Sitbone Pain from Yoga Asana

(proximal hamstring and adductor magnus tendon injuries)

by Jenni Crowther

Unfortunately enough yoga practitioners suffer from sitbone pain that it has been nicknamed ‘yoga butt’.  We may more correctly refer to this condition as ‘proximal hamstring tendon injury’.The length of time that it may take to heal and the way it will influence your physical practice make it a concern for both new and experienced practitioners.

hamstring-attachments-webI’m a Level one Anatomy and Physiology student of Stuart Girling, and not an expert in matters of the body by any stretch of the imagination.  I have myself struggled with pain from a proximal hamstring tendon injury for over a year and so I have much personal experience to go by. This article is the result of my research into what to do with my injury and how to heal it. The source articles of my research are listed at the end of the article, I have merely combined their findings and summarised them in my own words with my own experience overlaid.

What’s a hamstring?

The hamstrings are a group of three muscles on the back of the thigh that connect the pelvis to the knee and the lower leg. They are responsible for extending the hip, flexing the knee, keeping the body upright and the pelvis stable.

The individual muscles are called semimembranosus, semitendinosus (that sit on the medial side) and bicep femoris (that sits on the lateral side). Their proximal attachments are to the ischial tuberosity, or sit bone, at the base of the pelvis, and their distal attachments are to the outsides of the tibia and fibula (lower leg). The adductor magnus muscle, sometimes referred to as the fourth hamstring, also connects to the ischial tuberosity, just medial to the hamstring attatchments. Damage to its proximal tendon will cause pain to be experienced in a very similar area (although slightly more medial) especially in wide legged forward folds.

What are we calling this?
  • ‘Proximal hamstring tendinopathy’
  • ‘Ischial tendonitis’
  • ‘Sit/Sitz bone pain’
  • ‘Yoga butt’
What does it feel like?

Symptoms may include pain and discomfort in the sit bone area

  1. when sitting
  2. in forward bends
  3. when stretching or contracting hamstring
  4. when walking, climbing stairs or running
What’s causing the pain?
  • In some forward bends, the muscles in question are not engaged and cannot protect themselves, so rather than the belly of the muscle stretching, the tendon gives way, with tiny tears destroying blood capillaries and breaking down the collagen molecules in the tendon.
  • Left alone this will take a few days to heal, but if you keep practicing, more little tears build up faster than the body can repair them and scar tissue forms.
  • The more you try to ‘stretch through it’ the more scar tissue builds up and the weaker the tendon gets, becoming inflamed and sore.
  • The scar tissue limits blood circulation to the area, meaning the area is increasingly damaged, painful and less likely to heal.
Who is most likely to be affected?

Anyone can suffer, but those at greatest risk:

  • People with over-flexible hamstrings
  • Yoga teachers
  • Dedicated practitioners (Particularly of Ashtanga primary series.)
Theories of causational factors
  • The Ashtanga primary series has LOTS of forward bends with a straight back.
  • Dogma says you shouldn’t practice Intermediate series, which has lots of back-body strengtheners (counter-poses for forward bends), until you have mastered Primary.
  • Ashtangis quite often only do their practice, without any other form of physical exercise.  This means potentially weak glutes, obliques, hips and hamstrings (imbalance alert!!!)
  • Teachers often demo forward bending while too cold, or practice too hot and fatigued.
Bad technique – what might I be doing wrong?
  • Anterior pelvic tilt or over-arching the lumbar spine in forward folds (swan dive)
  • Flexible but inactive and weak hamstrings as you go forward, suddenly tightens at the bottom of the fold (bungee)
  • Lack of internal drishti (thinking about what you’re having for breakfast)
  • Going too deep if any discomfort occurs (choosing full expression of the pose over comfort)
Good technique – What could I be doing better?
  • Neutral pelvis: Tucking the tailbone, drawing in the ribs, slightly rounding the back
  • Engagement of the hamstrings as well as the quads as you forward bend to allow for eccentric stretching of the muscles
  • Be totally present in the body for each asana, no matter how routine it is or how ‘good at it’ you are
Prevention is better than cure: Teacher general guidelines
To bend or not to bend?

Some teachers tell you to always bend the knee(s) of the leg with the affected hamstring(s), some tell you to keep legs straight. Which is correct?

In my personal experience, some poses worked better with bent legs, some worked better with legs straight and just not going as deep into the fold. I would often modify differently to keep a balance, for example, Padangustasana with legs straight to gently elongate the hamstrings, then Padahastasana with deeply bent legs to get a lumbar spine stretch. I agree with David Keil’s findings on the bent knee causing more tension at the site of the injury, but sometimes I just wanted to extend my spine fully.

As a teacher, if you can see the student has a bent knee then you know that the student is being mindful and modifying the pose, with legs straight it’s less obvious if they are causing themselves pain. So my advice would be to, talk to the student, explain the problem, the options and the potential injurious consequences of not modifying, and then get them to try different versions, and let them know that it’s OK to choose their own modification on each day for each pose, depending on how it’s feeling. But really emphasise patience, some days it feels fine and that’s when they’re most likely to over-stretch and go back to square one.

DON’T
  • Allow yourself or anyone else to feel pain in the affected area
  • Demo poses yourself without being properly warm
  • Allow students to force themselves too deep into poses
  • Make adjustments without proper information about student’s injuries
  • Over-adjust your students in forward bends
  • Be too rigid or homogenous with your yoga asana choices
DO
  • Practice with complete compassion
  • Talk through poses, or make sure you warm up before taking class.
  • Emphasise conscious muscle engagement and proper focus
  • Educate yourself as to the poses that need modification or skipping
  • Be very cautious of the potential for injury
  • Create an all-round practice that strengthens sides and back of the body as well as the front.

Stage one: Inflammation.

The first 48-72 hours

The body needs to stop the bleeding, clear away damaged tissue and prevent infection.

  • REST:                           No forward bends, AT ALL!!
  • ICE:                              15 minutes every hour or so (make sure skin has returned to room temperature before you ice again. The more boney you are the less time you should ice for.)
  • COMPRESSION:           Strap the area up
  • ELEVATION:                 Get it higher than your heart
Recovery pose: 
Supported Setu Bandha Sarvangasana

Supported Setu Bandha Sarvangasana

Supported Setu Bandha Sarvangasana

 Stage two: Repair

6-8 weeks

The body needs to construct a delicate cellular and molecular matrix to reconstruct capillaries and connective tissue. It will then start filling it with haphazard fibres.

We need to gently stretch and strengthen to help align those fibres.

1. Frictioning

For long term injuries where scar tissue has already built up, start a program of frictioning to break down the scar tissue. Frictioning is ‘plucking’ the scar tissue with your fingers across the fibres of the tendon. Or you can sit on a tennis ball and rock back and forth.

5-15 minutes before asana practice.

2. Warm up

Walk for ten minutes before asana to warm up the muscles

Swing the leg like a pendulum back and forth gently to get the same effect.

3. Repair asanas: detailed later
4. RICE after practice – or just Ice if not entirely practical.
Week 1-2, daily practice

To strengthen the hamstrings and glutes

Partial Shalabasana – 5 reps each leg.
partial shalabasana

partial shalabasana

Lie prone drawing in the abdomen. Engage hamstrings and glutes as if lifting right leg into Sarvagasana but don’t lift the foot. Hold for 10 breaths, Repeat left.

Dhanurasana Prep.- 5 reps.
dhanurasana prep

dhanurasana prep

Both feet over a bolster, engage as if lifting legs off the bolster but don’t lift. Hold for 10 breaths.

Partial Supta Padangustasana – 5 reps each leg
partial supta padangustasana

partial supta padangustasana

Place right heel on a brick, press heel down, hold for 10 breaths. Repeat left.

Week 3-6, daily practice

To further strengthen the hamstrings and glutes

Partial Shalabasana – 5 reps each leg.
partial shalabasana

partial shalabasana

Weeks 3-4 Start to lift the leg an inch

Weeks 5-6 Lift the leg a few more inches, no more than 5.

Dhanurasana Prep.– 3-5 reps.
dhanurasana prep

dhanurasana prep

dhanurasana prep 2

dhanurasana prep 2

Weeks 3-4 Start to lift the feet off the bolster a little

Weeks 5-6 Remove the bolster and work on lifting the legs from the floor at a right angle

Partial Supta Padangustasana – 5 reps each leg
partial supta padangustasana

partial supta padangustasana

partial supta padangustasana 2

partial supta padangustasana 2

Weeks 3-4 Move up to a firm bolster

Weeks 5-6 Graduate to a chair, no more than a 45 degree angle

Week 1-6, daily practice

To further strengthen the glutes and then gently lengthen the hamstrings

Setu Bhanda Sarvangasana – 3 reps of 5 lifts.

 

setu bandha sarvangasana bridge

setu bandha sarvangasana bridge

Weeks 1-6

Very gently start working to lift into bridge, it may be that you start Week 1 just intending to lift and gradually work up a few inches at a time to full bridge.

Supta Padangustasana
supta padangustasana

supta padangustasana

Weeks 1-6 with a belt – 5 minutes each side

Loop a belt over the right foot and take it perpendicular to the body, on the comfortable side of the hamstring – no stretching sensation. Take the leg out to the side after 3 minutes, supporting the hip with a block. Repeat left.

Stage 3: Re-modelling

6-12 months of love

We need to help the body to strengthen the healing tendon and build long, strong hamstrings.

The number one rule is NO PAIN.

Any further damage will take you back to stage one and the whole process will have to be repeated from scratch.

Shalabasana – build up to full pose and then on to Urdhva Danurasana.

shalabasana

shalabasana

Setu Bandha Sarvangasana – 3 reps x 5 lifts
setu bandha sarvangasana bridge

setu bandha sarvangasana bridge

Come up into bridge and isometrically pull the heels towards the shoulders – without actually moving them, hold for 30 seconds.

Eka Pada Setu Bhanda Sarvangasana
Eka Pada Setu Bhanda Sarvangasana

Eka Pada Setu Bhanda Sarvangasana

When comfortable with stage one, add in a leg lift to further strengthen the glutes.

Supta Padangustasana with resistance
supta padangustasana 2

supta padangustasana 2

Working up from the chair at 45 degrees, to a doorjamb pressing the heel away to extend the leg from the hip. Gradually work up to 90 degrees with NO PAIN.

I hope you have found this helpful or at least a starting point for further research. Please feel free to contribute your own experiences in the comment area below.
Jenni

Jenni created a little iphone video to demonstrate some of the exercises mentioned above
Sources with gratitude

jenny
Bio: Jenni Crowther has been practicing Ashtanga Primary series since 2009, after attending her first class and becoming instantly hooked. Practice was initially with Joey Miles in Leeds, where she had a corporate office life, and it gradually took over her life (early nights, no booze etc) until eventually she quit it all to go to France, then Crete, then India as a yoga student and now qualified teacher, after recently completing her 200+ YTT with Heather Elton et al in Goa. She is also pretty injury prone – hence this article

You can visit Jennie’s website here.

I really hope this article can be a springboard for a discussion on this topic. Hamstring injuries can be an upsetting problem for many yoga practitioners . If you have found something that really worked for you it's time to share! Add you comment below and let's see if we can help as many people as possible.

I really hope this article can be a springboard for a discussion on this topic. Hamstring injuries can be an upsetting problem for many yoga practitioners . If you have found something that really worked for you it’s time to share! Add you comment below and let’s see if we can help as many people as possible.

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9 Responses

  1. Debra says:

    Jenni, YESSSSSS. I developed this problem 9 months ago. I thought it was merely due to my desk job and clenching due to divorce court battles. But relaxation was not THE answer. I intuitively sensed that I needed to stop the yoga. After much research, I found a Restorative Exercise (based on Katy Bowman’s program) at a nearby PT clinic. There I learned about week psoas and glutes.

    Part of the problem is that yoga studios often say that all you need is yoga to be fit — strengthen, get aerobic, etc. I was taking classes for about 5 years at my local Iyengar studio where attention to detail is given so I thought I was “safe.” The modern average 1-3 times a week practioner cannot rely on yoga alone to develop strength. I always touted the party line and espoused that to all my friends. But my injury has taught me otherwise. It is comparable to someone

    Plus I’m over 50 so I figure I’ve got a the added issue of loss of muscle mass. I also think that I might have one leg that is longer than the other too.

  2. Debra says:

    sorry about the typo’s above.

  3. Nadia Rihani says:

    Wow thank you so much for this article! Having practiced Ashtanga for close to 10 years I feel quite lucky that i only had my first hamstring injury 6 months ago. After it initially died down for a few months, now that the temperature in Sydney is dropping I am feeling it again.
    Having taught yoga for over 5 years i have always been telling students to bend their knees in all forward folds, which to my discovery only makes the tear feel worse. I am learning a lot from this injury but thats for adding an article that offers so many options for moving forward to heal the injury.
    Nadia

  4. Katy says:

    Interesting article – great practical tips on building up back into full practice.

  5. pete says:

    I have sit bone pain on my left side for several months. It is excruciating pain at all times when i am sitting. The only time that i found relief was taking prednisone. I had an m r i but that was of the hip area. The doctor told me that they can see the groin and sit bone area on the m r i . I do not believe her. What is your advice. The pain is substantially less when standing and laying down, but the very top of this area by the sit bone is always very tender and sore. I can not sit at all. Not even for 1 minute. Please can you give me some advice. It also is sore in the hip flexor area when sitting.

  6. Sandra Karallus says:

    Hi there!
    I have been experiencing very bad sitbone pain for over a year now. It has been at its worst while sitting and getting out of a car seat or any kind of chair. At the beginning I had an MRI of the lumbar spine and I was told that this pain in the butt is referred pain coming from the lower back where they found mild disc degeneration, mild facet joint disease, no bulged discs but a bursitis in the back. A cortisone injection into the lumbar spine did not help me at at all, and I was not convinced that my symptoms were purely coming from the lower back! I tried acupuncture, massage, Bowen Therapy, but nothing would help. My physiotherapist recommended Pilates which I have been doing now for the past 5 months after I had eventually given up on my vinyasa flow yoga practise, because every time I went back to practising yoga, it got worse, and the pain has been driving me nuts! I have been learning a lot about the whole hip area, the hip flexors, that I do not engage my core and pelvic floor muscles enough and that I am a butt gripper. The physiotherapist that I saw at the very beginning diagnosed me with trochanteric bursitis on the left and probably tendinopathy/tendonitis. After one year of pain I just recently had another MRI scan – this time of the lower back, the pelvis and the upper thighs. This MRI was reported by a senior sports injury radiologist and it pains me to say that the findings were bilaterial proximal hamstring tear(s), bilaterial trochanteric bursitis and tendinopathy! Sound like I have been suffering from Yoga Butt Injury, and I am still struggling to believe that my yoga practise is the culprit for my agony.
    I will now go and see another physiotherapist specialising in sports injury and on recommendation also an orthopedic surgeon. As every body is so different (musculoskeletal and other wise) I am convinced that not every yoga posture is for every body especially not the forward bends and that there is simply too much repetition of these in modern westernised yoga practices.
    Any recommendations on my very frustrating condition or with regards to practising yoga are very much appreciated. Namaste from QLD, Australia, Sandra

    • jogonjen says:

      Hey sandra, thanks for your lovely detailed comment, I have to say, it is against the common idea of yoga, but yes, it took me a while to accept that yoga was the cause of my injury too! once i accepted this though, I just had to let go of ALL ambition in my forward bends. If i felt ANY sensation in the area I had to back out immediately. I actually stopped my asana practice for a week or two to give it a rest and then worked with the programme above to heal. I now no longer care if i reach my feet in a posture, i’m more interested in healing my butt now!! It’s about 8 months on since i started healing – it still flairs up from time to time, but i only practice full primary once or twice a week now. Good luck – be kind to your butt 🙂 xx

  7. Pepa says:

    Hi Jenni,

    I just wanted to thank you for such a great and helpful article. 10 days ago I started feeling a strong discomfort and pain in the sit-bone… I stopped the practice for 5 days and followed your instructions, RICE the first 5 days; then re-started the practice (gentle, conscious 😉 ) and added the exercises.

    I am now feeling much better. I am aware of the hamstrings and trying to engage them as much as possible while practicing; it has made a big difference.

    I will see how it goes and keep on adding the exercises for the following weeks.

    Again, thanks for such a helpful piece of advice!!
    Cheers,
    Pepa

  8. Jooj says:

    Hi Jenni,

    What are your thoughts on getting a massage? I’m in week 4 of my injury and it hasn’t been getting better, if anything it has gotten worse a couple of days ago. Would a massage help at this point? And would you recommend the friction technique now or a bit later? Finally, would you discourage daily vinyasa or ashtanga practice. I was a bit unclear whether the exercise outlined were the only exercises you recommended during this time of recovery or if it was in addition to any daily practice.

    Thanks so much! I’ve found your article to be so incredibly informative and helpful!

    Best,
    J

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