Musculoskeletal Injuries Related to Yoga: Imaging Observations
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M u s c u l o s k e l e t a l I m a g i n g • C l i n i c a l Pe r s p e c t i ve
Le Corroller et al.
Musculoskeletal Injuries Related to Yoga
Musculoskeletal Imaging
Clinical Perspective
Musculoskeletal Injuries Related
to Yoga: Imaging Observations
Thomas Le Corroller 1 OBJECTIVE. The purpose of this article is to describe the imaging appearances of mus-
Alexandra T. Vertinsky culoskeletal injuries related to yoga. We performed an automated search in the database of a
Rikin Hargunani large tertiary care center and conducted a retrospective analysis of the imaging findings in 38
Khalid Khashoggi patients over a 9-year period.
Peter L. Munk CONCLUSION. The most frequently encountered musculoskeletal injuries were tendi-
nous lesions, including tears of the supraspinatus, Achilles, and peroneus brevis tendons and
Hugue A. Ouellette
fibrocartilaginous tears involving the medial meniscus, acetabular labrum, glenoid labrum,
Le Corroller T, Vertinsky AT, Hargunani R, Khashog- and lumbar disk with extrusion.
gi K, Munk PL, Ouellette HA
Y
oga, a discipline developed 5000 scribe the specific appearances of musculo-
years ago in ancient India incor- skeletal injuries related to yoga with imaging
porating and uniting principles studies from a general population.
of posture, breathing, and medi-
tation, is thought to bring physiologic and Materials and Methods
psychologic benefits to practitioners [1, 2]. This study was approved by our institutional
Characterized as a science of self-study and review board with exemption status for individ-
development of awareness through a series ual informed consent. A retrospective automated
of specific asanas (body postures), pranaya- search in the database of a large tertiary care cen-
ma (controlled breathing patterns), and med- ter radiology department was performed and re-
itation, yoga has been embraced in modern ports generated for 2,175,000 consecutive imag-
Western settings as a form of exercise and ing examinations from January 2002 to January
stress reduction. 2011. Radiology reports were filtered for selection
In the century since yoga was introduced of cases with yoga injuries by searching history,
into the West, there has been a substantial pro- body, and impression for the term, “yoga.” Exclu-
liferation in the number of schools of yoga. As sion criteria included duplicate cases and use of
of May 2011, the Yoga Alliance, a profession- the word “yoga” out of context. Demographic data
al credentialing body for yoga, listed 1220 ap- including age and sex of the patients, history, and
proved schools in the United States and 26,690 imaging modality were recorded.
registered yoga teachers. According to a 2008 Radiographic, sonographic, CT, and MRI
Keywords: complementary and alternative medicine, survey, an estimated 6.9% (15.8 million) of studies obtained were reviewed in consensus by
imaging, sports injuries, yoga people in the United States practice yoga [3]. one staff radiologist with 10 years of experience
Additionally, another 4.1% (9.4 million) of in musculoskeletal imaging and three fellows in
DOI:10.2214/AJR.11.7440
those who are not currently practicing yoga musculoskeletal radiology. Imaging analysis fo-
Received June 28, 2011; accepted after revision said they would definitely try yoga during the cused on bone and soft-tissue injuries, including
December 4, 2011. next year [3]. Currently, yoga programs are rel- fractures; dislocations; and muscular, tendinous,
1
atively low in cost; widely available in the form ligamentous, and fibrocartilaginous tears. Full-
All authors: Department of Radiology, University of
British Columbia, Vancouver General Hospital, 899 West
of classes or through home video or book pro- thickness tendon tears were diagnosed when com-
12th Ave, Vancouver, BC, V5Z 1M9, Canada. Address grams; and, when performed properly, have lit- plete rupture of the tendon was noted [11–13]. Par-
correspondence to P. L. Munk (peter.munk@vch.ca). tle risk of adverse effects. tial-thickness tendon tears were diagnosed when a
Despite a large number of yoga practitio- defect in the tendon was noted and when there was
AJR 2012; 199:413–418 ners worldwide, only a few case reports are evidence of at least some intact tendon fibers [11–
0361–803X/12/1992–413
available in the literature of injuries incurred 13]. The fibrocartilaginous tears were diagnosed
by practitioners of this discipline [4–10]. To according to previously published MRI descrip-
© American Roentgen Ray Society our knowledge, our study is the first to de- tions [14–17]. The selected patients were divid-
AJR:199, August 2012 413
Le Corroller et al.
ed into those with positive imaging findings and tear (4.3%, 1/23), and peroneus brevis par- TABLE 1: Imaging for 23 Injuries
those with negative imaging findings. tial-thickness tear (4.3%, 1/23) (Fig. 1). Related to Yoga in
Descriptive statistics were computed for all Fibrocartilaginous injuries represented 20 Patients
study parameters in both groups with positive and 34.8% (8/23) of all injuries. The lesions in- Parameter No.
negative imaging findings. Continuous variables cluded medial meniscus tears (8.7%, 2/23),
were described by the mean and range and quali- acetabular labrum tears (8.7%, 2/23), gle- Imaging modality
tative variables by the count and proportion. noid labrum tears (8.7%, 2/23), and lumbar Radiography 2
disk annular tears with disk extrusion (8.7%, Sonography 7
Results 2/23) (Fig. 2). Transient patellar dislocation
CT 3
The term “yoga” was found in fifty-six ra- was observed in two cases (8.7%, 2/23) (Fig.
diologic reports over a 9-year period at our 3). The other encountered injuries were one MRI 8
institution. The prevalence of the use of the disassociation of the polyethylene liner from Anatomic region
word “yoga” was low in radiology reports its acetabular cup in a total hip replacement Knee 5
(0.000026%). Eighteen reports were exclud- (Fig. 4), one inguinal hernia, and one frac-
Shoulder 4
ed, representing either duplicate cases or use ture of the proximal phalanx of the great toe.
of the word “yoga” out of context. A solitary joint effusion was identified in two Hip 4
Thirty-eight patients (10 men and 28 other individuals. No other musculoskeletal Ankle 4
women; mean age, 46 years; age range, 19– injury was diagnosed. Spine 2
67 years) with acute symptoms related to Eighteen individuals (three men and 15
Abdominal wall 1
yoga were included in our study. The select- women; mean age, 46 years; age range, 19–
ed patients were divided into those with pos- 67 years) presented negative imaging studies Elemental lesion
itive imaging findings and those with nega- (47.4%, 18/38). These imaging examinations Tendon 8
tive imaging findings. included CT (n = 9), MRI (n = 4), radiography Fibrocartilage 8
There were 23 injuries attributable to yoga (n = 4), and sonography (n = 1). The anatom-
Other 7
in 20 patients (seven men and 13 women; ic regions screened included the head in seven
mean age, 45 years; age range, 19–67 years). cases; the spine in three cases; the wrist in two
These imaging examinations included eight cases; the foot and ankle in two cases; and the life [1, 2]. Currently, the practice of yoga for
MRI, seven sonographic, three CT, and two elbow, abdominal wall, hip, and leg in one case fitness and wellness in yoga studios, gyms,
radiographic studies. The anatomic regions each. The most common symptom in our pop- and community centers is broadening into
screened included the knee in five cases, the ulation was headache after yoga observed in yoga therapy provided in schools, communi-
shoulder, hip, and ankle in four cases each, seven patients (18.4%, 7/38), which was con- ty treatment centers, and even hospitals. Al-
the spine in two cases, and the abdominal sistently associated with negative imaging. though many clinicians remain unfamiliar
wall in one case (Table 1). with the practice of yoga, a 2008 survey in-
The tendinous lesions represented 34.8% Discussion dicated that 6.1% (14 million) of Americans
(8/23) of all injuries. The lesions includ- Yoga classically aims at facilitating devel- said a doctor or therapist had recommended
ed Achilles tendon partial-thickness tears opment and integration of the human body, yoga to them [3]. Yoga is recognized by the
(13.0%, 3/23), supraspinatus tendon artic- breath, and mind to facilitate self-transfor- National Institutes of Health (NIH) National
ular-sided partial-thickness tears (13.0%, mation at every level of functioning, with Center for Complementary and Alternative
3/23), supraspinatus tendon full-thickness the goal of improving the overall quality of Medicine (NCCAM) as a form of comple-
A B
Fig. 1—55-year-old woman.
A and B, Longitudinal sonographic (A) and color Doppler (B) images show intratendinous tear (arrowheads, A) of Achilles tendon.
414 AJR:199, August 2012
Musculoskeletal Injuries Related to Yoga
A B
Fig. 2—Sagittal T1-weighted MR arthrography image Fig. 3—34-year-old man with transient lateral patellar dislocation.
with fat-saturation shows tear of anterior acetabular A and B, Transverse (A) and coronal (B) proton density–weighted MR images with fat-saturation show bone
labrum (arrowhead) in 36-year-old woman. marrow edema in medial aspect of patella (asterisks, A) and lateral femoral condyle (asterisk, B) in keeping with
transient lateral patellar dislocation.
mentary and alternative medicine (CAM) in [1, 2, 20]. However, given the great variabil- possibly resulting from muscle tension in the
the category of “mind-body” medicine [18]. ity of yoga practices and teaching styles, cau- supporting musculature of the head and neck.
Other surveys assessing the familiari- tion is required and yoga practices need to Flowing forms of yoga, for example ashtan-
ty and acceptance of CAM practices by the be tailored to the individual. Albeit rare in ga, vinyasa, flow, or power yoga, are popular
general public and medical practitioners re- the literature, a few yoga injuries have, in- and involve a repetitive connected and flow-
port that yoga was ranked fifth of 39 ther- deed, been reported including, pneumome- ing sequence of postures that often requires
apies in terms of its perceived effectiveness diastinum, traumatic lymphocele, cervical the practitioner to flex the shoulder joint with
and document a growing trend of yoga prac- artery dissection, and various musculoskel- or without weightbearing on the hands.
tice by adults and children, in particular by etal lesions [4–10, 35]. For instance, verte- In the setting of poor shoulder joint flex-
children whose parents use CAM [19]. Be- bral artery dissection has been described af- ibility, the larger stabilizers of the shoulder
sides, several studies have been conducted, ter minor head and neck trauma during yoga girdle, in particular the trapezius, rhomboid,
with recent epidemiologic research indicat- practice [35]. Subcutaneous emphysema, air
ing that many individuals perceive yoga to in the retroparapharyngeal spaces, and pneu-
be beneficial for musculoskeletal problems, momediastinum have been reported after a
mental health conditions, and overall health Valsalva maneuver during a yoga exercise
[1, 20]. In particular, yoga has been exam- called pranayam [5]. In a similar fashion,
ined in the management of asthma, chronic rectus sheath hematoma has been observed
obstructive pulmonary disease, cardiovascu- after a pranayama session of yoga [6].
lar diseases, irritable bowel disease, eating Pranayama consists of breathing exercises
disorders, anxiety, fibromyalgia, and even in whereby the breath is manipulated through
children with attention deficit or hyperactiv- varying the actions of inhaling and exhaling
ity disorder [21–28]. air, keeping the abdomen taut and relaxed
Only a few works have focused specifical- alternately [6, 7]. In addition, progressive
ly on the impact of yoga on musculoskeletal glaucomatous optic neuropathy with visual
conditions, such as chronic low back pain, field loss was reported, related to the sirsasa-
rheumatoid arthritis, hand osteoarthritis, na (headstand) yoga posture practiced daily
or carpal tunnel syndrome [29–33]. Stud- for many years [36]. In the same way, mus-
ies generally resulted in amelioration of pain culoskeletal injuries related to yoga, such
and improved mobility. One MRI study even as pseudoarthrosis of the first rib and later-
showed that a group of long-term practitio- al collateral ligament rupture, have been re-
ners of yoga studied had significantly less de- ported [8, 9]. Thus, there is a need to provide
generative disk disease than a matched con- clinicians with practical information about
trol group [34]. yoga-related injuries.
The popularity of yoga has created a need In our study population, headaches were
for empirical studies to evaluate the limita- the most frequent yoga-related symptom re-
tions and potential risks of yoga as a meth- quiring imaging. The frequent occurrence Fig. 4—Frontal radiograph of pelvis shows
disassociation of polyethylene liner from its
od of wellness. Yoga is thought to have great of headaches after yoga asana practice is not acetabular cup (arrowhead) in total hip replacement
potential mental and physical health benefits surprising. Tension headaches are common, in 65-year-old woman.
AJR:199, August 2012 415
Le Corroller et al.
A B C
Fig. 5—Yoga positions.
A–D, Photographs show padmasana or lotus posture (A), eka pada sirsasana or leg
behind head posture (B), salamba sirsasana or headstand posture (C), and adho
mukha svanasana or downward facing dog posture (D).
D
and levator scapulae, can become overused sure through increased resistance to venous headaches from yoga practice is certainly
and go into spasm in these yoga practic- drainage, although this is unlikely to affect the possibility of cervical artery dissection,
es. Inverted postures, such as the shoulder healthy individuals. Heated forms of yoga which can result from minor trauma, in-
stand (salamba sarvangasana) and head- (Bikram, Moksha, and hot yoga) are also cluding twisting or torquing motions of the
stand (shirshasana) (Fig. 5) can also put sig- quite popular, and practitioners may experi- neck. Any patient presenting with headaches
nificant strain on the neck when performed ence headaches due to dehydration or elec- should have a full neurologic examination,
with improper alignment because the body trolyte imbalances from excessive sweating and head CT and CT angiography from arch
weight is directed downward toward the in temperatures up to 108°F or may expe- to the circle of Willis should be considered in
shoulders, head, and neck in these positions. rience symptoms from hyperventilation patients with neurologic symptoms.
It is conceivable that such inverted postures or holding the breath during exertion. The Musculoskeletal injuries related to yoga can
also cause slightly elevated intracranial pres- greatest concern in patients presenting with occur as a chronic repetitive strain injury, an
416 AJR:199, August 2012
Musculoskeletal Injuries Related to Yoga acute event, or a combination of an acute event movements performed in all forms of yoga. juries related to yoga can occur as a chron- superimposed on chronic strain. Anatomical- If an intervertebral disk is already degen- ic repetitive strain injury, an acute event, or a ly, tendons, myotendinous junctions, and fi- erated, forward folding movements can in- combination of an acute event superimposed brocartilages are the most vulnerable struc- crease pressure on the disk and result in a on chronic strain. In this article, we have re- tures to injury [6]. Yoga postures can be fairly disk herniation. Yoga practitioners who per- ported our experience with imaging of yoga demanding of flexibility and require strength form deep back bends may put pressure on injuries in a retrospective analysis of radio- of the stabilizing muscles to be performed the facet joints if the backbend is performed logic studies performed at our institution. We safely and provide benefits. Particularly in in an unbalanced fashion with accentuation have observed that tendons and fibrocartilag- large classes without adequate instruction, of the bend usually in the lower back. Be- es are the most vulnerable structures to injury new yoga practitioners may attempt to per- cause yoga is more commonly practiced by and have described yoga postures that may be form postures that their bodies are not ready women, we found a higher prevalence of this linked to the reported cases. to accommodate. Even if a movement or pos- injury in women in our population. ture does not elicit immediate injury, if per- In our study, injury was more frequent in References formed incorrectly, it can strain structures women (65%). Note that, given the usual sex 1. Posadzki P, Ernst E. 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