Lower back pain after yoga: backbends, forward folds and twists, what to change and a plan back

Yoga is safe for most people, and it helps back pain a littleStrong evidence

In a Cochrane review of 21 trials (2,223 people with back pain lasting 3 months or more), yoga improved back pain and everyday function a little more than not exercising, and about as much as other back exercise. In 1,702 German practitioners, injuries ran at about 0.6 per 1,000 hours of practice, which the authors judged as safe as, or safer than, other exercise. The US National Center for Complementary and Integrative Health (NCCIH) calls yoga generally safe for healthy people when done properly with a qualified instructor, and says serious injuries are rare. Fewer than 1 in 100 US adults who had ever done yoga stopped because of a side effect, most often back pain.

Sources 1, 2, 3, 4

A short rise in back pain is the commonest side effectEmerging evidence

In the back pain trials, about 43 in 1,000 people had a side effect with yoga over 6 to 12 months, mainly more back pain, against 9 in 1,000 who didn't exercise (low certainty), and about as many as with other back exercise (84 against 91 in 1,000). In one trial, side effects were mostly mild joint and back pain that settled on its own, in 9 of 127 people doing yoga and 14 of 129 having physical therapy; in another, 13 of 87 yoga and 13 of 75 stretching class attendees had a mild or moderate flare, mostly more back pain, and one yoga attendee had a slipped disc; in the UK trial, 12 of 156 people doing yoga reported side effects, mostly more pain, against 2 of 157 with usual care. The earlier version of the Cochrane review found yoga wasn't linked with serious side effects.

These were beginners' classes for people who already had back pain, so they show how often a flare happens when people start, not how often yoga causes new back pain. In vigorous Ashtanga practitioners, the low back was one of the three commonest injury sites, with the hamstring and the knee.

Sources 1, 5, 6, 7, 8, 9

Which poses, and what they ask of the backEmerging evidence

At a US clinic, of 89 people whose injuries were put down to yoga, the poses most often blamed involved bending the spine forward or arching it back to its extremes. Most had overuse muscle pain (74.2%); others had a flare of pain from existing joint wear (51.7%) or facet joint arthritis (38.2%), and 14.6% had a spinal compression fracture, which the authors link with thin bones. It was a clinic's series with no count of how many people did yoga safely. In the German survey, forward and backward bends were linked with 23.8% of acute problems; in an Australian survey, forward bends with 4.8% of injuries and backbends with 3.1%; and teachers and clinicians in a survey of 1,336 linked lower back injuries with forward bends, twists and backbends.

No lab study has measured the load on the lower back in yoga poses: a study of older adults holding yoga poses measured the ankle, knee and hip only. In our reading, the deep, held, repeated or forced versions are where backs complain: wheel, camel and bow; seated and standing folds with straight legs, especially when tight hamstrings leave the lower back to do the bending; and twists levered deeper with the arms. Very rarely, a very hard class strains the back muscles badly: one case report describes swollen back muscles and muscle breakdown after power yoga in a 36-year-old man, who recovered fully.

Sources 10, 2, 11, 12, 13, 14

Telling the causes apartEmerging evidence

A GP or physiotherapist asks which poses and movements bring it on, where it hurts and whether anything spreads down a leg, and checks how you bend in each direction. The NHS says it's not always obvious what causes back pain, and it often gets better on its own. Many backs have a sore direction and an easy one: pain on arching that eases bending forward, or the reverse. Leg symptoms below the knee point to a nerve. Pain at the sit bone in a forward fold is often the hamstring tendon, not the back. One-sided pain by the dimple of the pelvis may be the SI joint, a source in 15% to 30% of long-lasting back pain without leg symptoms in one review, though no single test can pin it down.

In a teenager, pain on arching is typical of a stress fracture of the spine: of 733 children and teenagers with back pain who had a magnetic resonance imaging (MRI) scan, 94.2% of those with a fresh stress fracture had pain arching back. But no examination test can confirm it: two reviews found the one-legged backbend test isn't reliable enough to rule it in or out.

Sources 15, 16, 17, 18, 19

When a scan or test mattersStrong evidence

For most back pain, the National Institute for Health and Care Excellence (NICE) says not to offer imaging routinely outside specialist settings. A young person with lasting pain on arching is the exception: a stress fracture can't be diagnosed by examination alone and needs a scan. A review of imaging in children takes two plain X-rays as the best first test and uses MRI for early diagnosis, and MRI picks up early stress injuries without radiation (moderate evidence). In an older adult with sudden back pain and thin bones, an X-ray looks for a compression fracture. Leg weakness, numbness or bladder or bowel changes need urgent assessment, as the warning signs say.

Sources 20, 21, 22, 23

How it usually goesEmerging evidence

The NHS says back pain usually improves within a few weeks, though it can last longer or come back. The flares in yoga trials were mostly mild and settled on their own, and people in those trials still ended up with better backs on average. In the German survey, 76.9% of acute yoga problems recovered fully.

A stress fracture of the spine is much commoner in young athletes who arch and twist a lot (found in 41.7% of athletes with back pain across 9 studies, against about 6% of adults), and it usually heals well without surgery: athletes returned to sport after about 3 to 4 months on average across one review, and about 9 in 10 got back to sport in a meta-analysis (another group: athletes in arching sports; we found no published yoga cases). No one can promise a date.

Sources 15, 5, 7, 2, 24, 21, 25, 26

Keep moving, and keep practising with changesStrong evidence

The NHS says to stay active and carry on with your daily activities, and not to stay in bed for long periods, and NICE suggests a group exercise programme, which can include mind-body exercise such as yoga. The yoga trials used gentle beginners' programmes with props and still had flares in a few people, so the question is usually which poses to change, not whether to stop.

Sources 15, 20, 1

Change the deep poses for a while: a clinic series and our readingEmerging evidence

No trial has tested a change to yoga for back pain caused by yoga. The clinic series' authors advise care with positions of extreme spinal bending and arching. Our suggestion from that: smaller backbends for now (sphinx, a small cobra or a bridge instead of wheel, camel, bow and deep upward dog); bent knees and a fold from the hips in forward folds, with a strap or blocks; gentle twists from the upper back without levering deeper with the arms; and headstands, shoulder stands and plough left out while it's sore, since inversions were the practices most often blamed in the German survey.

The Ehlers-Danlos Society's physiotherapy advice says that when the hamstrings are tight and the lower back is more flexible, the lower back should be steadied before the hamstrings are gently stretched, which fits forward folds for anyone. People who mainly did power yoga reported the most injuries in the German survey (1.50 per 1,000 hours against 0.60 for all yoga, from 71 people with a wide margin of error), so a slower class for a few weeks is our suggestion.

Sources 10, 27, 2

Tell your teacher, and learn with oneEmerging evidence

The American Academy of Orthopaedic Surgeons (AAOS) advises discussing any illness or injury with the instructor before class so they can suggest changes, knowing your limits and not trying positions beyond your experience or comfort level. In the German survey, people who had only ever practised on their own, without a teacher, reported more acute problems (adjusted odds ratio 1.75).

Sources 28, 2

Thin bones: avoid deep rounding, keep doing yogaEmerging evidence

In older adults with low bone density, case series describe spinal compression fractures after yoga forward bends and loaded spinal flexion (9 people in one series, 3 in another), and the clinic series' authors advise people with osteopenia or osteoporosis to avoid extreme spinal flexion. These events are rare: a UK review found flexion activities such as certain yoga moves and sit-ups linked with more spinal fractures but rare ones, said people with low bone density can exercise safely, and noted that experienced teachers can offer modified versions of all yoga poses. Trials of yoga in people at risk of fractures reported no related side effects, on very low certainty evidence, and in an uncontrolled study 741 people, mostly with low bone density, practised poses chosen to avoid forward flexion for over 90,000 hours with no fractures reported. (Another group: older adults with low bone density.)

Sources 29, 30, 10, 31, 32, 33

Bendy backs: strength and control, not more stretchStrong evidence

Being bendy is common and isn't a problem on its own: in 5,072 adults, hypermobility wasn't linked with long-lasting low back pain. Flexibility-based activities attract hypermobile people: 72% of 85 elite dancers met the cut-off (another group), against about 1 in 8 university students; no study has measured it in yoga practitioners. When bendy joints hurt, the NHS says the main treatment is improving muscle strength and fitness so your joints are better protected, and not to overextend your joints just because you can, and the Hypermobility Syndromes Association suggests yoga focused on strength and control rather than more flexibility. Stopping at a position rather than at the feeling of a stretch is our suggestion.

Sources 34, 35, 36, 37, 38

A young person who bends back: rest from arching and rehabilitationEmerging evidence

Most young athletes with a stress fracture of the spine return to sport after rest from arching and rehabilitation: 98% of 201 adolescent athletes in one series, after about 3 to 4 months on average in a review (another group). Our spondylolisthesis guide has the plan, and the physiotherapist decides when backbends come back.

Sources 39, 24, 21

Hot yoga: the heat, not the back, is the main extra riskEmerging evidence

A review of 43 studies found a single hot yoga session raises core temperature and heart rate compared with unheated yoga, but not the effort. The American Council on Exercise's write-up of a study it sponsored reports average peak core temperatures of about 39.6°C in men and 38.9°C in women during a 90-minute class at 40.6°C, in 20 regular practitioners. In a survey of 157 hot yoga practitioners, just over half had had a problem in a class, most often dizziness, light-headedness or nausea. The review advises leaving the heat at once for dizziness, a headache or nausea, and warns against drinking very large amounts, since low blood sodium has followed it in case reports. No study has measured back injuries in hot classes; skipping hot classes, or going easier in them, while your back is sore is our suggestion.

Sources 40, 41, 42, 43

The SI joint: common, hard to pin down, and yoga can be part of treatmentEmerging evidence

The SI joint is a source in about 15% to 30% of long-lasting back pain without leg symptoms, and no single test identifies it. No study links SI joint pain to yoga, and an international consensus guideline lists yoga among the first treatments to try for it. Keeping wide-legged and one-sided poses smaller while it hurts is our suggestion.

Sources 16, 44

Your yoga for now (written steps)

Our 3D figure shows the moves, not how deep you go, your props, your class or what you tell your teacher. These steps come from the NHS, the AAOS, a clinic series, the hypermobility bodies, a hot yoga review and a national survey; where a step is our suggestion, it says so. None has been tested in a trial against back pain from yoga.

• 1. A warning sign first: numbness around your genitals or bottom, bladder or bowel changes, weakness or numbness in a leg, a fall from a headstand, or a teenager whose back hurts arching for more than a couple of weeks.
• 2. Tell your teacher before class what hurts and which poses you'll change, as the AAOS suggests. For example: "My lower back has been sore since last week. I'll keep the backbends small and bend my knees in forward folds; could you suggest options for the deeper poses?" If you'd rather not have hands-on adjustments while your back is sore, say so (our suggestion).
• 3. Backbends: sphinx, a small cobra or a bridge instead of wheel, camel, bow and deep upward dog, and come out when the lower back pinches rather than works (our suggestion, from the clinic series and the move pages).
• 4. Forward folds: knees bent, fold from the hips with a long back, a strap for the hamstrings, blocks under the hands, and no long holds at the end of the range (our suggestion; with thin bones, the move pages' and the bone review's advice).
• 5. Twists: gentle, from the upper back, only as far as is comfortable, without levering deeper with the arms or a hand on the knee; twist lying down if seated twists pinch (our suggestion and the twist move pages).
• 6. Leave out headstands, shoulder stands and plough while the back is sore; inversions were the practices most often blamed in one survey.
• 7. Choose the class: a slower, gentler class with props for a few weeks, with hot and power classes later (our suggestion).
• 8. A bendy back: stop at a position, not a feeling, and steady the lower back before stretching the hamstrings, as the Ehlers-Danlos Society and the Hypermobility Syndromes Association suggest.
• 9. Hot classes: skip them while the back is sore, or rest more in them; drink before and after, not huge amounts, and leave the heat at once if you feel dizzy, get a headache or feel sick, as the hot yoga review advises.
• 10. Thin bones: no deep or repeated rounding; fold from the hips, twist smoothly or lying down, and ask a teacher for the modified poses.
• 11. Between classes: keep walking and doing your daily activities, as the NHS advises.
• 12. Getting back to a full class: bring back one deeper pose at a time, a few breaths each, with the poses that rest the back between them (our suggestion).

Sources 28, 10, 31, 27, 38, 2, 40, 15

A teenager who bends back

A teenager in yoga, dance or gymnastics with back pain on arching that lasts more than a couple of weeks should stop the arching training and get checked by a GP or sports physiotherapist. A stress fracture of the spine is common in young athletes who arch a lot, and it usually heals well with rest from arching and rehabilitation; our spondylolisthesis guide covers it.

Sources 25, 21