In Part 1, we discussed general principles of working with yoga injuries. In this and the next column, we'll cover some specifics for a few common injuries, stressing how to avoid making them worse as you try to make them better. Since individual injuries vary as much as the individuals who have them—and because there are many useful approaches within the worlds of yoga—consider what follows simply as rules of thumb, not rigid principles. As always, what you observe and your students' actual experiences will trump any ideas about what's supposed to be therapeutic.
If the knee is swollen or shows other signs of inflammation (see Part 1), you may need to avoid most active asana practices, instead focusing on restoratives and breathwork. Until fully recovered, students should step, not jump, into poses. Be particularly careful with squats such as Utkatasana (Chair Pose) and Malasana (Garland Pose), as these can cause shearing forces (horizontally across the joint) on the knee. You may also need to avoid one-legged poses such as Vrksasana (Tree Pose), since the joints in the standing leg are under twice as much pressure. This is particularly true of students who are overweight (common in people with knee injuries).
If poor alignment of the knee is an issue, rather than going directly after the knee, especially in the early stages when swelling and inflammation are present, turn your attention to the foot and ankle and the hip. Misalignments in these neighboring joints can lead to knee misalignment, while correcting them can make a big difference in knee function. If tight hips are contributing to misalignment, a variety of hip openers may be useful. One that I like is the supine pose sometimes called Threading the Needle, in which, from a supine position, you first bring the right ankle over the bent left thigh, holding onto the back of the left thigh, moving the left knee toward you and the right knee away from you, before repeating on the other side. Although Virasana (Hero Pose) can be therapeutic for students with knee problems, you'll usually need to support the hips with blankets or a block or you risk torqueing the knee, potentially exacerbating the problem. In this and other bent-knee poses, some students with knee pain benefit from placing a tightly-rolled washcloth or other prop behind the knee to create additional space in the joint.
If the knee joint is painful but not acutely inflamed, several brief repetitions of standing poses may be preferable to longer holds. You can take some of the burden off the joint in standing poses by supporting the body's weight. In Virabhadrasana II (Warrior II Pose), for example, have your students place their hands on a table or platform behind them, or use a chair under the front thigh. Even using a block under the hand in Trikonasana (Triangle Pose) can take some of the weight off the knee. In Triangle and other poses, be sure your student is not locking the front knee, as this can compress the medial meniscus, the cartilage that cushions the portion of the knee closest to the body's midline. If you find this pattern, instruct the student to place more weight on the ball of the front foot and less on the heel, and to keep a "micro-bend" in the front knee (which actually isn't a bend at all; it just feels that way if your habit is to hyperextend the joint). For a student who has trouble breaking this habit, try wedging an angled block between the floor and the student's front calf.
Back injuries come in so many varieties that it's difficult to come up with useful rules of thumb that will apply to all of them. People differ in their postural habits and patterns of muscle tightness and weakness, as well as the precise location of their injuries. Dozens of different muscles can go into spasm, numerous ligaments can be strained, and a variety of joints can be inflamed, and from a yogic perspective each may require a different response. Even what's contraindicated may vary based on the mechanism of injury. Most cases of what doctors lump into the categories of low back strain and sciatica respond to gentle backbends, including Bhujangasana (Cobra Pose), while many forward bends may exacerbate the problem and are generally contraindicated in the early stages after the injury. Seated and standing forward bends, in particular, can compress the front of the lumbar spine, causing the spinal discs in between the vertebrae to budge backward and to the side, potentially pushing on nerves exiting the spinal cord. On the other hand, yoga injuries caused by overarching the lumbar spine may benefit from forward bends such as Uttanasana (Standing Forward Bend), whereas even gentle backbends may make matters worse.
One thing doctors have learned in the last couple of decades is that babying a sore back is not the best way to go. When I was in med school, we were taught to put people with acute back pain on strict bed rest for several days at least. We now know that's ill-advised. Studies show that people do better when they resume gentle exercise soon after injury. First try to find poses in which the student is pain free, such as Pavanmuktasana (Supine Knee-to-Chest Pose), and then gradually work up from there over the coming days and weeks, always being guided by what you observe and what the student reports.
As always, try to personalize your approach based on the specific pattern of tight muscles, underworking muscles, and postural misalignments you observe—as well as your student's response to the therapeutic measures you try. One-size-fits-all back exercises, such as the kinds doctors often recommend to strengthen the abs, don't work well, and recent evidence suggests they may actually be counterproductive. This should come as no surprise to the yogi, since we know that some people get back pain from an unhealthy flattening of the normal inward curve of the lumbar spine. Stomach crunches, which can tighten the hip flexors, may only make matters worse. Luckily in yoga, particularly with students who've developed good body awareness, pain (or the relief of pain) as they do the poses you suggest—as well as their breathing and the balance of effort and ease—will indicate whether the poses are likely to be harming or helping.
In Part 3, we'll look at wrist, hamstring, and shoulder injuries.
Dr. Timothy McCall is a board-certified specialist in internal medicine, Yoga Journal's medical editor, and the author of book Yoga as Medicine: The Yogic Prescription for Health and Healing (Bantam). He can be found on the Web at www.DrMcCall.com.