Heel...Heal

‘AYURVEDIC MANAGEMENT OF PAIN IN HEEL’
* Dr. Sandeep K M. *


Introduction and extent of problem

Pain in heel is major cause for physical disability causing economical burden in terms of medical cost, work related sickness payment, time lost from the work. 80% of people suffering with OA are showing clear radiographic evidence of heel spur and 25% have symptoms. In India 10 million people are suffering with the same. 0.8 % of population
Suffering with RA annual incidence0.02% and is the Primary cause for physical disability in 1/3 of people.

Pain in heel in different conditions –

• Neurologic
• Traumatic
• Systemic inflammatory conditions

In systemic inflammatory condition
• RA
• Ankylosing spondylitis
• Psoriatic arthritis
• Reiter’s syndrome
• Gout
• Behcet’s syndrome
• SLE
• Gonorrhoea
• Tuberculosis


Causes
• Most common cause – plantar fasciatis
• Less common cause –
• Sciatica
• Tarsal tunnel syndrome
• Entrapment of lateral plantar nerve
• Plantar fascial rupture
• Calcaneal apophysitis




Ayurvedic prospective

Vatakantaka

Nija vyadhi –
• Sandhivata,
• Amavata
• Vatarakta
• Ashti vikara
• Gulphasandhi vikara
• Anya vikara

Agantuja vyadhi

Vata kantaka
• Khuddakavata
• Padakantaka(YR)
Parshnyashrita (D)

Vishama Pade –
vishama pade iti vishame sthane nikshipte pade ithyarthah-dalhana)
• Agantuja karana.
• Not only calcaneal spur rather it may be sprain, strain and acute suppurative arthritis
• If gulpha sandhi - ashraya stana for vata kantaka – sthanika chikitsa along with vata shamanopaya

Nidana
• Walking in an uneven surface / excessive walking / activities leads to high pressure over the heel
• Wearing high heeled & hard foot wears
• Exposure to excessive cold or working in water
• Vatavardhaka diet
• Over weight lifting /Overweight


Ruk Padee vishamany:
• Feet that flatten and roll inwardly
• Shoes with inadequate arch support
• Sudden turns that put great stress on the ligaments
• Running on hard surfaces or uphills



Shramath - RSI




Treatment principles to follow…
• Assessment of condition
• Acute pain management
• Local treatment
• Shodhana and shamana
• Proper follow up
• Surgical intervention

Before entering in to treatment….

• If Gulpha sandhi is considered as the Ashraya stana - Dosha nimittaja
• Agantuja karana - sprain, strain etc -karya karana sambandha for the Rakta mokshana.
• Adoption of Rakta mokshna as the major line of treatment should be re-thought on the basis of karya karana sambandha
• calcaneal spur- Agni karma is done routinely at the most tender points in the heel.

Samprapti Ghataka
• Dosha – Vata
• Dooshya – Gulpha sandhi, Parshni
• Agni – Asthidhatwagni
• Ama – Asthidhatwagnimandhyajanya
• Srotas – Asthivaha, Mamsavaha,
• Srotodusti prakara- Sanga
• Udbhava sthana -
• Sanchara stana – Gulpha sandhi, Parshni
• Vyakta stana – Gulpha sandhi, Parshni

Samanya Chikitsa

• Vatavyadhi samanya chikitsa
• Acute pain management

Bahya parimarjana-
• Snehana - Abhyanga
• Swedana – Isthika sweda
• Lepa – Haridra + Saindhava lepa
• Nimajjana - MN Taila (Shatavari, Laksha &
tila)
Abhyantara parimarjana -
• Shamana -
• Tab Rasnadi Guggulu
• Rasna Eranda Kwatha
2. Shodana

Shodhana Chikitsa


• Repeated Rakta mokshana
• Eranda taila pana
• Soochi dahana

A Case Report

Smt. Krishna Veni,
• 39/F,
• Weight – 65kg
• Pain in heel which aggravates in morning since 6 to 7 months
• No other systemic deformities
• Vitals – normal
Prescriptions on visits
First visit :
• GT Ghrita 5gm in E.stomach
• Tab Maha YRG 1 tid
• Cap KB 2bd
• MN taila
Second visit :
• Treatment continued
Third visit :
• Cap. Pavanam 1tid
• Tab Reosto 1tid
• Tab Rasnadi Guggulu 1bd
• MN taila for Ex application and nimajjana

Mode of action of Bahi Parimarjana chikitsa
(Padabhyanga, Lepa and nimajjana)

Multidimensional benefits
• Pressure electricity
• Counter irritant action
• Action over the skin
• Action over neural controls
* Drug absorption
01. Pressure electricity
* Dilutes the toxins accumulated.
* Due to rhythm a specific pressure is developed & creates magnetic field and electricity in the body.
02. Counter irritant action
• Pressure acts as an irritant - raising the peripheral vascularisation.
• Pain is relieved by the counter irritation produced by massage by the process of phagocytosis.
03. Action over the skin
• It induces softness in the external skin
• Soothens internal viscera and tissues.

04. Action over neural controls

• Blocking the transmission of impulse across the motor nerve
• Inhibiting the synthesis of acetylcholine in motor nerve

• Inhibiting the release of acetylcholine as with the toxin produced by the organism
• Modifying the motor end plate so that it does not respond to acetylcholine.

05. Drug absorption

* Percutaneous absorption is more in the inflammatory conditions and it enable better drug absorption
Drug absorption
• Permeation of the layers of skin can occur by diffusion via:
• transcellular penetration (across the cells)
• intercellular penetration (between the cells)
• transappendageal penetration (via hair follicles, sweat and sebum gland, and pilosebaceous apparatus)
• Factors Affecting Percutaneous Absorption
• Drug concentration
• Surface area
• Drug's attraction to the skin vs. attraction to the vehicle
• Vehicle
• Hydration of the skin
• Rubbing or inunction
• Statum corneum (thin vs. thick)
• Time of application
• Multiple application

Isthika Sweda
• Ushma sweda
Procedure :
• Preparation to patient - Snehana by Tila taila
• Hot isthika –pour (ganji /kanji /dashamoola kwatha)
• Others: lavana pinda sweda and kulatha sweda, Arka pushpa sweda
How it works?
• Regulates Vata
• Helps to discharge morbidity from micro channels and counteracts Vata
• Counteracts the stiffness, heaviness and coldness
• Relaxation of muscle and tendons
• Improves the circulation and activates the local metabolic process which may be responsible for most of relief in pain, swelling and stiffness
• Massage during sweda may cause displacement of exudates and thus may reduce the tension and the pain
Rakta mokshana
• Shonitavrita vata – Ardha chikitsa
• 2 angula above kshipra marma
• Raga, vedana, toda and daha – jalouka
• Chimchimayana, kandu, peeda, daha – shrunga and tumbi
• Prasarana sheela – prachhanana
• Vata pradhana – contraindicated
Agni karma
• In acute pain – potent analgesic effect
• At most tender point in heel - Direct or indirect
• KV shamaka due to Usna, Teekshna guna
• May increase local Dhatwagni and aid in Samprapti vighatana

How it helps??
• Blockage of pain impulses along nerve – analgesic
• Depression of cortical and thalamic centre
• Raises the pain threshold
• Sectioning of nerve pathway
Selection of specific Guggulu
• Simhanada - Amavata
• Yogaraja - Saama sandhivata
• MahaYRG - Nirama sandhivataja
• Kaishora – Vataraktaja
• Lakshadi – Abhighataja karana janya

How it acts??
• Resin of commiphora whighetti – acidic (4%) – anti inflammatory action

Selection of specific taila
• In OA - Nirgundi taila
• Burning, redness - Pinda taila
• Fractures and sprains – Gandha taila

• Rheumatic pain – GHC internally
• Niramavasta in amavata – MVG taila

Anubhoota yogas

• Fenugreek + cummin + pepper (100:50:05)
• Hot cow dung fomentation – spur – (Badami)
• Arka patra swedana in swollen joints

Common practices which may aid indirectly

• Bamboo shoots – Calcium oxalate – during monsoon
• Tamboola vidhi
• Taila Abhyanga in menarche
• Manipulation techniques
• Taila dana

In case of Sandhivata
• General line of treatment
Internally
• Shotaghna, brimhana, vatahara, rasayana and vedana shamaka
• Panchakarma
• Matra basti
• Adoption of sthanika basti
• Rasayana
Sthanika chikitsa :
• Abhyanga:
Amritadi, balashwagandadi, bala chinchadi, dhanwantari, pinda taila
• Swedana
• Sthanika Basti
• Lepana - Shothahara drvvya,
Vedana shaamaka
In case of Amavata
Jwaravasta:
• Deepana: pippali, amlavetas, hingu, jeeraka
• Pachaka: shunti, chitraka
• Langhana
Jwara jeernavastha:
Shodhana
• Virechana: eranda taila
• Basti: vaitarana basti
Shamana:Agni tundi vati, simhanada guggulu, rasona pinda, amavatari rasa
Sthanika chikitsa:
01. In amavasta
• Swedana
• Lepa: jatamayadi lepa with marmani vati
02. In jeernavastha
• Abhyanga – mahavishagarbha, saindava, kottamchukkadi tail
In case of Vata Rakta
General line of treatment
• Restoration of joint functions – Raktamokshana, vyayama, Rasayana and Pralepanadi yojana
• Bahya shodhana: Basti and Rakta mokshana
• Shamana: rasna, neeli, duralaba, palashapushpa, kokilaxa, shalmali
• Ashwatta twak kashaya with madhu
• Shatavari ghrita. Guda haritaki, Kaishora guggulu
Sthanika chikitsa
Abhyanga – pinda taila
Swedana –
• Dhanya sweda with amla kanji, jadamayadi/ghruha dhoomadi choorna pinda sweda with kanji
Lepa –
• Nimba patra kalka with kanjika lepa
• Shighru, varuna twak kalka with kanji lepa
• Ghrita, Godhuma choorna lepa with ajaksheera
In Anya vikara
S no
Anya vikara
Chikitsa
01
Mamsagata vata
Virechana
02
Medogata vata
Basti
03
Astimajjagata vata
Bahya and abhyantara sneha/maha sneha
04
Snayugata vata
Snehana,swedanand upanaha
05
Siragata kupita vata
Snehana, swedana and upanaha
06
Mamsavrita/medavrita/asthiavrita vata
Avarana hara chikitsa
07
Saama asthi dhatu janya vikara
Saama asthi dhatu janya vikara hara chikitsa??
08
Vipadika
Abhyanga, sweda and lepa

Rajo Nivritti kalaja
• Low level of estrogen – hampered calcium absorption – osteoporotic changes
• Drugs which contaion phyto-oestrogen such as amalaki, shigru, agasthya, kaidarya, shatavari- also vit C and calcium supplementation
• In acute condition – shunti, haridra and shallaki

In case of Gulpha Sandhi vikara
01.Sandhi moksha:

Parisheka-
• Nyagrodadi kashaya (p), pancha moola siddha ksheera(vp), chakra taila(vk)

Lepa-
• manjista, madhuka, rakta chandana, shatadhouta ghrita and shali pisti (su.chi 3/7)

02. Sandhigata vrana:
• Lepa - ghrita pradhana nyagrodadi kalka, barks of madhuka, udumbara, ashwattha, palasha, kakubha

• If sandhi doesn’t acquire shudda vrana lakshana – Agni karma
• Seevana - As vrana in chala sandhi
Bandhana – sadharana and shithila bandha


03. Sandhisthita shalya:

• Aharana with swastika yantra after bhedana karma
• If aharana is not possible – chedhana

04. Sandhimarma Abhigata:

• If Ruja- Rakta mokshana / if pain and deformity - Agni karma
• Chedhana at level of sandhi to stop bleeding
In case of Anukta vata vyadhi (RSI)?
• Rest
• Immobilization
• Hot and cold compresses
• Exercise and physical therapy
• Vedana shamaka dravya yojana
• Surgery


Prevention Swastha Vritta paripalana
· Dinacharya
§ Abhyanga & Udvartana
§ Vyayama
§ Vatasya Upakrama
· Sadvritta
· Ritucharya



01.Primordial prevention
• Child with strong family history of O.A. or R.A.
• Avoiding risk factors

02. Primary prevention
· Nidana parivarjana
· Sheegra ayana, atyadhwa, pradhavana, bharavahana, sahasa
· Dhukha asana, Ativa cheshta
· Ati vyayama


Non pharmoco therapeutic Interventions
· Self care
· Nutrition
· Weight reduction
· Exercise promotion
· Health education

What to avoid and how to avoid?
· Avoid standing more than 10 minute, instead use of high stools or take frequent rest
· Limit stair climbing, take elevator, escalator or ramp
· Avoid bending and squatting, keep items at waist level or use a reacher
· Avoid low beds, chairs, toilets and elevate them when possible
· Shoe orthotics with heel wedge for better alignment
03. Secondary prevention
· Early case detection, treatment
· Screening population

04. Tertiary prevention
· Physiotherapy
· Surgical interventions
Role of Yoga, Nature cure & Physiotherapy


Yoga
Nature cure
Physiotherapy
Acute
Pranayama,rest, shavasana
Rest cure, mud application
Vibroacoustic and shock wave therapy
chr
Plantar fasciatis – pawanmuktasana, uttana padasana, vajrasana, supta vajrasana

Spur -Sirshasana, sarvangasana, supta vajrasana, bekhasana, supta bekhasana

Flat foot – sirshasana, sarvangasana, supta vajrasana, bekhasana, gomukhasana
Massage, Affusions.
Hot and cold application
IRR,
Active exercise,
Stretch exercises
Wax therapy, moist heat therapy.
Chromotherapy




How Asanas help?
• Alternate the standing asanas with sitting, prone or supine postures based on the principle of stretch followed by rest.
• Improves blood flow and hastens healing.
• Excellent for calming nervous system, which aids in healing, anxiety and muscle spasm
• Regulates movement of prana (vata)
• Compression and elevation
• Puts pressure on the vajra nadi, the acupressure point to correct the prana imbalance.

Specific posture
How Exercises are going to benefit?
• Ligament becomes more flexible and can strengthen muscle that supports the arch, thereby reducing the stress on ligament
• Protect fascia from injury and inflammation by increasing the flexibility of fascia and calf muscles
Strengthens muscle of foot and ankle that support the arch

- Repeated movement exercises should be avoided
Stretching and Strengthening exercises
• Wall exercise
• Rolling over ball
• Towel pick ups
Calf stretches
Towel stretches
Wall exercises
Stretch exercises
Effect of heat and cold packs
Cold packs
• Reduces swelling following a traumatic injury
• Reduces inflammation
• Produces a numbing effect than can reduce pain
• Decreases blood flow to an area
• Decreases muscle spasms

Heat therapy
• Increased blood flow to an area
• Relief from tension or tightness in muscles
May reduce joint stiffness
• Optimizes healing/rehabilitation environment in tissues
• Provide pain relief
• Increase in flexibility
Recent advances in treatments
01. Vibroacoustic technology
• Moves more blood, increases production of synovial fluid
• Regenerate cartilage, remove cartilage byproducts
• Increases resistance of nerve fibres to pain electric impulses
• Increase production of somatic stem cells, needed to repair damaged cartilage
02. Shock wave therapy
• The high pressure is the "shock"
• Repeated applications - break down scar tissue & calcifications in the area.
• Body starts building up new tissue
• New blood vessels grow into the new tissue
• Stimulates the spontaneous healing process.
Plantar fasciitis
• Straining the ligament that supports arch.
• Repeated strain - tiny tears in ligament.
Risk factor
• Excessive pronation
• high arches or flat feet.
• Excessive activities on hard surfaces.
• overweight.
• Ill fitting shoes
Management
• Rest
• Correction of biomechanical factors - stretching and strengthening exercises
• Night splints and orthotics
• NSAIDs
• Surgical management

Management

Surgery
Heel spur
• Body tries to repair itself by building extra bone.
• It generally forms in response to pressure, rubbing, or stress that continues over a long period of time.
Treatment
• Do not require treatment unless they are causing pain or damaging other tissues.
• Treatment directed at the cause, symptoms and bone spur it self
• weight loss to take some pressure off the joints
• ultrasound or deep tissue massage may be helpful
Surgical intervention
Diet
• Rich in calcium & magnesium.
• Juices – Carrot, Beetroot, Spinach, Cabbage.
• Fruits – Guava, Pomegranate.
• Less carbohydrate, adequate vitamins, calcium, phosphorus & iron.
• Cabbage, carrot, onion, radish, tomato for salad.
• Beet, cauliflower, peas, mushrooms, spinach as cooked vegetables.
• Juice – Wheat grass apple, raw vegetables

In surgical conditions:

• Protein - proliferation of fibroblasts
• Vit C – ascorbic acid deficiency –
collagen formation affected
• Vit D
• Calcium – calcium phosphate
• Vit K – formation of pro-thrombin
• Neurological – vit B complex
• Minerals – potassium, phosphorus,
Zinc hastens the healing
Night splints
Immobilize and stretch fascia.allow passive stretching of the calf and plantar fascia during sleep
minimize stress on the inflamed area.
How the Shoes should be?
• Thicker
• Well cushioned mid soles – high density ethylene vinyl acetate
• Flat feet – better longitudinal arch support
Comfortable shoes
To conclude….
• Nidana and chikitsa of Gulpha sandhi vikara are identical in Ayurvedic and contemporary sciences

• Pain management principles are aimed at local or systemic based on etiological factors

• Kevala vatajanya vikara are asadhya but those due to secondary causes may be treated

• Prevention measures should aim at modifiable risk factors

FEEL LIGHTER

“WEIGHT LOSS DIET”

The following diet and health programme is conducted by Research and an Analysis wing from “Sandeepani Ayurveda Shala” .It will also improve your attitude and emotions because of its systemic cleansing effect. The effectiveness of this seven day plan is that the food eaten been more calories, than they give to the body in caloric value.

This plan can be used as often as you like to without any fear of complications. It is designed to fresh your system of and give you feeling of well being. After 7 days you will begin to feel lighter by at least 10 pounds. You will have an abundance of energy and an improve disposition. During the first 7 days you must drink 10 glasses of water each day.

DAY ONE

All fruits except BANANA. Your first day will consists of all fruits only.

Note: It is suggested you consume lots of melons the first day especially water melon.

You are preparing your system for the upcoming programme.Your only source of nutrition is fresh fruits.

DAY TWO

All vegetables you are encouraged to eat until you are stuffed with all the raw and cooked vegetables of your choice. There is no limit on the amount or type. Avoid oil and coconut while cooking vegetables. Have a large boiled potato on breakfast.

Starts with a fix of complex carbohydrates in the form of a boiled potato. This is taken for the energy and balance the rest of the day, consists of vegetables which are virtually calorie free provide essential nutrients and fiber.

DAY THREE

Any mixture of fruits and vegetables of your choice. Any amount any quantity. No banana, no potato today.

Eliminate the potato because because you get your carbohydrates from fruits. your system is now to start burning excess fats. You will still have cravings which would start to diminish by day four.

DAY FOUR

Today you will eat as many as eight bananas and drink three glasses of Milk. You can also have a bowl of vegetables soup.

Bananas and milk sound the least desirable. Today is the day you have coffee with milk. You probably not be able to eat all the bananas allowed but they are there for the potassium you have lost and the sodium you may have missed the last three days. You will notice a definite desire for sweets.

DAY FIVE

Rice and Tomatoes.The rice is for the carbohydrates and the tomatoes are for the digestion and the fiber. Lots and lots of water to purify your system. You should notice colorless urine today and do not fast you to eat one cup rice and you may eat less. But you must eat the 6 tomatoes.

You will eat one cup of rice you will have to eat 6 whole tomatoes. Drink 12 glasses of water today to cleanse your system of excess uric acid you will be producing.

DAY SIX

Similar to day five. Vitamins and fiber from the vegetables and the carbohydrates from the rice.

Today is another all vegetables day. You may eat one cup of rice today. Eat all the vegetables you want, cooked and uncooked to your wish.

DAY SEVEN

Today your food intake will consist of one cup of rice, fruit juices and all the vegetables you have to consume.



ADDITIONALLY

The most important element of the programme is having 10 tall glasses of water a day. You can also flavor the water with some lemon to make drinking easier.

While on this programme take only black coffee or black tea.

Never use more than 1 tea spoon of oil. Preferably do not use oil because of the high caloric content to fruit juice before day seven.

The key thing to remember is that if you are hungry at any time, then take raw or boiled vegetables.

Ayurveda

AYURVEDA - HISTORY
Ayurveda, Ancient Indian System of Medicines deals with knowledge that can define the quality and quantum of social and personal health status and ways to restore, maintain and upgrade it based on the principles of Vedic metaphysics[charaka samhita].According to the Ayurvedavatarana (the "descent of Ayurveda"), the origin of Ayurveda is stated to be a divine revelation of the Hindu deity Brahmaas he awoke to recreate the universe. It was revealed to the gods through the means of the divine physician Dhanvantari who emerged from the churning of the celestial ocean. This knowledge was passed directly to Daksha Prajapati in the form of shloka sung by Lord Brahma, and this was in turn passed down through a successive chain of deities to Lord Indra, the protector of dharma. According to this account, the first human exponent of Ayurveda was Bharadvaja, who learned it directly from Indra. Bharadvaja in turn taught Ayurveda to a group of assembled sages, who then passed down different aspects of this knowledge to their students. According to tradition, Ayurveda was first described in text form by Agnivesha, in his book the Agnivesh tantra. The book was later redacted by Charaka, and became known as the Charaka Samhitā. Another early text of Ayurveda is the Sushruta Samhitā, which was compiled by Sushrut, the primary pupil of Dhanvantri, sometime around 1000 BC. Sushrut is known as the Father of Surgery, and in the Sushrut Samhita, the teachings and surgical techniques of Dhanvantri are compiled and complemented with additional findings and observations of Sushrut regarding topics ranging from obstetrics and orthopedics to ophthalmology. Sushrut Samhita together with Charaka Samhitā, served as the textual material within the ancient Universities of Takshashila and Nalanda.These texts are believed to have been written around the beginning of the Common Era, and are based on a holistic approach rooted in the philosophy of the Vedas and Vedic culture. Holism is central to ayurvedic philosophy and elements of holism is found in several aspects of ayurveda.