Yoga Therapy for Hamstring Injuries

If you’ve ever had an injury at your hamstring injury, you will know about it! You’ll go from comfortable forward bending one day to dramatically restricted, often painful forward bends the next day. This injury occurs where the tendon of the hamstring muscle knits into the membranous lining of the bone, the periosteum. In this case it is where the periosteum covers the ischial tuberosity or sit-bone. Often this is not a tear of the tendon itself but an avulsion, where the periosteum has been pulled or torn away from the bone. This injury can, of course, happen to varying degrees and brings pain and stiffness in forward bends.

 

If you especially feel discomfort in wide-legged forward bends it is most likely the hamstring portion of the adductor magnus muscle where it inserts onto the sit-bone that is injured rather than one of the hamstrings themselves. Unfortunately, this is a common injury in yogis and one of the reasons we recommend that students not be adjusted in wide-legged forward bends, eg Upavishta Konasana. As you can imagine, in these postures the adductor magnus is being asked to stretch as an adductor on the inner thigh as we widen our legs as well as a hamstring muscle on the back of the leg as we flex forward.

 

There are a couple of possible reasons why the muscle insertions at the sit-bones are so susceptible to injury. The main one seems to be when ones practice is dominated by straight-legged forward bends. Especially when standing the insertions at the sit-bones are under the large load of the entire upper body as we fold forward. A flexion-dominant practice also tends to weaken the hamstring muscles. This is due to the reciprocal inhibition [1], where the activation of the hip flexor muscles means that the extensor muscles (of which the hamstrings are one) are inhibited or switched off. In standing forward bends the extensor muscles are working eccentrically, i.e., against gravity. This helps a muscle to strengthen more effectively, however, at the same time it also places greater stress on the muscle, which makes it more prone to injury.

 

Whether the injury is in the periosteum, the tendon, the hamstring or the hamstring portion of the adductor magnus muscle the same therapy protocol will apply. The therapy needed to enable this injury to quickly heal is to take stress off the insertion and strengthen the extensor muscles, especially the hamstrings. In standing forward bend postures this is easily done by bending or at least softening the knees on entering and exiting forward bends. The deeper you bend your knees the faster your extensor muscles will strengthen. The other benefit of this method is that all your leg and lower trunk muscles must work together synergistically and a natural balance and harmony of strength of all the leg and lower trunk muscles is achieved. This is why squatting is an ideal strengthening movement and a very functional one that we can incorporate into our daily lives, not just our practice. I recommend doing this with different stance lengths: feet together, hip-width apart, wide apart and everything in between! Specifically in postures like Trikonasana and Parshvottanasana you can activate and strengthen your hamstrings by drawing your leading foot back towards the other foot, without moving the feet. If you find that you are unable to avoid pain at the ischial tuberosity (sit-bone) in any of the standing forward bends then omit practicing them until the injury has healed sufficiently.

 

In seated forward bends you can activate the hamstrings by pressing the heels of your feet down into your mat. This turns your stretch into a more regulated stretching method called Post Isometric Relaxation or PIR. PIR is when the receptors in your tendons (golgi tendon organs) sense how much pull is being exerted onto the tendon by the contraction of the muscle. After being activated by muscle contraction these receptors then signal the muscle to relax. These very receptors are in charge of monitoring the amount of muscle contraction that happens and protecting the tendons wherein they reside. Stretching in this way helps to balance strength with flexibility and thereby is not only a very effective method of stretching but is also very safe, especially when self applied. Additionally, pointing the feet in forward bends seems to relieve some stress off the sit-bones.

 

Of utmost importance is when you arrive in the forward bend that you do then straighten out your legs. This stretches the entire length and belly of the muscle (the reason you are doing a forward bend) and most importantly, takes the stress of the insertion at the sit-bones. To keep the knees bent once in the forward bend will transfer the tension of the stretch back up to the hamstring insertion at the sit-bone instead of distributing it over the whole muscle. With this injury it is better to not go as deeply forward with your trunk but instead to keep the legs straight. The enemy here is not stretching the hamstrings per se. Instead we want to reduce the stress upon the insertion at the sit-bone.

 

Worth noting is that there is a difference between an inhibited muscle and a weak muscle although both with appear to be weak. Inhibition is a neurological state, which can be due to the antagonist muscle being contracted (here the hip flexors) equating to reciprocal inhibition or otherwise from an imbalance of the position of the pelvis. This pelvic torsion usually results in one-sided weakness and would preferably require therapy to correct quickly. In this case the muscle is not inherently weak but appears so due to its handicapped position. On the other hand, weak hamstrings take longer to restore to strength although both will benefit greatly from strengthening movements and postures.

 

For a speedier recovery focus on some specific postures that target strengthening the hamstrings, eg: Shalabasana and Purvottanasana. Also very effective is a one-legged Purvottanasana. This will further challenge your hamstrings and also highlight for you the comparative strength of your hamstrings from right to left.

 

Overall, what is important is that in you remove the stress from your hamstring insertion and at the same time strengthen these muscles. Bending your knees, like transiting through a squat, on entering and exiting your forward bends will aid both of these goals. In your forward bends ensure that you are using all your leg muscles and not just your hip flexors, which will inhibit and thereby weaken your hip extensors. Additionally, adding in some postures that target hamstring strength will speed up your recovery. With this simple protocol I have had students heal their long-standing sit-bone pain within a few weeks. Left untreated this injury can take between one and two years to heal! Wishing you a speedy recovery back to pain-free forward bends.

 

Monica

 

 

[1] Reciprocal inhibition is when activation of one muscle (the agonist) inhibits the action of the antagonist muscle, relaxing it and allowing us to effectively stretch it.

 

About Dr. Monica Gauci

Monica has studied and practiced Yoga for 39 years. She is dedicated Yogi, a compulsive Educator, a registered Yoga Therapist and a rehabilitative Doctor of Chiropractic.

Posted in Anatomy/Rehabilitation, Asana.

14 Comments

  1. Hi Monica, very informative article, thank you for taking the time to share your knowledge and experience. I was wandering whether the same suggestion “of utmost importance is when you arrive in the forward bend that you do then straighten out your legs […] this takes the stress of the insertion at the sit-bones” applies when the injured portion of the hamstring is not the one at the the sit-bones insertion but the lower one, behind the knee. Or, in that case, would it be better to keep the knee bent during forward bends? Thanks! Dunia

    • Thank you Dunia for your expression of appreciation.
      Yes, if you have a hamstring injury behind your knee then you would be best to keep the knees bent and only stretch gently to avoid a shortened scar. However, it is very uncommon to injury the hamstrings here and I wonder if that is an accurate diagnosis. What are your symptoms and where exactly do you feel the pain?
      Namaste
      Monica

  2. Thank you Monica for your reply. Well mine is really a self diagnosis as my doctor wasn’t able to help much except for telling me to ice it, rest and take NSAID. The pain started off in January as tightness behind my left knee after the practice. I told myself it would go away if I stayed mindful and did not overstretch the leg. However, the pain got worse, at its peak it would bother me to walk long or to bear weight on it. I would have bouts of pain as if the whole area (starting behind the inner knee and going up the inner leg about 15-20 cm) was suddenly heating up. By practising with my leg bent and focusing more on strength than flexibility the pain has decreased but whenever I try to gradually straighten the leg it comes back within a few days…

    • Hi Dunia
      Without being able to examine and test you it is difficult to work out… it could also be your popliteus muscle. If you let me know where you are in the world I can see if I can find a musculoskeletal professional who could help you. I have access to a great group of practitioners… I am confident this can easily be resolved!
      Namaste, Monica

  3. Hi Monica, thank you for the clue. I had never heard of the popliteus muscle (and I’m a little ashamed about it!); I’m surprised none of the articles I read while researching around my symptoms did even mention it. It does indeed seem like it could be a popliteus tendinitis. Two of its common causes appear to be the tendency to hyperextend the knee and previous knee injury, both of which apply to me (I have a medial meniscus tear and a slight thickening of the medial collateral ligament on both legs due to years of bearing weight on knees that are naturally inwardly-rotated).
    I’m Italian but recently moved to Paris, France, so unfortunately I don’t know any good musculoskeletal professional here, neither do I have a trusted yoga teacher that could help me adjust my practice, thus I am trying to figure it out myself by observing how my body responds to different variations. Thanks again for your time and knowledge, you have given me a new “track” to follow 🙂

    • Hi Dunaia
      Popliteus is a major trouble maker in knee problems and you are right usually ignored! It is often facilitated and can inhibit or ‘switch off’ other important muscles like glute max and rectus femoris…
      I am on the search for someone for you, however, Europe is more difficult. In the meantime try to release it off yourself. Warning! It is quite painful. All the best with it. ; )

  4. Dear Monica,
    Thank you for the tips in this article, I will most certainly incorporate some of the asanas into my own (now recovery) practice. My question was actually similar to Dunias – my injury is more towards the belly of the hamstring (most articles on this topic for yogis focus on injurys close to the sittbone) but mine is more where semitendinos attaches to the femur on the back of the leg. I sustained it from some very forceful forward bend adjustments a very long time ago now (almost 10 years!)
    My guess is it never healed properly and as soon as I go into practice it returns giving me trouble. I nearly gave up doing yoga because of this (I would always end up in a lot of pain after practice) but Im now back on the mat and have managed to heal my left hamstring (where I had the same issue) – but my right is still giving me trouble despite me taking care not to force or go too far. I suppose it must be scar tissue that is the problem.
    Would you recommend keeping a bend in the knee at a sitting forward bend for me?
    Do you recommend any particular treatment such as dry needling for this form of stubborn injury?
    I have tried something called ‘radial extracorporeal shock wave therapy’ – stötvågsbehandling – where I live, Sweden, and it provided some relief. But not fully, Im still struggling 🙁 …

    Many thanks 🙂
    Namaste Ulla

    • Dear Ulla

      I’m sorry to hear of your injury and forceful adjustments and very happy that you are persevering. Well done, it is not easy. Semitendinosis attaches to the proximal part of the medial tibia so check your anatomy and see what else is there where you feel the pain – let me know.

      What is unusual is that you have had this on both sides. Many people injure their hamstring from a preexisting pelvic torque, however, this usually does not change sides. This is my second reason for thinking there is something else going on here…

      Namaste, Monica

  5. Hi Monica,
    Thank you so much for listening!
    These strong adjustments took place on both legs hence the injury occurred to both R & L hamstrings. So for a long time I had symptoms on both legs simultaneously, and there were times in the past where my left side (always the belly of the muscle) was causing me more pain than the right.
    Now thankfully, it seems the Left side has stabilized (virtually symptom free there – just the normal soreness you would get after a workout, nothing that linger for days or I can feel when resting). Fingers crossed the Right side will stabilize some time too – with some TLC and patience.
    Having had a quick look at some anatomy drawings, I can say that the pain I’m now having (L) is not located at the origin, nor the insertion point for Semitendinosis or Semimembranosus. When Ive had a massage, these two muscles tend to be very sore – and stiff – and I can tell this is where the pain & stiffness originates. I dont think it could be Bicep femoris, definitely not the Gracilis muscle. It ‘feels’ very deep – as if the pain is hidden underneath. I have to sort of dig with my fingers to reach the point where I can find it.
    And it is located – halfway up the thigh – closer to the pelvis than the knee – and slightly in towards the midline of the body – if that makes any sense 🙂
    I’m too attached to yoga to let it go because of this. I will keep on modifying – one day hopefully Ill be free from all pain and have my mobility back!

    Thank you so much
    Namaste 🙂
    Ulla

    • Dear Ulla

      Unfortunately it does sounds like your injury is just from being over adjusted.

      Without being able to test or examine you I’m thinking it must be the short head of biceps femoris which attaches right there. If you can find any trigger points in this muscle release them off and see how your body responds to this.

      Namaste
      Monica

  6. Dear Monica,

    I had a wakeboarding accident a couple weeks ago and ripped the muscle fibers in my hamstring and adductor muscles in my left leg. I luckily did not break any bones or sustain any damage to any tendons. It’s only been a couple weeks and I still have significant bruising but the swelling has gone down and I am able to walk again. Sitting is still painful and my range of motion is still very limited so forward bends are still quite out of the question. I think I would like to try getting back on the mat to do a bit of soft strength building and recovery- would you deem the afore mentioned poses safe? Would it be ok to begin now or should I wait til the bruising and swelling is completely gone? I just want to do whatever I can to aid the healing process.
    Thank you for you time and such an informative article,
    Jessie

    • Hi Jessie
      Sorry to hear of your injury.
      It is good to dampen the inflammation before you stress the muscle.
      For you it would be best to start with a few repetitions of single-legged Salabasana rather than holding it for a long time. If you have your legs wide this will incorportate the hamstring portion of your adductor muscle as well.
      Remember, you body will tell you what is good and if it is too early to be working the muscles. Try, then listen and keep increasing the load as your body accepts it without complaint.
      Wishing you a speedy recovery…
      Namaste
      Monica

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