Upper Traps & Softening the Shoulders

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“Relax your shoulders”, “soften your shoulders”, “release the tension in your shoulders” - I don’t know about you, but I’ve heard all of these instructions and more (and definitely said some myself!) in my many years in the yoga world.

Part of the reason for these cues is the widespread belief that just about everyone’s upper traps are pesky, misbehaving muscles that inevitably cause pain in our shoulders & neck.

This is an interesting idea, though, because:

1) The upper trapezius muscle is actually a very thin, superficial structure that seems pretty low on the list of “most likely to be evil” muscles.

2) Pain isn’t an input from the periphery, but an output from the central nervous system - so a muscle doesn’t really *create* pain.

3) Even if the upper traps *were* the widely misbehaving, rude muscles we often think they are, why would constantly relaxing or “releasing” them cause them to behave well?

This “relax your shoulders” narrative has seemed questionable to me for years, but I recently learned about a brand new study in which people with neck & shoulder pain were given a 5-week upper trap strengthening program. (That’s right - a *strengthening* program!)

And after doing this upper trap strength work, their pain decreased!

This evidence seems to run counter to popular belief. Instead of relaxing the upper traps and “releasing” their tension all the time, perhaps we should consider strengthening them and *increasing* their tension!

Just one more reason why “tension” isn’t necessarily a bad thing, even though our language often tends to imply that it is.

EXPERT Q&A ON YOGA, STRETCHING & INJURIES W/GREG LEHMAN

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As a member of the yoga community for many years, I regularly hear claims made about how stretching affects the body. These claims vary widely, and I’ve heard everything from “stretching is a magical cure that will heal all of your ailments” to “stretching is damaging for the body, and therefore yoga is bad for us.”

I try to be as evidence-based as possible in my approach to yoga, so I’m naturally skeptical of claims that appear to lack scientific support. In order to clarify some of the truth versus fiction regarding stretching for both myself and the greater yoga community, I decided to consult with an expert who is extremely up-to-date on the most current scientific research on stretching.

Dr. Greg Lehman, BKin, MSc, DC, MScPT, is a Clinical Educator, Physiotherapist, Chiropractor, and Strength and Conditioning Specialist. He travels the world teaching his Reconciling Biomechanics with Pain Science course to health & fitness professionals. He is also the creator of the “Recovery Strategies” pain workbook, which is an amazing, informative, and free resource for anyone in pain. Greg’s work has had a profound impact on the therapeutic, fitness, and yoga/movement worlds, and I am incredibly honored to feature his insight on my blog!

YOGA & STRETCHING Q&A W/GREG LEHMAN

QUESTION 1: In the yoga world, there is a widespread claim that stretching can lengthen connective tissues like ligaments & tendons, causing them to become lax and leading to "joint instability". Is this a biologically plausible assertion?

ANSWER: There is no evidence that this actually happens.  Pretty unbelievable, eh? There is certainly more evidence that suggests when you pull (apply tension) to connective tissue it responds by getting stiffer, stronger and sometimes thicker.  Old research by Dr. Woo has shown this consistently.  The only consistent thing that can make connective tissue less stiff is immobilization and injury.  So, it is possible that people who gain massive amounts of flexibility may have at some point damaged their tissue. 

If people feel “lax” because they stretch I would guess that it would be more of muscle or nervous system change.  People may not have the strength in those ranges to control the motion rather than the idea that they lengthened connective tissue constraints.

 

QUESTION 2: What exactly does "stability" mean when it comes to our joints, and is there evidence to support that a lack of joint stability causes pain and/or dysfunction?

ANSWER: A stable joint system just means when it gets perturbed or jostled it comes back to its resting place.  But, people have expanded the definition to mean that a joint just moves a lot when you don’t want it to move.  Joint instability is a problem when a joint pops out of place and does not readily go back into place.  It certainly does happen but I doubt it’s that common.

 

QUESTION 3: Can passively stretching a muscle compromise its strength (i.e. decrease its ability to produce force)?

ANSWER: Not significantly, meaning 1-5% of max force production [if stretching immediately prior to a strength activity].  And since we regularly don’t need to produce max force it’s not really an issue.  And you only get this transient force reduction when you hold a static stretch for 45 or more seconds.  Some research (Blazevich) even suggests that these max force/power losses are mitigated or completely ameliorated provided you do a warm up.

There is no reason to think that long-term stretching will make you weak.

 

QUESTION 4: Aside from concerns about lengthening ligaments & tendons that we've already covered here, is it inherently injurious or damaging for the body to spend time in passive end range stretches? What about for someone with a connective tissue disorder such as generalized joint hypermobility (GJH) or Ehlers-Danlos Syndrome (EDS)?

ANSWER: I think with EDS it makes sense to limit those movements and get strong instead.  That’s one of those conditions where shit really does pop out of place.  But for other people, who cares if you hang out at end range. You are just applying tensile load to tissue (pretty much what strength training does but at other ROMs) and the tissue will adapt by getting stronger. 

We aren’t made of taffy.  We don’t really “stretch” that way with applied loading like end ROM stretching.  I don’t think it’s injurious but you could certainly argue that there are better options to achieve health and mobility – like adding strength training or even resistance throughout the range of motion.

 

QUESTION 5: There is a growing dialog in the yoga world about the distinction between active & passive stretching, with a new emphasis being placed on the benefits of training active strength & control through our ranges of motion ("active stretching") and a de-emphasis being placed on passive stretching. The reasoning goes that if we have more passive ROM available at a joint than active ROM, we are more susceptible to injury because we lack "control" in those end ranges. Would you agree with this line of thought?

ANSWER: I think you should do both.  I wouldn’t be worried about injury though.  I don’t think most people are getting injured because they have lost “control” of the joint.  Further, if you get injured because the joint suddenly goes to end ROM, it’s not strength at end ROM that would have helped you - it’s the strength and control that you needed before you went to end ROM. 

 

QUESTION 6: Many long-term yoga practitioners have discovered through imaging that they have a hip labral tear, and yoga is often blamed as the cause of this tear. Given that yoga is a low-load activity and that a majority of people in general will develop an asymptomatic labral tear as they age [Ref, Ref, Ref, Ref], is a long-term yoga practice a likely cause of a hip labral tear?

ANSWER: Labral tears are common. Heck, they might even be beneficial for performance.  It’s not unreasonable to think that ANY activity can predispose you to joint changes.  They happen and I doubt there is much we can do about it.  You will see labral tears and bony changes in most sports. 

So should we stop physical activity because of the chance of a labral tear? No. There are way too many benefits from a movement practice that far outweigh the negatives of a potential increase in the chance of having a labral tear.

 

QUESTION 7: In terms of stretching physiology, I believe that many people conflate the "muscle spindle stretch reflex" (reflexive muscular contraction during a stretch) with "stretch tolerance" (tolerating the discomfort of stretching) in their minds. Could you describe the difference between these two phenomena? Do they both play a role in stopping us at the end range of a stretch?

ANSWER: I’m not sure to be honest.  Stretch tolerance definitely plays a role as the stretch is stopped (in the experimental studies) when the participant says its too much.  What happens with long term stretching is that you are able to go farther without there being a dramatic change in tissue qualities.  Meaning we assume that the changes in ROM are due to your tolerance or perhaps habituation rather than a structural change.

The muscle spindle stretch reflex is assumed to not be occurring during end ROM stretching because in these studies they monitor muscle activity.  Meaning, they try to make sure there is no measurable muscle activity that occurs at end ROM.  We assume its just a passive resistance to stretch.  However, it is plausible that there is minor amount of activity that isn’t being picked up and this could be “putting on the brakes”.

 

QUESTION 8: Do you believe there are ways in which passive stretching could actually be beneficial for the body on a musculoskeletal level? If so, how?

ANSWER: Yes.  I think long term stretching is just passive tensile force and tension has the ability to create positive structural adaptations in tissue.  Some (Kubo) have argued that passive stretching can make tendon more efficient.  Others suggest that passive stretching influences muscle stiffness which might be good to balance the stiffness changes in a tendon that can occur with injury.

I certainly don’t view stretching as a negative which I once did.  I think if you argue against stretching you are really not “against” stretching but more pro some other intervention.  So, if you like to stretch and its helpful for you I would encourage you to keep it up. 

THANK YOU AGAIN TO GREG FOR HIS GENEROSITY IN SHARING HIS KNOWLEDGE AND INSIGHT WITH THE YOGA COMMUNITY. I HOPE YOU FOUND THIS INTERVIEW INFORMATIVE AND HELPFUL FOR YOUR YOGA PRACTICE & TEACHING! -JENNI

Learn much more from Greg Lehman on his website here, and follow him on Twitter!


Expert Q&A On Yoga & Breathing Misconceptions, Part 2 of 2

Welcome to Part 2 of my interview with Rich Severin, PT, DPT, PhD(c), CCS on yoga and breathing misconceptions! As you might remember from last week, I recently reached out to Rich because I had accumulated a number of questions regarding claims about breathing that I commonly hear in the yoga world that seemed questionable to me. As a physical therapist and board certified cardiovascular and pulmonary clinical specialist, I knew that Rich would have an extremely informed perspective from which to address my questions. (Please see Rich's full bio included at the end of this piece!)

Today I present to you the much-anticipated second half of our Q&A. Between these two installments, I feel that this is a very valuable and fascinating offering for yoga teachers who are interested in becoming more evidence-based in their teaching. I hope that you enjoy, and don't hesitate to share your comments and thoughts below!

 

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YOGA & BREATHING Q&A WITH RICH SEVERIN PT, DPT, PHD(C), CCS - PART 2 OF 2

 

QUESTION 4: Is there an alignment relationship between the rib cage and the pelvis (or between the diaphragm and the pelvic floor) that ensures optimal physiological function in the body? We often hear in the yoga & movement worlds that it’s important that the diaphragm be "stacked above" the pelvic floor so that these two structures can move in concert during breathing. If the rib cage and pelvis are habitually aligned in such a way that these two structures are not “stacked”, can this result in pain (especially around the spine and pelvis) and/or dysfunction in the body?

ANSWER: Everyone’s anatomy is unique. Everyone’s anatomy is slightly asymmetrical. Everyone’s. Our bodies respond and make adaptations to stresses over time as well. The ability to respond and adapt/remodel while preserving physiological function is how we’ve survived as a species for thousands of years.

The ability to respond and adapt/remodel while preserving physiological function is how we’ve survived as a species for thousands of years.
— Rich Severin

Now that’s not to say that sudden or gross changes to posture can’t result in problems. It can and most of that has to do with exposing the body to stresses and loads exceeding its capacity or without enough time to make adaptions. It’s also not to say that just because someone has a slight deviation from our socially constructed (and not biologically constructed) ideal posture they will have pain or dysfunction. So no I’m not certain that I would agree with that statement or line of thinking.

 

QUESTION 5: Is there a known causal relationship between specific patterns of breathing (for example habitual “belly breathing”) and specific core conditions such as pelvic organ prolapse and diastasis recti?

ANSWER: Like I mentioned above there’s a lot of things that go into disease and dysfunction. I wouldn’t ascribe one mechanism to any disease or dysfunction. There is some research suggesting that individuals with COPD might have a higher risk for urinary incontinence and pelvic floor dysfunction but that’s at the extremes of respiratory muscle dysfunction. I don’t think most people in yoga are at that level of disease. However if one were to bear down long enough and they had pelvic floor weakness/laxity I could reasonably see a prolapse develop. However even in that example it’s not a one to one relationship. I would caution against making that sort of relationship. 

 

QUESTION 6: In yoga class, we are always taught to breathe in and out through our nose rather than through our mouth. I can see how cultivating nasal breathing during yoga might slow the breath down and could therefore offer a meditative benefit to one’s practice. But are there significant physiological benefits to breathing through the nose instead of the mouth in a yoga practice - and in daily life in general?

ANSWER: Most people will generally breathe through their nose. Even those who use their mouth to breathe often still breath through their nose too. Nasal breathing is reflexive and as long as nasal airway resistance doesn’t get too high (like when you have a cold or congested nose), the lips maintain their seal and the tongue maintains contact with the back of the mouth cavity, you will breathe through your nose. Nasal breathing is innate and it allows us to warm, humidify and clean the air we breathe before it gets down to our lungs.

Nasal breathing is innate and it allows us to warm, humidify and clean the air we breathe before it gets down to our lungs.
— Rich Severin

The research is a bit limited and conflicting regarding whether mouth breathing or nasal only breathing is more efficient. Some studies demonstrate that nasal breathing is more energy efficient during exercise, however some have shown that there is no difference. Oral breathing definitely tends to dehydrate your oral passages and could make talking more challenging. 

 

QUESTION 7: If someone desired to change their habitual way of breathing (i.e. breathe more into their rib cage and less into their abdomen, for example), how easily can she/he re-set the way that their autonomic nervous system controls their ~20,000 breaths per day?

ANSWER: There’s a lot to unpack in this question. Without diving into too much respiratory physiology, the cadence and depth (pattern) of your breathing is automatically controlled by the respiratory control center in your brain stem. The pattern of breathing can be modified by various sensory inputs to activate different neural circuits of the respiratory control center to modify the pattern to match the stress, activity or condition the body is undergoing. The most notable and potent sensory input is the pH of your blood and concentration of carbon dioxide (CO2) which are monitored by nerves called chemoreceptors. When pH or CO2 gets too high or too low, breathing cadence and depth will respond instantaneously in order to maintain a cellular environment conducive to metabolic work to keep us alive. The body is incredibly efficient and effective at this process, and control of pH will always “win”. 

...the evidence that exists now does not suggest that we can change our pattern of breathing permanently due to the role breathing takes to keep us alive.
— Rich Severin

We can make temporary volitional changes to our breathing pattern. We can even temporarily stop breathing. However as I mentioned above the control of pH will always win. So while we can absolutely make these changes temporarily, the evidence that exists now does not suggest that we can change our pattern of breathing permanently due to the role breathing takes to keep us alive.

What many people might observe is that when one is stressed or in pain it usually results in hyperventilating or rapid breathing. This is due to our respiratory control center responding to the sensory and emotional inputs and thus selecting an according breathing pattern to match this “perceived threat”. By practicing slow breathing it may allow one to achieve a more relaxed state or distract themselves from pain or stress. If this relaxed state is achieved, the sensory input of a perceived threat has been absolved and different circuitry in the respiratory control center will be activated producing a more relaxed pattern of breathing. We’re finding that some of the circuitry used or involved in these breathing “programs” utilized might be hardwired. 

 

QUESTION 8: The term “breathing dysfunction” is a commonly-used label in the yoga & movement worlds these days. Do yoga and movement teachers with no concurrent medical training have the authority and expertise to identify and label breathing dysfunctions and disorders?

ANSWER: Breathing dysfunction is a bit of a nebulous term. We encounter this issue often in physical therapy practice too. Unfortunately this term is often used cavalierly and done without performing a reliable, valid and objective assessment of breathing performance such as spirometry (lung volumes), respiratory muscle performance, pulse oximetry or arterial blood gases, and markers of ventilatory efficiency during exercise.

Visual inspection and manual assessment of breathing function are very subjective and are not sufficient to determine if someone’s breathing is dysfunctional.
— Rich Severin

Visual inspection and manual assessment of breathing function are very subjective and are not sufficient to determine if someone’s breathing is dysfunctional. So unless those objective measures mentioned previously are being used I would strongly caution against labeling anyone’s breathing as dysfunctional; especially if they are walking and talking into your clinic or studio. Remember there are so many things involved with breathing and we generally do a pretty good job at it.

 

THANK YOU AGAIN TO RICH FOR HIS GENEROSITY IN SHARING HIS KNOWLEDGE AND INSIGHT WITH THE YOGA COMMUNITY. I HOPE YOU FOUND THIS INTERVIEW INFORMATIVE AND HELPFUL FOR YOUR YOGA PRACTICE & TEACHING! -JENNI


Rich Severin PT, DPT, PhD(c), CCS is a physical therapist and board certified cardiovascular and pulmonary clinical specialist. Currently he serves on faculty as a Clinical Assistant Professor at Baylor University in the Hybrid Doctor of Physical Therapy program and The University of Illinois at Chicago (UIC) Department of Physical Therapy as a Visiting Clinical Instructor. At UIC he also serves as the program coordinator for the Bariatric surgery rehabilitation program and is working on a PhD in rehabilitation science with a focus on cardio-respiratory physiology and obesity.  He earned his Doctor of Physical Therapy Degree from the University of Miami. He completed a cardiopulmonary residency at the William S Middleton VA Medical Center/University of Wisconsin-Madison and an orthopedic residency with a focus on clinical research at the UIC. He has made scholarly contributions and presented both nationally and internationally on topics relating to cardio-respiratory physiology and clinical practice. He is an active member of the America Physical Therapy Association (APTA), The American Physiological Society and several other professional and scientific societies. He serves on the board of directors for Cardiopulmonary Section of the APTA as the chair of the communications committee and as a member of the nominating committee. Dr. Severin is also a member of the APTA Cardiopulmonary Section Heart Failure Clinical Practice Guideline development team, the Specialization Academy of Content Experts, and the editorial board for Cardiopulmonary Physical Therapy Journal. Follow him on twitter @PTReviewer.

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!