Response: William Broad, FAI.

I am several months delayed in posting this response to William Broad’s “Woman’s Flexibility Is a Liability (in Yoga)” [NYT, November 2nd, 2013], in which Broad, in his own slightly bizarre effort to make yoga a kinder, safer practice, warns us about the dangers of Femoroacetabular Impingement, or FAI. Shortly after the publication of his op-ed piece, it was picked up, recycled, and elaborated upon by numerous news outlets, and commented on by many yoga practitioners on the web.

FAI occurs when either the head or neck of the femur (thigh bone) repeatedly scrapes against the acetabulum (the shallow hip socket that it sits in), causing bone-on-bone pain, degeneration, tears in the labrum, or arthritis. The cause of FAI is anatomical. According to the American Academy of Orthopedic Surgeons (AAOS), FAI “occurs because the hip bones do not form normally during the childhood growing years… When the hip bones are shaped abnormally, there is little that can be done to prevent FAI.” This condition can lead to injury, and of course presents a true potential danger, to both men and women, but especially to women, who have shallow hip sockets and a wide range of motion. But the AAOS goes on to inform us:

“Because athletically active people may work the hip joint more vigorously, they may begin to experience pain earlier than those who are less active. However, exercise does not cause FAI.

I have seen just a few cases of FAI, that I know of, in the twenty-five years I have been teaching. Did yoga cause these instances of FAI? Not according to the description of FAI above. Did yoga exacerbate it? Yes, most certainly. But yoga did not, however, create in anyone’s bodies an anatomical structure that makes such an impingement a possibility. Last question: Would I have liked to have had more information about the potential for such a thing to occur, and ways to prevent it? Absolutely.

Even though the occurrence of injury that Broad is writing about is valid, the vocal blowback that he often incites (with every article he writes on yoga) is perhaps largely in objection to his tone and his lack of scientific rigor. “From my own practice and research,” Broad blithely begins, “I know that yoga is generally a good thing.” This is an affront to those who “know” that yoga is much more than a good thing. In many cases, it is a life-saving thing, a purifying thing, a trauma-reducing thing, a “This is helping me deal with dying from cancer” thing or a “This is saving me from trips to the hospital when I have PTSD flashbacks” thing. I would venture that many of the twenty million Americans who are practicing yoga are not going to necessarily take comfort in Broad’s tone. So though Broad qualifies his statement by stating that the benefits are many, and the dangers few and rare, his articles constantly seem to indicate the opposite.

As Broad’s by-line lists him as a ‘science reporter for the NYT’, there are, at the least, three characteristics to his writing that undermine his mission by negating scientific rigor, and also seem to be a catalyst of annoyance for many readers.

1. His research methods: “…in late summer, I got around to making some calls.”

2. The types of supporting evidence he cites: “I found that hundreds of orthopedic surgeons in the Mediterranean region heard a conference presentation in 2010 that linked FAI to middle-aged women who do yoga.”

3. His needlessly sensationalist tone: “To my astonishment, some of the nation’s top surgeons declared the trouble to be real—so real that hundreds of women who did yoga were showing up in their offices with unbearable pain and undergoing costly operations to mend or even replace their hips.”

The takeaway? Mr. Broad made some phone calls; surgeons (as they are prone to do) heard a paper read; and other surgeons, whose bread and butter depends on performing said surgeries, performed surgeries. This does not add up to a very deep investigation of the syndrome, or its true relation to yoga. The one yoga teacher referenced in his article, Michelle Edwards, is authenticated because she posted an article on the yoga website Elephant Journal—hardly a peer-reviewed portal of scientific rigor.

Marshall Hagins, a researcher and Professor of Physical Therapy at Long Island University, sent the below letter to the New York Times. This letter astutely sums up one of Broad’s several flaws as an investigator of yoga, pain, and injuries:

Dear NY Times,

Mr. Broad fails once again in his musings on the dangers of yoga to inform his readers of a basic fact that stands his argument on its head—a lot more people do yoga now than before. Are more women coming into orthopedists offices with hip arthritis, or are the same number of women coming in with hip arthritis that happen to mention to the doctor they just came from yoga class? Without this clarification we know absolutely nothing about the relationship of yoga to increased rates of hip arthritis. It would be interesting to ask orthopedists who focus on the shoulder to ask their patients, who presumably do not have hip pain, if they take yoga. I wonder if the NY Times would publish an article composed solely of physician anecdotes (like Mr. Broad’s article) recounting the ever-increasing number of women who have no hip pain after starting yoga?

His last point is to be well considered—where are accounts of the women who have healed or lessened their hip pain (not to mention the unfortunately unknowable number of women who have prevented hip pain) through a regular yoga practice? If you are going to make a thorough examination, then solid evidence necessitates that you research all angles of your topic, in the same way that a scientific study requires a control group. Broad’s research is rife with confirmation bias—he is fishing in a fish bowl for the thing he is looking for, to the exclusion of all else.

If we look to the general numbers, such as those presented by a recent Sports Marketing Survey, there were 20.4 million Americans practicing yoga in 2012 (8.7% of the country), and 82.2% of them were women. This means that of the roughly 18 million women who practiced yoga last year, there were possibly several hundred who had hip pain, and perhaps surgery.

Even though the numbers that Broad presents are relatively low, we as yogis should never allow ourselves to think that the pain of even one person is acceptable. Though I take issue with Broad’s approach and his general attitude, I believe it is wise to always take the opportunity to educate ourselves, and to attempt to live by the yogic dictum of the Rishi Patanjali, heyam dukham anagatam [the pain which is yet to come should be avoided].

That being said, a glaring aspect of Broad’s presentation is that he does not give any concrete suggestions as to what can be done to prevent FAI by building structural integrity in the hip joint. He stops at the extremely vague “You may want to back off” and “Listen to your body.” If people already knew how to listen to their bodies, they wouldn’t be coming to a yoga class! We go to yoga classes in order to learn how to listen, and it is the job of a teacher to help their students do so.

Anatomically, there are some people who may in fact be predisposed to FAI (the heads of the femur may have bumps on them, or the rim of the acetabulum hangs out too much). Dr. Hagins warns that in these cases, too much bending forward with a deep crease may create pain in the front of the hip. “FAI doesn’t happen overnight or with a couple of poorly performed poses. People with consistent pain in the front of the hip when they create a deep hip crease should respect that pain and not push it,” he says. “For those people, exercises to strengthen the back of the hip can be helpful (gluts and external rotators). For those people, relaxing and lengthening the hip outward from the socket and rolling the entire leg back and forth may be helpful. It’s important to also note that a large number of people have the anatomical predisposition to FAI and do not have symptoms. In fact, it is not even known if the anatomic predisposition precedes the onset of symptoms or if in some cases the knocking of the bones together creates the anatomic bumps (called “osteophytes”). No one knows precisely why some people get FAI and some don’t.”

Maria Gerlich, a physical therapist who practices in NYC, has noted that with the advent of MRIs we now see a rise in diagnosed FAI simply because the technology is better—and not because the patient necessarily is having pain as a result of FAI.

So although we do not know what causes FAI with any certainty, we do know that the pain arises from the femur moving anterior to (toward the front of) of the hip socket. Hence, exercises or yoga poses that help relax the head of the femur posterior to (toward the back of) the hip socket can sometimes provide relief. I have actually experimented on myself with this, and with success. In the past I have had pain in the front crease of my hip that made it difficult to walk or get out of a chair; I did not get an MRI, but I somehow relieved the pain and strengthened my supporting hip musculature using some of the exercises below.

If you like, you can try some of them. If you have any of the aforementioned pains, see if these exercises make you feel a little better. If you are not experiencing pain, but want to try the exercises, simply notice if the movements help you feel more supported in your posture, particularly when seated. Of course, if you are already at the point where you have sharp and enduring pain, have trouble walking, getting up from a chair, or getting out of your bed, it is time to visit your doctor.

Further, if one combines lengthening of the hamstrings with strengthening of the quadriceps and the external and internal rotators, you could quite possibly end up with a nicely stabilized hip. And for fun, throw in some core strengtheners to balance everything out. There are a lot of variations of the exercises listed below that can be done, but for simplicity sake, I just illustrated seven of them. Next time I’ll use a better looking model.

And Mr. Broad, may I suggest that you consider your intentions before going on another yoga rant in the Times. I would question whether your approach is harmful or helpful. Perhaps it is a mix of both – but my guess is that it might be time for a new approach.

In any case – here are the exercises. Special thanks to Dr. Marshall Hagins for his suggestions and edits to this article; Dr. Maria Gerlich for her comments and suggestions; Amelia Saul for the photographs, and Barry Silver for the captions and thought bubbles that help make me look as silly as possible.

Feel free to write with questions or comments:

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