIGNMENT IS LESS ABOUT INJURY-PREVENTION AND MORE ABOUT LOAD-OPTIMIZATION

We generally learn in our yoga teacher trainings that alignment is important in yoga poses primarily because it prevents injuries. However, we’re now learning that the categories of alignment, injury, and pain are not as interrelated as we have previously been taught. Many people exhibit “poor alignment” and are pain-free, while many others exhibit “stellar” alignment and have chronic pain (and to make matters more confusing, pain and injury (i.e. tissue damage) are also not always correlated either.) [Link]

It turns out that the human body is more resilient and adaptable than previous models of alignment and pain have accounted for. Our body actually has a remarkable ability to adapt to become stronger in response to the loads it experiences (as long as those loads aren’t beyond the ability of our tissues to withstand.) [Link] Therefore if we habitually position ourselves in a way that is different from “ideal alignment”, it’s less likely that our body will sustain inevitable damage from the “misalignment” and more likely that our body will simply adapt to better handle the loads of this alignment. (This is assuming that the joints in question are asymptomatic and healthy, of course!)

Now in a high-load situation, such as squatting in the gym with a 300-pound barbell on one’s back, alignment is undeniably an important tool for minimizing risk of injury. [Link] Activities like this involve high forces that are more likely to be beyond the ability of our tissues to withstand, and so aligning our joints intelligently is definitely recommended.

But compared to heavy weightlifting scenarios, yoga is for the most part a low-load activity. Small variances in alignment under low load are not enough to cause inevitable injury and damage in most bodies. For example, if someone’s front knee drifts inward a few centimeters in warrior 2 (breaking the classic alignment rule of keeping the knee stacked directly over the ankle), the tissues of the knee will most likely respond to that load by adapting to become stronger at that angle. And if the shoulders drift slightly out of “joint-stacked” alignment over the wrists in plank pose, the shoulders, elbows, and wrists should be signaled to grow stronger and better able to handle load from this new angle.

In fact, exposing our body to variable loads like this is actually a great way to prevent injury because it helps condition our tissues to become stronger at all angles, rather than strong in only the classic “joint-stacked” position of traditional alignment rules. I would argue that increasing the ability of one's tissues to tolerate load by strengthening the body at all angles and ranges is a much more effective strategy for injury-prevention than "alignment" is.

These days I view alignment as a tool that helps my students direct the loads in their bodies where I intend for those loads to go, rather than as a necessary tool for injury-prevention.

 

MOVEMENT SCIENCE INSIGHT #4: WE USE TOO MUCH FEAR-BASED LANGUAGE AROUND ALIGNMENT IN YOGA

This insight piggybacks right onto insight #3. It’s very common in the yoga world to pepper our alignment instructions with cautionary language, such as “Align your front knee right over your ankle in Warrior 2 to protect your knee” or “Press your pubic bone into the floor in shalabhasana to keep your low back safe.”

As well-intentioned as they are, warnings like this can actually serve to instill a false sense of fragility in our students, which can counterintuitively result in their experiencing pain. We know now that pain is a creation of the nervous system in response to a perceived threat. And our beliefs about our body are actually one influence that can directly escalate or de-escalate our nervous system’s perception of threat and output of pain. [Ref], [Ref], [Ref] Therefore the more we trust in the robustness and resiliency of our body, the more we communicate a message of confidence to our nervous system, which is likely to result in lower threat levels and decreased pain. And conversely, the more we believe that our bodies are innately fragile and vulnerable to injury from low loads and small micro-“misalignments”, the more likely our beliefs are to contribute to increased threat levels and increased pain.

In warrior 2 pose, stating that keeping the knee directly above the ankle is important “to protect your knee” is a potentially nocebic suggestion to offer to our students. (A nocebo is a negative expectation of an otherwise harmless event or action that causes negative consequences like pain.) Likewise, stating that the pubic bone should stay grounded in shalabhasana “to keep your low back safe” suggests to our students that their spines are fragile structures that will experience damage if their pelvis is tilted a few millimeters in the “wrong” direction.

Instead of using cautionary, nocebic language about alignment in our yoga classes, consider talking about alignment in terms of what it helps us achieve in our poses. For example, in warrior 2 we could say “Keep your front knee lined up over your ankle to engage your lateral hip muscles” or “Press your pubic bone into the floor in shalabhasana to lengthen your low back and direct the backbend into your thoracic spine.” These types of cues utilize alignment more for load-optimization reasons and less for injury-prevention reasons. Instead of instilling a sense of fragility about their bodies, these types of cues encourage increased body awareness in our students, which can be confidence-building and empowering.

 

MOVEMENT SCIENCE INSIGHT #5: TWO COMMON YOGA CUES WE CAN STOP USING

We often teach yoga poses in a way that tells our students which specific muscles they should (or should not) be contracting in particular movements.

In certain contexts, suggesting which muscles a student should be using at any given time can be a useful type of guidance. But it's helpful to realize that as a general rule, our nervous system actually does a good job of automatically organizing and coordinating the movement of our body all on its own, without needing much conscious input from our thinking mind. In fact, consciously "micromanaging" which muscles our nervous system chooses to recruit can often interfere with our built-in, sophisticated motor control system in a way that results in less efficient movement. [Ref]

With this in mind, here are two cues that are very common in the yoga world today that we could all use to stop giving:

1) The glutes & bridge/wheel: there is no need to tell our students that they should "soften their glutes", "relax their glutes", or otherwise disempower the main muscles of hip extension that their bodies naturally recruit when they lift their hips up into bridge pose (setu bandha sarvangasana) and upward-facing bow pose (urdhva dhanurasana). [Ref]

2) Arms overhead & shoulder positioning: there is no need to cue our students to "pull your shoulders down your back" when their arms are overhead. When our arms lift up, our shoulder blades naturally rotate and lift along with the arm movement. [Ref] This is a normal, optimal movement that is often referred to as "scapulohumeral rhythm", and it is not helpful to interfere with this natural coordinated action by trying to consciously pull the shoulder blades down the back to prevent them from lifting.

 

Thank you for reading these Top 5 insights with an open mind, and I hope to see you on the mat virtually or in person in the near future!

**Related: Keeping Your Yoga Teaching Current Online Training

Podcast Interview: Pain Science For Yoga/Movement Teachers

I was lucky enough to get to talk about pain science and what implications it has for us yoga/pilates/movement teachers on the wonderful Moving Well podcast! Nikki Naab-Levy and Janet Sunderland are the very smart and engaging hosts of this podcast, and I really enjoyed having the opportunity to talk with them about one of my favorite topics to geek out about. :)

I hope you enjoy the interview if you have the chance to listen to it!

Fascia Myths and Fascia Facts

Have you noticed that the word “fascia” has become somewhat of a buzzword in the yoga world lately? There have been lots of articles written about this newly-appreciated bodily tissue (I myself have written two of them in the past few years!), and fascia has become a focus in many yoga classes - especially those that include rolling on self-massage tools like balls and foam rollers.

I understand this preoccupation with fascia, because it is a truly fascinating topic. Fascia is a type of connective tissue that forms a continuous body-wide web inside of us, surrounding and interpenetrating all of our muscles, bones, organs, nerves, and blood and lymph vessels. In fact, in addition to forming the architecture that weaves our inner structures together, our connective tissue system as a whole also absorbs and transmits force inside of us, working in conjunction with our muscular system to create smooth, efficient movement. Such insights have the power to expand the way we understand movement, which is very exciting!

In addition to these inherently interesting facts, there are other claims commonly made about fascia that are widely-believed, but reach a bit too far ahead of the research to be actually supported. Today I’d like to address a few of these specific claims in an attempt to encourage our yoga community to embrace a more science-based, productive dialog about the popular topic of fascia and the wonderful practices of massage and rolling.

 

MYTH #1: ROLLING ON BALLS AND OTHER MASSAGE TOOLS BREAKS DOWN FASCIAL ADHESIONS, KNOTS, AND SCAR TISSUE

Every massage therapist knows the experience of finding a tight spot in her client’s body, massaging it, and feeling it “release” or “relax” underneath her hands. It seems natural to assume that through her hands, she physically broke down a knot in her client’s fascia - and that through rolling on massage tools, we can do the same to ourselves too.

But one lesser-known fact about fascia is that its collagen fibers are literally as strong as steel. [Ref] To actually “break them up” would require so much force application that one’s body would sustain serious injury - this is not something that is achieved by a massage therapist’s hands or by a pair of massage balls.

Although you may feel a tight spot in your body change its texture after rolling or being massaged, this change was not due to the architecture of the fascia changing. For fascia to actually change its architecture, many, many inputs are required over a long time - collagen takes about three years in order to completely change and remodel. [Ref] Any instantaneous changes in tissue quality that you experience as the result of a massage are not the “breaking down” of adhesions, knots, or scar tissue - they are instead changes in tissue tone that are mediated by the nervous system. [Ref]

Once we understand that soft tissue treatments like massage and rolling work primarily via neurological communication instead of via physically breaking down adhesions, knots, and scar tissue, we might be encouraged to administer these treatments more gently than forcefully. When we roll and massage ourselves with deep, forceful pressure, this can often increase nervous system threat levels and sensitivity, which can be counterproductive to our efforts. Gentler, milder work is often more successful at decreasing threat levels and coaxing the nervous system to relax our tissues.

Massage and rolling on balls are undeniably wonderful, potent tools that help so many of us feel better in our bodies, but when we understand more about the mechanism for why they work, we will naturally be able to use them more wisely.

 

MYTH #2: WE FEEL PAIN IN OUR BODY BECAUSE OUR FASCIA IS FULL OF KNOTS, ADHESIONS, AND SCAR TISSUE

This is a very common belief, but it turns out that it is based on some inaccurate information about how pain works. I’ve written about the science of pain before [here and here], but one of the most foundational aspects of pain is that it is an output from the central nervous system, not an input from the periphery. It’s easy to be confused about this concept because when we feel pain, we feel it in a particular area of our body. It feels like the pain is in our tissues, and it’s our tissues that are therefore causing it. But the pain doesn’t actually reside in our tissues at all - it is 100% an experience that our nervous system has created for us to perceive - most likely to serve as some sort of protective signal.

Because pain is an output and not an input, adhesions, knots, and scar tissues - which are located in the periphery of our body (if they exist at all - but that’s a whole other topic!) - are not actually capable of creating pain. This concept might be tough to grasp, especially because we know that a massage therapist can touch a certain “knotty-feeling” spot on our body and it might feel tender or painful. But the pain you feel there was not created by the knot - it was created by your brain and experienced in that spot. Additionally, we know that we can have other painful-to-the-touch places in our body that do not actually correspond with a “knot” or tight spot that resides there. The flesh in those painful spots instead feels smooth and knot-free. And there are probably quite a few other locations in your body that definitely feel “knotty”-like when palpated, but are not associated with pain at all. [Ref]

As it turns out, pain and tissue quality are separate entities that sometimes overlap, but oftentimes do not. While it's easy to believe that all tight spots underneath our skin are problematic, the truth is that many of them are probably just normal, healthy variations in our tissue texture. And pain, regardless of where it is felt in the body, has less to do with knots, adhesions, and scar tissue, and more to do with a nervous system that has been sensitized around a particular area. This is a helpful, progressive change in perspective because the less that we pathologize the physical feel of "tightness" and "knottiness" in our tissues, the less likely we are to create nocebos for ourselves or our yoga students and massage clients. (A nocebo is a negative expectation of an otherwise harmless event or action that causes negative consequences like pain.)

 

MYTH #3: OUR FASCIA CAN BECOME DEHYDRATED AND ROLLING ON MASSAGE TOOLS HELPS TO RE-HYDRATE IT

This is an absolutely appealing and intuitive idea, but to the best of my knowledge, we don’t have research that supports this claim. Part of the problem lies in a lack of specificity for how this proposed dehydration/rehydration process would work.

 An artist's depiction of connective tissue.

An artist's depiction of connective tissue.

In simple terms, our connective tissue is made up of cells, collagen fibers, and a non-living gelatinous matrix called ground substance. When the claim is made that fascia can be dehydrated, I believe the notion is that its ground substance is dehydrated.

It’s unclear to me how it could be determined that someone’s ground substance is dehydrated, however - can you tell by looking at someone from the outside? Maybe by looking at their skin? Can you tell because they feel pain somewhere? (As we mentioned earlier, pain and tissue quality are poorly correlated.)

Even if there was a reliable way to assess fascial dehydration, it is unclear to me how a massage or rolling on balls or other tools would hydrate it. The ground substance of connective tissue definitely has some water content, but how would the pressure from rolling change this water content? (Water that you drink goes through different channels in your body than water in your ground substance, so that's a different type of hydration than fascial hydration.) Does rolling add new water to fascia (how?), or does it move already-existing water from another part of the body to the deydrated one? If rolling did increase water content, wouldn’t everyone’s glutes be extra hydrated and especially healthy because so many of us squash them with pressure by sitting on them for hours every day?

Most of us believe this hydration claim because we heard it from someone knowledgeable like a smart yoga instructor or an experienced bodywork teacher. But if we actually look to connective tissue biology for some factual basis to the claim, we find that there is little support there. It may be true that massage can hydrate our dehydrated fascia, but research has not yet demonstrated this in a clear way. I believe we would do more of a service to our yoga community by waiting to make claims like this until science begins to produce some solid evidence for them.

 

In summary, fascia is an incredibly fascinating tissue of the body for an abundance of reasons. But we will better serve ourselves and our students if we shed some of our language about fascia that implies that it is full of painful adhesions and scar tissue that need to be broken down and hydrated. Additionally, massage therapy and self-massage tools like balls and foam rollers are absolutely wonderful, helpful practices that offer great results for so many people. But when we recognize and teach an awareness of the often-overlooked role that the nervous system plays in many of these massage benefits, we will be able to utilize these tools even more powerfully for ourselves and our students and clients.

 

(If you're interested in exploring these ideas further, you might appreciate this video from Quinn Henoch, Doctor of Physical Therapy:)

Jumping Back To Plank: What's the Big Deal?

All my life in the yoga world, I have heard the instruction that one should never jump back into plank pose. Instead of landing in plank, this core yoga rule goes, we should land directly in chaturanga dandasana - in other words, we should always jump into the bottom of a push-up and never jump into the top of a push-up. The reasons usually cited for this instruction are that jumping back into plank is injurious for any number of body parts including the wrists, shoulders, low back, knees, ankles, and big toes.

I used to believe and teach this yoga rule as well, but in more recent times I have changed my perspective on the issue. I don't think that there is anything inherently wrong with jumping back into plank pose, and I think the widespread prohibition of this movement mostly serves to create some unnecessary fear and worry about our yoga practice.

Here are my main reasons for this viewpoint - I hope you use them to examine your beliefs and then come to your own conclusion about the "never jump to plank" rule!
 

Reason #1: You can certainly injure yourself jumping into plank, but...

I definitely agree that it's possible to injure oneself while jumping into plank pose. If you lack the ability to engage through your core, press strongly through your arms, and land lightly, some areas of your body may experience a higher-than-optimal level of stress, which could lead to injury. But I fail to see how this is different from so many other movements in yoga that can also be injurious if one lacks proper technique and body awareness - yet we don't make blanket statements about the importance of "never" doing most of these other movements.

 If we jump back to plank with no arms, will this protect our shoulders? :)

If we jump back to plank with no arms, will this protect our shoulders? :)

One yoga transition that stands out to me as especially risky for the body if one lacks the proper strength and control is, ironically, jumping straight into chaturanga. Even though chaturanga is traditionally considered the safer asana to jump into, this pose is actually much more challenging to execute skillfully than plank pose. Chaturanga involves much higher loads to the neck, shoulders, and spine than plank pose does, and these loads are significantly higher if we jump into the pose (especially if we slam down with a lot of velocity like many yogis do) instead of lower slowly into it. In fact, so many yoga students lack the foundational skills to practice chaturanga well that I created a whole online tutorial on how to approach this pose with integrity.

I would suggest that contrary to popular teachings, one is at greater risk of injury from performing a sloppy jump-back into chaturanga than they are from performing a sloppy jump-back into plank pose.

 

Reason #2: Jumping Into Plank Is Commonly Practiced In Other Movement Systems Without Concern Or Widespread Injury

 The "burpee", a common warm-up exercise that includes a jump-back to plank.

The "burpee", a common warm-up exercise that includes a jump-back to plank.

If you ever visit a gym or other fitness setting, a common movement used for warming up that you'd likely see is something called a burpee. (Yes, I agree that this is an odd name for an exercise, but a fun trivia note is that the burpee is named after the person who founded it - a physiologist named Royal H. Burpee.)

To perform a burpee, one begins in a standing position, lowers down into a squat, jumps back into plank pose with straight arms, often performs one push-up, jumps forward again into a squat, and then jumps up and lands back in a standing position. A typical "set" of burpees is anywhere from 10-15 done in a row, and people typically perform at least 3 sets (and often many more) in one workout. In addition to this classic exercise, there are many variations, such as the one-leg burpee, in which one jumps back into a one-legged plank instead of a traditional plank, the side burpee, in which one jumps into a variation of side plank, and the one-arm burpee, in which the entire movement is performed with one arm lifted.

In addition, multiple research studies have been done by exercise scientists which include the burpee as a movement alongside other classic fitness exercises. (Examples here and here.)

The fact that the burpee, which involves jumping back into plank pose repetitively, is so prevalent in the fitness world and is also included in research studies suggests to me that it has not been found by fitness professionals or sports scientists to be particularly injurious for the body.

 

Reason #3: Jumping Into Plank Could Actually Have Some Benefits

To be honest, even though I don't believe that jumping into plank pose is inherently dangerous, I don't tend to teach this movement very often in my yoga classes. But I do believe that jumping into plank (and chaturanga for that matter) could have some benefits for the body that we often overlook when we focus on fear and worry about this transition instead.

There is a type of fitness training called plyometrics which utilizes jumping exercises to increase a person's power, or the speed at which they can use their strength during a task. Plyometrics are also known to enhance one's endurance and agility, and several studies have actually shown that they can increase bone density (examples here, here, and here).

There is some debate about whether a burpee (a.k.a. the fitness world's version of "jumping into plank") can technically be considered a plyometric exercise. But I believe there is enough crossover between the two to suggest that they would offer some similar benefits.

 An example of a plyometric exercise.

An example of a plyometric exercise.

Additionally, we know that movement variability is important for neural learning, tissue health, and overall graceful aging, so the argument could be made that learning how to jump back skillfully into both plank and chaturanga - and not just one or the other - could be beneficial.

 

Reason #4: There Are No Inherently Bad Movements

You might recall a controversial blog post I wrote earlier this year called Are Some Movements Inherently Bad? (also re-published in Yoga International with a far more angry comment thread here.) In this post, I argued that instead of looking at a movement as inherently bad and damaging for the body, we should reverse our reasoning and instead look at an individual body and ask if it is adapted and prepared to handle the loads of that particular movement.

For example, a beginning yoga student with an office-working, sedentary lifestyle who has never borne weight on her arms might be prone to injury if she tries jumping into plank (and even more so if she tries jumping into chaturanga - yikes!) But because the biological reality of our bodies is that they adapt to become stronger to the loads they experience on a regular basis, most practiced yogis who have a good sense of body control and core stabilization should be able to jump lightly into plank pose without causing injury.

 

CONCLUSION

To be clear, I'm certainly not suggesting that all yoga teachers run out and start teaching everyone to jump into plank during every vinyasa. I'm simply questioning the reasoning behind the ubiquitous "never jump into plank" warning that nearly every yoga teacher learns in their yoga teacher training. Is this transition necessarily dangerous for everyone, and is jumping into chaturanga somehow innately safer? Where do these beliefs stem from? I believe that questioning our biases about these transitions can help us to become more critically-thinking yoga teachers who can serve our individual students better.

**Related: Keeping Your Yoga Teaching Current Online Training

4 Basic Pain Science Concepts For Yoga Teachers, Part 1

I recently created a series of social media posts designed to help yoga teachers become better-informed about the complex topic of pain science. Pain science is growing in its reach in the therapeutic, fitness, and movement world, and even though yoga teachers generally don't treat people for pain (unless you're also a physical therapist or other health care professional in addition to being a yoga teacher), pain science actually has many important implications for us beyond the subject of pain itself. As yoga teachers, if we take the time to learn about even a handful of some of pain science's most fundamental insights, we'll be rewarded with a more current and accurate paradigm for approaching and dialoguing about not only pain, but movement, yoga, and bodies in general.

Here is a re-cap of the series of four posts that I shared through my social media channels so that they can be read all in one place together, and I'll follow up with Part 2 of this blog post series with some additional, new thoughts on how and why all of this might matter specifically to us as yoga teachers. I hope you enjoy perusing this info - feel free to share with your networks if you feel that it would be beneficial!


PAIN SCIENCE FACT #1: Pain and tissue damage do not always correlate. In fact, when it comes to persistent pain (often defined as pain lasting more than 3 months), the link between pain and tissue damage is often significantly weaker. (And yes, if you experience a pain that "comes and goes" versus a constant, steady pain that is always there, that is still considered persistent pain if it's been going on for longer than 3 months.)

Reason this is important: just because someone experiences pain somewhere in their body, this does not necessarily mean that there is *actual injured tissue* inside of their body. It might mean that, but it also really might not. (Remember, this is more likely the case when we're talking about persistent pain - not so much with acute pain. Acute pain is the direct result of a recent injury - like stubbing your toe on the door jam or spraining your ankle due to an accidental fall. Acute pain usually lessens and then stops once the injury has healed. Persistent pain, on the other hand, is also often also called chronic pain and is pain that lasts for a longer amount of time.)


PAIN SCIENCE FACT #2: Pain is an output of the brain. This is an often-cited pain science insight - but what does it actually mean? Remember that pain science involves a major perspective shift in how we see the body, so we really have to wrap our minds around some new concepts here. Typically, when we experience pain, we tend to think of the pain as being located "in our tissues", and our brain then senses it there and THEN we feel it. In this view, pain is an INPUT to the brain because it first exists "out there" in the periphery of our body, and then we sense it centrally (in our brain).

As intuitive as this "input" idea seems, it's actually the opposite of how pain really works! In reality, there is no pain *anywhere* in our tissues that is inputted to our brain. Instead, pain is a creation OF the brain that is meant to signal us to take protective action against a perceived threat. If you feel pain in your shoulder, for example, it's because your brain is *outputting* a warning signal to you about that area for some reason. Pain is therefore not an input from your tissues to your brain - it's an output from your brain to your tissues! How mind-trippy is that?

Now your brain might be correct that this painful area is under threat (especially if you recently injured that spot - too many sloppy chaturangas, anyone? Heh heh...) But your brain might also be wrong in its conclusion that the area is under threat - especially if there is no recent tissue damage there. And pain without tissue damage (and vice versa - tissue damage without pain) happens ALL. THE. TIME. Refer back to Pain Science Fact #1 to review this concept, and then see if you can put Fact #1 and #2 together to start to build your new pain science-informed paradigm.


PAIN SCIENCE FACT #3: We've already covered (in a very simplified way) the fact that pain is an output FROM the brain, not an input TO the brain. Pain doesn't exist in one's tissues to be sensed by the brain - it is instead a creation OF the brain to be sensed in one's tissues. But why and when does the brain choose to create pain?

We used to believe that all pain experienced in the body was the result of tissue damage somewhere inside of us - in other words, we thought pain was always the result of some structural problem. But we now understand that tissue damage is just *one input* that the brain considers when deciding whether to emit a pain signal. In addition to tissue damage, the brain considers inputs like past memories, emotions, expectations, beliefs, one's environment, things that health professionals say, and more when deciding whether to output a pain experience in any given moment. All of this information processing happens unconsciously, and in just a fraction of a second.

Now that you know this, think about someone who experiences a persistent pain in their low back (like 80% of us will at some point in our lifetimes). Here is a list of common reasons given when someone has back pain: your spine is out of alignment, you have a herniated disc in your spine, you have poor posture, you flex your lumbar spine too much, your SI joint is dysfunctional, you sit in a chair too much, you have SI joint instability, your core is weak, you have a vertebral subluxation, you lack core stability, your back muscles are tight, etc., etc.

This is a really long list of commonly-cited reasons for back pain, but the interesting thing is that they are ALL structural reasons - meaning that they all have to do with the physical structure of the body. But remember our new Fact #3 from today: the brain takes MANY inputs into consideration before deciding to output pain, and structural inputs are just ONE category of inputs. Combine Fact #3 with Fact #1 (the link between persistent pain and tissue damage is often quite weak), and your paradigm for how you think about someone's back pain might begin to shift and expand.


PAIN SCIENCE FACT #4: We often believe that our body is naturally vulnerable in certain movements or postures, like lumbar flexion, forward head posture ("text neck"), etc. We believe that these positions will injure our tissues and create pain, often blaming someone's low back or neck pain on these "bad postures".

What this viewpoint (that I used to share too!) overlooks is the fact that the tissues of our body are adaptable and become stronger when they are loaded (as long as the load isn't too high). Any movement that you desire to do is a "good" movement as long as your tissues are adapted to withstand its loads. (This is a super oversimplified explanation, but for more info, check out my blog post Are Some Movements Inherently Bad? (which was also re-printed in Yoga International).

Additionally, recall Fact #3 of this series - *many* inputs contribute to pain, not just structural ones. Recent research has strongly suggested that our *beliefs* about pain can directly influence our pain. For example, if we believe that a certain movement is bad for us, this can create what's called a nocebo - the creation or increase of pain or dysfunction based solely on negative expectations and beliefs.

BIG TAKEAWAY: The issue isn't that we need to *avoid* certain "bad" postures and catastrophize them - it's more that we want to move our body in a *wide variety of ways* so that we can be strong and adapted to many different positions. Movement variability is more important than fear of movement!


That concludes the series of posts that I shared through social media, but keep your eyes out for Part 2 of this series, which will attempt to address why all of this matters specifically to us yoga teachers. In the meantime, I also wrote a helpful introduction to pain science in Yoga International earlier this year (see "Yoga & The New Science of Pain"), and at the bottom of that article I included a lengthy list of links for further reading for those interested. Enjoy exploring this topic further if you feel so compelled!