August 06, 2014

Marma Chikitsa in Knee pain due to repetitive muscular strain – A Case Study

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

Name, Age & Sex: - Mr. X.Y.Z; 40 yrs; Male

Height & Built: - 6 feet tall & lean stature.

Nature of job: Standing for 6 to 8 hours, Machine operator in a Lathe factory

History of past illnesses: - Nothing specific. He is adiabetic; normotensive & no cardiac or respiratory ailments.

Presenting symptoms: -
1.       Pain in the lateral aspect  of Lt.Knee
2.       Pain in the hollow of the knee
3.       Radiation of pain from the region of knee to the left hip & buttock
4.       Aggravating factor:
Walking fast; walking over uneven surface of road; climbing down the stairs; inversion of foot; crossing the legs over knee & squatting posture.
5.       Relieving factor: -
Sleeping straight; at resting posture of knee; active hyper extension of foot or stretching of the calf muscle.

On examination:-

The range of movement of the knee joint is normal, except the forced flexion which was painful in 110 degrees.
Negative observation of scars; effusion; atrophy of local muscles; crepitus; Lateral & medial joint lines non tender; Mc Murray’s & Appley Grind test negative.
2+ Tenderness present over the lateral femoral epicondyle.
Hip abductors observed to be weak & the Tensor fascia lata was taunted
X-ray & MRI of affected joint – within normal limits

On questioning, whether he had any fall when at work some 20 days, got a negative reply from him. But, the taunting of the tensor fascia lata, muscle weakness of the abductors along with the pain in the lateral femoral epicondyle, were very much clinically akin to the condition of the ITBS (Ilio Tibial Band Syndrome), which usually occurs in sports persons due to sudden inversion of the foot or due to change in the plane of the pelvis angle as seen in certain sports activities like cycling.

On further questioning, regarding his way of standing while working, it is then the cause for the strain of the IT band surfaced.

20 days prior his job was in the loading and packing section, which he was accustomed of doing it for the past 15 years. But, since 20 days, he had been switched over to a new assignment of handling the compressing machine, as a substitute for the absence of a regular worker.
Weight Bearing Lt.Knee

And he explained that since he was new to the job of compressing, he used to feel tired over legs due to prolonged standing. Hence would be switching over his entire body weight by slanting his body to either left side or the right side. Else would keep his left foot over the foot rest beneath the machine with his hip diagonally adducted to a degree of 5 to 10 in want of grip and comfort while working. 

Diagonal Adduction

 But, most of the time he felt loading his body weight over the left side, makes him feel comfort from the vague discomfort felt at the lt. knee joint and was indulging in it.
And this was conclusive of coming to the diagnosis of ITBS, clinically speaking.

The Literature about ITBS from other web sources for better understanding:-

Iliotibial band syndrome
is one of the leading causes of lateral knee pain in runners. The iliotibial band is a thick band of fascia on the lateral aspect of the knee, extending from the outside of the pelvis, over the hip and knee, and inserting just below the knee. The band is crucial to stabilizing the knee during running, as it moves from behind the femur to the front of the femur during activity. The continual rubbing of the band over the lateral femoral epicondyle, combined with the repeated flexion and extension of the knee during running may cause the area to become inflamed.

·         Excessive lower-leg rotation due to over-pronation
·         Positioning the feet "toed-in" to an excessive angle when cycling
·         Muscle imbalance caused by Weak hip abductor muscles &
·         Uneven left-right stretching of the band, which could be caused by habits such as sitting cross-legged

The function of themuscles inserting into the ITB (Tensor Fascia Lata) is to abduct the leg. If the hip abductors are weak, then the ITB is being overworked. The ITB does not have an insertion that offers a favorable mechanical advantage. In fact, it is at a considerable disadvantage for the purpose of hip and leg abduction activity. Therefore when the hip abductors are weak, the tensor fascia lata must contract harder and over a longer period of time thus straining the ITB. Make sure that part of your cure is to strengthen your hip and leg abductors.

The treatment modality planned & clinical observation:

The case involving the IT Band over its insertion point in the lateral epicondyle of femur, gets responding well to the marma chikitsa in giving a speedier relief from the pain.

But, the classical manipulation of the marmas with Tadana (application of pressure) or Shrnga application (Cupping method) are not suitable, since in certain cases, we have observed the aggravation of pain immediately after the first sitting, followed by relief from second or third sittings onwards.

Hence, it was decided to do Marma Taping over the affected muscle and the JANU MARMA.  The effect used to be referred as Reverse Healing Mechanism by me.  The adhesive tape was prepared with the sufficient length covering the taunted areas of the It band and the upper shaft of Tibia. It was later applied by stretching the tape at the therapeutically needed level starting from the lower end to the upper end, with knee flexed @ 30 degree.
Post Marma Taping

Soon after the application of the marma taping, he was asked to do the activities which used to cause pain for the past 20 days. If the stretching of the skin over the affected marma be therapeutically correct, then the result usually will be immediate, with the patient feeling 75 to 100 % of relief from the pain, for which the marma taping was applied. If the taping is therapeutically applied in a wrong method, the relief may not be felt by the patient.

This patient felt much relieved from the pain. When asked to express to the scale of ten, he with rejoice mentioned 9 scale as the relief. He was adviced to come after 2 days, for removal of the marma taping and re application of the same.

And on the day of 2nd sitting, the tape was removed. Examination revealed 70% improvement clinically speaking with the tenderness over the epicondyle being 1+, and with the possibility of squatting, walking swiftly, climbing down the stairs, forced flexion everything being absolutely pain less.The muscle taunting over the IT band got reduced and the tone was equal when compared with the right band.

This time, the taping was applied horizontally in the infra patellar area and was sent home with an instruction to come for a review after 7 days, but to remove the tape 3rd day from the 2nd sitting.

Tailor suited exercise was adviced to him to be followed after removing the tape.
On the day of review, the patient was completely normal without pain & hence no further taping over marmas applied.

The interesting fact in this case is that no internal medication was given as a matter of trial and error method. And the result obtained was productively satisfactory, with relief from the pain.

Exercises advised based on the muscle kinetics are Piriformis stretching & Iliotibial band stretching.

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