Anatomy, Resources

Paul Grilley’s Response to NY Times article on Women’s Flexibility

28 Comments 05 November 2013

Paul Grilley’s Response to William Broad’s NY Times article, Women’s Flexibility is a Liability (in yoga.)

I appreciate this article by Mr. Broad, and I appreciate the concerns of Michaelle Edwards, whom Mr. Broad acknowledges in this article. I would like to add my two cents to the conversation about making yoga safer. I have inserted my comments into the body of the article in red font and in parenthesis.

My contributions are three interrelated ideas: skeletal variation, tension, and compression. Skeletal variation is the recognition that all skeletons are different and that the final mechanical limit to range of motion is when bones contact. This contact is compression.  It is critical in yoga to discriminate between the sensations of tension and compression.

All sciences develop a jargon because it is necessary to become more accurate in description. In yoga the word “flexible” is used indiscriminately. It is more helpful to use the conception “range of motion” – which refers to how much one bone moves relative to another. There are two possible limits to range of motion: tension or compression. Tension is a synonym for ‘stretching’, it is the resistance of fascia (ligaments) or muscles. Compression is bone contacting bone or pinching tissue between bones. To say a person is ‘flexible’ doesn’t discriminate between a large range of motion due to the shape of the bones or a large range of motion due to fascia and muscles being elastic.

The complement to the word flexible is the word “tight”. If a person cannot perform a pose in an aesthetically pleasing way they consider themselves “too tight to do the pose”. It might be true that their fascia or muscles are too tight but it is also possible their bones are compressing and if they try to push through it they will eventually become injured.

- Paul Grilley, Nov 4, 2013. -

Women’s Flexibility Is a Liability (in Yoga) By WILLIAM J. BROAD
Published: November 2, 2013, The New York Times 

FROM my own practice and research, I know that yoga is generally a good thing. The bending, stretching and deep breathing can renew, calm, heal, strengthen, lift moods, lower the risk of heart disease, increase flexibility and balance, counter aging and improve sex. In short, the benefits are many
and commonplace while the serious dangers tend to be few and comparatively rare.

Even so, last year, after my book on yoga came out, letters from injured guys prompted me to see if the practice, despite its benefits, was hurting one sex more than another. To my surprise, reports from hospital emergency rooms showed that, proportionally, men got injured more often than women and suffered damage that was far worse, including fractures, dislocations and shattered backs.
It made sense. Women are well known to be more flexible than men. Macho guys, yoga teachers told me, too often used their muscles to force themselves into challenging poses and got hurt. The overall numbers were relatively small but large enough to argue that men who did yoga should exercise caution.
(I propose that masculine skeletal variation tends toward deeper hip sockets and retroverted hip socket orientation (they point sideways or back). These variations lead to compression contact before the aesthetic completion of “classic” poses. Wrongly assuming they are “tight” these men try to “push through it”, creating compression injuries.)

Earlier this year, the picture of female superiority began to blur when a prominent yoga teacher in Hawaii wrote me about a poorly known threat to women.
The teacher, Michaelle Edwards, said that women’s elasticity became a liability when extreme bends resulted in serious wear and tear on their hips. Over time, she said, the chronic stress could develop into agonizing
pain and, in some cases, the need for urgent hip repairs. Ms. Edwards sent me her book, “YogAlign.” It described her own hip pain long ago and how she solved it by developing a gentle style of yoga.
Her warning contradicted many books, articles and videos that hailed yoga’s bending and stretching as a smart way to fight arthritic degeneration.
I put her cautions aside. Finally, in late summer, I got around to making some calls.
To my astonishment, some of the nation’s top surgeons declared the trouble to be real — so real that hundreds of women who did yoga were showing up in their offices with unbearable pain and undergoing costly operations to mend or even replace their hips.
“It’s a relatively high incidence of injury,” Jon Hyman, an orthopedic surgeon in Atlanta, told me. “People don’t come in often saying I was doing Zumba or tai chi” when they experienced serious hip pain, he said. “But yoga is common.”
(This is because it is compression, not stretching tissue or range of motion that is the culprit. It doesn’t matter how “flexible” one’s ligaments are if the range of movement in the exercise is not enough to create compression.)

Dr. Hyman said his typical yoga patient was a middle-aged woman, adding that he saw up to 10 a month — or roughly 100 a year. “People need to be aware,” he said. “If they’re doing things like yoga and have pain in the hips, they shouldn’t blow it off.”

(Agreed. And most important they should try to discriminate between pain of compression and pain of tension).

Bryan T. Kelly, an orthopedic surgeon at the Hospital for Special Surgery in Manhattan, echoed the warning, saying yoga postures were well known for throwing hips into extremes. “If that’s done without an understanding of the mechanical limitations of the joint, it can mean trouble,” he said in an interview.

(“Mechanical limitation” means skeletal variation leading to compression. It is compression, not range of motion or stretching that is the culprit. If a
person’s bones allow a 190 degrees of motion in the splits then doing splits 180 degrees is impressive and not creating compressive stress. But if a person’s bones only allow 179 degrees of motion then trying to do splits “perfectly” is causing compression.)

The same kind of damage, Dr. Kelly added, can strike dancers who overdo leg motions. Each year, he said, roughly 50 to 75 of his patients who danced or did yoga underwent operations. Most, he noted, were women.

Curious about the back story, I found that medical detectives in Switzerland had pinpointed the origin of the hip trouble more than a decade ago. Arthritis is usually associated with old age, but they discovered it can also strike the young and active.

Women’s hips showed particular vulnerability. By nature, their pelvic regions support an unusually wide range of joint play that can increase not only their proficiency in yoga but, it turned out, their health risks. The investigators found that extreme leg motions could cause the hip bones to repeatedly strike each other, leading over time to damaged cartilage, inflammation, pain and crippling arthritis. They called it Femoroacetabular Impingement — or F.A.I., in medical shorthand. The name spoke to a recurrence in which the neck of the thigh bone (the femur) swung so close to the hip socket (the acetabulum) that it repeatedly struck the socket’s protruding rim.

(FAI means Compression.)

The main investigator was Reinhold Ganz, an orthopedic surgeon at the University of Berne, in Switzerland. Between 2001 and 2008, his team published many studies, the 2008 one noting that women between 30 and 40 years of age whose activities made “high demands on motion” tended to show the hip damage more often. The paper specifically cited yoga.

(Read “high range of motion” creates more numerous and aggressive instances of compression. It is the compression, not the flexibility that is culpable.)

The discovery resonated. I found that hundreds of orthopedic surgeons in the Mediterranean region heard a conference presentation in 2010 that linked F.A.I. to middle-aged women who do yoga.

Michael J. Taunton, an orthopedic surgeon at the Mayo Clinic, told me that he first learned of the danger a half decade ago and now annually performs 10 to 15 hip replacements on people who do yoga. About 90 percent, he added, are women.

(Correlation is not causation. Would these 10 – 15 women have had their hips replaced anyway?)

Stuart B. Kahn, a rehabilitation doctor at the Beth Israel Medical Center in Manhattan, called F.A.I. “an emerging topic as we learn more about what causes hip pain and osteoarthritis.” He said much remains unknown.

Hip damage, for instance, can have complex causes. In addition to yoga, contributing factors can include bone misalignments, excess body weight and subtle joint deformities that differ from person to person. Hip scientists are exploring such factors, but the variations make it hard to predict who is most likely at risk.

(“Bone misalignments”, “subtle joint deformities”, and “variations” are all subsumed under the concept of skeletal variation.)

Another complication is that yoga probably does help millions of people cope with arthritis, which can strike not just the hips but fingers, knees and shoulders. Scientists have long reported that yoga’s movements can help fight joint inflammation.

Gentle yoga probably helps the hips, too. But, as Dr. Taunton put it, the bending can become “too much of a good thing.”

(Agreed.)

Ms. Edwards, the yoga teacher in Hawaii, said she warns practitioners to be cautious if doing seated forward bends (like Paschimottanasana), standing forward bends (like Uttanasana) and forward lunges (like Anjaneyasana) — moves that can force the neck of the femur into the socket’s rim.

(Ms Edwards doesn’t mention compression, she asserts that over-stretching ligaments causes “destabilization” which causes degeneration.)

Recently, she aired her warnings in Elephant Journal, an online yoga magazine. If a woman feels hip tenderness when walking, or sharp pain
when doing poses like the revolved triangle, Ms. Edwards said, “you may want to back off.”

(Agreed, but this is due to compression, not over stretched ligaments.)

Surgeons agree that women who moderate their practice can probably avoid hip trouble.
Unfortunately, yoga teachers too often encourage students to “push through the pain.” That’s not smart. Pain is nature’s warning system. It’s telling you that something has gone awry.

(Pushing through compression is impossible.)

Better to do yoga in moderation and listen carefully to your body. That temple, after all, is your best teacher.

(Nice sentiment but listening needs to be informed by the conceptions of tension and compression so that a more accurate interpretation of sensations is possible.)

Link to NY Times Article

Your Comments

28 Comments so far

  1. yogabud says:

    undiagnosed connective tissue disorders may come in to play here, such as Ehlers-Danlos Syndrome, where over-stretching ligaments does cause acute pain, chronic pain, and destabilization which ultimately causes degeneration.
    I am still not clear on the distinction between the sensations used to distinguish compression and stretching.

    • I like what you have to say, but I do also think that there can be such a thing as pain caused by overstretching of the ligaments, not just compression of the joint. Compression is not just bone on bone, it’s also bone pinching soft tissue (as you state), and when the soft tissue (a ligament or tendon) is inflamed due to over-stretching, it is more likely to be “compressed”. This also results in F.A.I. Finally, any teacher that tells me to “push through the pain” is a teacher I won’t visit again. There is discomfort in yoga, due to muscle fatigue or a good stretch in the belly of a tight muscle, but there should NEVER be pain.

  2. lisa says:

    i am a long time student of paul grilley and i am so happy to see him respond so thoughtfully to the reckless writing by mr. broad.

    after meeting paul in 2005, my concept of my own body and yoga became so clear. what i can do and what i can’t do based on my own skeletal design. what a relief!

    i let go of my perfectionist tendencies and found the real yoga.

    i wrote a response to the article too (on yogacitynyc.com which will be posted on the 6th) about mr. broad’s reckless use of the term yoga as if asana is the end all be all. which it is not. his stance perpetuates the outer expression of yoga. real yogis know this whole thing is an inside job. he is dissuading people from the real practice. sad.

    thank you paul for being my teacher and having the platform from which to state the truth.

    lisa
    new york city

    • here is the only response you have had to your post on yogacitynyc.com

      “This writer obviously hasn’t read Mr. Broad’s excellent book, “The Science of Yoga”. He’s been a yogi since the ’70s and has really delved into yoga from the scientific and anatomical aspect. The book itself is quite joyous and respectful of the history and methods of yoga. His articles are rooted in medicine and in the idea of mindfulness combined with moderation. Perhaps the writer should look deeper into the subject she writes about, just as she asks Mr. Broad to do. The book is a New York Times best seller that is also highly recommended by Yoga Journal.”

  3. Thanks for posting this. Very informative.

  4. Darina says:

    Agree w lisa. Glad that paul replied as these things get lost in translation. Thank you paul grilley. His yin yoga training is amazing in opening not only hips…eyes mostly:-). …definitely changed my practice and I am trying to pass it on my clients. .and no one get injured. ..quite on contrary. .most of my clients have issues. .and yin yoga is a magic healing if done w awareness presence and listening to body. .not ego.

  5. samantha ong says:

    how can one differentiate between compression & tension? thanks!

    • lisa says:

      you should go to pranamaya and buy one of paul’s dvds or watch the video “the bare bones of yoga.” the explanation is there for you to see and it will change your life. basically, tension is muscular meaning that muscles can be stretched but then there comes a point of compression which is when the bones restrict the range of motion due to the design of the skeleton. i promise once you watch paul grilley your life will be changed forever in the best way possible!

  6. Kim says:

    Not ten minutes ago I replied on Elephant Journal about an article promoting the same misinformation. I wish more Yogis were exposed to Paul’s teaching and could learn the often overlooked queue of yeilding to compression. The western interpretation of Yoga is so asana heavy that I fear we will one day squash its real purpose with fear and ego.

  7. Jason Z. says:

    Paul has taught us so much about this compression and tension. Great comments Paul.

    I’m no Dr and may screw up this explanation for those not familiar with how to tell the difference between TENSION and COMPRESSION, but here goes :

    If you are bending at a joint area and feel pain on the inside of the bend, then its compression. Imagine peeling your skin away you’d see the two bones squeezing the cartilage together to the point where it’s compressed as much as it can. You can’t go any further due to the skeletal make up. it’s literally impossible to ‘work through that pain” as Paul mentions above. It’s bone on bone technically. Some people (me included) just can’t bend or spread our legs as wide due to our skeletal build. It’s compression that prevents this, not cold or infrequent yoga class attendance :)

    However, if you have pain or discomfort on the outer edge of the joint area, where these ligaments & muscles are pulling away from each other, this is TENSION, and can usually be worked through over time and careful & attentive stretching.

    I’m just a huge fan of yoga and it’s physical and mental benefits and love to help spread the good word :)

  8. Marie says:

    Discount code didn’t work.

    • Evelyn Krull says:

      Thank you, Paul, for adding crucial detail to this article and particularly pointing out that “correlation is not causation”. We all now that statistics is a fine art that can be (if wanted to) manipulated to one’s heart content. I particularly agree that the women who needed hip replacements probably would have needed them as well had they been doing aerobics or running. It is the mindset (not praticing mindfully!) that causes the damage, but blaming the yoga practice or one’s body is not a constructive way forward. Thanks!

  9. ambroyogini says:

    Without a doubt, Wm Broad’s articles and book have brought out some very important points to the general public regarding the possible negative physical aspects asana practice presents if the practitioner and/or instructor is/are not mindful, and at least marginally educated in anatomy and mechanics of the body. Unfortunately, the often over-generalized and sometimes skewed data presented creates an environment of confusion, fear and misinformation.

    Thankfully, Paul has been instrumental in filling in the knowledge (reality) gaps so that, especially new teachers and practitioners, have appropriate tools to start or continue a physically safe yoga practice. We teachers who have taught for many years and have solid backgrounds in biomechanics salute you for helping us guide our students forward with deeper personal awareness! (The more people guiding them, the better!)

  10. Paul, thank you for adding to the discussion on the hip injuries occurring in women who practice yoga asana.
    I am very familiar with your Yin techniques having taken a workshop with you but also studying your DVDS. I think that your information on bone anatomy is very informative and its important that more yogis and yoga teachers understand how the body is strung together.
    However if you consider the natural design of the human body which is made of curves supported by a balance of tension and compression forces strung in a fascia web, injuries occur because we are moving beyond normal ranges of motion to perform as you say aesthetically pleasing poses.
    Ligaments need to be strong and tight enough to hold joints stable and when we stretch them by doing positions that over-ride natural function, joint functions are compromised. The loose ligaments cause the joints to become loose in a way that bones are no longer strung with the necessary tension.. Then the loose ligaments lead to the compression of the femur joint in a way that leads to the FAI syndromes which are bone spurs, labral tears, and over types of hip joint deterioration.
    Straight leg seated forward bends represent a compression force on the anterior surfaces of the vertebrae while simultaneously one is over-stretching the ligaments that string the sacrum to the hips as well as the entire posterior longitudinal ligament of the spinal column.
    Fascia pulleys string muscles together in chains such as the flexors in the anterior body which connects the dorsal surface of the foot to the mastoid process of the skull. When people flex the ankle and lean over with the knees straight, the necessary ligament tension in the plantar surface of the foot as well as the posterior side of the knee and the sacral platform are getting stretched flat. The curves and springs that the foot , knee, and sacral platform provide get stretched out. That leads to compression of the bones of the foot, the knee joint and of course the lumbar/sacral joint… Stretching parts does not contribute to an overall picture of good alignment. And passive stretching of the joints to explore tension or compression as a way of creating natural functions just makes no anatomical sense to me.
    Just watch a toddler bend over and move. They do not do anything that stretches the necessary ligament tension to keep joints stabile. I must persist with my work and try to inform yogis that pulling your joints apart by the seams or ligaments will lead to hips so open that they no longer support you in a stable way. Poses need to relate to real life functions . Walking without bending your knees is something we would never do…… When we stretch without bending the knees, the necessary tension needed to keep our parts together gets loose and then we get to compression which leads to labrum tears, bone spurs and a loss of the shock absorbing forces needed when walking, standing or sitting.
    Just because someone can do splits at 180 degrees without compression does not mean that it is leading to a favorable outcome in the long run. The word impressive you used is the issue here. The only thing that should be impressive is whether one has good posture in real life movements and not doing body positions that we do for artistic reasons that is not related to natural biomechanics . Is yoga becoming more of a performing art than a healing art?
    And people may try to downplay the number of injuries and hip replacements by discrediting William Broad is not going to make this go away. As yoga baby boomers age, this is going to become a huge issue as people find out that years of toe touching without bending the knees undermines the tensegrity of the human body. check out the toddlers in the video. They are the posture gurus I study with. http://www.youtube.com/watch?v=jCXohKKyuZI&feature=c4-overview&list=UUn5J-os1wJvuhfwU7iMuq4w
    Flexibility is over-rated and the looseness created by trying to find the compressive edge is Russian roulette to the joints.
    My email box if FULL of letter from all over the world where people are injured from being too loose and trying to find the edge in positions like straight leg forward bends and down dog with the chest dropping to the floor. Just because you are flexible and your bones can hyperextend or flex to extreme degrees without reaching compression does not mean that you are contributing to how joints function naturally in real life movement. Flexibility is a liability and what is needed is a balance of tensile forces. Stretching your parts will not lead to a change in the big posture picture.

    • A voice of reason says:

      Michaelle, you do realize that toddlers move the way they do because they are lacking brain, skeletal, and muscular development. The spine of a toddler has not yet fully formed the lumbar curve. Bending the knees in various movements is the only way they can keep from falling down.

      “The secondary curve of the lumbar region starts to form between the fifth and the thirteenth month of an infant’s life. This curve, which is responsible for the arch of the lower back, is not fully developed until a child reaches 8 to 10 years old. The development of this secondary curve parallels other developmental markers, such as unsupported sitting and eventually standing, walking and running. The development of this curve is essential to human upright posture. The secondary lumbar curve is not well developed in nonhuman primates, and their spinal configuration is less suited to an upright posture compared to humans.”

      We could all bend our knees, flatten our lumbar spines and perhaps slowly devolve our posture to that of our primate ancestors.

      However, I’d prefer to follow alignment advice from a 90 year old yogi who can balance on one leg in a backbend. Can you imagine the difference in body-mind connection between this and a toddler?

      • My son could run and dance by the time he was one years old and he may not have had fully hardened bones yet or the development of all of his connective tissue but he certainly was agile, aligned, fit and comfortable in his body. Making the premise that bending your knees in forward bends will lead to a flat lumbar posture like our primate ancestors is what is happening now. People are getting flat butts because we are not bending our knees!
        The gluteus gets stretched not strengthen in straight knee forward bends. This is why strong athletic men cannot do it because we are not designed to move that way.
        Forward head carriage, flat lumbar curves and over-stretched hyper extended knee joints have become almost ‘normal’. Mannequins are now made with bad posture so that they will look more like the people buying the clothes.
        Bending over with straight knees especially while sitting undermines the ligament tension needed to keep joints stabile when moving. I have many clients with labral tears in the hip socket caused by flexing forward in deep bends enlisting all the trunk muscles including the psoas as flexors. What happens next is the perfect storm. The psoas being connected to the lesser trochanter or inner surface of the upper leg bone shortens and pulls the femur against the rim of the acetabulum . In some this leads to a tearing of the labrum. At the same time, they are training the trunk muscles to engage primarily as flexors instead of stabilizers, this pose also has the insidious additional over-stretching of the natural 30 degree nutation of the sacral joint. Try tucking your tailbone and walking and you will get the picture. The body does not lie. I suggest any of you reading this to check out the anatomy trains fascial tensegrity work of Thomas Myers. The body is global.. All parts affect the whole and passively stretching joints to contribute to the bigger picture is anatomically questionable.

      • Helga says:

        Actually, toddlers move the way they do because their natural instincts are still intact, unsullied by phys-ed classes, and cash-crop fitness fads.

        The alignment advice from that 90-year-old yogi isn’t worth the parchment it’s written on, because balancing “on one leg in a backbend” is ALL he can do. Ask him to kick a ball across a field or disable an attacker, and he’d collapse in a heap — aesthetically, of course.

        Michaelle Edwards, YOU are the voice of reason here.

      • Since the development of the lumbar curve is essential to upright human posture and takes years to develop, why do any body position that flexes and flattens the lumbar/sacral region? All yoga forward bends from sitting or standing with the spine flexed and the knees straight flattens the curve in the lower or lumbar spine and stretches out important ligament stabilizers connecting the sacrum to the hips.
        This is the huge blind spot in the practice of yoga asana very few people seem to understand. When bending forward, the hip and knee joints should flex to allow the trunk to move forward but not at the expense of the spinal curves or the sacroiliac joint. Bending the knees and flexing the hips but not the spine is how to avoid low back/sacral dysfunction and keep your spine and hips healthy and strong. We are naturally wired to move and bend forward by bending our knees where we can enlist the hamstrings and gluteus muscles to support the upper body. Bending over by flexing your knees makes you strong and flexible at the same time. Asking your spine to bend while you keep your knees straight is like driving with the brake pedal down. ( Try to walk without bending your knees and it will become very clear why you should not try to stretch and bend forward with your knees straight)
        All movements reverberate throughout the entire body and all parts affect the whole. This is why doing yoga poses that sacrifice spinal integrity ( flatten that essential lumbar curve) make no anatomical functional sense and will not lead to a favorable outcome. Yoga injuries will keep happening until we figure out the world; I mean the body, is not flat.

  11. Paul, Thank you for your comments. I was glad to see you mention. “correlation is not a causation…”. Although I respect that Mr. Broad is trying to keep an eye on safety in the practice. I have been deeply dissapointed by his continued references in these articles and in his book to injuries and number of people with specific injuries as if just because they practice yoga, that had to be the cause. Yes, they question remains would those individuals with injuries have them anyway without the yoga. Hip replacements and injuries are more common in women than in men on the whole so it is not surprising that the numbers of hip injuries in yoga were higher in women than in men also…. Mr. Broad seems to grab any injury and immediately blame it on yoga if the practitioner has practiced yoga. Thank you for bringing the clarifications to the light for the public.
    In Joy and Service,
    Chris


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