Joint Rehab 101
Mark’s knee doesn’t look good. And, actually, his feet and ankles don’t look much better. I told you in my last discussion of Mark that I didn’t want to focus too closely on his injury because there are larger, more systemic issues that he also need to address, like stress management and overall conditioning. What’s more, Mark needs to connect to a philosophical system that provides him with the new identity that is beginning to form inside. All of this is well and good, but, sadly, we still have a major knee injury to address, so let’s get down to it.
When I look at his swollen knee and his limp, it is evident that he has chronic pain. Also, his range of motion is severely limited: He can only bend his left knee 20 degrees or so in standing poses; basic backbends such as Setu Bandha Sarvangasana (Bridge Pose) are off limits due to pressure and strain in the posture; and, very little external rotation is available. So, what’s a yoga teacher to do?
We’ve got to start strengthening the leg right away, right? If there’s a problem in the body, we need more strength, right? I hear this most days of the week, and, at least in the case of Mark’s knee, I don’t think focusing on strength, strength, strength is the first course of action. I won’t bore you to tears, but I have a feeling that the "strengthen first" solution has more to do with cultural, ethical biases than it does effective problem solving. And, here is the reason: Since Mark is profoundly misaligned from his left toes to his left hip, focusing on strengthening too early will make him stronger but not necessarily in the right ways. Instead, we’ve got to properly align the guy so that his body stops fighting himself so much. Of course, strengthening and aligning are not mutually exclusive. One should do both. However, this isn’t just an issue of semantics, it’s an issue of orientation. Strengthening his quadriceps until he can pull a semi-truck down the street is not necessarily going to make his knee feel better and it certainly isn’t going to reform his feet and ankles. It might present us with a temporary fix, but unless we develop good alignment in his feet, ankles, knee and hip he will continue to be vulnerable to severe knee problems.
So, before we strengthen we’ll align. Then, after creating better alignment, we’ll work to increase his range of motion. Once both are looking better, then we will shift the focus to strength. Sure, all of this happens simultaneously—sort of. But our awareness has to be concentrated on the topic of alignment so that we can cultivate greater physical integrity.
We’ll keep working his standing poses intelligently (and with the proper support). We’ll also increase his range of movement throughout his hips and various supported hip-openers. Then, we will support and deeply relax his legs in poses like Viparitta Karani (Legs-Up-the-Wall Pose). I’m sure with this work that his knee discomfort will begin to subside, though, he may still feel some pain for the foreseeable future.
Comments
Sounds like a good plan! I hope it goes well and his pain starts to lessen.
Posted by: Liz | March 13, 2007 02:09 PM
Jason,
First and foremost the modified doctor's oath "do no harm" seems to be the critical directive for all yoga health parishioners. I, like Mark, have a knee that swells and a hip that does not rotate efficiently. These problems are exasperated by being over weight and having a career that requires hours of sedentary concentration.
So, where does yoga fit in? I think your concern that about doing harm by 'strengthening' is a realistic evaluation of what would happen if classic strengthening is done to an unstable physical system of joints, ligaments, muscle and bones. Your first article’s suggestions I think are true for me and true for Mark and put into Bikram’s terms I outline them bellow with, of course, a small amount of my own commentary. Before I begin these are my views on my experiences as I try to realign my-self at fifty they are not necessarily good for everyone else that is fifty.
Bikram number one – “Fat boy! You could do lotus if you lost 20 pounds!”
A. It is unrealistic to think that the joint will stop swelling and hurting when it is supporting 30-50 pounds more weight than it was designed to handle. This is doubly critical for the forty and older male who is losing muscle mass due to the aging process. Bikram states the case clearly so even a thick skulled, stuck in his ways spud like myself can understand the message – change or the weight of the gods will crush you.
B. Being an overweight man ensures that the belly is thrust forward throwing the lower back and hips off of the center of balance. The contortions the back goes through to support this belly mass ensures that the hips will be stiff and that the weight loads will be supported by points in the muscle/bone/joint/ligament structure rather than the loads being spread over the entire structure. Overtime, this point weight load ensures swelling, injury and finally failure (knee/hip replacement.)
Bikram number two – “Fat boy! You must KILL yourself.”
A. Many people misunderstand or mischaracterize Bikram when he says ‘Kill Yourself’. Neither Birkam nor his wife has ever suggested that I work in yoga beyond my ability. In fact, Bikram is saying just the opposite. When the ‘Kill Yourself’ command is given he is describing killing the self defeating mental processes we all go through that defeat our ability to enter into a yogic peace. These self defeating processes are what one must die to enter yoga. It does not matter that Bridge Pose is always done with a prop it only matters that this is the best I can do without recrimination, without doubt, without complaint, without desire for what it is not. Said more profoundly – “Give me the strength to accept…”
Bikram number three – “Good Boss, You got it!”
A. This is a truly unique Bikram piece of wisdom. He sees the change in people who truly desire change. I think this is a key to why Bikram is successful and why he can creates some controversy. He does not give a DAMN for the people who don’t want to change, who rather complain than change, which would wallow in self pity rather than change. BUT and this is a BIG but if you want to change, if you try to change, if your have the courage to change you will find no better cheerleader than Bikram.
B. This trait is what I think defines all the good/great yoga teachers I have worked with. They know that there is not enough energy in the world to change a person unless they decide to change. Therefore they always focus their energy on where change is happening.
Finally, Jim Smith’s number four
A. Lose 30 pounds
B. Leg up at night with Ice/Warm treatments to alleviate swelling.
C. Ibuprofen for three times a day at the max level tolerated to get ahead of the swelling and pain.
D. Careful yoga practice (not overly stretching/weighting swollen joints) in a hot room.
E. Low impact aerobic exercise like biking on flat terrain.
Posted by: Jim Smith | March 16, 2007 03:51 PM
Although I like to crow about being in great shape for my age (43), I have weak knees from old injuries.
An intense week of skiing left me in acute pain... I have been doing a lot of physical work in the last year and rely on my knees! ... and I need to fit my practice around chasing 2 babies...
So back to good old Mountain Pose, multiple times over the day, with focus on aligning the feet and the back, often using a wall for reference. As one ages and gravity takes its toll, it becomes more and more important to suck up the pelvic floor and work the lower abdomen to stabilize the back.
I'm also practicing Tree Pose with eyes closed - this humbling exercise is best started with one toe on the floor, using hip strength to draw up the leg and hold it in place, instead of jamming into the other knee.
Recovery is a slow process and part of the process is accepting one's current state, just as it is. That acceptance can be the hardest practice of all.
Good luck Mark!
Posted by: Claudia | March 19, 2007 08:58 PM
I wish Jason was my teacher.My teacher resolutely will not listen to anything I try to express to her about injuries.
She always harps on living in the now.But even though my injuries were sustained in the past, they remain in the now, and not because I choose to "dwell" on them.
Does anyone have any advice, other than switching teachers? That is not a possibility for me, as I attend classes thru the Y, and what you see is what you get.
Posted by: John | March 20, 2007 07:51 PM
Jason,
I was thinking about why there are so many responses to Leah and Mark and less so for Edith. I think it has to do with timeframes and fitness. For must of us, myself included, Yoga is a journey that evolves over several years with change coming gradually as the fitness level increases and the old habits die a slow, painful death.
For Edith, the change is measured in a couple of work outs - advice -> translation -> benefit in overall performance.
As opposed to the average Jane or Joe (or in my case Jim) whose path is advice -> ouch that hurts! yo! my body doesn't move that way! -> months of practice and patience...->glimmer of what is possible... This is the conundrum of yoga or as Bikram would say it "never to old, never to sick, ...." and I might add be sure of the yardstick that measures progress.
Regards,
Jim
Posted by: Jim Smith | April 13, 2007 02:12 AM