January 20, 2011

Ilio Tibial Band Syndrome - Marma chikitsa and Sthanika vasti

                                 Dr.Bhat.A.Rangaprasad -Sarve janah Sukhino Bhavanthu || Sarve santhu Niramayah ||

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 left 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 right leg, involved in compensatory mechanism of switching the body weight over the right 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
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.



dr suneel krishnan said...

thanks a lot sir for sharing a case -which was neatly presented .

drrangaprasadbhat said...

Thank you Dr.Suneel Krishnan.

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