HAMSTRING STRAIN AND TEAR 

This injury is often called a “pulled hamstring”. The three large muscles connecting the pelvis to the lower leg are called the hamstrings. Part of the adductor magnus is often referred to as the fourth hamstring as it plays a similar role. They extend the hip and flex the knee. 

Muscle (hamstring) injuries are divided into 3 categories:

• Grade 1 aka “overstretch” (rest, ice required)
• Grade 2 aka “partial tear” (rehab required) 
• Grade 3 aka “complete tear” (surgery required)

Worst case scenario

•  Avulsion – the tendon is torn from the bone, in some cases a piece of the bone is broken off. 

Common causes include:

• Muscle overload where the muscle is stretched or bears weight beyond its capacity 
• Sudden contraction in a lengthened position (eccentric contraction)

Contributing factors

•  Adolescence – the bones grow faster than the muscle
•  Poor warm up and stiffness before athletic activity such as sprinting 
• Muscle fatigue from overwork or poorly conditioned muscles and tendons.
• Poorly conditioned and strengthened backline..

 Good to know

• Without proper rehabilitation, hamstring sprains are known to reappear and persist for months. Many yoga practitioners suffer with recurring hamstring issues due to too much stretching and not enough strengthening. 

It feels like the stiffness needs to be stretched but actually stretching the injured tissues may slow their healing. Postures that require activation of the hamstring such as lifting the left in extension will be beneficial.

 Reference: orthoinfo.aaos.org/en/diseases–conditions/hamstring-muscle-injuries/

ACHILLES TENDONITIS/TENDINOPATHY

The Achilles tendon connects the calf muscles (Gastrocnemius and Soleus) to the heel bone (Calcaneus).

Tendonitis is the general term for a tendon that is inflamed, while the term tendinopathy includes both inflammation and tearing of the tendon. This can occur either insertional (near the bone) or mid-portion (in the belly).This is an overuse injury.

Stages include:

• Reactive tendinopathy – a microtrauma caused by an overload beyond its physiological ability. It is non-inflammatory and reversible, stiffness around the ankle is to be expected.
• Tendon disrepair – the tendon is not offloaded and allowed to return to its natural state, a series of microtraumas without adequate recovery. Inflammation may present with increased pain and stiffness.
• Degenerative tendinopathy: Non-reversible stage where there are severe adhesions to the tendon.
• Worst Case Scenario – Rupture (would require surgery to reattach/stitch the tendon)

Contributing factors and causes:

• A sudden change in exercise surface can prompt a microtrauma – e.g. from grass to tar/turf or increased uphill running.
• Increased hyper pronation of the foot is one of the most important malalignments that cause tendinopathy.
• Inflexible hamstring and calf muscles (back line), combined with poor eccentric strength

General treatment:

• Subscribed exercises to help strengthen and mobilize the tendon will most commonly involve Controlled Tendon Loading. In basic terms, this loads the tendon with as much weight and range before pain is felt to help build circulation in the tendon without damaging it further. These often include a combination of eccentric and concentric work.
• E.g.: Standing with the ball of the foot on the edge of a stair, the heel is lifted (plantarflexion) and slowly lowered with body weight into dorsiflexion, watching carefully that the pathway avoids pronation or supination. The heel is lifted again, without weight, onto the ball of the foot and the exercise repeated.
• For chronic conditions, orthotics may be prescribed for inside the patient’s shoes for supporting the alignment of the ankle.

 Good to know

• Blood supply to the Achilles tendon is low due to the limited amount of blood vessels, which affects the recovery time.
• The tendon is known to vary between the first two stages for long periods of time depending on the amount of strain placed on it.
• It feels like the stiffness needs to be stretched but actually stretching the injured tissues may slow their healing. Postures that require activation of the hamstring such as lifting the left in extension will be beneficial. 

 Reference:

 https://physioworks.com.au/injuries-conditions-1/achilles-tendonitis-tendinitis 

https://www.physio-pedia.com/Achilles_Tendinopathy

http://www.feetlife.co.uk/blog/active-feet/achilles-tendonitis-achilles-pain/

CHONDROMALACIA PATELLAE (CMP)

Also Known as  ‘Patellofemoral Pain Syndrome’. Used as an umbrella term for anterior knee pain. It is however a specific condition which presents as pain behind the patella as the cartilage on the retro patellar surface softens and degenerates gradually.

The cause of this condition is mainly biomechanical, described as the mal-tracking of the patella on its retro patellar surface. There are several reasons for the patella to misalign:

• Weakness in the quadriceps (Rectus Femoris, Vastus Lateralis, Vastus Medialis and Vastus Intermedius) during knee extension. 
• The Vastus Medialis Obliquus (VMO) and Vastus Lateralis (VL) are key stabilizers of the patella during movement – any imbalance between these muscles can cause the patella to pull medially or laterally. The VMO does not extend the knee but is the only medial stabilizer of the patella as it keeps it centered in the trochlea
• Tightness in the ITB, tensor fascia latae on the lateral side of the knee can cause ‘tilting’ in the patella
• Q-angle is the relationship between the hip, femur, tibia and patella. I high q angle (more common in women) is a contributing factor.

Good to know:

• High risk factor after a growth spurt during adolescence in which the muscles are generally weaker
• Most common in runners, dancers and gymnasts as the associated training requires the repetition of the same movements on a daily basis – if mal-tracking is present, it will rapidly assist in the degeneration of the cartilage.
• More common in Hyperextended “swayback’ knees.

Conservative treatment

will focus on correcting the biomechanical alignment from hip to knee to ankle:

• Tightness in the front of the hip and Achilles tendon tends to place the knee as the main shock absorber, it’s important to both strengthen and increase flexibility in these areas.
• Specific attention to overpronation and weakness in the Vastus Medialis 
• Surgical options include shaving the retro-patellar surface, which has also been criticized widely as patients don’t ordinarily recover fully. Another option is to perform a lateral release of the fascia by making small incisions – it should be noted that this results in further loss of quadricep strength and should only be considered after extensive conditioning to try to lengthen the lateral side.
  

Yoga treatment:

Focus on careful alignment. Asana that elongate the outer hip, thigh including the lateral quadricep (eg The Fish twist, Revolved Triangle and figure four stretch) , are helpful especially when combined with strengthening the inner line of the leg including the VMO. Improving the mobility of the hip especially the active external rotators of the hip (deep and superficial) help to correct the inward turn of the femur thus stabilizing the pelvis over the leg.

 Reference:

• Dance Technique and Injury Prevention; Justin Howse and Shirley Hancock (1992). Pg 131 – 132. A & C Black Ltd, 35 Bedford Row, London
• Patellofemoral Joint Pain Rehabilitation: How to Strengthen the Quadriceps and Limiting Joint Stress. First Ascent Physical Therapy (Nov 2014). Retrieved on 28-05-2018, 16:56 from
•  https://firstascentpt.com/2014/11/20/patellofemoral-joint-pain-rehabilitation-how-to-strengthen-the-quadriceps-and-limiting-joint-stress/
• Chondromalacia Patellae. (2018, April 26). Physiopedia, . Retrieved 16:17, May 28, 2018 from https://www.physio-pedia.com/index.php?title=Chondromalacia_Patellae&oldid=187079.

FEMORAL ACETABULAR IMPINGEMENT (FAI)

A motion related syndrome where the acetabulum and the proximal femur come into contact prematurely due to a morphology of the bone.

Two types of ACI 

• Pincer (more common in women) morphology refers to an over coverage of the femoral head by the acetabular lip/rim
• Cam (more common in men) morphology refers to a flattening of the head-neck junction of the femur 
• A combination of the two is most common

Although it is estimated that FAI is present in 30% of the population (often without symptoms), the syndrome is developed among athletes where the range of the hip joint is maximized repetitively, e.g. in dancers. 

Symptoms:

• Pain may be felt  in the  hip/groin on internal rotation and flexion of the femur. The typical indicator for Yoga practitioners is The Rotated Sage pose Marichyasana B and D  as the neck of the femur is pressed in (adducted) against the Labrum of the acetabulum.
• FAI symptoms will start to occur due to inflammation of the articular cartilage and labrum, caused by repeated forceful end range of motion in the hip. Range of motion will decrease and pain may present in buttocks and back with stiffness, clicking and ‘shifting’
  

Contributing factors and treatment

• The weakness of deep hip stabilizing muscles causing the secondary hip movers to become overloaded placing more weight on edge of the joint and labrum. 
• Over active anterior flexors and an excessive anterior tilt of the pelvis tend to create FAI on the anterior aspect. (more common in women) While dominant Glutes and Extensors and a posterior tilt create the problem towards the posterior aspect (More common in men) . Hence the importance of balancing the postural position of the pelvis.
• A surgical procedure called an osteoplasty can be performed to remove the part of the bone that causes the impingment. In severe cases where the labrum has been torn, it generally needs to be surgically repaired. Rehabilitation exercises are important to return to full function.
  
  
• Worst case scenario: the cartilage and labrum are severely worn due to the load on the morphology, possibly leading to arthritis, the hip would be replaced.

Effects of yoga:

This is an example of where stability is better than flexibility. Hypermobile athletes should develop the skill of holding back a little from full range in the hip and creating a stabilizing “banda” the “roots down from the Ischium towards the knee while folding forward at the hip. 

Collapsing into flexibility of very mobile hips will create this problem . 

Getting to know the correct alignment principles of finding a neutral pelvic tilt is part of managing FAI.

 Reference:

https://mospace.umsystem.edu/xmlui/bitstream/handle/10355/13353/FemoralAcetabularImpingement.pdf?sequence=1

https://www.physio-pedia.com/Femoroacetabular_Impingement

 http://www.jointpain.md/procedures/ImpingementSyndrome.aspx (image)

INTERVERTEBRAL DISC INJURIES

Intervertebral discs are the ‘shock absorbers’ of the spinal column and also known as Living Adaptive Force Transducers (LAFT). It consists of fibrous outer rings, the annulus fibrosis and the gel-like center, the nucleus pulposis. When this structure is displaced in the direction of the spinal column , it can increase pressure on the nerve  root which results in pain and/or discomfort. In order of severity, the four variations on a herniated disc are as follows:

 Bulging – the disc margin is extended beyond its normal shape

Protrusion – the nucleus is pressing into the annulus fibres

Extrusion – the nucleus has broken through the annulus fibres

Worst Case Scenario:
Sequestration – the nucleus has broken through the annulus fibres and the ligaments are disrupted. A portion of the nucleus occupies the epidural space.

Good to know:

• Injuries usually heal by themselves within a few months.
• Worst case scenario it may require disc replacement or fusion surgery
• They may occur due to old age as the fibres of the annulus become worn or as in active individuals, by placing a heavy load onto the spine while not in an upright position
• It can happen to any disc, but is most common in the lumbar L4/L5 or L5/S1. 
• Referred pain will occur as the nerves involved near the herniated disc will ‘send pain’ to corresponding parts of the body. A disc injury in the lumbar spine may for example refer pain to the hip, knee and foot – known as sciatica.

Yoga practice adaptation and treatment

• Avoid flexion of the injured part of the spine during acute phase and until well after the inflamation has receded. 
• Practice gentle low Cobra (Bujangasana) and Pulling Cobra for a lumbar disc injury. This elongates the front of the spine without shortening the back  to relieve pressure on the nerve root and assists in returning the disc to normal shape. 
• Maintain movement within pain free range. 
• Balance, breathing and mobilising hips and the rest of the body will help to maintain strength, coordination during the recovery period. 
• Gradually introduce spinal flexion during the recovery phase.
  

 Reference:

Alexander, M.J., 1985. Biomechanical aspects of lumbar spine injuries in athletes: a review. Canadian journal of applied sport sciences. Journal canadien des sciences appliquees au sport, 10(1), pp.1-20.

 https://www.physio-pedia.com/Disc_Herniation (all images)

SUBACROMIAL PAIN SYNDROME (SIS)/ROTATOR CUFF IMPINGEMENT

Also known as Swimmer’s Shoulder.

Common cause of irritation and pain on the lateral side of the shoulder, in and around the glenohumeral joint, particularly during overhead movements.

Categorized according to cause and grade:

• External/Primary Impingement: This is due to structural narrowing of the subacromial space (hooked acromion). This can be congenital, or acquired from bone misalignment after injury, increase in soft tissue or osteophyte formation.
• Internal/Secondary Impingement: most applicable to athletes/ active individuals: due to repetitive overhead movements such as swimming, with incorrect technique. Rotator cuff weakness, previous injury, inactivity and/or bad posture are significant contributors to unsafe rotation and abduction of the upper arm. This can be greatly improved by yoga and correcting the alignment. 

Good to know:

• Overdeveloped pectoralis major and minor pull the humeral head forward. This is common among cyclists , swimmers and kyphotic postures. 
• The repetition of the action (abduction to shoulder height/overhead) into the impingement area will compress the supraspinatus tendon and the bursa in the glenohumeral joint. In most cases this leads to tendonitis and/or bursitis.
• Physiotherapy targeted at strengthening the Infraspinatus muscle (external rotation) is often prescribed to take pressure off of the supraspinatus
•  Surgery should only become an option after all conservative treatments have been exhausted

Yoga practice

Improve active external rotation of the humorous and stability of the scapular. 

Release tension in the chest (Pectoralis major and Minor)

While raising the arms above the head allow the arms to make a wide V rather than bringing the hand together above 

Raise the scapular up with the arms rather than attempting to “draw the shoulders down”.

 References:

https://physioworks.com.au/injuries-conditions-1/rotator-cuff-impingement

 https://www.physio-pedia.com/Subacromial_Pain_Syndrome

File:SIS CP.jpg. (2017, December 17). Physiopedia, . Retrieved 14:00, May 19, 2018 from https://www.physio-pedia.com/index.php?title=File:SIS_CP.jpg&oldid=181331.