When yoga’s a pain in the butt

Sometimes, in the midst of doing the best you can do to be healthy, a part of your body begins to aches and pains. This can happen due to unresolved old injuries, increasing your training load too rapidly, or just simple repetitive overstraining of a particular tissue.

This latter reason is why yoga is often have a “pain in their butt”.

The fact is, we do a lot of forward bending. And bending forward puts a big stretch on the hamstrings by increasing the distance between the ischial tuberosity and the back of the knee. (see picture to right)

But it turns out that stretching is not the problem. You see, tendons and muscles are really very good at stretching. This is what they were made to do. Sort of like the rope in a tug-of-war.

The thing that tendons can’t tolerate though is being compressed. And recent research has shown that what is happening to the hamstrings tendon near where it attaches to the sit bones is a compressive force of the hamstrings tendon on part of the ischial tuberosity. This is like the the same tug-of-war rope which on one side, at the very end, is being pulled around a tree.

When we bend over fully, we put a minor compressive load near the insertion of the hamstrings, and in some people this causes micro-trauma that eventually adds up to produce tissue breakdown, aches and pains.

Now, here comes the complicated stuff. This paragraph describes why we now treat it the way we do. Skip it if want to just learn the treatment.

We used to call this type of injury a tendinitis, which is an inflamed tendon. To treat it, most doctors would prescribe a dose of anti-inflammatories and rest. It rarely helped, and most people would have chronic pain for years and years. What we know now is that there is rarely inflammation present. (This is why the anti-inflammatories didn’t help.) What’s happening is that the tissue (which, remember is normally a tensile tissue – good at tolerating stretch) is gradually changing into a tissue that will tolerate compression. Not a good situation since it still needs to tolerate stretching too. Once this change occurs, the tendon becomes very ineffective doing it’s job, and because it is painful, we gradually become weak. A vicious cycle begins.

If you are suffering from this problem as a yogi, you’ve probably already had to give up most forward bending poses. That’s a bummer, but it’s necessary. At least for now. The main goal in this early stage is to find ways to put tension on the tendon without pain, and without compressing it. An easy way to do this is to sit in a chair, and drive your heel into the leg of the chair. You’ll be contracting the hamstrings in a position where there is a direct pull on the tendon’s attachment, therefore, it is not being compressed. Push as hard as you can without causing pain, and hold for 15-30 seconds. This should be done 2x/day for about 10 reps each set. Do this program for a week or two building up force and hold time.

Next, to continue to strengthen the hamstrings tendon, begin double-leg, or single-leg bridging with different amounts of knee bending.  Again, try to do this for 10 reps, with 15-30 second holds if you can. (Notice how the the line of pull of the hamstrings is straight? This prevents the compression.) This could be your program for the next week or two.

By this time, you should be noticing that your strength is improving, and your butt is not nearly as painful. It’s not resolved though, even though it feels so much better. The training you’ve done up to this point still does not prepare you for forward bending. That starts now.

The next exercise provides an eccentric load on the hamstrings. That means that while the muscle is contracting, it is in the process of lengthening. This is a very powerful contraction for a muscle, and it’s exactly what is happening when we go into a forward bend. As we bend over, our hamstrings contract while slowly lengthening at the same time. This has the effect of slowing our decent toward the fully flexed position. If this eccentric contraction weren’t happening during a forward bend our trunk would quickly fall toward the ground.

To do this exercise, you’ll need someone to hold your ankles. The top right picture shows what you do. You lean forward until you can’t support yourself. then you fall to the ground catching yourself on your hands. Alternately, you can have one of those big gym balls in front of you, and use it to lower yourself gradually. I’d recommend doing 5-10 reps for 1-2 sets. Over 2-3 weeks, you’ll try to lower farther and farther under control, and try to gradually increase your reps as well.

In each stage of this program, there is an appropriate response you should be aiming for. You might experience a strain during the exercise, and possibly a short time afterwards. That’s OK. You should not feel like you’ve provoked your main symptoms much though. And the next day, you should be none the worse – a little post exercise soreness is all that’s allowed.

After a few weeks of this final stage of exercise, you should be able to start doing some gentle forward bends. Proceed slowly with this, adding only about 5-10 forward bends per week. I’d recommend exercising for another month before you try anything like Warrior 3 since that pose requires a strong contraction of the hamstrings in a position where the hamstrings are being compressed.

This is a tough program to stick with, but it’s well-researched and it works.

Good luck, and let me know how it goes for you. And, of course, if you’d like my assistance, I’d be more than happy to help.

Keith is the owner of Essential Physical Therapy where he works with people of all ages, and athletes of all levels who are having aches and pains or difficulty functioning. To set up an appointment, call 458-210-2940.

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