Sitbone Pain from Yoga Asana

(Proximal hamstring and adductor magnus tendon injuries)

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.

I’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

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

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. Ice after practice – or just Ice if not entirely practical

Week 1-2, daily practice

To strengthen the hamstrings and glutes

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. 5 reps each leg.

Dhanurasana Prep.

Both feet over a bolster, engage as if lifting legs off the bolster but don’t lift. Hold for 10 breaths. 5 reps.

Partial Supta Padangustasana 

Place right heel on a brick, press heel down, hold for 10 breaths. Repeat left. 5 reps each leg.

Week 3-6, daily practice

To further strengthen the hamstrings and glutes

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. 5 reps each leg.

Dhanurasana Prep.

Weeks 3-4

Start to lift the feet off the bolster a little. 3-5 reps.

Weeks 5-6

Remove the bolster and work on lifting the legs from the floor at a right angle. 3-5 reps.

Partial Supta Padangustasana 

Weeks 3-4

Move up to a firm bolster

Weeks 5-6

Graduate to a chair, no more than a 45 degree angle. 5 reps each leg.

Week 1-6

Daily practice. To further strengthen the glutes and then gently lengthen the hamstrings

Setu Bhanda Sarvangasana 

 

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. 3 reps of 5 lifts.

Supta Padangustasana

Weeks 1-6

With a belt –  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. 5 minutes each leg.

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.

Setu Bandha Sarvangasana 

Come up into bridge and isometrically pull the heels towards the shoulders – without actually moving them, hold for 30 seconds. 3 reps x 5 lifts

Eka Pada Setu Bhanda Sarvangasana

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

Supta Padangustasana

with resistance

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 created a little i-phone video to demonstrate some of the exercises mentioned above. The quality isnt brilliant but you will get the idea.

Sources with gratitude:

• Protect hamstrings in forward bends, Roger Cole
• http://www.yogajournal.com/for_teachers/981
• Yoga for the hamstrings, Jude Gudmestad
• http://www.yogajournal.com/practice/1391
• Recovering from upper hamstring tendon injury – Doug Keller
• http://yogainternational.com/article/view/healing-or-preventing-hamstring-injuries
• ‘Yoga Butt’ injury – Niki Vetten
• https://nikivetten.wordpress.com/2011/07/04/yoga-butt/#more-841
• David Keil: Got sit bone pain. What to do with that hamstring.
• Got sit bone pain what to do with that hamstring/