Working With Pain

therapeutic yogaLearning from Injury

Moving from knee injury through rehabilitation, I learn 6 mental, physical, and spiritual truths along the way.

Do you have good knees? I thought I did. My knees carried me through 38 years before giving me a serious wake-up call. Had I, as a kid, asked my pediatrician whether something was wrong with my knees because I could not run very fast? Yes. The response: “Your knees are normal.” Had I checked in with a physical therapist in college due to some aching in my knees? Yes. The response: “Use these exercises.” But overall, my knees worked without complaining, even as they carried anywhere from 25 extra pounds on a routine basis to more than 70 extra pounds at the end of pregnancies; lifted weights; rowed; ran recreationally; and carted small children.

I had been practicing yoga about 14 months when my right knee spoke loudly enough that I had to stop and listen. As I placed my right foot on my upper left thigh to perform a variation of tree stand (this variation is not in B.K.S. Iyengar’s book Light on Yoga, but I might call it ardha baddha padma vrkasana), I heard my right knee crackle. No pain, just sound. I completed the pose, then moved into the next pose, called toe stand (I do not know of a Sanskrit equivalent). As I bent over to put my hands on the floor, pain told me the right thing to do was to let my right leg slide off my left knee. I stood in mountain pose, tadasana.

I finished class, went home, iced and elevated my knee. I slept, iced, and elevated my knee the next day too. I did the same the following day. The third day, I started a set of yoga asanas in my home. I got to floor bow, dhanurasana, and thought I would cry from the pain, more intense than any I experienced during the natural birth of my two children. I got my legs straight and thought about stopping. But I did not really want to. I am grateful to yoga for the tremendous physical, mental, and spiritual benefits I have received from practice.

I took some time and remembered some of the mantras said over and over again, by many different instructors, in many different classes I had attended. “All you have to do is what your body can do today. Every day is different. If you can, you must. Doing even 1% of the posture 100% correctly, if that is what you can do today, gets you 100% of the benefit.” I moved on to reclining hero’s pose, supta virasana, and finished, to the best of my ability, the asana set. The next day, my knee felt a little better. Amazing.

I took a day of rest, and then the next day did another set of asanas. Again, the day after, my knee felt slightly better. I went back to the yoga studio two days later, and did yoga every other day, allowing a day of rest for healing. My knee continued to improve. Four weeks later, my knee pain felt tolerable in everyday activities.

I did yoga three days in a row, but my body felt it was too much. I backed off again to practicing every other day. Over time, my healing went through variations in which my knee felt “o.k.” to, 6 months after the initial injury and despite most days being “o.k.”, being completely unable to support any weight.

I kept practicing, reading, and learning how I could heal. Four and a half years since I started practicing yoga and about 3 years after I injured my knee, I was to able to sit in lotus, padmasana, a pose well beyond my reach before my injury. I consider my knee 100% healed, thanks to yoga.

How was it, that after hundreds of yoga classes, doing yoga 5 to 6 times a week, I could be at the point of pain? At the time, I could not understand a reason. In the process of healing, I opened my heart to learning, and found six lessons.

Lesson 1. My Body is Wise – Pay Attention

My knee injury enabled me to hear my body. I knew I must have been doing something wrong to have this result. What was it? I figured if I got the signal doing yoga, I could find help through yoga. First, I found Sandy Blaine’s book, Yoga for Healthy Knees. In it, she provides a description of mountain pose, tadasana, which moved me one big step in the right direction. She addresses the question of whether one should lock one’s knees. She says that the short answer is “No.” Instead, she explains that we should stack our leg on top of itself. This led me to look at my fellow practitioners and compare my posture. I found that my fellow practitioners had legs that were straight, thighs together, knees pointed directly forward. In contrast, my legs bowed out slightly, and my knees tended to point slightly in towards each other, rather than forward.

So, two immediate opportunities for realignment presented themselves to me. First, straighten my legs. Second, point my knees forward. I moved my legs straight with knees pointed directly forward and found two results. I learned that “lock the knee” does not mean lock the knee. It means lock the muscles around the knee, while keeping the knee itself relaxed. Second, I learned that by standing properly, my hips took more weight and my body felt lighter overall, reducing the strain on my knees.

I wondered how I could have missed this correct alignment earlier. I went back and looked at Light on Yoga. At the beginning, Mr. Iyengar emphasizes how important it is to stand properly. Despite having read his words several times, I had never before shifted my perspective. I understood the concept and thought I was executing properly. I was not. Pain told me so. I also went back and looked at other resources with which I was familiar. In Bikram Yoga, Bikram emphasizes the importance of “safely and powerfully” locking the knee (at 123) and states that the way to do that is to tighten the quadricep muscles. I had been doing this – but I had also been doing something else. I had been pushing my knee back, and my legs were bowed. An early instructor had told me not to hyperextend my knees, but I did not really understand what this meant. With my injury, I went to Bikram’s website, and found a question about knee pain ( It is unlikely I would have read this before, since I considered myself to have good knees, but this time I was focused on it. The site says to keep the knee “pointing straight ahead.” It also says if the “knees are bowed (hyperextension) you should bring the weight forwards towards the toes”. I found some good information to use in specific poses, but am uncertain whether before injury I would have recognized myself in the descriptions given. My injury opened my eyes so I could actually see how I was standing. Now I get it. Legs straight and touching each other, knees pointed directly forward.

My new understanding has translated into every part of my life. I am completely relearning how to move, and in the process have become much more mindful of my body. I check to make sure my toes and knees are pointed straight ahead when I walk. I swing both legs in or out of the car as I enter and exit, rather than putting one leg in or out at a funny angle. I work to feel my body weight all over my feet, evenly distributed on my legs. I understand how to get out of a chair, pushing my weight equally onto both legs, feet aligned. I understand how to sit down, distributing my weight equally and keeping my knees over my toes.

Most surprising to me has been the tremendous progress I have made in opening my hips. My new knee alignment is changing the shape of my entire pelvis. In the other direction, my calves and shins feel much stronger, and my feet walk evenly enough now that I want new shoes rather than walk in the old shoes worn thin in the outer heel due to supination. The old song about one bone being connected to another has new, personal meaning for me.

Lesson 2. There Is No “Should”

I believe another factor in my knee speaking up was a desire to please and succeed. Several classes earlier, an instructor had encouraged me to take the next step in a posture. My mind was kind of wondering, too, when I would be able to take the next step. My mind was saying “Why” can’t I do it? I “should” be able to do it. So I pushed my knees. No immediate pain, just shaking legs. I did this for several classes. Then, my knee said “No,” loud and clear. Now I know that “why” and “should” are words and thoughts that have little place in yoga, particularly when tied to ego.

I also experienced the swing of the pendulum to the other extreme. As I healed, I became extremely protective of my knee. Almost two years into the healing of my knee, I found my knee felt normal in everyday activities, but that at times I would experience a “click” at a certain flexibility point. Aware of that potential “click,” I unconsciously placed excessive limitations on myself. Under the guidance of an experienced Iyengar teacher, I realized that my knee had healed enough that I could do more.

In both cases, an instructor thought I could do something. In the first case my ego agreed and my body did not. In the second case my body agreed and my ego did not. Mr. Iyengar, in Light on Yoga, talks about it being important for us to include practice on our own as part of our yoga, so we are driven from inside, rather than by the external “fieriness” of the instructor. I seek now to draw on my internal motivation while honoring it as one part of a triumvirate: instructor, self, body. The instructor thinks I can do it? What would I do if practicing alone? My ego says I can do it? What does my body say? Then, I choose consciously whether to take the next step. There is little to be accomplished in yoga by force. Rather, I find I make the greatest strides when I simply relax. If I were lazy, I might say otherwise, but my tendencies tip to the other end of the scale. Relax my mind. Relax my body. Relax into posture, asana.

Lesson 3. The Unexpected Is A Signal

In my early yoga practice, several instructors had emphasized the desirability of distinguishing between good pain and unexpected, sharp pain. I understand the distinction much better now, not because of what happened in the moment with my knee, but because of the healing process. As I worked with my knee, I could feel, as in reclining hero post, supta virasana, that there was a stretch of my knee that felt a little painful, but was a good pain, as long as I moved slowly. In contrast, there was pain in floor bow, dhanurasana, which was warning pain. If I moved past a certain point, there was sharp, sudden pain, my face expressed it, and I could not make my leg straight again without moving through that sharp pain again. I gained a personal understanding of unexpected, bad pain, and an appreciation for how good pain can help healing.

More than pain, I learned that even the unexpected, without pain, can signal a need to re-examine what is happening. The first signal my knee gave me was a simple set of crackles as I moved into the variation of tree pose. When I put my leg down, I felt fine. I heard the sound, knew the sound was different from any I had heard before, but had no context, no reason to think this signaled a problem. It was not until I went into toe stand that I felt pain.

The sound was sending me a message I did not know how to interpret. Over the prior months, I had heard occasional joint popping, but had thought little of it. I have heard it said that cracking and crackling is a good sign, a sign that synovial fluid is moving. I think now that such sounds are perhaps an early, early warning system, one to which I should be very attuned. If I hear them, my job is to check my posture and alignment to see what work I have to do.

Lesson 4. Even Pain Has an Upside

Just as the butterfly dies unless it is the one to free itself from the cocoon, thus creating enough strength to fly, even before my injury I believed that pain has a purpose. I was attuned to the physical purposes of pain, such as serving as a warning or providing information about the natural process of birth. Through injury I learned that pain can have not just a physical, but an emotional and mental purpose. There was no gliding through my yoga practice. I was utterly present, moment-by-moment. I listened very, very carefully to every move of my body. My normally chattering mind was quiet, senses wide open and receptive, listening to my knee and keeping open to every other part of my body in an effort to monitor and maintain health. In some ways, I came out of the yoga classes I took while my knee was healing more relaxed than from any other since the early days of my practice, because my intense focus kept me present in the moment. My opportunity now is to identify ways to maintain that crystal clarity, that presence in the moment. Some ways I am exploring include coming to practice with the mindset of a beginner; reminding myself that my objective is to be present and focused; and learning from different traditions. I am grateful in that pain helped me be on the path of developing the skill of presence.

Lesson 5. Every Body is Perfect

A tremendous benefit I have received from my own injury is an increased level of empathy. I understand much more about limits and how a particular posture may be causing someone to feel pain. We do the best we can, on any given day. The beauty is that we are all there, practicing, and supporting each other.

Lesson 6. Everything is Perfect

I remind myself as I practice and live that everything is perfect. If my mind strays to thoughts that my practice is moving slowly or that I am having a setback, I think, “Actually, this is perfect. I would rather correct this now.” As Bowen instructor Vicki Mechner once told me, proper alignment alone can lead to lasting good health.

Coming to life with the attitude that everything is perfect also reminds me to live in flow, rather than desire control. This has two parts for me.

First, I recognize that my body does things, and the more I accept what my body does, without judgment, the better integrated are my mental, physical, and spiritual selves. My choice is to simply accept my body as it is, rather than attempt to control by force. Brains, not brawn, as my father taught me. When the time is right, my body and brain act congruently, moving toward the same end.

Second, knowing that everything is perfect helps me to release attachment. At the time of my injury, I did not know how I could have been at the point of pain. I might have had a hint if I had recognized how little I knew (and know), known where to turn for expert guidance, or ever heard the term “therapeutic yoga.” But in accepting that through injury and healing I learned lessons perfect for me, I have started to embrace, “Who cares?” Who cares if I never get to the full expression of a particular pose. Who cares if I never look like that person over there. Sometimes I phrase this as “What can I let go of now?” I do not know what tomorrow, or the next moment, brings. What matters is that I do as I am able in this moment, and find joy in that expression.

~Leanne Cusumano Roque