Does Yoga Cause Hip Replacements?

Transcript

so welcome to the K yoga podcast today's guest again on for the third time is Bernie Clark welcome Bernie thank you Adam ni to be back I consider Bernie one of the foremost experts in the yoga Anatomy field in fact his books your body your yoga I think it's a Trilogy your lower body your yoga and your yoga your spine or something along those lines uh anyway put put them into Amazon you could find them I'm highly recommended I've read them loads of times still reading them because I find Anatomy hard to understand but if anything I've learned my anatomy a lot is down to Bernie's book so for better or worse in terms of my own Anatomy understanding don't put it down to the books anyway on that note today yeah Bernie yeah you're welcome it's you've done a service to the industry honestly U but today we're going to talk about my hip uh well hips in general but my hip uh come clean recently and said look it's about time for for you guys to know that I'm in line for a hip replacement a bilateral hip replacement not a resurfacing the whole thing um Bernie's prompted me on a number of uh discussions we've had about exactly what's going on and I realized that there was a a couple of details that well I W wasn't quite clear of um and also just kind of debunking or going through these ideas now that uh yoga causes hip replacements I'm certainly something that stuck in my head people have said it to me um all these yogis now are having early hip replacements so having spoken to BU a little bit about that we wanted to talk a little bit more about that having a little bit more information so uh yeah the claim that yoga causes serious hip injuries Bernie which you start there and your research or your understanding on it yeah I mean definitely anything can cause a problem in the hip playing sports can cause it having accidents car accidents can happen uh yoga could be a cause but generally it is and I'll talk a little bit more about why that is it could make it worse if you have uh some sort of thing but maybe just as an overview let's define what we mean by a hip just a little bit of anatomy because a lot of people they put their hands on the where the belt is and they say that's my hip or then we reach down the side of the the Torso and say that's my hip so what exactly is the hip well anatomically we're talking about the top end of the femur this called the proximal end just about where the greater tranter is and the neck of the femur and the ball of the femor so if you reach down to your side and you feel that bony bump that's called the greater tanter we have a lesser tranter inside you can't feel that one but that part upwards into the acetabulum which is the hip socket that's generally what an anatomist call The Hip this is the area that we're talking about here and there's roughly six causes of pain in this region it goes by the acronym stairs I know if you've heard this before but s t a i RS the first s stands for strains so we got a whole bunch of muscles here we have the muscles on the side that abduct the leg apart that's mostly your gluteus medius we have the muscle on the back your gluteus maximus that can extend the leg you have in the inside of the groin the adductor muscles that can adduct the leg you have the muscles in the front like the alio soaz and your erectus florus and that flexes the leg then we got the seven external rotators and a few internal rotators so we got those kind of six groups of muscles if you pull a muscle that could be a strain so you might feel pain here due to muscle string and generally that will resolve itself over a few weeks just conservative treatment don't do anything too fancy to it the next one is called trochanter pain which is again that big pumpy bone hair this is where your IT band goes and a lot of Runners and people do a lot of outdoor activity that IT band can get quite tight and you can compress the tranter Bersa here and that can cause a lot of achy pain so for a lot of people you just got to stretch that out and kind of lay off it for a while let the inflammation die down some people it's so bad they actually have to have the Bersa taken out but often it'll grow back again so that's the tanter pain then we get the next one's arthritis A is for arthritis the I is for impingement these are the big ones so we'll come back to those so we got the strains we got the trochanter arthritis impingement and then we have the next R is for referral if you have back issues like you've got a slip disc not literally a slip disc there's a bulge in the disc it might be compressing a nerve root or you got some bony grow growth or senosis and you got pinching on the nerves itself in your lower back that may show up anywhere that nerve goes so there's big long nerve called the sciatic nerve it goes from kind of your Lumbar and sacral region all the way down to your foot and if you compress those nerve Roots you can feel a burning in your foot you can feel ning in your butt you can feel pain in your hip so these are referred pain there's nothing matter with your hip but you feel it there the sixth one s again is sciatica or the sacc region there can be a lot of pain there and some instability usually the sacrum and ilum these bones here they're fairly tightly bound together there's very little movement there on the order of a millimeter or two but for some people especially if you've had a baby and all that got loosened up and stretched out there's some instability there which can cause pain in the pelvic region so those are kind of the main causes but if we go to the a again and the I the impingent Sy syndrome these are the areas a lot of people think that yoga has been causing my problem so let's let's start with the ey for impin basically you think of the neck of the femur there's the big long shaft of the femur and then there's the head or the ball of the femur it's joined with the neck and then the hip socket itself has got this fancy Latin name for it it's called The acetabulum which means vinegar cup like you drink vinegar out of this cup here more like a saki cup to me well it's a weak wine I guess you just drink your wine out of the stuff so you got the rim of the acetum you got the neck of the femur and for some people these two bones hit and that's called an impingement if you try to get maximum range of motion out your hip socket say an external rotation you're more likely to come into that point of impingement but it turns out that most of the impingment happens in the front part of the hip now everyone's femur is different the angle of the neck of the femur is different the orientation of the curve of the the the femur is different so some people will never get impingement it's never going to be a problem some people very easily get impingement there's a condition that usually only men well mostly it happens to men but one in four men have it it's called a cam and that's where the neck of the femur instead of having a nice narrow waist it gets a bit thicker there and it always tends to be thicker in the front top part of the neck so this front part top of the neck is because it's thicker in about 25% of men and about 14% of women it leads to impingement on the rim of the hip socket more easily than the people have that nice waist shape neck ha here those people don't normally get it on the other hand the acetabulum has a lip of cartilage here called the labrum and for some people mostly women that labyr room can be quite overgrown it can happen about 14 15 20% of women hardly ever happens to men though so men tend to have the cam the thicker neck women tend to have this this penser they call it the laboral overgrowth here and either case if you have too much of that you're going to get more likelihood of an impingent happen now I spent a lot of time playing with the bones and saying well how does the bone move where would impingement arrives and if you actually play with a bone and you internally rotate the femur eventually the front part of the neck of the femur is going to impinge on the front part of the hip socket that's called Fai for moral acetabular impingement sometimes there's a Ness on it moral acetabular impingement syndrome so you get that pinching there and over time it can start to wear away the laum or you can start to crush the cartilage inside the hip socket all the bones are lined with cartilage very slippery thing so the inside of the hip socket is all cartilage you got that lip around it album cartilage at the end of the femur you got cartilage and that lubricates the movement but if you Contin to get to this point of impingement sometimes you can start to crush the cartilage underneath there and delaminate it now not everyone will get impingment a lot of I've heard some yoga teachers warn about Flex they're afraid that if you do too much flexion in yoga like lunges we always flexing the hip you're going to increase your impingement yeah but if you ever get a a pelvis and a femur together there's no impingement in flexion you can Flex all day long and the two bones won't hit if you add a bit of internal rotation and then flexion that's when the roof of the acetabulum starts to impinge on the neck of the femur and that's when you get the FAL so it's not just pure flexion it's flexion with ad or internal rotation sorry and also it can be with some degree of adduction if you abduct you actually go away from that impingement there is a study done in Switzerland that showed who is most likely to get impingement and they they showed that this happens mostly the people who for genetic reasons when they're growing up they had a big cam in the neck of their femur and these are the ones that later in life when they're an adult they get the impingement people who don't have that big cam never seem to get it but even if you get that big cam you also have to do the internal rotation do internal rotation and adduction sorry flection internal rotation and flection then you can get the impen so what poses here's a quiz for you Adam what poses in yoga do we do in rotation and flexion well first of all I mean first of all I'm going to say if you're listening on the on the podcast uh go to the YouTube video and watch this because if you're anything like me it's not it's not simple to follow um but answer you a question about internal rotation and fle internal rotation and flexion I mean is this something to do with that the article you sent me with Michelle Edwards and and the um the impingment of the hip situation yeah yeah her and William Brad wrote this thing decade ago saw that claim that we're getting a lot of hip replacements because of flexion because well it's not flexion it's flexion in internal rotation yeah yeah yeah yeah so we'll ask we'll link that article because it's very interesting and you can see Bernie's replies and it'll give you a lot more thorough in-depth uh ideas that you could Ponder in your own time because not simple in um to answer your question about inter um I mean would it be a standing forward fold would there be interation there kind of kind of exteral isn't it I mean um well yes no it maybe that that's one of the answers yeah the most obvious one is when you're doing Eagle Eagle rotating and then you're folding so that is the most obvious case or if you're doing barasa where you're sitting between the feet you have to internally rotate to sit between the feet and then your hips are Flex 90 degrees to sit sitting there so those two cases definitely you're doing internal rotation and flexion no matter who you are now there are some people because of the orientation the hip socket you you were talking before we started about these two terms antiv verion and retroversion yeah the average pelus has a hip socket that you can see when you look straight to the front y that is an anti- verted it's its version its angle is forward but for some people the hip sockets are retroverted they're pointing out to the side and when you look at a pelvis from the front you wouldn't see the hip sockets now these people when they stand their feet are turned upward they're very externally rotated and yet a teacher may come to them they want to stand with their feet pointing out like 40° or more and the teacher will say in Mountain pose have your feet pointing forward well that's causing them to internally rotate in the hip soag that's not their neutral position the teacher with best intentions has taken that student out of their neutral position and internally rotated the femurs to a Max and then they have them do a forward F Well that's the the recipe for impingent right it's not the flexion itself but combining that internal rotation for that person now if you have antivert hip sockets you don't have to worry about it you'll never reach impingement because you're not internally rotating your feet you can stand a mountain pose your Anatomy is such that that is neutral in your hip socket it feels natural for you to to fold forward but these people that have the external rotated hip sockets it's unnatural for them they hate it because they get that pinching in the hip and at the end of their sun salutations you notice their feet to the side again and these people just don't listen they should have very good um external rotation right yeah they have no problem doing Lotus pose and maybe bring their feet behind their head because their pelvises are already pointing out that way but when is the point in your I was reading through your book before before we came on I told you when is the point when the the angle of the hip actually is is to the side but it's it's up like it's quite so that instead of the the the acetabul being at the bottom it's to the and then you say the external rotation hits the uh hits the ilam too quickly yeah that's a different angle this is called version so there's antiv version and retroversion the one you're talking about is called the acetabular angle of abduction okay that's this angle here so am I'm looking there's a plane here and some people it's more vertical in which case they can easily abduct quite a bit some people it's it's almost to horizontal and when they abduct the Lego to the side the greater chanter hits the pelvis the side of the pelvis very quickly so you can see if I had a a very vertical acetabulum I could move my legs quite wide apart in side splits if I had more a horizontal acetone I couldn't move very much before the bones hit so that's another Factor that's an kement at the top of the acetabulum in the neck here so abduction definitely can get you into impingement flexion won't get you into impingement unless you're internally rotating and if you've got a retroverted hip socket and your teacher is always nagging you to have your feet pointing forward then you're internally rotating now you're flexing that's when the roof of the acetum comes to impinge on the the neck of the femur yeah so not everyone is going to be bothered by this but again 25% of men do have a anounced Cam and with internal rotation they could reach that impingement so first of all what we can highlight here is the massive discrepancy between hip joints and even I think between in individuals that as you point out in your book there may be differences between each hip on an individual but obviously between individuals huge variation um and where this in aanga considered to be doing the same practice and in an idealized form of the posture and that's when people will get into trouble you should do the posture in this way and obviously everyone's hips are different we don't need to point that out anymore but is not the same as your right here're not symmetric yeah and also you know we're always told try and pull the body into symmetricity that's the you know especially in Ashtanga there's an idea about know symmetry in the primary series and you do one side you left side you try to bring you know which I've always said is a dangerous idea trying to pull the body into symmetry when it isn't necessarily symmetrical possible recipe for injury there but I what is the problem with the external rotation again I kind of feel that my understanding pre prst was definitely that con extreme external rotation things like Lotus posture things like leg behind the head would be the most risky postures in terms of causing uh hip damage well it could be look at the pelvis from The Backs side the head of the femur goes into the hip socket as you externally rotate now the back part of the neck of the femur is going to come into contact with the posterior rim of the hip socket so there you may get impingement if you're externally rotating a lot but these angles change depending on what you're doing with your pelvis here I'm showing if you're watching this on YouTube a standing up and there's only so much room I have to externally rotate for these particular bones everybody's bones are different but if I'm sitting now as I externally rotate notice I don't hit there because of this acetabular angle of abduction these hip sockets are on a slant if I'm standing I hit this part the back part but if I'm sitting the neck of the femur is actually going to the inferior the lower part and there's a lot more room to do that and the more I flex the more room I have so if you're ever sitting in a pose like um gacasa um calfas pose your both legs are externally rotated and some people they can't get their feet too wide apart they're not too extremely rotated but soon as they start to fold forward in the pose suddenly their feet can come forward because you're increasing the range of motion you have before the bones hit the more you Flex the more room you have for external rotation so doing lus pose you got more room to extend your rotate than when you're doing that standing uh what's that AR motion yeah yeah standing up one yeah which used to come at the end of primary series which is moved to the start of the to the standing postures unfortunately because it's a much more challenging posture should come at the end when you've done Lotus inflection but unfortunately yeah it's a half Lotus but the hips are not flexed so you actually have less room much harder yeah yeah exactly yeah so it is true that you will get compression impingement the back of the the neck of the femur against some part of the hip of the rim socket but most people who have hip injuries that's not the problem I I talked earlier about the labrum you can crush the labam you can get a laboral tear as they call it but that's not always a problem by the time you're 40 most people have a laboral tear and they don't even know it they're it's asymptomatic there's not a lot of nerve endings in there so the whole impingement thing yeah it could be a problem but the real problem of impingement is when you're hitting the bones and then you keep going and the head of the femur is now diing into the cartilage of the hip socket that's the real danger it's not what's happening to the rim of the hip socket a torn laboring can be a problem especially in your 20s or 30s especially if you're an athlete it could be very painful as I say as you get older most people have these tears and they don't realize it what we really need to talk about is the a so we went through the acronym stairs s a i RS so the a the arthritis this is the big problem this is when people start to need hip replacements or hip arop plasty they call it just it could be a replacement could be a reinforcement could be a resurfacing lots of different options so it's really what's causing the arthritis is the big concern and first of all let's just say what what is arthis exactly Define that yeah it comes from a Greek word arthos means joint yeah anything that ends with the suffix itis I means inflammation so appendicitis inflammation of the appendix okay bronchitis inflammation of the bronchial tubes in your lungs so arthritis is an inflammation of the arthos The Joint so it's a catchall phrase it means inflammation of the joint but it's more than just that generally there's a lot of different causes the one that we worry about in our field is Osteo arthritis where the bone is hitting the bone and it's wearing away the tissues there are other forms of arthritis there's rheumatoid arthritis this is where the immune system for some reason thinks cartilage is bad and starts to attack the cartilage so the body is destroying its own cartilage hopefully you won have that but the overuse type of C arthritis test for that yeah yeah yeah so there's lots of other ways that a joint can degenerate but if we just look at the arthritis one type of arthritis is something called a vascular necrosis which is a word I gather you're familiar with so if we break that word apart that's my hip diagnosis is a vascular necrosis yeah so necrosis necropolis means death death avascular vascular is your blood system avascular means no blood system so basically what happens in it in the head of the femur here the neck of the femur so it's not really in the hip socket itself but there are blood vessels that feed the bones the bones need blood to get the calcium to build no bone running in front of the femur is a a major artery called the femoral artery it sends a couple of little arteries into the bone one's called the medial circumplex artery and the other is the lateral circumplex artery these arteries go right inside the bone and they feed the bone there's another one I don't know if you can see this there a little dimple in the head the femur there yeah there's a ligament that goes from the hip socket to the femur so that you don't pop your femur up it's there's actually a ligament holding it together and there's a blood vessel going through that ligament so we get these blood vessels bringing nutrients to the neck of the femur for a lot of different reasons that blood supply starts to get cut off or weakened it could be diabetes it could be too much steroids it can be alcoholism and it can be a usually it's an injury of some sort you've had a fall at some point and those blood vessels got pinched or destroyed you don't really notice it for the first six months or so then you start to notice a little twins there two or three years later this whole bony region has decayed if you look at the x-rays instead of it being a nice angle between the neck of the femur and the shaft of the femur it's like this whole thing is swollen up and dropped down and sometimes it even comes out of the hip socket completely so this whole tissue there is basically dying that's necrosis once you're at that stage unfortunately there's nothing we can do to bring it back and that's when this the doctors will come and say well we're gonna have to replace all this apparently the case so when you get to that stage of vascular necrosis unfortunately and yoga doesn't cause that yeah yeah yeah yoga actually can be very periodic for it in the early days moving the joint is going to help to bring the blood flow to it so this is actually less frequent in yogis than it is in the general population because they're moving around a lot but if you're doing extreme type of yoga practice contortionism and so forth where you're trying to go to your maximum end range of motion and then some more that's when you can start to do too much damage there so as long as you're playing within your bounds of what you naturally can do yoga is very therapeutic for this if you go beyond that you're trying to bring the foot behind the head I mean I was speaking to a surgeon in India about it and he was like you know yoga would never have done that it's very you know very therapeutic yoga you know I like well you know I don't think he'd seen the kind of yoga that I was doing like you know the kind of extreme Advanced postures of ashang yoga he would have said something different and I think that's the general misapprehension potentially when people say well you know yoga won't damage it it's like the level of or the degree of leg behind the head putting leg behind the head putting another leg in Lotus bending over with leg behind all the kinds of things things twisting with leg behind the head you know that is extreme stress on that joint for for someone who has a propensity in that joint already yeah yeah but I I suspect he's right in that what you're talking about could lead to that impingement syndrome which could then lead to the crushing of the C the cartilage and the delamination of the cartilage so that type of arthritis definitely could be caused by just too much over aggressiveness but a vascular necrosis probably is not being caused by yoga I think probably right yeah no I don't think it was um I I had yeah we can probably rule it alcoholism steroids so we have to go with diabetes diabetes so we're gonna have to go with injy but I don't remember an injury but uh yeah when you look at not be one dramatic injury it could be cumulative injury like somebody cly in a labor intensive job they're constantly putting a waste strain onto this and over time that could damage the Y it's really interesting on the MRI you can see this whole uh dark area like there's no blood there like the bone is dead and the rest of it bright you know in the MRI and there's a complete dark area like so he always said you know when I was talking to this guy over quite a period of time he very interesting um in in India about the Hipp he it's like it's like you're tiling it's like you you've got the tiling and then underneath the tiling the concrete's all broken right you know so you can tile over that surface but it's going to be a problem because you've got nothing to really hold it underneath it you know so unfortunately the diagnosis is such that you'll have to have it replaced at some point but I was holding off for for a long period of time um and certainly wasn't doing those Advanced postures in terms of yoga therapy for for a good period of time um but I mean going back to the the the original question can femoral imp I me we're saying femoral impingement can then be a cause of osteoarthritis which are then you know then cause you to have some problem with the hip or possible necessary but can can um Can the the yoga postures do you think cause for moral impingement themselves right so the cause then is Yoga rather than some pre-existent injury or propensity you have you know could it could you actually do yourself a danger that were then you know well let's not demonize any movement impingement is okay we need to have the bones hitting the bones carage only grows stronger through compression different tissues react to different stresses our muscles or tendons or ligaments they react to tensile stresses so if you put a stress into them like pulling on a spring or elastic band that's how they get stimulated to grow thicker and stronger and longer cartilage only gets turned on when you compress it so you can press the cartilage leave it alone compress it leave it alone this stimulates the condra sites the cells that live in the cartilage to turn on and make the cartilage thicker and stronger bones can be stimulated in both directions bones can be stimulated through compression but also through tension like if I bend a bone then I'm going to increase the strength from the outside into the bone if I compress the bone I'm going to increase the strength in the inner bone the bones are kind of unique tissue that they grow thicker and stronger through both types of stresses so we need to stress the bones we need to have impingement that's not a problem every time you take a step the head of your femur is pressing into the card ledge of your hip socket that's good you need that walking is very healthy because that's stimulating the cartilage to grow thicker and stronger but like anything you can do too much so think of it with goalie loocks rule remember go loocks and the Three Bears some porridge was too hot some was too too cold you want that's just right so moving your leg through its full range of motion is not a problem overdoing it under high stress loads where you're just continually damaging a little bit you need a lot you don't need so the people are type A yogis a first Stanga maybe in this case uh yeah they tend to overdo it and that could cause um catastrophic impingement but again it's not the impingement necessarily that's causing the problem that would affect the laum it's the crush underneath here that starts to break apart the cartilage and you're not giving the cartilage a chance to regrow and recover so that definitely could happen that's a different type of arthritis it could still lead to this case probably a resurfacing of the hip socket right so definitely some people can do too much of that we should maybe back up and talk about are more yogis needing hip replacements these days than in the past yeah I was think there's a lot of conf there's a lot of confusion between causation and correlation yeah to understand that we have to look at in the past let's say 20 years ago if somebody had to have their hip replaced they would get maybe a steel implant here now hip replacement is carpentry the surgeon goes in they used to go in from the backside so they cut away a lot of the the Theus Maximus and the ligaments in the back that restrain certain movements and they' get the hammer out and they'd saw off cut cut cut like a carpenter that saw off the top of the femur and then they screw in a metal piece there they would tap in or glue in a metal piece on the side of the pelvis and then they would line the help us with a bit of plastic and that technique would last six seven 10 years oh you could only do that twice because everything would be so destroyed you couldn't do it again so generally they only allowed hip replacements to be done to people in their 70s and 80s because they probably GNA not live as long as this thing would last but somebody in their 60s and 50s uh they would outlive their their Prosthetics and you can only do this once or twice and so you would be be bedridden for the rest of your last 20 years of life so we didn't do hip replacements for younger people back then but today we would put a titanium plate in there and we got some good new Plastics sometimes ceramic but it's a highdensity plastic that never wears out I mean these these hips today can last 30 40 years and you if you do that twice no it's going to last you the rest of your life so today we don't have to worry about it plus the surgery itself we go in from the front and it's minimally invasive we don't have to destroy all the Caps ligs all the side as well you can do a Lal it's not coming from the back yeah or it can do it can they do still do the back um you know in certain cases because they say it's the argument is that it's um it's it's less chance of hip displacement um you know um out of the joint again so they do still do the back but the anterior is what people often favor or the side as well they say because it's minimally evasive it's not it's not it's tissue sparing you know they say yeah yeah it depends on the surgeon and what exactly he's going to do he'll he'll he'll tell you what you need but the thing is because these last so long now people in their 50s and 60s can now get a hip replacement whereas before you just wouldn't be allowed so now this surgery is available to a younger C group of people so is it the fact that people are getting more hurt no it's the technology has now come down so that it's so much easier to do this and and more and more people are doing people in their 40s are getting it because it can last 30 40 years yeah and then you can repeat it again yeah very important point to be made yeah because it is a very changed playing film where they say more people are getting it well exactly that's why and uh still though I think that even among surgeons that that idea exists that well you know they said they were saying to me similarly we don't want to do it too early you're a little bit young you know these last 20 years then it's hard to replace again so I think there is still still this mentality because obviously just like anything else you know there's different information to different surgeons they only have their own opinions then other surgeons will say you know there's no problem you can have it replaced numerous times there's no you know we can do this numerous times so there's there's definitely still a multitude of different opinions out there so if you are listening to this then at least go and see a couple of different people and have different opinions on this because I certainly for one person I was told we need to go in from the back you know and I've done my research obviously and I said I don't want you to go from the back and Destroy cut through certain muscle tissues that seems like a really bad when one can just go in from the front and they were imper you know completely impervious to reason on that one right where you get part of is where you get it done the going in from the front is more expensive technology so I'm in Canada some of the hospitals here don't have the new techniques they don't have the new equipment yet so they still only have to going from the back part right now I I'm dating myself maybe it's not the case today but 5 10 years ago when I looked at it a lot of hospitals only did the posterior one because that's the equipment they had that was the training they had but now if you go to the more Elite centers in the US they'll they'll almost all come in from the front or something that's more Mally invasive they can do it as well yeah titanium plastic camic I think it's a I think it's a titanium replacement and a ceramic cup because they can do different versions of these kind of things as well and yeah it's different uh byproducts like steel would create ions and those ions would create free radicals which was the cheaper plastic the plastic could break off and get into the immune system and so forth but today the more advanced Plastics are even better than Ceramics but you're your surgeon will give you the best idea but depends on where you go if you're going to San Francisco you're probably getting at one view but if you're going to I don't know uland Bor in Mongolia you're probably going to get different op which very true really unfortunate a general kind of point about Healthcare really is that it's it's still it's still El system you know it depends on how much money you've got in terms of getting the best situation you can which is yeah which is which is unfair obviously but uh the other thing is that when you go in I mean I've had this situation and my wife as well on a particular occasion you go in and you you respect their opinions the doctor or the surgeon there's so authoritative in that position that you you you as a lay person feel like well they must know you know they're so sure right you know so you really you know and I I suggest of course they know more than we do but you're still worth questioning opinions because they do have different opinions and having you know had the situation I say in other occasions and had had a lot of appointments with surgeons Etc you find that yeah it's best not to just go yeah we'll trust that straight away but go to have different opinions because there are very different opinions on these things I think that's really important you know point for anyone listening do your research as well yeah in the previous discussion I think I talked about flying lessons and you're flying the plane all these doctors are Ground Control they may know more than you about an airplane and even how to land it but you're the one in the plane you're the one that's going to crash if you don't do it right so yeah getting lots of different opinions from lots of knowledgeable people but you have to decide what you're gonna do because it's your plane he's not on the plane with you if it goes wrong he he's may be a great guy or she may be a great doctor but no they're not on the plane with you so you have to take responsibility for your your health there yeah I was going to say backing up on on the on the level of where does it hurt could you say like can can you give any kind of qualifications about certain postures hurting in terms of where you might have done a damage or is there anything like that I mean for me for example for um for moral rotation in um something like a straight leg utas now I me I know you talked about that on the article that we l with u the broad article with Edwards as well when you're talking about forward folds and it was very interesting to me this idea about forward folds with straight legs or bent legs now for me doing a straight leg forward fold now would involve aoral rotation of the joint which would be excruciating painful so I'd have to keep my legs bent there for example I know I'm kind of going off point there but um it was just an introduction really to you know where if there's certain pain in certain postures do that indicate certain places that the The Joint of the acetab might be injured right or if you got leg behind the head you try to put the leg in Lotus or you know can you say front or back or can you say anything more about the subject yeah that's one of the clues the doctor will use to diagnose you is well where does it hurt and they'll also palpate and push to see if it's a tender area um again the side of the hip that could be a traner issue if it's in the buttock itself that could be a sacral issue or it could be performas if it radiates down the leg that could also be some referred pain so will look at the paint if it's more of the inner groin and you're kind of grabbing the front here that would tend to designate more in the hip socket itself right uh knee pain can be caused by hip stuff an interesting thing is when somebody gets really worn out and they might have a foot a Talis problem a knee problem and a hip problem maybe they're an athlete or a runner which do you replace first well generally the advice would be fix the hip first because it's easier than the knee and once you fix the hip maybe the knee problem goes away don't start with the knee and then work your way up start from the core and work your way down so yeah the pain can be diagnostic where it gets tricky is if it's referred pain it could be something in your in your disc or your lumbar spine there's a bone spur it's right on the nerve root and it's you're feeling it in your leg but it's actually coming from the back so what the doctors will do is they'll try to provoke the pain they'll do a few tests like one's called a slump test they'll just have you sit in a chair and slump over bring your chin to your chest your chest towards the thighs does that increase the pain well we haven't really changed the flection of the hips here we're just rounding the spine and if that increases the pain chances are it's discogenic it's coming somewhere from your lumbar spine area if that doesn't cause the problem then they may try thing think one's called fair f AI R which stands for flexion adduction internal rotation so they'll put you'll just cross your legs over sit down cross your legs over it does that make it hurt more if it does maybe that's a s condition there could be something the sacrum they'll do some things to try and make it hurt and that will give them some clue as to maybe where the cause of the problem is also look at the time of day does it always hurt does it only hurt in the morning do it only hurt in the evening that can also be diagnostic so a lot of things the doctor will put you through to figure it out pain always seems to come more than night time time I think found so many things the body's tried to kind of like repair itself right so if everything's okay in the day or maybe just like you're less focused on on pain when you're doing stuff in the day but when you're at night time you know you're lying down yeah you might be more inflamed at the end of the day too so true yeah yeah I know I know that there was a particular point in that article that we refer to about you say you you telling the uh the the person you were talking to that it wasn't about the hip when she was talking about uh forward folding and flexion do you can can you go through that a little bit again the idea of that the straight leg I think what the argument was that straight leg forward folds were dangerous and shouldn't be it should be avoided and you were suggesting not yeah well the first the whole discussion there was a few other articles that preceded the one I sent you but one of the William broad came up with this book a long time ago about yoga hurting the body and he was saying too much flexion and Michelle Edwards was kind of saying the same thing she that was his fundamental point was it the broads I mean we we'll reference William broad's book but that was his fundamental point of the book you think too much flexion in yoga was a problem well no I wouldn't say it was just that but that was one of the things he mentioned his main point was that yoga was causing damage and I can agree that yoga can cause damage I don't think it necessarily will cause damage so my point was let's not demonize movements because we're designed to flex you look at people in the third world Primal countries working in the rice patties they're flexed all the DME and they're spying is rounded and they spend hours and hours a day but they're used to doing that so this is a natural human movement let's not demonize it but if there's pain if there's a problem yeah okay let's be careful so she the point was that flexion was causing all these problems it was causing hip replacements and impingement syndromes and there was citations of all these yogis senior yogis who are getting hiped so I thought okay well let's check I'll call them so I called up about five of these yogis and said do you think that your hip replacement first of all did you get a hip replacement yeah except for one exception they said yes do you think yoga caused that and they got very upset and said no definitely not in the case of like barl Bender bur she said I think she was the one that said it she was in a car accident in her teens and yoga saved her hips it delayed her hip replacement by like 10 years so did not cause that so maybe it was a vascular necrosis and it was just going to eventually work its way through but because she was doing her yoga that kept the blood flowing long enough that she was able to get around it so again correlation is not causation just because a lot of yoga got hopl placement doesn't mean that yoga caused the need for the hip replacement it may delay it so then we come back to well does flexion cause impingement and the study that both William and Michelle cited is twist study didn't say what they said it said it said with internal rotation and a cam then impingement would be caused so that was internal rotation with flexion for these people who during their youth had that genetic predisposition to a cam they would get impingement I'm saying so 75% of the people don't have a cam they're not doing internal rotation like when I'm doing a mountain pose to a forward fold uasa I'm not internally rotating my feet now some people do have to internally rotate their feet because they got that an uh retroversion of the hip socket so yeah I'm not saying it can never happen I'm just saying by and large this just pure flexion is not going to lead to impingement if you add other things to it it could so that was my point but then she started saying well flection is bad because of the spine and I said well that's a whole other argument but she kept going there and I it's a great it was a great little debate in the comments and one of those things he was like you know the comments the comment but back the back and forth was good and you'll say well you've written 50 1500 words here and I'm not even talking about the spine I'm talking about the hip why do you keep talking about the spine very funny so if we want to talk about the hip I the spine fine let's go there too but again it's like everything else the spine needs to be flexed let's demed flexion we do it all the time it also depends some yeah yeah I mean it depends on what you're doing you could go forward with a flex spine in a forward fold or a standing forward fold or seated forward fold but I mean like looking at people doing deadlifts now I originally would have thought that that would be good to had to try and flatten the curves of the lumber spine but quite the opposite they do the very opposite right they they're trying they they're keeping that Lumber curve in in place very much they're not they're not flattening it or ing it they want to keep the neutral spine here's a mistake a lot of yoga teachers make a straight spine is not neutral a straight spine is as far away from neutral as you possibly can get because the lumbar spine has a curve called lordosis on most people it's about 30 degrees or so some people a little bit more might be 39 degrees some people a little bit less might be only 10 or so but everyone's got a lordotic curve there and that is the neutral position that's where there's maximum contact between the top vertebra and the bottom vertebra the bones are have got the biggest surface area connecting to each other soon as you flex the spine you're reducing the surface area contact and you're putting most of the stress to the front of the disc and the front of the vertebrae so with a straight spine and if you feel your lumbar spine and it's flat it's fully flexed the lumbar spine will never go past straight so as soon as you put your hand in your lower back and you feel it straight you've now fully flexed your lumbar spine which is the worst time to put a big load on it but we're designed to fully Flex our lumbar spine now Michelle quoted in that article or in her comments Stuart Migel so I called Stuart and Stuart I I've spent a lot of time with Stuart he he and I have done a video together on the the spine um he wrote the introduction to my book your SP your yoga so I know him fairly well and I had a feeling he didn't say what people said he said and he complains about this all the time he's quoted out of context if you ask steuart is it a good idea to do X he'll always say it depends you can't give a blanket yes or no depends on the situation it depends on the person it depends on their Anatomy depends on how old you are have you had an injury a condition so you're never going to get a black or white statement that always bend your knees never bend your knees it depends where're do to be able to fold over pick up our baby from the floor a lot of people think bending the knees is a guarantee of preventing flexion on lower back but Stuart shows in his books he's done L test of people picking up something in a workplace like picking up a heavy box and they know they have to bend the knees so they bend the knees pick up the box and then Stuart takes a picture at that moment and their back is completely flat even though they're bending up the knee so just bending the knees is no guarantee that going to keep the Lord out curve because people think oh I just have to bend my knees but now they flatten the back so they're still putting a big load on a flat back so if you're deadlifting you want to make sure you've got that lumbar curve there a lot of weightlifters have to wear wed shoes because they can't squat they can't get their heels all the way to the floor if you can't get your heels all the way to the floor you tend to round your spine so you wear the wedge shoes so that you keep that L curve stand them stand them black but professional weight lifters they use the the Olympic wedg wed do they that's interesting yeah I it depends what you're doing um and how you do it and um yeah um it's not it's not as simple as all that really um but going back to the article thing I think is important to say that you know when you looked at that article and picked it apart and what was said there was like some serious problems with with what was said so I mean you've written another article on how to critique uh articles I think right like which yeah which is really relevant because I mean we phoned up I mean dmaa never even had a hit replacement he had a knee replacement due to an accident he had in the Brazilian Air Force so I mean it just goes to show that when you're reading things like like broad's book and William broad being a great journalist you read it makes sense he okay yes that's it you know and actually when you look at the stats or look at the studies yeah there's a lot of cause for questioning yeah and I gota give you know I'm not I'm not critiquing William I think it was a great book I really enjoyed it and Michelle's a wonderful teacher she's helped a lot of people but I'm not saying oh she's a bad person for saying this I just disagreed with some facts that she presented yeah and in the world of science we're allowed to disagree all the time you just make their case with your facts they make their case with that facts I think they both had the best interest of their readers and their students at a heart so I'm not critiquing the people at all I just disagree with a couple of their points yeah yeah yeah this is great this is the the whole point of the podcast in the first place just like discussion and and we all learn out of that what what do you reckon about um General diagnosis someone was said in my comment to which is I thought was interesting when I posted something about this situation on my hip why don't we all have diagnosis like I'm MRIs when we're young and then we can know whether there's fural impingements and then we can act accordingly to that which I thought first of all what that never thought of that idea the second I thought well you talk a lot about fear mongering in yoga and you know and I think it's now what do you think about that do you think it would actually just cause fear I mean you know kind of is it helpful to know yeah I can give you an anecdote there's another guy in the spying biomechanics Community Serge grovy now Serge came into this community from the physics background so he used a lot of his physics knowledge into spine I remember talking with one time and he held up an x-ray and he said okay now here's a rexray can you tell me is this person alive or dead it can't even tell you that basic information so all these Imaging things we have to take with many grains of salt I mentioned that by time you're in your 40s most people have a torn labrum and they don't notice it yeah by the time you're like I think one of the SES was they had men who were over 43 and men who were under 43 and the men who were over 43 onethird of those men had a torn meniscus and they didn't know it in the spine this statistic it's easy to remember because of the little pattern 30% of 20-y olds when you take an x-ray of their spine or an MRI 30% of 20-y olds have a buling disc and they don't know it they're asymptomatic 40% of 30-y olds 50% of 40y olds 60% of 50y olds 70% of 60 year olds 80% of 70 year olds and 86% of 80y olds have a bulging disc and they don't know it they resolve by themselves after a year or so the Bulge kind of gets dissolved away so taking an image doesn't tell you anything can't even tell you if you're alive so just because you've got a certain morphology showing up in the image doesn't mean it's a problem but it can scare people they thinking they've got a problem and therefore they'll correlate oh You' got pain look there's a bulge in your disc ah let's take the Bulge away now this happened a lot in the 1950s and 60s it used to be people who suffered sciatica they go to the doctor they got this radiating pain down their leg and in their butt burning sensation all the time they get an x-ray you got a bulging disc okay they do a disectomy they take away the Bulge and about a year later after all the recovery everything's fine but then in the 70s and 80s they started realizing most people have a bulging disc it doesn't mean it's causing the sciatic it might be causing it but it could be a performance thing or something the sciatic the sacc joint or something something else happening inside the buttock itself or the pelvis so just because you've got a buling disc doesn't mean it's causing the problem so just having an image by itself is not really that diagnostic you have to use it with all the other things like the provocation let's try to make the pain happen see what's causing there and if it is discogenic let see it probably it's only if the Bulge is actually going in a certain direction and it's compressing one of the nerve roots or maybe the little bony holes where the nerves come out they're getting smaller it's called sosis or there's a bony growth called an osteop and that's compressing the nerve some of those things might show up in the Imaging but other things might show up and you can have stenosis and you feel fine other people have stenosis and it's definitely the cause of the problem yeah Imaging is one tool but it's not the only tool yeah important to make clear yeah that um doesn't necessarily like I mean I think it can easily kind of almost be like a no sio where you feel like there's a problem so then overprotective or perhaps you don't even stress that area because you worry about it and then it weakens because you don't actually use it I mean I think again to go back to your analy of the goldie looks principle it's a question of well you've got to move you got to be dynamic because that's a problem if you're not the worst problem but obviously dynamism you know causes problems as well depending on on pre-existent um propensities um yeah oh what I had another question for you oh yes um so okay so the situation with my hip is that um because of the avascular necrosis the the the hip is feeling weak the whole joint is feeling weak um in itself not not I'm feeling I'm and it's created yeah and and the bone itself looking at it it's created a like it's not round anymore it's created a lot of these flat little bits to try and bear the weight you you know you imagine obviously you know the situation there a weight straight down on it and if you so the head if it's not strong then it kind of tried to disperse that weight by by kind of creating this uh this more Square kind of hip joint and that causes a lot of pain because it's not moving freely anymore yeah what's happening with the necrosis that means the calcium in your bone is not being replaced because the blood is supposed to bring the calcium back so the bone is getting softer and softer it's becoming like cartilage so it can be deformed so now the weight of your hip socket is pressing onto it and it's deforming all this this why it's tends to start to drop down here you might start to notice one leg is shorter because oh so yeah right right yeah it's not do reaction to try and make itself stronger but just like the the simple weight of compression on it because it's not strong is happening making that happen it's getting remodeled over time because there's not much calcium in there why would it make the the the the muscles around the leg feel so weak like I've got like I've got no strength to say like walk up a hill with that right leg like none why is that there's a couple of things one is um there could be a neurological damage happening here too so all this Decay and inflammation could be compressing nerve roots or things that in innervate the muscle groups so you just muscles aren't acting as well the blood flow can also be cut off to the muscles or more likely I think that the The Leverage is no longer there like if you have a long lever it's easy to move something if you have a short lever it takes much more work to do it I mentioned this little bony bump here called the ler tranter earlier the one you feel in the outside of the hips called the draer Craner some people that ler tranter is actually quite far down the Sha of the femur and that gives a lot of Leverage so when your ilos soas tendon hits here and you have to lift that leg up what's that called the Pango stasa C or something like that you lift the leg up and you keep it there if somebody's got a very low situ ated lesser torque caner they can keep that leg up all the time for me I could be able to get the leg up to horizontal but it could be that I've got a very high one here and the leverage of my ilos SS is just not good enough it's not that my ilos soad is weak it's just that the lever arm has been reduced so now you're changing the whole architecture of your hip socket and where your muscles were attaching here you may not be having the same amount of Leverage that you had before and it could be a combination of all of that yeah it's a really curious phenomenon I don't think anyone's given me a a satisfactory answer yet I'll bear that in mind why there's no power when they replace it and they put that angle back and you get the right orientations you might I got my power back no apparently you the muscle will be stronger again or can be trains to be stronger again so to that end just to wrap it up do you know anything about I mean people are going to be listening to this that obviously particular interested if they have an an issue already an injury um do anything about recovery recovery times or anything you know to avoid or any ideas about recovery at all that people might be thinking if they were thinking about having a procedure done hit replacement resurfacing y well the general rule of time is whenever somebody comes into my yoga room and says I just had hip replacement I always defaulted what did your surgeon say because the surgeon is the only one that knows what they actually did in there yeah they may tell you what they plan to do but once they open you up all the plans may get thrown out the window because okay this isn't quite right you'll have a a range of Prosthetics he's going to find the one that hopefully he's pre-ordered the right ones but once you get in there you're gonna notice H it's not quite the one I wanted I'm going to use B I use the B one so she's the only one that knows what she did so she will tell the physical therapist who will tell you okay here's what we're going to do so I always start by asking what' your physical therapist say now with the modern techniques recovery from hip replacement is amazingly quick I mean there's going to be a postop pain for the first couple of days you'll get some uh nid some steroid non-steroid pain killers and anti-inflammatories but after a couple of weeks I you you'll be walking that day and you might have a walker for a couple of days or maybe up to a week but after that you'll be kind of walking around it may take three months until you feel kind of normal again but that that's amazing three months and you had a whole Hy absolutely yeah yeah yeah one caution you're going to have metal put in you when you go through airplane security you will forget that you've had the separation and may be five or six years and they're gonna say oh you got some metal in your pocket no no metal no you got some metal you get into an argument with the guy and then you oh yeah I had hipper pice I forgot because I got some metal in there so you're going to be card or something don't you you get a card remember to show yeah yeah yeah um what about pretty quick can they do their old yoga again and and accompanying that um how do you call it dislocations hip list dislocations people really worry about that on the old days when you came in from behind the key was to never cross the midline with your leg and don't do internal rotation because what happened there was they were sing the back of the capsular ligaments and that was what prevented you from internal rotating too much or conducting too much but now those have been severed so if you do too much of that you could pop the head of the femur out of the hip socket but today we don't do all that major cutting of the capsular ligaments so you don't have to worry about that you won't get these restrictions like in the old days or never cross your legs we're never internally rot that's what it says yeah so now with the new techniques you can do all that stuff if you couldn't put your foot behind your head before don't try to do it now you'll probably have similar motion what you have because the Prosthetics will be similar you're going to try to make your angles pretty much close to what you have now but forget the type a yogi stuff yoga is GNA be great for you Gentle movements moving the joint through it six degrees of freedom but don't try to go for a new world record that's not the point you're not going to get the four series forget it just you want to be healthy your intention is just to be healthy so move it stress it not too much not too little but yeah you'll be great for you it is recommended after hip replacement all right thanks Bernie I think yeah yeah no no plans yet so give it a couple of years anyway well thank you for coming on um we'll put a few notes in in the uh in the show notes uh to reference what we've been talking about um and yeah being a pleasure Bernie third time podcast please listen to one and two that we've done together Bernie's Trilogy of podcasts from ke Yogo as well as his books get the books I mean they're totally possible to read as a lay person the second half of them I believe is a bit more technical but the first half is always a you very very accessible uh excellent information so please uh use Bernie's resources that he's very helpfully put out there and I look forward to speaking to you perhaps um after after I've had it done and and let let let you know how the fourth series is coming on y well thank you Adam it's great to be back and good luck with the procedure thank you [Music] V