Syringing method as an alternative to Śṛṇga therapy in Vātakaṇṭaka.

Calcaneus forms the bone of the foot. Due to abnormal pressures, foot muscles and ligaments are stretched beyond their normal limits that lead to chronic plantar heel pain, among which calcaneal spur tops the list. In Ayurveda, it can be correlated to "Vātakaṇṭaka" (pricking sensation in the foot)-a painful condition of heel caused by its improper placement on the ground. To assess the effect of syringing method (modified Śṛṅga) in the treatment of Vātakaṇṭaka. A 10 ml syringe was for ease, hygiene, and to enable the case to be managed in the outpatient department. A diagnosed case of calcaneal spurs with pain, tenderness, and swelling visited KLE University's Shri BMK Ayurveda Hospital and Research Centre, Belgaum, Karnataka, India. After Snigdha Patrapoṭṭali sveda (a form of sudation therapy), bloodletting was performed by syringing method. In total procedure was performed for 4 times on the patient. Marked subjective relief was observed. Pain from 8 visual analog scale (VAS) came to 2 visual analog scale (VAS) and tenderness and swelling relived completely.

INTRODUCTION

The classics opine that in case of blood being vitiated by Vāta, Pitta and Kapha doṣa, the blood should be let out by Śṛṅga (cows or deer horn), Jalauka (leech) and Alābu (cupping), respectively. In cases of vitiation by two or all the three doṣas together, Sīravyādha (phlebotomy) or Pracchanna (scraping) karma is practiced.[1]

Application of Śṛṅga is said to bring out blood from an area of about 10 angulis (10 finger breadths) around the diseased part; Śṛṅga is advisable if a disease is in an Uttāna (elevated) stage.[2]

Plantar heel pain is a commonly encountered orthopedic problem that can cause significant discomfort and a limp because of the difficulty in bearing weight. The pain due to calcaneal spur forms about 25% in chronic plantar heel pain, however its pathophysiology is poorly understood. calcaneus or calcaneum is the largest bone of the foot. Calcaneal spur is an abnormal growth of bone in the form of a hook either underneath the foot (inferior aspect of calcaneus) in relation to the attachment of the plantar fascia or behind the heel (posterior aspect of the calcaneum) at the insertion of the Achilles tendon. It is estimated that 1 in 10 people will develop heel pain in their lifetime. Incidence occurs between 40 and 60 years of age.[34] Vātadoṣa situated in the heels, when vitiated and produces pain when the heel is regularly placed on uneven surfaces.[5]

CASE REPORT

A 59-year-old, diabetic patient, nonhypertensive male on medication for diabetes since 14 years and having history of alcohol consumption and tobacco-chewing since 10 years presented with pain in right heel which had persisted for 8 months. Pain was of a throbbing type and tended to aggravate on standing. The patient was treated with Matrābasti (Ksheerbala taila enema) and Sthānika iṣṭikā sveda (a form of sudation therapy performed with bricks) following which a clinical improvement was noted. One month later, the patient reported with similar complaints with severe intensity associated with swelling and tenderness. The pain aggravated on standing, walking and used to get relieved with rest. With these complaints when patient reported to our hospital he was advised for radiograph of right heel, which revealed presence of the calcaneal spur.

Examination

Respiratory and cardiovascular parameters were under normal limits. Local examination revealed swelling and redness over the area, increased local temperature and tenderness with grade 4.

Treatment schedule

Sthānika abhyaṅga and Patrapoṭṭali sveda using Nirgundi and arka patra (local oleation and sudation therapies) were performed to achieve utkleśana (elevation of doṣas). Using a syringe, blood was removed for the purpose of reducing raktāvraṇa (a stage where channels are blocked by blood). This stage clinically diagnosed by grade 4 tenderness. After the first bloodletting, a marked reduction in pain, swelling, and tenderness were seen. The bloodletting procedure was repeated for 3 times on every alternate day.

Assessment

Pain, swelling, and tenderness were assessed. Pain was assessed on visual analogue scale, where “0” is no pain and “10” is severe pain. Local swelling was graded where grade “4” indicates severe swelling and grade “0” indicates no swelling. Tenderness was also graded with a grade “4” indicating not allowing to touch and grade “0” indicating no tenderness. All these parameters were evaluated before and after the treatment.

Procedure

The procedure was divided into preoperative, operative, and postoperative.

Preoperative procedure

The procedure was explained to the patient. Written consent was taken. Necessary investigations (HIV, hepatitis B surface antigen, bleeding time, and clotting time) were carried out. Patient was made to sit on the examination table, with his lower limbs hanging down from the table, and a stool was used as a support. Sthānika abhyaṅga of the affected site was done with Mañjiṣṭhādi taila[6] and Snigdhapatra poṭṭalīsveda were performed [Figure 1]. Mañjiṣṭhādi tailam contains Mañjiṣṭhā as the main ingredient, and it has Vāta hara and Pitta hara properties. Materials needed for the procedure were collected, among them were: A 10 ml disposable syringe with 18 gauze needle which formed the modified Śṛṅga, cotton and haridrā (Curcuma longa).

Figure 1

Before treatment

Operative procedure

Under aseptic conditions, a vein was identified around the affected heel, and ankle joint and 10cc of blood was drawn from it [Figure 2].

Figure 2

Procedure of application

Postoperative procedure

After dressing, patient was hospitalized for 2–3 h for observation. Foot-end elevation was given [Figure 3].

Figure 3

After treatment

RESULTS

After 1 h of application, there was a significant reduction of pain and redness. Results are shown in Table 1.

Table 1

Pain, swelling, and redness intensities on application of blood-letting procedure

DISCUSSION

Calcaneal spur was first described by Plettner in the beginning of the 20th century. In “plantar heel spur,” bone formation occurs at the plantar insertion of plantar fascia and muscles, whereas in “dorsal heel spur” bone formation occurs at the insertion of Achilles tendon.[7] These features roughly correspond to a disease entity mentioned in Ayurveda classics namely Vātakaṇṭaka. Repeated placing of the foot on uneven surfaces is mentioned as a causative factor for the disease.[5]

In the present case, tenderness with a grade 4 was noted. It indicates involvement/engorgement of local blood vessels that can be considered as raktāvaraṇa (rakta = blood, āvaraṇa = obstruction). Raktamokṣaṇa was chosen as a method to remove raktāvaraṇa. Śṛṅga, one of the methods of raktamokṣaṇa, was chosen because it has ushṇa vīrya (hot potency), Madhura (sweet) and Snigdha (oleative) guṇas (characters), and thus recommended in vitiated blood with vāta. Here Śṛṅga as indicated by classics is a cow's horn. Considering practicality, an alternative for cow's horn is desirable. In the present case, we tried substituting cow-horn with a syringe and achieved the same desired results.

Using a syringe is also more practical, hygienic, and can be practiced effectively done in OPD with least complications. In the case a cow-horn is to be used, sucking is required, which is not necessary in case of a syringe. In the present study, using a syringe has shown encouraging results. The chūṣaṇa kriyā (creating a vacuum and sucking out blood) creates a low pressure locally and improves venous circulation thus raktāvṛtavāta is relieved, and relief in pain is observed instantly. The swelling is reduced with the reduced tenderness and provides an anti-inflammatory effect. On repeating the procedure, there is a reduction in the tenderness grades, thus alleviating the pathology stages. The condition then becomes amenable to cure with oral medication.

CONCLUSION

Syringing method can be used as an alternative to Śṛṅga therapy which is shown encouraging results in the present case and it needs to be studied on a large sample size.