I’ve had a lot of requests lately to write about damage to the hip labrum and whether or not it can be caused by yoga asana practice. Many people became concerned about this issue following the NY Times article entitled: Women’s Flexibility Is a Liability (in Yoga). The article discussed a particular type of labral damage referred to as FAI or femoral acetabular impingment. FAI is exactly what the name says. The femur impinges on the rim of the acetabulum in certain hip joint positions. With enough pressure, the labrum (the cartilage ring that encircles the acetabular rim) can be crushed or torn between the impinging bones.
FAI injuries can be quite painful and create great limitations in hip range of motion. They have been proposed as one mechanism for early osteoarthritis of the hip joint. Recent studies have shown that a large number of hip labral tears are associated with structural abnormalities in the hip joint itself. The common structural abnormality typically involves excess bone on either the neck of the femur (cam type) or on the rim of the acetabulum (pincer type). In either case, the excess bone can impinge upon the labrum in certain positions of the hip. If the pressure is great enough the labrum can be damaged.
To better understand this issue, let’s begin with some basic anatomy of the hip joint. The hip is a ball and socket joint. The ball is the proximal head of the femur and the socket or acetabulum is part of the pelvis.The head of the femur attaches to the shaft via the femoral neck.
The acetabulum is deep and provides a lot of stability as the ball rotates in the socket. However, the body provides an extra layer of stability to the joint by surrounding the rim of the acetabulum with a cartilage lip called the labrum that effectively makes the socket deeper and helps hold the femur head in the socket.
For normal bone morphology (shapes), the labrum receives minimal wear during movement and can maintain healthy function for a lifetime. However, for an abnormally shaped femur or acetabulum, there are certain positions in which the labrum can become pinched between the bones and be damaged. This is known as a torn labrum, specifically, the injury cause is FAI.
There are three types of FAI bone lesions: pincer, cam, and mixed impingement.
Can Yoga Cause FAI Injury?All three types involve excess bone that impedes free movement of the femur head in the acetabulum. When the excess bone is on the rim of the acetabulum, this is called Pincer FAI. Excess bone on the neck/head of the femur that distorts the normal rounded shape is called Cam FAI. If there is excess bone in both locations, we call this Mixed FAI. Click on the image to see how each of these conditions can restrict normal range of motion and create the possibility of damaging the labrum. Be sure to return to the email after the cool video!
This is the question raised by the NY Times article that is causing concern for so many in the yoga community. It is a valid question. Yoga can play a role in FAI injury. So can any number of activities that require moving the hips in a way that compresses the labrum. Injury is more likely when there is some type of obstruction so that the hip joint cannot move freely. For individuals who have Pincer or Cam or Mixed
How can you protect yourself if you are an athlete or committed yogi trying to get that next deep pose? The answer is quite straightforward.
Listen to your body and respect what it tells you.
The tissues of the hip labrum contain nerve endings that can tell you if you are creating harmful compression(4). Feelings can range from pain to nausea. If you respect those signals you can protect your labrum. Does that mean you cannot progress in a particular pose?
Discomfort in a pose can come from many sources. Pain from tight muscles can stop your progress temporarily until you identify it and apply healthy, engaged alignment in your practice. If aligning well and engaging your muscles reduces/eliminates the pain, you have a signal to proceed. If you always reach the same deep ache and/or nausea in a certain position despite good alignment, DO NOT PUSH to go deeper. Your body is telling you there is a problem. It may or may not be an FAI condition. Listen and respect your body anyway. That’s skillful yoga.
In a recent advanced yoga therapy training, I worked with a volunteer who was suffering hip pain and was diagnosed with FAI. Here is her story.
Cheryl (Phoenix): For the last 3 years, I’ve suffered from deep hip pain. It was diagnosed as osteoarthritis & torn labrum. I did a 12 week course of PT, but it didn’t really help. It limits my yoga practice, and the limitations are building, rather than receding. Walking for long distances is painful. Sometimes sleeping on my L side is painful.
Martin: How did it start?
Cheryl: I have a feeling the torn labrum was from an over-zealous adjustment in baddha konasana. I was in BK and a girl came behind me and stood on my thighs. She was close to my hips. At first, it was ok, but soon I could actually feel something tear. Too late, I told her to get off.
Cheryl’s injury was one in which an outside force (someone’s body weight) created compression of her labrum and tore it. She could feel the injury occur but because someone else was controlling the force, she was powerless to stop the injury.
Other types of forceful adjustment can also damage the labrum. For instance, attempting to push a student deeper into a forward bend from behind is very dangerous. That adjustment can damage FAI vulnerable hips, spinal discs and/or tear hamstrings.
How to Help
Cheryl reported that she felt pain in lunges and poses that compressed the space between her front thigh and her belly. That would imply that her labrum injury was in the groin region of the acetabulum (anterosuperior labrum). She feels the pain when there is compression between her femur and belly in a high lunge or in Warrior 1. The therapy I gave Cheryl involves making space in the compressed area to see if she can eliminate the pain. Here are some samples.
High Lunge Therapy
On the front (right) leg, scoop your buttocks flesh under toward the back of the front knee. Use this action to create space between your front thigh and your belly. At the same time press down with your inner front foot and widen to the right from your right thigh.
Warrior 1 Therapy
On the front (right) leg, scoop your buttocks flesh under toward the back of the front knee. Use this action to create lift on your right abdomen (making space above your right thigh). At the same time press down with your inner front foot and widen to the right from your right thigh.
Start with your right elbow on your thigh and your top hand on your hip. On the front (right) leg, scoop your buttocks flesh under toward the back of the front knee. Use this action to create lift on your right pelvis away from your thigh. If you are able to eliminate the pain, stretch your top arm over you head. If you can stay pain free, try putting your right hand on a block. If you are still pain free try putting your right fingertips on the floor for the full form of the pose. You can hold this pose at any level where you can avoid compressive pain in your hip.