Ilio Tibial Band Syndrome - Marma chiktsa and Sthanika vasti

Ilio Tibial Band Syndrome - Marma chiktsa and Sthanika vasti


Name:Mr.S.K           

Age:36 yrs

Sex: Male

Occupation: Auto driver (Goods transportation)

Date of consultation: 6th of jan 2011


H/O present illness :


Mr.S.K was suffering from severe spasm in the  lateral aspect of  supra-patellar region and the lateral epicondyle of tibia of the left lower limb from 28th of Dec.2010. Negative history of Back ache at the onset of above pain. But complains of mild back ache on the day of consultation.

Knee movements restricted due to stiffness and lateral swelling of knee joint. Negative history of crepitation or morning stiffness.


Associated complaint : Swelling on the medial aspect of right ankle,since 2 days prior to consultation.


H/O past illness :


The subject was a k/c of Chr.Rheumatoid Arthritis, under our care since 3 and a half years. He was totally asymptomatic for the past 2 years or so before the current ailment.H/o increased R.A factor; CRP ratio etc., were present in the past.


Clinical observations and analysis :-


R.O.M of affected Lt.Knee : 0° - 30°

S.L.R  of both limbs :- Rt : 70° & Lt: 80°

Negative findings of  redness, deformity, skin changes

On palpation :-

warm + in both lt.knee and rt.ankle;

tenderness 2+ in lateral aspect of lt.knee and 2+ in medial aspect of rt.ankle

sensations- NAD.
Gait : Limping (more inclined towards left lower limb while walking- compensatory gait to feel less pain in the lt.knee)

Patella- Freely movable


Considering the past history the R.A factor, CRP ratio were adviced and found to be WNL.

Even though the symptoms and past history suggest R.A, the signs and lab investigations are not quite conclusive to substantiate the same.

It is at this juncture, while interrogating we got a clue with regards to his occupational factor.

Being a load auto driver (in the sense auto for goods transportation), he has an habit of driving by keeping his right toes overstretched and always kept over the clutch of the vehicle, even while waiting in the traffic signals. This overstretching of the toes has been one of the reason for stretching of the Ilio-Tibial Band (henceforth referred as ITB), which is is a longitudinal fibrous reinforcement of the fascia lata, attached to the anterolateral iliac tubercle portion of the external lip of the iliac crest and to the lateral condyle of the tibia.

Ilio-Tibial tract


The ITBS (ITB Syndrome) usually affects persons in the sports field due to continuous stretching of the band caused by the extension and continuous usage of the tip of the toes.


The action of the ITB :

- thigh flexion at the hip, abduction, and medial

- stabilizes the knee

- iliotibial band moves forward in extension and backward in flexion but is tense in both

- during flexion iliotibial band,  popliteus  tendon, and LCL cross each other, whereas iliotibial band and biceps tendon remain parallel to each other in extension, all serving to enhance lateral

- in addition to lateral ligaments and lateral capsular structures, stability is significantly dependent on iliotibial band, biceps tendon, and the popliteus

- w/ flexion of iliotibial band, the popliteus tendon, & LCL cross each other, therby greatly enhancing lateral

- it thus acts as a supplement ligament across lateral aspect of joint.(Reference:- vide:- http://www.wheelessonline.com/ortho/tensor_fascia_lata_iliotibial_band)


The kinesiological investigations

of Inman revealed the interrelation of the hip abductors and the tensor fasciae latae

with the iliotibial tract as an abductor of the thigh. (reference- The Journal of Bone and Joint Surgery  The Iliotibial Tract: Clinical and Morphological Significance ;  EMANUEL B. KAPLAN J Bone Joint Surg Am. 1958;40:817-832__ vide:- http://www.ejbjs.org/cgi/reprint/40/4/817.pdf )


In the above case too the ITB was found to be taunted even in resting posture, and when pressed along from the insertion point to the origin point of the ITB, the subject expressed pain suggesting 2+ tenderness up to mid-way of the ITB, almost near the mid of the thigh region.


The cause for the swelling in the right ankle was found to be due to sprain of the medial collateral ligament, caused due to over usage of the left leg, involved in compensatory mechanism of switching the body weight over the left leg, during the  limping gait,due to pain in right knee.


Diagnosis :

 

Left Ilio-Tibial Band Spasm/ Syndrome & Right Ankle sprain


Modalities selected :-


Marma Chikitsa and Local svedanam in the form of sthanika vasti.

Even though the marma chikitsa was selected in the modality of treating the above case, the vasti played a main role in controlling the stiffness if the IT Band. Withe the amount of muscular taunting and tenderness presented by the subject, M/C could not be done vigorously, since the subject felt it to be highly intolerable becoz of the natural pain involved in the pathology itself.

So, it was decided to give a secondary importance to M/C and primary focus was laid up on the local vasti modality.

Vasti over the lower aspect of left Ilio-Tibial tract

Vasti over the medial aspect of the Right Ankle



The areas where the vasti was done are, (1) in and around the insertion point of the ITB over the Lt.knee joint on its lateral aspect & (2) along the medial aspect of the right ankle.


The following marmas were selected supplementarily for supporting the above modality in controlling certain nuance form of pain felt by the patient in the following manner.

When pain felt along the medial aspect of the thigh - Lohitaksha manipulated

For severe muscular stiffness in the calf muscle - Poppliteal fossa manipulated

In case of tingling pain in the foot from the region of ankle - Kshipraand Tala hrudaya were manipulated.

Oorvee was very rarely manipulated, since it was the most tenderful marma in the above subject, and he never was co-operative to even touch that marma for manipulation.



Observation :-


With in 3 days the swelling in left knee got subside completely and the resultant pain too got relieved completely.

The swelling of rt.ankle was responding to the treatment, but, since the subject was still adviced to follow his job of driving the auto (to earn his daily bread and butter), it persisted to a moderate extent.

Hence, he was adviced to be under crepe bandage for immobilisation of the left ankle for the next 10 days.( The band was changed frequently once in 2 days, since he was still riding his auto).


Medications adviced during the treatment are :-


Ajmodad churn

Gulgul thikt Ks

Murvenna

Bryo.30 of homeopathy (indication:- slightest movement aggravates the pain).


Post treatment review :


The PTR was done on 19th of Jan 2011.

Lt. Knee : ROM 0° - 120° ; devoid of pain and stiffness.

Rt.Ankle - Pain and swelling reduced.Hence crepe was removed.

Gait - Normal.

Advised to avoid over usage of the tip of the toes while driving the vehicle, which the subject has started following.



-Sarve janah Sukhino Bhavanthu ||

" Sarve santhu Niramayah" .

Prof. (formerly) Dr.Rangaprasad Bhat,

SPKVCC (Saroja Panchakarma & Varma Chikitsa Centre),

15/7,

Thiruvalluvar koil st,

Mylapore,

Chennai- 4

Mobile- +919841218802 (for appts only)

Tags: ITBS;Ilio Tibial Band Syndrome

0 comments View Entry

Most of the general population face the difficulty in making their child sleep at proper time in the night.The children who sleeps for a longer time in the day and those children who miss their dad and mom due to their work often tend to stay active at night playing with their parents. At such circumstances, what so ever measures like turning the light off; switching off the source of sound like television,music players etc.,; bed time stories and many other methods, we find the children not sleeping but playing.

Just try the following methods of manipulation of certain marma points to find your child doze off at bed or over your legs.

Position of the child:

Place your child over your legs in supine posture so that his/her head lies in your thighs.

Marmas selected for this purpose:

अधिपति

शंख

आज्ञा चक्र

Method of manipulation:-

Use the index and middle fingers to tap alternatively and simultaneously but with a very soft landing over the surface of the skin of the marmas mentioned.

If the above version could not be understood or followed, then.........
"assume that you are to type the letters O & P in your keyboard of P.C. The amount of pressure exerted by us, in making the letter O & P appear on the computer screen , is the sufficient pressure required for the above purpose of manipulation.
More over mentioning of the the above two letters is with regards to the proximity of the two fingers in use for the manipulation (the index and middle), the proximity should be so close such that the ring finger pressing the letter "O" and the middle finger the letter "P".

1. Initially fondle the hairs present above the adhipathi marma, in a circular fashion,slowly and steadily .The circular movement should be concentric starting from the mid point of adhipathi and slowly reaching farther away from the region of adhipathi. ( For concentric movement_ if one would have seen the old Hindi movies when ever a flash back scene is being narrated a circular movement of concentric circles will be shown).

Dr.Rangaprasad bhat,

http://drrangaprasadbhat.blogspot.com/

Tags: Marma Chikitsa;disturbed Sleep

0 comments View Entry

The management of Sensory loss associated with total thermanaesthesia with marma chikitsa and applied treatment modes of panchakarma have been elaborately discussed in the followingArticle

Mr.Mohan aged 55 years, approached and consulted at S.P.K.V.C.C, in the month of December 2009,inquiring about the possibility of getting relieved from his current problem of peripheral sensory loss in the form of analgesia and thermanesthesia at the region of left flank and left lower limbs associated with weakness of right upper & lower extremities.He was presenting with mild kyphosis at the level of T-12 - L-1 too.
The above case is being described henceforth.

History of present illness :

In march 1999, when at New Delhi, he developed Right Hemiplegia due to T.I.A ( Transient Ischemic Attack). Three days later, developed Peritonitis due to Perforated Duodenal Ulcer for which surgical intervention in the form of Peritoneal lavage was done.In January 2003, he was diagnosed & operated for C5 - C6 subluxation.

History of present illness :

* Weakness of right lower limb.

* Numbness of left hypothenar eminence in associated with thermanaesthesia.

* Weakness of right little & ring fingers.

* Total thermanaesthesia & loss of sensations of touch; pressure;& pain, in the flank, portions of lower abdomen, groin, lateral aspect of thigh, dorsal aspect of foreleg, dorsal aspect of foot etc., on the left side.

*Half circumduction and high stepped gait.

*Lower limb length discrepancy noted with right leg shorter by 10 m.m than the left leg.

*Pain & tenderness in the region of T12-L1.

*On examination, the T12 spine was found to protrude out with 2+ tenderness associated with stiff right para-vertebral muscle.Mild kyphosis too was observed (T12 over riding L1 due to Thoracic spondylolisthesis).

Treatment Modules selected :

* Marma chikitsa manipulating the vertebral column; Nabhi; Lohitaksha; Urvi; Ani; Indrabasti; Gulpha; Talahrdaya; Kshipra; Parshva & Brhati were done.

* Susumna vasti @ the regions of T12-L1 & L4-L5-S1.

* Masha pinda svedam were done for 20 days in 2 different sessions of 10 days each with a gap of 1 month in between.

Improvement observed in the patient during the course of treatment :

# On completing the 3rd sitting Mr.Mohan got relieved of the stiffness @ back & left lower limb.

# After 6th sitting, sensation of pain and pressure at the affected areas started regaining slowly.

# The otherwise protruded vertebral spine at the regions of T12 - L1 got depressed and became even with that of the other adjacent spines, on completion of 8th sitting.

# 10th day he started regaining the touch sensation to a little extent. And his gait improved from half circumduction to almost normal, but with little limping (due to length discrepancy of legs).

After a gap of one month, the patient maintained a good sign of improvement with regards to peripheral sensation in terms of touch,pressure and pain.but, the thermanaesthesia remained the same.


# The next 10 days of sitting were fruitful with regards to the improvement in regaining the peripheral sensation in terms of touch,pressure and pain. But, with regards to the perception of heat or temperature, there was quite an amount of fluctuation. In the sense, Mr. Mohan was able to perceive the heat at some times and not so definitive at other occasions of the 2nd session of the traetment scheduled.

Conclusion :

The patient felt happy in getting relieved of almost 80% of the symptoms,in post treatment period.The only suffering of total thermanaesthseia remains to be a bitter one in the mind of both patient and myself.for further strengthening of the nerve in enhancing it's conduction internal medicines prepared with herbals like Withania somnifera, Mucuna pruriens, Apium graveolens etc. and others have been prescribed.


Warm regards to all those who read this. 
"Let humanity live in peace and health".
“Sarve Janaah Sukhinoh Bhavanthuh ”.
"सर्वे जनाः सुखिनो: भवन्तु:"
"ಸರ್ವೇ ಜನಾಃ ಸುಖಿನೋ: ಭವಂತು:"

"வாழ்க நலமுடன்".    

http://drrangaprasadbhat.blogspot.com/2010/02/peripheral-sensory-loss-and.html

Please give your valuable opinion regarding the above case.

With warm regards,

Dr.Rangaprasad bhat,

"Sarve Janaah sukhinoh Bhavanthuh"

3 comments View Entry

A short History of the case :
Mr.K.C.S came to my clinic SPKVCC one month back complaining of bilateral knee pain while walking. On subjecting him to screening I found the Para spinal muscles at his back to be taunted, associated with the features of Kyphosis, Lordoisis and scoliosis. This is a rare combination of spinal deformity come across by many of us.

On asking him to walk I found that he was flexing (bending) his knees to almost 15 degree and his gait were little bit limping in spite of bending the knees. He could not sleep in supine position, if does so would feel much pain at the back and knees due to overstretching of the para-spinal muscles. The vector of the pelvis was tilting obliquely, which means that he must be having variation of length in either one of the leg. And of course his right leg was shorter than the left one.

Mr.K.C.S, while explaining the history of his ailments, said that he had a fall from the height nearly 20 feet, some 20 years back, while working in a transformer since he was an Electrical Dept. person, in charge of maintaining the current supply. This fall had caused him fracture at the neck of Right femur. It was duly rectified by conducting internal fixation of the fractured bones with Mac Murray’s Osteotomy method, which was a popular surgical intervention by that time.

But, unfortunately, his destiny made him to suffer another fall fro a height of 18 feet, once again after two years of the previous episode and now he broke up his left femur at it’s neck region. Mac Murray’s Osteotomy was conducted for this limb too. It is only after this second surgery, he developed Limb Length Discrepancy, and not after his first surgery. It is this limb length discrepancy, as of my opinion, has led to a great mechanical strain for the longer limb (Left leg over here) thereby causing a greater displacement, vertically, against the centre of body. This variation in the vector of planes had caused an asymmetrical gait, especially while landing the shorter leg (Right leg in this case) and longer legs respectively. Wearing a shoe lift would have helped him maintaining the symmetrical position of both of his limbs. But, he had not opted for it, considering the fact that such shoes were of much weight in those days, unlike the present scenario. Slowly, because of the above reasons, he started developing the vertebral deformities in the following order, Scoliosis-Kyphosis-Lordoisis. Observations during & after the course of Marma Chikitsa treatment: The main complaint of Mr.K.C.S was his joint pain. Since he had no degenerative changes in his knees, I explained him that the cause of the knee pain was the deformity in his vertebral column. We decided to conduct Marma Chikitsa, specifically to tailor suit and rectify his spinal deformity. Astonishingly from 2nd sitting onwards, his body showed a collective response to the treatment. The distance of the lumbar curvature which was as10 centimeters near a natural mole present on the right flank got further reduced to 9 centimeters after the completion of 10th sitting of Marma Chikitsa. In the same way the distance of mid point of superior iliac spine which was 15.7 cms from ground level on 2nd sitting came down reducing to 12.8 cms on the completion of 10th sitting of Marma Chikitsa. The S.L.R test was 5 degree and 0 degree on right and left limbs respectively on the first day before starting the treatment. The subject started getting relief from knee pain after the second day of treatment, and the S.L.R test showed a moderate improvement with 15˚ on right side and 20˚ on left side. After completion of 10 days of treatment S.L.R. test revealed 50˚ in right leg and 70˚ in left leg. The gait which was limping, with 15˚ bent knees and swaying to right side before treatment got improved after 10 days, with almost a straight vertebral column but with minimal scoliosis and 5˚ bent knees. There was much variation in the swaying to right side while walking and he felt nil pain in knees while walking. The above details explained may better be viewed in the images shown below.

Conclusion:
The result obtained after the treatment was so satisfactory to the patient, since he was able to walk freely with out any pain in the knee, and that was able to sleep in supine posture devoid of any pain or stretching at his back, and that he was able to ride his bi-cycle with out any distress, he was over whelmed with joy and blessed me for the relief given to him. All I had to say to him was that the credit given by him is not owed by me, but to the Almighty, because without whose blessings to both of us, the success of the treatment would’ve not been a reality.

Warm regards to all those who read this. Let humanity live in peace and health.

“Sarve Janaah Sukhinoh Bhavanthuh ”.
-Prof.Dr.Rangaprasad Bhat, Chennai,
Mobile:09841218802

Tags: Scoliosis;kyphosis;lordoidis;knee Pain;sciatica;hip Fracture;

4 comments View Entry

Is Ayurveda competent with Allopathy in giving QUICK relief to the patients?

 The above question validly runs in the mind of many a people. There is a myth in the mind of people that Ayurveda is a slow acting system of medicine. But, it is not the fact.

Other than Pancha maha bhoothas, we take into consideration of other factors like the Tridosha (3 vitiators); Trimala (3 excretas); Sapta Dhatu (7 Tissue elements); Avarana avrta (blockage of one particular dosha by another particular dosha in its channel); Rasa (Taste propria), Virya (potency) & Vipaka (end product after digestion) of the medicinal herbs selected etc.,

Say for example, in case of Acute or chronic Bronchitis, wherein the patient presents with difficulty in breathing, productive or non productive cough(i.e. with sputum or with out sputum), malaise(generalized body ache) with or with out sub acute fever etc., - according to Ayurveda, the doshas involved are vata & kapha, the dhatus involved are Rasa (Lymph). More over the channels of Prana vayu (Vital energy in the form of air) are obstructed by the accumulation of kapha in the form of vitiated phlegm. At such a circumstance an Ayurvedic physician will have to select an appropriate medicine which contains the herbs with the guna, Virya and Vipaka opposite to that of the factors involved in causing the bronchitis.

It would be appropriate to explain hence forth. The gunas of Kapha are Sheeta cold in potency), Drava (liquidity) etc., the phlegm with such characteristics gets solidified in the channels of the bronchus or bronchioles thus causing an obstruction to the pathway of air. And since the air is not able to reach the alveoli in sufficient quantity, due to less amount of oxygen reaching the alveoli, the person gasps in want of oxygen. This causes the difficulty in breathing. We will have to understand one fact that it is in the alveoli, the diffusion and exchange of gases in the form of oxygen or carbon-di-oxide takes place. Only hence the alveoli are also called as the functional unit of Lungs.

Now having made one to understand the pathology of Bronchitis as per our science, let me help how the Ayurveda medicines in this case will give a quick relief and what is the proportionate amount of relief being given by allopathy medicines.

Medicinal preparations like lehyams; kashayams; aristams; asavas; churnams; vatis etc., prescribed by an Ayurvedic physician will surely contain one or more than one of the following herbs like Piper longum; Piper nigrum; Pushkaramoola; Kanaka; trikatu etc., All these drugs are Usna (hot) in potency and are capable of penetrating deeper in to the kapha obstructed channels (teekshna). By the above qualities, those herbs start liquefying the kapha immediately and tries to bring out the vitiated phlegm from the affected system of our body, it also cause broncho-dilatation (slight & temporary broadening of the diameter of the bronchus) thereby quickly establishes the patency of the airway. Whence an airway is cleared of the obstruction, the air flows freely in and out, thereby giving immediate relief to the patient from dyspnoea.

Where as allopathy medicine always thinks of counteracting the infection by means of anti-biotics & some broncho-dilators trying to create a patent airway, but nevertheless thinks of eliminating the phlegm, thereby leaving some amount of dampened base in the form of phlegm. This left over base, becomes a source of reproduction for the aerobic (requires oxygen to reproduce) or anaerobic (do not require oxygen to reproduce) organisms responsible for recurrence of the bronchitis, in the near future.

Practically speaking, there have been instances of giving a quicker relief to the patients of Bronchitis in my clinical career who are living healthily with a very less chances of recurrence. And this particular fact made me to think of enlightening and sharing the experience with everybody in the universe. I hope the above post of mine would have eliminated the doubts creeping in the mind of many a people regarding the action potential of Ayurveda medicines.

Hail Ayurveda.

The journey of explaining Ayurveda will continue in the up coming posts

“Sarve Janaah Sukhinoh Bhavanthuh (Let the humanity live in Health and Peace)”

Tags: Ayu Ayurved Relief Quick Slow

2 comments View Entry