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GULPHA SANDHI SHAREERA W.S.R TO SPORTS INJURIES, VIPIN P.C, , SHAREERA RACHANA, S.D.M. COLLEGE OF AYURVEDA, UDUPI

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Gulpha sr

  1. 1. A COMPREHENSIVE STUDY ON GULPHA SANDHI SHAREERA W.S.R TO SPORTS INJURIES BY DR. VIPIN P.C, B.A.M.S Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka In partial fulfillment of the requirements for the degree of DOCTOR OF MEDICINE (AYURVEDA) IN SHAREERA RACHANA UNDER THE GUIDENCE OF DR. G. M. KANTHI. B.S.A.M.; D.H.A.; Ph. D (RACHANA) PROFESSOR DEPARTMENT OF P.G. STUDIES IN SHAREERA RACHANA DEPARTMENT OF P. G. STUDIES IN SHAREERA RACHANA S. D. M. COLLEGE OF AYURVEDA, UDUPI 2010 - 2011
  2. 2. Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka DECLARATION BY THE CANDIDATEI hereby declare that this dissertation entitled “A COMPREHENSIVE STUDY ONGULPHA SANDHI SHAREERA W.S.R TO SPORTS INJURIES” is a bonafide andgenuine research work carried out by me under the guidance ofDr. G. M. Kanthi, B.S.A.M.; D.H.A.; Ph. D, Professor & Head, Department of P.G. Studies in BasicPrinciples. .DATE: Signature of the CandidatePLACE: UDUPI (DR.VIPIN P.C)
  3. 3. Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “A COMPREHENSIVE STUDYON GULPHA SANDHI SHAREERA W.S.R TO SPORTS INJURIES” is a bonafideresearch work done by Dr. Vipin.P.C, in partial fulfillment of the requirement for thedegree of Doctor of Medicine in Ayurveda, under my guidance. Signature of the Guide Dr. G. M. Kanthi B.S.A.M.; D.H.A.; Ph. D Professor,DATE: Dept, of P.G Studies in Shareera Rachana,PLACE: UDUPI S D M College of Ayurveda, Udupi
  4. 4. Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka CERTIFICATE BY THE H.O.D, / PRINCIPAL HEAD OF THE INSTITUTION This is to certify that the dissertation entitled “A COMPREHENSIVE STUDYON GULPHA SANDHI SHAREERA W.S.R TO SPORTS INJURIES” is abonafide research work done by Dr. Vipin.P.C, under the guidance ofDr. G. M. Kanthi, B.S.A.M,; D.H.A,; Ph. D, Professor & Head, Department of P.G. Studies inBasic Principles.Signature of the H.O.D. Signature of the PrincipalDr. U. Govindaraju Dr. U. N. Prasad M .D (Ayu) M. D (Ayu)Dean & Head. PrincipalDept. of P.G Studies in Shareera Rachana S D M College of Ayurveda, UdupiS D M College of Ayurveda, UdupiDATE: DATE:PLACE: UDUPI PLACE: UDUPI
  5. 5. COPYRIGHT DECLARATION BY THE CANDIDATE I hereby declare that the Rajiv Gandhi University of Health Sciences, Bangalore,Karnataka shall have the rights to preserve, use and disseminate this dissertation in printor electronic format for academic / research purpose.DATE: Signature of the CandidatePLACE: UDUPI (DR.VIPIN P.C) © Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka
  6. 6. Abbreviations ….    LIST OF ABBREVIATIONS cÉ.xÉÇ : Caraka Samhita cÉ.ÍcÉ : Caraka Samhita Chikitsa Sthana cÉ.ÌlÉ : Caraka Samhita Nidana Sthana cÉ.zÉÉ : Caraka Samhita Shareera Sthana cÉ.xÉÔ : Caraka Samhita Sootra Sthana xÉÑ xÉÇ : Susrutha Samhita xÉÑ.ÌlÉ : Susrutha Samhita Nidana Sthana xÉÑ zÉÉ : Susrutha Samhita Shareera Sthana xÉÑ xÉÑ : Susrutha Samhita Sutra Sthana A.¾û. : Ashtanga Hrudaya A.¾û.zÉÉ : Ashtanga Hrudaya Shareera Sthana
  7. 7.        DEDICATED TO MY BELOVED PARENTS & TEACHERS  
  8. 8. Acknowledgement ACKNOWLEDGEMENT I offer my salutations to the almighty God the discernment of one is still eludingfor me, for giving me strength to venture and overcome the hurdles pave my way towardsachievement of this work. I grab this opportunity to express cordial thankfulness to my FatherK.P Venugopal who carved my individuality, for trust he has bestowed and for hissupport at places I faltered, my Mother P.C Kamalakshi who has been instrumental inshaping up my perseverance and commitment, My brother Vimal P.C who always whotook greater interest in my curricular activities throughout my preliminary education, Myyounger cousin brother Dr Arun Kumar P.P (Physiotherapist) for his support during mydocumentation of the work. I would like to express my heartfelt gratitude to The Principal, SDM College ofAyurveda, Udupi, Dr. U.N Prasad for giving me the opportunity to carry out this work. I genuinely feel that any words of gratefulness are derisory to express my cordialthanks to my guide, Dr. G. M. Kanthi, Professor and Head, Dept. of Post GraduateStudies for Basic principles, who was like a solid rock in an itinerant ocean, always therewith valuable guidance and a kind word during all my highs and lows. I express my earnest gratitude to Dr. U. Govindaraju, Professor, HOD andDean, PG faculties Dept. Of Shareera Rachana, for his all timely support, generous helplove and affection during this work. My sincere requital to Dr. V.K. Shridhar Holla , Professor, PG faculties forDept. Of Shareera Rachana, for his critical suggestions and scholarly influence during mystudy will be felt in the forth coming pages of my dissertation. My deep sense of gratitude to former Deans Dr. B. V. Prasanna andDr. U.Shrikanth, of PG Studies. I am forever indebted for their formidable, yetconstructive criticism which made this work possible.
  9. 9. Acknowledgement I express my gratitude to Dr Krishnamurthy, lecturer, Dept. of ShareeraRachana, for his advice not only in this work but throughout my entire P.G studies. I express my deepest feeling of gratitude towards Dr.Nitin kumar, lecturer, Dept.of Shareera Rachana, for his suggestions and thought provoking ideas during my study. I also wish to record my gratitude towards Dr Rajendra Pai, lecturer, Dept. ofShareera Rachana, Dr Pralhad, lecturer, Dept. of Shareera Rachana. I consider it a great privilege to record my hearty gratitude to Dr Ajith Kumar(M.B.B.S; DMRD) and wife Dr. Priya for their liberal and helpful attitude during mystudy. I take this opportunity to express my whole hearted thanks to my friends DrVijaynath, Dr Sibgath, Dr Tushara lal, Dr Seetharam, Dr.Rahul, Dr Riyas for theirsupport and suggestions. I would like to thank my seniors Dr Amardeep, Dr Harshavardhan Dr Pratibha,Dr Indu, Dr Anju, Dr Amarnath, Dr Praveen, Dr Murali for their support and suggestionswhich have been of immense help in the achievement of this work. I would also like to thank my juniors, Dr Parameshvaran, Dr Jyothi, Dr ShaktiKumar, Dr Vibha, Dr Ramita, for their love and support. I am very thankful to Mr. Prabhakar, & Mr. Sadhu attenders dept. of ShareeraRachana, staff of Library, Hospital, Samruddhi Xerox and all my volunteers for theirbrand teamwork, which was very much requisite for the blooming of this study. I thank all those who have directly or indirectly contributed to the successfulcompletion of my dissertation work . VIPIN P.C
  10. 10. Abstract ABSTRACT The Sandhi word is derived from the root Sam+dha+ki which meansSandhanamiti – Holding together, joining, and binding. Where two or more articularsurfaces of bones are joined together is known as Sandhi. This Sandhi’s are essential forlocomotion and various movements of the body. Injury to these structures may lead tomany complication even may end up with morbidity. Gulpha Sandhi is a joint of thelower limb, lies in between the leg and the foot. It is one of the marmasthana and a koratype of Sandhi explained by Acharya’s. Ankle joint is a complex, hinge variety ofsynovial joint. The term Sports injury in the broadest sense refers to the kinds of injuries thatcommonly occurs during Sports or exercise. Ankle joint is the most vulnerable to getdamaged because of the stresses to which it is subjected especially in Sports. The Gulphamarma viddha lakshana’s has been explained in the Ayurvedic classic may be correlatedwith the Sports injuries in ankle joint. The references of Gulpha Sandhi are available in the Ayurvedic classics, but theyare scattered and are not available in a single place. Only few gross anatomical featuresdescribed in relation to its applied aspects are present in the Samhita’s. Hence to fulfillthese lacunae in the subject and to study the comprehensive anatomy of Gulpha Sandhialong with its structural abnormalities in the case of Sports injuries present work ischosen.Key words: Gulpha Sandhi, Sandhi marma, Sports injuries.
  11. 11. Lists INDEX Sl. No. Contents Page No. 1 Introduction 1 2 Objectives 2-3 3 Review of literature 4-65 4 Methodology 66-68 5 Observation 69-92 6 Discussion 93-100 7 Conclusion 101 8 Summary 102-103 9 Reference 104-108 10 Bibliography 109-119 11 Annexure 120-125 
  12. 12. Lists LIST OF TABLESTable No. Description Page No. 01. Types of Sandhi’s 9 02 Types of Kora Sandhi’s 9 03 Sandhi Sankhya 10 04. Sakha marma 13 05. Prognostic classification of marma 14 06. Description of Sandhi marma 16 07. Fibrous joints 20 08. Cartilaginous joints 21 09. Structural and functional classification of joints 24 10. Muscles contributing to foot and ankle movements 30 11. Lakshana of Gulpha marma kshata 41 12. Effects of injury 48
  13. 13. Lists LIST OF FIGURES Figure number Description Page no. 01 Ankle bones 26 02 Deltoid ligament 28 03 Lateral ligaments 29 04 Muscles at the ankle joint 30 05 Blood supply of the foot 32 06 Venous drainage 33 07 Nerve supply 34 08 Ankle joint movements 35 09 Ankle sprain 45 10 Tear in LCL 46 11 Dissection photos 72-76 12 Radiological findings 88-89 13 MRI 90-92  
  14. 14. Lists LIST OF CHARTS & GRAPHS Chart number Description Page no. 01 Age wise distribution of cases 77 02 Sex wise distribution of cases 78 03 Occupation wise distribution of cases 79 04 Injured site wise distribution of cases 80 05 Distribution of sports events 81 06 Presence of Ruja 82 07 Presence of Stambha 83 08 Presence of Khanjata 84 09 Sparsha Sahatva 85 10 Presence of Shopha 86 11 Details of radiographic findings 87 
  15. 15. Introduction 1 INTRODUCTION It has been said that no law of nature however general has been established all atonce that its recognition has always been preceded by many presentiments. The wisdomof Ayurveda certainly was not delivered in a day. It is the sum total of the collectivewisdom of countless seers gathered over a period of time. There are many ways toapproach a contemporary topic to give its Ayurvedic perspective. Any approach howeverwould have to be aware of the pitfalls of unnecessary unjustified and erroneouscorrelation. It has to provide a comprehensive view of the Ayurvedic outlook, which canbe only possible if all references all possible sources are gleaned and analyzed critically. Detailed knowledge of human body is conducive to the wellbeing of theindividual. Asthi’s play a vital role in the dharana karma of shareera and they are joinedtogether with the help of mamsa, sira, snayu binding together to form the Sandhi’s.Gulpha Sandhi is a joint of the lower limb and it may considered as the Ankle joint. The proper functioning of the ankle joint is a must in the field of sports, games, inperforming dance, drama etc. A slight swelling, pain or sprain at ankle joint makeshumans incapable of moving freely. Any injury to this point with sufficient thresholdmay lead to a fracture, dislocation or a sprain with symptoms of pain, spasm, limping,loss of function and rigidity. Modern world has given priority to sports. During the sports events, injuries arecommon. Injuries to soft and hard tissues are the problems faced by sports persons asthey have to undergo physical strain or stress in the field If Ayurveda can provide aremedy which is cost effective, easily available and free from side effects, it would be agreat boon to the field of sports. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  16. 16. Aims and Objectives 2 AIMS AND OBJECTIVESAIMS The main aim is to study the Gulpha Sandhi and its structural abnormalitiescaused during various Sports activities.OBJECTIVES OF THE STUDY 1. To make the comprehensive and the conceptual study on Gulpha Sandhi shareera as mentioned in the Ancient texts, in the view of regional and applied anatomy described in the contemporary science. 2. To study the Anatomical features and the structural abnormalities thereby in Sports injuries in the Gulpha Sandhi. 3. To study and stabilize the Gulpha Sandhi by Ayurvedic view. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  17. 17. Aims and Objectives 3 PREVIOUS WORK DONE1) Dwivedi S.K- has done work on “A study on marma w.s.r to Sports injuries”1994,State Ayurvedic college ;University of Lucknow.2) Suvarna kakiwar-has done work on “Vankshana sandhi ki namyatha Gymnastic khiladiyo mein ek pareekshanatmaka adhyayana”2001,Govt. Ayurvedic college; Nagpur University. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  18. 18. Historical Review 4 HISTORICAL REVIEWVeda kala Veda’s are the first written documentation of Indian civilization. In Atharva vedareferences are available about Gulpha Sandhi. There is a query regarding how have theankle’s articulations been planned and formed.1Marma in Upanishad Following references can be consider regarding Marma and associated subjectavailable in different Upanishad. • Description of vessels and blood circulation2 • Vascular injuries. 3 • Characteristics of Sira and Dhamani. 4 • Marma 5. • Dhamani6. • There are 107 marma mentioned in Garbhopanishad7. • In Yogopanishad 18 marma has been explained and Gulpha is one among them.Samhita KalaCharaka Samhita Acharya Charaka has explained about Sandhi’s in Charaka shareera 6th chapter8.Susrutha Samhita Acharya Susrutha has mentioned Gulpha Sandhi as Kora sandhi among the eighttypes of Sandhi’s9. Acharya Sushruta gave much importance to marma, he givesdescription on marma, their types, numbers, locations, viddha lakshana in shareera sthana6th chapter10. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  19. 19. Historical Review 5Astaanga Sangraha and Astaanga Hrudaya Reference of marma and Sandhi marma is available in both the grantha’s,Vruddha Vaagbhata mentions in 7th chapter and Laghu vagbhata in 4th chapter.11,12Bava prakasha Samhita In Bavaprakasha Gulpha Sandhi and Gulpha marma has been explained in thePurvakanda, garbha prakarana adhyaya13.Saranghdara Saamhita Explanation about Sandhi and can be seen in Saranghdara SamhitaPurvakanda ,5th chapter14.Bhela Samhita Acharya Bhela has explained about Gulpha while mentioning the pratyanga’s inthe 7th chapter of Shareera Sthana15. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  20. 20. Review of Literature 19 MODERN REVIEW Joint review75 The joints of the skeletal system contribute to homeostasis by holding bones together in ways that allows for movements and flexibility. Bones are too rigid to bend without being damaged ,fortunately flexible connective tissue form joints that hold bones together while still permitting, in most cases, some degree of movements .A joint also called an articulation or arthrosis is a point of contact between two bones, between bone and a cartilage or between bone and teeth. When we say one bone articulates with another bone means that the bones form a joint. You can appreciate the importance of joints if you have ever had cast over your knee joint ,which makes walking difficult ,or a splint on your finger ,which limits your ability to manipulate small objects. The scientific study of joints is termed as Arthrology .The study of motion of the human body is called Kinesology. Joint classifications76 Structural classification Joints are classified structurally, based on their anatomical characteristics. The structural classification of joints is based on two criteria: 1) The presence or absence of a space between the articulating bones called a synovial cavity. 2) The type of connective tissue that binds the bones together.Structurally the joints are classified in to;1) Fibrous joints 2) Cartilaginous joints 3) Synovial joints.Functional classificationThe functional classification of joints is based on the degree of movement they permit.Functionally they are classified in to ;1) Synarthrosis 2) Amphiarthrosis 3) Diarthrosis. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  21. 21. Review of Literature 20Summary of structural and functional classification of joints771) Fibrous jointsIn these types of joints there is no synovial cavity and articulating bones are held togetherby fibrous connective tissue.Structural Functionalclassification Description classification ExampleSuture Articulating bones united by a thin Synarthrosis Coronal layer of dense irregular connective suture. tissue, found between bones of the skull. With age some, sutures are replaced by a synostosis in which separate cranial bones fuse in to a single boneSyndesmosis Articulating bones are united by Amphiarthrosis Distal tibio more dense irregular connective fibular tissue usually a ligament jointInterosseous Articulating bones united by a Amphiarthrosis Betweenmembrane substantial sheet of dense irregular the tibia connective tissue. And fibula. Table no.7: Fibrous joints A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  22. 22. Review of Literature 212) Cartilaginous jointsIn these type of joints there is no synovial cavity,the articulating bones are united by ahyaline cartilage .Structural Description Functional Exampleclassification classificationSynchondrosis Connecting material is a hyaline Synarthrosis Ephiphyseal cartilage, becomes a synosotosis plate when bone elongation ceases. between the diaphysis and epiphysis of a long bone.Symphysis Connecting material is broad, Amphiarthrosis Pubic flat tissue of fibro cartilage. symphysis and inter vertebral joints. Table no.8: Cartilaginous joints A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  23. 23. Review of Literature 22 SYNOVIAL JOINTS78 Synovial joints have certain characteristic that distinguish them for other joints.The unique characteristics of a synovial joint are the presence of a space called synovialjoint cavity between the articulating bones. Because the synovial cavity allows a joint tobe freely movable, all synovial joints are classified functionally as diarthrosis. The bonesat a synovial joint are covered by a layer of hyaline cartilage called articularCartilage .The cartilage covers the articulating surface of the bones with a smoothslippery surface but does not bind them together. Articular cartilage reduces frictionbetween bones in the joint during movement and helps to absorb shock.Articular capsule A sleeve like articular capsule surrounds a synovial joint encloses the synovialcavity and unites the articulating bones. The articulating capsule is composed of twolayers, an outer fibrous membrane and an inner synovial membrane. The fibrousmembrane usually consists of dense irregular connective tissue that attaches To theperiosteum of the articulating bones. The flexibility of the fibrous membrane permitsconsiderable movement at a joint, while its great tensile strength helps prevent the bonesfrom dislocating .The inner layer of the articular capsule, the synovial membrane, iscomposed of areolar connective tissue with elastic fibers. At many synovial joints thesynovial membranes includes accumulation of adipose tissue called articular fat pads.Synovial fluid The synovial membrane secretes synovial fluid, a viscous clear pale or yellowfluid named for its similarity in appearance and consistency to uncooked egg white.Synovial fluid consists of hyaluronic acid and secreted by fibroblast-like cells in thesynovial membrane and interstitial fluid filtered from blood plasma. It forms a thin filmover the surfaces within the articular capsule. Its functions include reducing friction bylubricating the joint, absorbing shocks, and supplying oxygen and nutrients to andremoving carbon dioxide and metabolic wastes from the condrocytes within articular A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  24. 24. Review of Literature 23cartilage. Synovial fluid also contains phagocytic cells that remove microbes and thedebris that results from the normal tear and wear in the joints.Accessory ligaments and articular discs Many synovial joints also contain accessory ligaments called extra capsularligaments and intra capsular ligaments. Extra capsular ligaments lies outside the articularcapsule . Intra capsular ligaments occur within the articular capsule but are excluded fromthe synovial cavity by folds of the synovial membrane. Inside some synovial joints, suchas the kneepads of fibro cartilage lie between the articular surface of the bones and areattached to the fibrous capsule. These pads are called articular discs or menisci.Bursae and tendon sheath The various movements of the body create friction between the moving parts. Saclike structures called bursae, are strategically situated to alleviate friction in some joints,such as the shoulder joints and knee joints. Structures called tendon sheath also reducefriction at joints, tendon sheath are tube like structure that wrap around certain tendonsthat experience considerable friction. Tendon sheath are found in wrist, ankle, wheremany tendons come together in a confined space.Nerve and blood supply The nerves that supply’s joint are the same as those that supply the skeletalmuscles that move that the joint. Synovial joints contain many nerve endings that aredistributed to the articular capsule and associated ligaments. Some of the nerve endingsconvey information about pain from the joint to the spinal cord and brain for processing.Other nerve ending responds to the degree of movement and stretch of a joint. Althoughmany of the components of synovial joints are a vascular arteries in the vicinity send outnumerous branches that penetrate the ligaments and articular capsule to deliver oxygenand nutrients. Veins remove carbondioxde and waste from the joints. The arterialbranches from several different arteries typically mere around a joint before penetratingthe articular cap. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  25. 25. Review of Literature 24 SUB CLASSIFICATION OF SYNOVIAL JOINTS Structural Description Functional Exampleclassification classificationPlanar Articular surfaces Many biaxial Intercarpal,Int are flat or slightly diarthrosis back and ertarsal curved forth and side to side Sterno costal. movementsHinge Convex surface fits in Monoaxial diarthrosis Elbow ,Ankle,i to a concave surface Flexion and Extention nterphalngealpivot Rounded or pointed Monoaxilal diarthrosis Atanto-axial surface fits in to an Rotation Radioulnar partly by a ligament joints.condyloid Oval-shaped Biaxial diarthrosis Radiocarpal projection fits in to Flexion, Extention and an oval-shaped Abduction, Adduction Metacarpophal depression angeal joints.Saddle Articular surface of Triaxial diarthrosis Carpometacar the bone is saddle Flexion, Extention, pal between shaped and the Abduction,Adduction Trapezium articular surface of and Rotation and thump the other bone “sits” in the saddle.Ball and Ball-like surface fits Triaxial diarthrosis Shoulder andsocket in to a cup like Flexion, extension hip joints depression abduction adduction and rotation Table no.9: Classification of Synovial joint A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  26. 26. Review of Literature 25Ankle foot complex79 The ankle/foot complex is structurally analogous to the wrist-hand complex of theupper extremity but has a number of distinct differences to optimize it’s primarily role tobear weight. The complementing structures of the foot allow the foot to sustain largeweight –bearing stresses under a variety of surfaces and activities that maximize stabilityand mobility. The ankle/foot complex must meet the stability demands of; 1) Providing a stable base of support for the body in a variety of weight-bearing postures without excessive muscular activity and energy expenditure. 2) Acting as a rigid lever for effective push-off during gait. 3) The stability requirements can be contrasted to the mobility demands of; a. Dampening rotations imposed by the more proximal joints of the lower limbs. b. Being flexible enough to absorb the shock of the superimposed body weight as the foot hits the ground. c. Permitting the foot to confirm to a wide range of changing and varied terrain. The Ankle/foot complex meets these diverse requirements through the integratedmovements of its 28 bones that form 25 component joints. These joints include *Proximal and distal tibiofibular joints *Talocrural joint or Ankle joint. *Talocalcaneal or Subtalar joint. *The Talonavicular and calcaneocuboid joints. *The five tarsometatarsal joints. *The five metacarpophallengial joints. *Nine interphalangeal joints. To facilitate description and understanding of the Ankle/foot complex, the bonesof the foot are traditionally divided in to three functional segments. These are the: Hindfoot (posterior segment)-composed of Talus and Calcaneous. Midfoot (middle segment)-composed of the navicular, cuboid and three cuneiform. Fore foot (anterior segment)-composed of the metatarsals and phalanges. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  27. 27. Review of Literature 26 The terms are commonly used in descriptions of ankle or foot dysfunctions aresimilarly useful in understanding normal ankle and foot function. The frequency of many ankle or foot problems can be traced readily to thecomplex structure of the foot and their participation in all weight-bearing activities.Structural abnormalities can lead to altered movements between joints and contribute toexcessive stresses on tissues of the foot ankle that result in injury. THE TALOCRURAL JOINT OR ANKLE JOINT80 The talocrural joint is of uniaxial type, the lower end of the tibia and itsmalleolus ,the malleolus of the fibula, and the inferior transverse tibiofibular ligamenttogether form a deep facet in which the body of the Talus is embraced ,the line of thejoint can be gauged from the anterior margin of the lower end of the tibia which can befelt through the skin in the living when the overlying tendons are relaxed, althoughanatomically this joint appears simple hinge ,and is usually styled “uniaxial” it must beemphasized that the axis of rotation is dynamic ,taking up a series of different positionsduring dorsiflexion-plantar flexion changes. Figure 1: Ankle bones A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  28. 28. Review of Literature 27 The articular surfaces are covered with hyaline cartilage .The trochlear surface ofthe talus, which is convex from before backward and gently concave from side to side, iswider in front than behind and the inferior articular surface of the tibia is reciprocallyshaped.Articular surfaces The articular surface for the medial malleolus is restricted to the upper part of themedial surface of the Talus. It is fairly flat and comma shaped, being deeper in front thanbehind. The articular surface on the lateral side of the Talus is triangular in outline andconcave from the above downwards; that on the lateral malleolus is reciprocally curved.Posteriorly, the edge between the trochlear and fibular articular surfaces of the talus isbeveled form a flattened triangular area which articulates with the inferior transverseTibio-fibular ligament. It is to be emphasized that all these talar surfaces are continuous;separate description is a mere convenience.Ligaments The bones are connected by a fibrous capsule and by deltoid, anterior andposterior talofibular calcaneo fibular ligaments. The fibrous capsule surrounds the joint; itis thin in front and behind and attached above to the borders the articular surfaces of thetibia and malleoli, and below to the talus close to the close to the margins of the trochlearsurface except in front where it is attached to the dorsum of the neck of the talus at somedistance in front of its superior articular surface. It is supported on each side by strong collateral ligaments. The posterior part ofthe capsule consists principally of transverse ligament and is somewhat thickenedlaterally where it reaches as far as the malleolar fossa of the fibula. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  29. 29. Review of Literature 28Medial ligament or deltoid ligament The medial ligament or deltoid collateral ligament is a strong, triangular bandattached above to the apex and anterior and posterior borders of the medial malleolus. Itconsists of superficial and deep fibers, of the superficial fibers the anterior(tibionavicular) pass forwards to the tuberosity of the navicular bone ,and immediately behindthis they blend with the medial margin of the plantar calcaneonavicular ligament ,themiddle fibers (tibiocalcanean) descend almost perpendicularly to the whole length of thesustentaculum tali of the calcaneous ,the posterior fibers (tibiotalar)pass backwards andlaterally to the medial side of the talus and and to its medial tubercle. The fibers are welldeveloped and are fixed above to the tip of the medial malleolus and below to the nonarticular part of the medial surface of the talus. The deltoid ligament is crossed by thetendons of tibialis posterior and flexor digitorium longus. Figure:2 Medial or Deltoid ligament A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  30. 30. Review of Literature 29Lateral ligament The anteriror talofibular ligament passes from the anterior margin of the fibularmalleolus, Forwards and medially to the talus, where it is attached in the front of thelateral articular facet and to the lateral aspect of the neck. The posterior talofibularligament strong and deeply seated ,ran’s almost horizontally from the lower part of thelateral malleolar fossa to the lateral tubercle of the posterior process of the talus a bundleof fibers (the ‘tibial slip”)leaves it to be attached to the medial malleolus. The calcaneofibular ligament is a long rounded cord, running from the depression in front of theposteror talo fibular ligament. Figure 3: Lateral ligamentsMuscles Muscles give shape to the body by holding the bones in position. It expand andcontract to impart movement. The muscles act on the ankle through three separatecompartments such as Anterior Posterior and Lateral compartments Anterior compartment muscles cross the ankle joint anteriorly to act asdorsiflexors. The muscles of posterior and lateral compartments cross the ankle joint,posteriorly to form plantar flexors. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  31. 31. Review of Literature 30 Figure 4: Muscles at the Ankle joint Dorsiflexion Extensor digitorum longus Extensor hallucis longus Peroneus tertius Tibialis anterior Plantar flexion Flexor digitorum longus Flexor hallucis longus Gastrocnemius Peroneus longus Peroneus brevis Plantaris Soleus Tibialis posterior Inversion Extensor hallucis longus Flexor digitorum longus Flexor hallucis longus Tibialis posterior Tibialis anterior Eversion Extensor digitorum longus Peroneus brevis Peroneus longus Peroneus tertius Table no.10: Muscles contributing to foot and ankle movements81A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  32. 32. Review of Literature 31Surrounding structures Ankle joint is surrounded anteriorly by tendons of tibialis anterior, extensorhallucis longus, tibial vessels, tibial nerves, tendons of extensor digitorum longus andposterior tibialis in order. These structures are held in position by superior and inferiorretinaculae. Posteriorly, ankle is surrounded by tendons of tibialis posterior, flexor digitorumlongus, posterior tibial vessels, tibial nerves and tendon of flexor hallucis longus pass inorder behind and below the medial malleolus. Flexor retinaculae hold them in position.Posteriorly tendo - Achilles and plantaris. These tendons are all covered by synovialsheath with no muscular covering82. Postero-laterally peroneus longus and brevis held in position by superior andinferior peroneal retinaculae.Tendons Ends of muscles are attached to bone, cartilage or ligaments by a cord of fibroustissue called tendon83. They vary in length and thickness according to the site within thebody. A tendon may be enclosed in a sheath to prevent friction and may be separatedfrom neighboring structures by a bursa. They are very strong structures and so are rarelyruptured but injuries occur at the attachment to bone or the tendo-muscular junction. Theforces applied to a tendon may be more than five times of body weight. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  33. 33. Review of Literature 32 Blood supply Popliteal artery Posterior tibial artery Anteriortibial arteryPeroneal, Medial & Lateral plantar artery Dorsalis pedis artery Figure: 5 A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  34. 34. Review of Literature 33Venous drainage External iliac vein Dorsal venous arch Great Saphenous drains in to Femoral Small Saphenous drains in to Popliteal Peroneal Posterior tibial Medial and lateral plantar Dorsalis pedis Anterior tibial Figure 6: Venous drainage A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  35. 35. Review of Literature 34Nerve supply to lower limbs Below the knee, the sciatic nerve divides into the common peroneal and posterialtibial nerve. Sciatic nerve arises from L4 – S2 spinal segments, supplies motor function offoot and ankle. Figure 7: Nerve supply A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  36. 36. Review of Literature 35 BIO MECHANICS OF ANKLE JOINT84The primary motion allowed at the ankle joint is:Dorsiflexion.Plantarflexion. Figure 8: Ankle joint movements Normal ankle joint ranges of motions are reported to be 10 degree for dorsiflexionand 20 degree to 50 degree for plantar flexion. The three motions of the ankle complexthat approximate cardinal plane and axis are dorsiflexion/plantarflexion,inversion/eversion and abduction/adduction. Dorsiflexion and plantar flexion are motionsthat occur approximately in the sagittal plane around a coronal axis. Inversion andeversion occur approximately in the frontal plane around a longitudinal axis that runsthrough the length of the foot. Abduction and adduction occur approximately in the transverse plane around avertical axis. Abduction is when the distal aspect of a segment moves away from themidlines of the body (or away from the midline of the foot in the case of the toes);adduction is the opposite. Pronation/supination is the terms used to describe “composite”motions that have components of, or are coupled to, each of the cardinal motions. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  37. 37. Review of Literature 36Ankle dorsiflexion and plantarflexionJoint involved:Talo crural joint.Inferior tibio fibular joint.Axis of rotation: A frontal axis passing through the gender of the lateral malleolus of the fibularand lower tip of the medial malleolus of the tibia. At an angle of 13 degree to 18 degreelaterally from the frontal plane and angle of 8-10 degree from the transverse plane.Osteo kinematic movementROM: 0-20 for dorsiflexion. 20-50 for plantarflexion.Triplanar motion: Since the joint axis of the ankle is not just in the cardinal plane, the motionsoccurring at the ankle joint present a triplanar motion patterns. Dorsiflexion with eversionand adduction. Plantar flexion with inversion and abduction.Functional range:At least 10 degree of ankle dorsiflexion is necessary for normal gait.Arthro kinematic movementTalo crural joint:Posterior glide of the talus on the ankle mortise with ankle dorsiflexion .Anterior glide of the talus on the ankle mortise with ankle plantar flexion.Inferior tibio fibular joint: Separation of the fibula from the tibia, superior glide of the fibula on the tibiawith dorsiflexion. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  38. 38. Review of Literature 37Sub talar joint: When the talus moves on the posterior facet of the calcaneous, the articularsurface of the talus. At the middle and anterior joints, the talar surfaces, glide in adirection opposite to movement of the bone-convex surface moving on a stable concavesurface.Factors limiting ankle dorsiflexion: Ankle mortise. Passive tension of the Achilles tension.Factors limiting ankle plantar flexion: Calcaneous. Tension of the anterior component.Muscle at the ankle Ankle dorsiflexion and plantarflexion movements are limited primarily by softtissues restriction .Active or passive tension in the triceps surae(medial and lateral headof gastronemius and soleus muscles) is the primary limitation to dorsiflexion. Dorsiflexion is more limited typically with the knee in extension than with theknee in flexion because the gastronemius muscle is lengthened over two joints when theknee is extended .tension in the tibialis anterior, extensor hallucis longus and extensordigitorum longus muscle is the primary limit to plantar flexion. The ligaments are assisted in that function by the muscles that pass on either sideof the ankle. the tibialis posterior, flexor hallucis longus, and flexor digitorum longusmuscle help protect the medial aspect of the ankle; the peroneus longus and brevismuscles protect the lateral aspect. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  39. 39. Review of Literature 38Ankle stability:Factors affecting ankle stabilityBony configuration: Shape of dome of the talus. Anterior edge greater than lateral edge. Medial edge less than lateral edge.Tension of ligaments or other connective tissue: Deltoid ligament (MCL) prevents valgus stress. LCL prevents varus stress. Anterior talo fibular ligament prevent a stress towards plantar flexion and inversion. Calcaneo fibular ligament prevents a stress towards plantar flexion and inversion. Posterior talo fibular ligament. Antero infero tibio fibular ligament hold two bones together.Muscle arrangement: Peroneous longus and brevis. Tibialis posterior A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  40. 40. Review of Literature 39MOTION OF THE ANKLE JOINT The movement about the ankle joint is of greater importance as it allows shockabsorption at heel strike, progression of the body forward during the stance phase. Duringthe swing phase the motion of the motion of the ankle joint allows foot clearance .Anklehas 4 phases of motion.Phase 1 At initial contact, or heel strike, the ankle joint is in a neutral position it thenplantar flexes to between 3&5 degrees until foot flat has been achieved. During thisperiod dorsiflexion muscle in the anterior compartment of the foot and ankle are actingeccentrically, controlling the plantar flexion of the foot.Phase 2 At the position of foot flat the ankle then begins to dorsiflex. The dorsiflexionreaching in a maximum of 10 degrees as the tibia moves over the ankle joint. During thistime the plantarflexor muscle are acting eccentrically to control the movement of the tibiaforward.Phase 3 The heel then begins to lift at the beginning of double support, causing a rapidankle plantar flexion, reaching an average value of 20 degrees at the end of the stancephase of toe off. During this phase, plantar flexor muscles in the post compartment of thefoot and ankle concentrically contract, phasing the foot in to plantar flexion andpropelling the body forwards.Phase 4 During the swing phase the ankle rapidly dorsiflexes to allow the clearance of thefoot from the ground. A neutral position is reached by mid swing, which is maintainedduring the rest of the swing phase until the second heel strike. During this phase the ankledorsiflexes concentrically contract to provide foot clearance from the ground and preparefor the next foot strike. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  41. 41. Review of Literature 40 DISEASE REVIEW The story of trauma and its management rounds around the tissues and injury andits response. Whenever the physiology and anatomy of any tissue tend to be altered itresists and reacts to physics. Ruja(pain) is the first sign of morbidity of any tissue thisphenomenon has already been observed in Indian classic by father of surgeon Susrutha.This is cry of tissues for want of oxygen giving rise to changes in polarity. According tothe followers of Acharya Susrutha there are certain places in the body where normally theloss of tissue is not amounting to functional loss that further means its anatomy is not somuch altered that the function of the tissue suffers85. However the micro anatomy of thestructure is changed affecting the physiology of the tissue but not amounting to thefunctional observation. Gulpha situated in ankle involving the ankle joint and surgicalcondition is due to chronic inflammation of capsular and extra capsular tissue. The riskfactors that predispose a sports person to ankle trauma should be understood before anintervention study designed to reduce the incidence of these debilitating injuries isimplemented. Ankle injuries can be painful and can make it hard to carry out dailyactivities. Without adequate care, acute ankle trauma can result in chronic joint instability.There are mainly two types of rogas mentioned in Ayurveda .They are 1) Nija. 2) Agantuga86. Abhigata come under agantuja roga87, 88. Till the seventh day it is considered asSadyovrana. Later there will be involvement of Tridoshas. Kshathoshma that spreadssoon after trauma obstructs the path way of Vata by vitiated Rakta89. This gives way forthe manifestation of clinical symptoms. Susruthacharya says that Vata aggravates as a result of Marmabighata andproduce severe pain90. Astangasamgrahakara has mentioned about Pitta prakopa alongwith Vata. Vagbhatacharya mentions about Raktasrava – Internal bleeding resulting inRakta Dhatu kshaya and has mentioned about Raga and Paka as symptoms. According to Susruthacharya, Doshas stay in between Twak, Mamsa and Snayuin sopha91. On injury – bones, muscles, blood vessels and joints do not inflict the personso as the ligament92. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  42. 42. Review of Literature 41 Marmabhigata result in sudden onset of pain, irregular pulsation, numbness,heaviness, unconsciousness, affinity to cold, sweating, vomiting and dyspnoea.Convulsions, weakness of body, vertigo, shivering, tachycardia, heartburn andrestlessness indicate a bad prognosis93. Acharya Susrutha in Sutrasthana, mentioned about the lakshanas of Sandhi kshata asincreased swelling, severe pain, Slitting type of pain in the small joints, Loss of strength,Oedema, loss of function of joints94. Shortening and debility of body parts, pain and delayed wound healing are theconsequences of injury to the Snayu95. Acharyas have mentioned the GulphaMarmakshatha lakshanas according to the table as follows. . . . Susrutha Samhitha96 AstangaSamgraha97 AstangaHridaya98 Ruk Ruk Ruk Sthamba Stabda sakthi Sthamba Khanjatwa Shantata Mandhyakrith Table 11: Lakshana of Gulpha Marma kshata Indu, the famous commentator of Astangasamgraha describes that Shantata means‘Ayoshithyogyathwam99’(sexual inability). This is not mentioned in any of the otherBrihatrayees. The injury of ankle joint can be studied under three headings namely tendon,ligaments, and bones100 .The ligaments predominate in sports injuries .This joint is oneof the most frequently areas of this body since being the connecting link between stableleg bone and the mobile foot. It is subjected to great variety of forces in walking, running, and standing.Abnormal or excessive forces produce injury to the bones and ligaments, usually byindirect violence. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  43. 43. Review of Literature 42 The sports is one of the commonest events, which takes major share, fracturesabove the ankle are classified according to the force producing injury. The talus may berotated medial or Lateral or compressed directly upwards. A combination of this forcemay take place, producing a variety of fractures, dislocation and stress. Since the malleoli are attached to the talus by the joint capsule and collateralligaments, the fragments follow the displacement of the foot on the leg bones andunderstanding of the mechanism of the fracture and the anatomy involved is essential forintelligent management of this injury. A tendon can be damaged if sudden force is applied to it, happens in a veryvigorous push off as in sudden lurch forwards in athletics sport, and when try to return aball in squash or a shuttle –cock in badminton or it could occur in a sudden reflexcontraction to stabilize the ankle or sub talar joints as a lending offer jumping to hit orcatch a ball. No documentary prove is available regarding the Gulpha marma and its injury insports in any classics but it cannot rule out the existence of sports in the era of ourAcharya’s because the high cavalry warriors cannot be produced without the help ofsports101.SPORTS INJURIES102 Sports injuries are injuries that occur to athletes participating in sporting events.In many cases, these types of injuries are due to overuse of a part of the body whenparticipating in a certain activity. For example runner’s knee is a painful conditiongenerally associated with running, while tennis elbow is a form of repetitive stress injuryat the elbow, although it does not often occur with tennis players. Other types of injuriescan be caused by a hard contact with something. This can often cause a broken bone ortorn ligament or tendon. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  44. 44. Review of Literature 43Classification Sports injuries can be broadly classified as either traumatic or overuse injuries.Traumatic injuries account for most injuries in contact sports such as Association football,rugby league, rugby union, Australian rules football, Gaelic football and Americanfootball because of the dynamic and high collision nature of these sports. These injuriesrange from bruises and muscle strains, to fractures and head injuries. A bruise orcontusion is damage to small blood vessels which causes bleeding within the tissues. Amuscle strain is a small tear of muscle fibers and a ligament sprain is a small tear ofligament tissue. The body’s response to these sports injuries is the same in the initial fiveday period immediately following the traumatic incident - inflammation.Signs and symptoms Inflammation is characterized by pain, localized swelling, heat, redness and a lossof function.Mechanism All of these traumatic injuries cause damage to the cells that make up the softtissues. The dead and damaged cells release chemicals, which initiate an inflammatoryresponse. Small blood vessels are damaged and opened up, producing bleeding within thetissue. In the body’s normal reaction, a small blood clot is formed in order to stop thisbleeding and from this clot special cells (called fibroblasts) begin the healing process bylaying down scar tissue. The inflammatory stage is therefore the first phase of healing.However, too much of an inflammatory response in the early stage can mean that thehealing process takes longer and a return to activity is delayed. The sports injurytreatments are intended to minimize the inflammatory phase of an injury, so that theoverall healing process is accelerated. Ligament and capsular injuries at the ankle areusually referred to as a sprained ankle. A ligament or a capsule supporting the fine anddelicate nerve fibers are also stretched and laid to partial joint differentiation which maybe permanent. The tendon injuries are less common as compare to ligaments arecomparatively more vulnerable due to mobility. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  45. 45. Review of Literature 44ANKLE SPRAIN Foot and ankle injuries comprise up to 25 percent of sports injuries. Out of this,eighty -five per cent of ankle injuries are sprains. There are pre-existing tendencies due toprevious injury, increased height and weight, and inherent joint laxity103. In basket ballthey comprise more than 50 percent of major injuries and in soccer and volley ball morethan 25 percent. In addition, football players, gymnasts and team handball and fieldhockey players have a significant number of acute ankle injuries104. Ankle sprain is mostcommon in volleyball, broad jump – due to improper jumping, cricket – uneven surface,tennis, badminton etc. Injuries to the foot and ankle, like those of other parts of the body,occur as a result of excessive loading. The ability to withstand loading is termed “stresstolerance”. This loading may occur in one or two modes. It may happen as a single eventthat exceeds the mechanical tolerance of the tissues being loaded or it may occur as aseries of repeated events105. Sprained ankle or twisted ankle as it is sometimes known is acommon cause of ankle pain. A sprain is stretching and or tearing of ligaments (yousprain a ligament and strain a muscle).Ankle sprain are of two types- 1) Inversion sprain. 2) Eversion sprain.Inversion sprain: The most common is an inversion sprain where the ankle turns over so the sole ofthe foot faces inwards, damaging the ligaments. It causes injury to the anterolateral part of the joint capsule and one or all thelateral ligaments. When sudden inversion force occurs with the ankle in mid position ofdorsiflexion and plantarflexion, the injury involves the talofibular ligament. Whereas,when the excessive inversion – adduction movement is associated with forced plantarflexion, the injury commonly involves calcaneofibular ligament. This can be identified bythe site of pain and tenderness. Pain and tenderness over talus indicates injury to thetalofibular ligament, while the same over calcaneus indicates involvement of thecalcaneofibular ligament. The pain increase with ankle adduction – inversion in neutral inthe former and adduction – inversion with plantar flexion in the latter106. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  46. 46. Review of Literature 45 The initial injury at the ankle as a result of inversion is a sprain of the anteriortalofibular ligament; with increase in stress rupture, followed by rupture of the posteriortalofibular ligament and in dislocation. Figure 8: Ankle sprain A major mechanism of inversion injury is landing from a jump. Particularly incrowed situations around the basket in basket ball or the net in volley ball, severe injuriesare caused by landing on another player’s foot. Changing direction, particularly ifassociated with deceleration, may be a vulnerable movement as well this tendency isexaggerated where there is an uneven surface with divots and ruts. In contact sports, adirect blow or an opponent grabbing the foot may also precipitate a sprain. Othercontributing factors of injury include a significant varus heel, weak musculature, tightheel cods and tarsal coalition107. Peroneal muscle weakness is a primary cause of lateralankle sprains. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  47. 47. Review of Literature 46Eversion sprain – Excessive pronation - abduction, eversion and dorsiflexion – isreferred as an eversion sprain. It is caused by pronation or eversion of the foot combinedwith internal rotation of tibia on the fixed foot108. The talar dome is wider anteriorly thanposteriorly. During dorsiflexion, the talus fits more firmly in the mortise supported by thedistal anterior tibiofibular ligament. With excessive dorsiflexion and eversion, the talus isthrust laterally against the longer fibula, resulting in either a mild sprain to the deltoidligament or if the force is great enough a lateral malleolar fracture. If the force continuesafter the fracture the deltoid ligament may rupture or may remain intact, avulsing a smallbony fragment from the medial malleolus and leading to a bimalleolar fracture109. Thisinjury is serious as it may produce a fracture along with tear of the deltoid ligament,tibiofibular ligament and the interosseous membrane. Following an injury there will be swelling and tenderness directly over theligaments. It will be present below medial malleolus when the deltoid ligament is injuredand over the anterior aspect of ankle over the dorsum when the anterior talofibularligament and interosseous membrane are involved. Figure 9: Tear in LCL A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  48. 48. Review of Literature 47Grades of severity for sprained ankles110: Sprained ankles, as with all ligament sprains, are divided in to grades 1-3A first degree sprain is the least severe. It is the result of some minor stretching of theligaments, and is accompanied by mild pain, some swelling and joint stiffness. There isusually very little loss of joint stability as a result of a first degree sprain.A second degree sprain is the result of both stretching and some tearing of the ligaments.There is increased swelling and pain associated with a second degree sprain, and amoderate loss of stability at the ankle joint.A third degree sprain is the most severe of the three. A third degree sprain is the resultof a complete tear or rupture of one or more of the ligaments that make up the ankle joint. A third degree sprain will result in massive swelling, severe pain and grossinstability. One interesting point to note with a third degree sprain is that shortly after theinjury, most of the localized pain will disappear. This is a result of the nerve endingsbeing severed, which causes a lack of feeling at the injury site. From the explanationsabove you can see that pain and swelling are the two most common symptoms associatedwith an ankle sprain. You can also expect some bruising to occur at the injury site. Theassociated swelling and bruising is the result of ruptured blood vessels.Causes and Risk Factors There are a number of causes and risk factors associated with an ankle sprain.One of the most common causes is simply a lack of conditioning. If the muscles, tendonsand ligaments around the ankle joint have not been trained or conditioned, this can lead toa weakness that may result in an ankle sprain. A lack of warming up and stretching isanother major cause of ankle injuries. In an article titled, "Ankle Injuries in Basketball:injury rate and risk factors," by McKay, Goldie, Payne & Oaks, in the British Journal ofSports Medicine; the article states that "Basketball players who did not stretch during thewarm up were 2.7 times more likely to injure their ankle than players who performedstretches.". However, the most common risk factor associated with ankle sprains is a previoushistory of ankle sprains. In other words, if youve had an ankle injury in the past, chances A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  49. 49. Review of Literature 48 are youre going to suffer another one if you dont take some precautions and do some conditioning exercises to strengthen your ankle. Grade I Grade II Grade IIIDefinition Few fibers of Partial tear of Complete tear of ligament are torn. ligament. ligamentMechanism of Over load & over Over load & over Over load & overinjury stretch stretch stretchPain Minimal Moderate SevereSwelling Minimal Moderate SevereLoss of function Minimal Moderate SevereBruising Usually not present Frequently present PresentDifficult weight Absent Usually present Almost alwaysbearing presentRange of motion Decreased Decreased May increase or decreaseAnterior drawer test Absent Present Highly positiveVarus laxity Absent Absent Highly positive Table no.12: Effects of injury111. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  50. 50. Review of Literature 49Ankle sprain symptoms: When an ankle is injured with a sprain, tissue injury and the resultinginflammation occur. Blood vessels become “leaky” and allow fluid to ooze in to the softtissues surrounding the joint. White blood cells responsible for inflammation migrate tothe area, and blood flow increases as well. Typical changes that happen withinflammation include the following:Swelling because of increased fluid in the tissue is sometimes severe. Pain because thenerves are more sensitive. The joint hurts and may throb, the pain can worsen when thesore area is pressed, or the foot moves in certain directions (depending upon whichligament is involved) and during walking or standing. Redness and warmth caused byincreased blood flow to the area.Medial ligament injury Injuries to medial ligament are much less common, as it is strong. Suddeneversion violence causes injury to the medial ligament. The tenderness is at the upperattachment of the medial ligament to the medial malleolus. In mild sprains, only thesuperficial part of the deltoid ligament is torn, but in severe forms, the deep part of thedeltoid ligament is also torn resulting in a lateral talar tilt. For severe sprains, surgicalreduction and repair are considered.Lateral ligament injury The lateral ligament is damaged by excessive inversion accompanied by eitherplantar flexion or rotation. Supination of the foot in neutral flexion usually results ininjury of the calcaneofibular ligament. Supination and adduction injuries tear both theanterior talofibular ligament and the calcaneofibular ligament. The posterior talofibularligament is the strongest of the lateral ligaments and extreme inversion with plantarflexion is required to place the posterior talofibular ligament under stress; as a result, theposterior talofibular ligament is less commonly injured. Transient subluxation ordislocation of the talus from the tibial mortise usually results in injury of all three lateralligaments. Prevention of anterior displacement of the talus is primarily a function of theanterior talofibular ligament. Little additional motion occurs when the calcaneofibular A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  51. 51. Review of Literature 50ligament also is damaged. Instability to inversion is greater when both the calcaneofibularligament and the anterior talofibular ligament are injured than when either ligament isinjured alone. A complete rupture of the lateral ligament occurs only when the adduction -inversion force is severe. With severe inversion – adduction stress the talus gets tiltedmedially in the tibiofibular mortise. To confirm the rupture, antero-posterior radiographis taken while adduction stress is applied to the heel under local anesthesia. When themedial tilt of talus in ankle mortise happens to be more than 20 degrees, it confirmsdiagnosis of a complete rupture.Fractures112 Most unstable ankle fractures are the result of excessive external rotation of thetalus with respect to the tibia. If the foot is supinated at the time of external rotation, anoblique fracture of the fibula ensures. If the foot is pronated at the time of externalrotation, a mid- or high-fibular fracture results. The lateral complex consists of the distalfibula, the lateral facet of the talus, and the lateral collateral ligaments of the ankle andsubtalar joints. Lateral malleolus injury (most common type of fracture involving theankle) typically occurs with supination external rotation forces. The inversion force firststrains the lateral ligament complex or avulses (transverse fracture) the lateral malleolus.With continuation of this force, the talus impacts the medial malleolus, causing anoblique fracture of the distal tibia. Inversion ligamentous injuries of the ankle are themost commonly observed soft-tissue trauma in sports. Posterior malleolus injurytypically occurs with a supination-external rotation or a pronation-external rotation injuryand represents avulsion of the posterior tibiofibular ligament from the posterior distaltibia.Fracture classification Ankle fractures can be classified as single malleolar, bimalleolar, and trimalleolarif the posterior part of the tibial plafond is involved. Careful attention must be paid to allsingle malleolar fractures because ligament instability is frequently associated with the A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  52. 52. Review of Literature 51contralateral side. Distal fibula fractures are the most common fracture type to the ankle,and the Danis-Weber classification system is listed below.The Danis-Weber classification for ankle fractures is simple and is the most useful forprimary care management. This classification scheme is based on the level of the fracturein relationship to the joint mortise of the distal fibula.Type A fractures are horizontal avulsion fractures found below the mortise. They arestable and amenable to treatment with closed reduction and casting unless accompaniedby a displaced medial malleolus fracture. Type B fracture is a spiral fibular fracture thatstarts at the level of the mortise. This type of fracture occurs secondary to externalrotational forces. These fractures may be stable or unstable depending on ligamentousinjury or associated fractures on the medial side. Type C fracture is above the level of themortise and disrupts the ligamentous attachment between the fibula and the tibia distal tothe fracture. These fractures are unstable and require open reduction and internal fixation.CausesAnkle injuries are caused by acute trauma.Potts Fracture A fracture affecting one or more of the malleoli (lateral, medial, posterior) isknown as a Potts fracture. It can be difficult to distinguish clinically between a fractureand a moderate to severe ligament sprain. Both conditions may result from inversioninjuries, with severe pain and varying degrees of swelling and disability. Isolated spiralfractures of the lateral malleolus (without medial ligament instability) and posteriormalleolar fractures involving less than 25% of the articular surface are very stable. Thesefractures can be treated symptomatically with immobilization and crutches in the earlystages for pain relief only. Lateral malleolar fractures associated with medial instability,hairline medial malleolar fractures or larger undisplaced posterior malleolar fractures arepotentially unstable, but may be treated conservatively. Displaced medial malleolar, largeposterior malleolar, bimalleolar or trimalleolar fractures, or any displaced fracture whichinvolves the ankle mortise, should be internally fixed. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  53. 53. Review of Literature 52 SPECIFIC SPORTS INJURIES113Soccer injuries In soccer running, jumping, tackling, kicking, and heading are all involved.Injuries therefore in soccer can result from direct blows or from indirect methods.Injuries to lower limb Most of the injuries in soccer are seen in lower extremity .The most commonfracture is probably due to a direct blow to lower part of tibia and fibula .While turningactually a player can damage his ankle or strain his ankle in association with fracture of afibula due to foul, tackling. Young players are prone to injures of the epiphysis. Repeatedtrauma to ankle joints can lead to exostosis (bony growth) in the joint and can causepersistent pain. The sliding tackle can result in severe grass “burns” or “astro burns”.Quadriceps strain occurs most commonly during kicking, sprinting and over stretching.Injuries to thigh can also result in hematoma. Hamstring strains are seen when playingsurface is soft. Injury to the adductor group of muscle is less common. When a playerturns quickly the cartilages of knee are unable to absorb stress and may tear. Collapse ofknee and locking of the joint are evidences of cartilage injuries. An opponent striking orfalling against the outstretched leg can damage the collateral ligament on the oppositeside of the knee. The anterior cruciate ligament can be torn in the process of heading theball, is knocked off, balance while jumping in air and falls on ground with his leg twistedunder him. If the goal keepers body strikes, the lower leg of an inrushing player candamage posterior cruciate ligament .Patella can be dislocated if a player receives a kick tomedial border of patella. Chondromalacia patella and less frequently insertion tendonitisof biceps femoris are also seen. When the muscle hypertrophies inside the legcompartment, circulation may be restricted leading to pain. Pain in the calf muscle isusually a result of a pulled muscle or a cramp. Rupture frequently occurs medially at themuscle tendon junction. Achilles tendonitis and inflammation of the bursa sac behind theAchilles tendon can occur in soccer player. Partial and total rupture can take place. Theremay be inflammation of the bony attachment of the plantar fascia (fasciatis). Fracture ofthe metatarsal bones can occur both by direct and indirect mechanisms. Stretch fracturesparticularly occur in metatarsal bones. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  54. 54. Review of Literature 53 The toe nail may be damaged and a hematoma may result producing acute pain.Blisters of the toes and soles of the feet can be seen at the beginning of the season and inconditions where the playing surfaces are hard. Injuries in track and field athletes The injuries in track and field events may be contributed to lack of physical fitness, quality of surface, excessive training load, musculoskeletal deficiencies/ deformities and in adequate footwear.Common injuries in running events Achilles tendon rupture Complete rupture of Achilles tendon can occur during violent contraction of the plantar flexors as in steep uphill running, during acceleration phase in a sprint start or diving off the long jump board. The player is unable to walk on tip toe and there is a characteristic step in normal heel outline. Partial rupture of Achilles tendon will cause a lack of thrust in running or jumping.Stress fractures of tibia and fibula If stress fractures are suspected early they could e prevented. If ignored it leads toa stress fracture. Pain develops gradually at the junction of the mid and lower third oftibia. In the initial stages the symptoms occur after training session. Pain becomescontinuous in later stages. Tenderness can be elicited over the muscles and over muscularattachment to the bone. Rest for two to four weeks is essential n treating stress fractures.Injuries in racket sports Tennis, badminton and squash all require frequent changes of direction in aconfined place. It also involves abrupt deceleration and fast acceleration. Obviously theankle the knee and the thigh are the sites of common injuries. Rupture of the medial bellyof gastronemius can occur when the foot is exposed to violent dorsiflexion from plantarflexion while the knee joint is in extension. The frequent change of direction can causestress on the ankle joint and exaggerated dorsiflexion can lead to rupture of Achillestendon. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  55. 55. Review of Literature 54ANKLE IMPINGEMENT114 Tissues in the ankle joint can become trapped between bones in the ankle. This isknown as impingement and occurs when the ankle is bent full up or down. Posteriorimpingement (as it is known) in the back of the ankle is more common in ballet dancersand can be due to a bony protrusion at the back of the ankle.Causes Anterior impingement (at the front of the ankle) can occur from a bad or repeatedankle sprain as the ligaments thicken and get pinched between the bones (tibia and fibula).As the torn or ruptured ligament heals, the boy forms too much scar tissue along the frontand round the side of the ankle joint creating a meniscoid lesion.Symptoms of anterior ankle impingement • Pain at the front or side of the ankle which dos not go after ankle sprains. • Weakness in the ankle. • Pain when the ankle is forced or passively moved into dorsiflexion (toes and foot pointing upwards). Symptoms of posterior impingement • Pain at the back of the ankle. • Tenderness behind the bottom tip of the fibula bone .Pain which is worse at the end of the movement when the foot is pointed down into plantarflexion • Pain when going up onto the toes. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  56. 56. Review of Literature 55FLEXOR HALLUCIS LONGUS TENDINOPATHY115 The flexor hallucis longus muscle originates from the back of the fibula .It thentravels down along the inside of the lower leg and ankle where it inserts into the base ofthe big toe via the flexor hallucis longus tendon. The flexor hallucis longus muscle is primarily responsible for bending the big toe.It also assists with pointing the foot and ankle down and maintaining the arch of foot.Whenever the flexor hallucis longus muscle contracts or stretches, tension is placedthrough the flexorhallucis longus tendon. If this tension is excessive due to too muchforce or repetition, damage to the flexor hallucis longus tendon may occur. Flexorhallucis longus tendinopathy is a condition characterized by damage to the tendon withsubsequent degeneration.Causes Flexor hallucis longus tendinopathies may occur traumatically due to a high forcegoing through the tendon beyond what it with can withstand or more commonly due togradual wear and tear associated with overuse. Flexor hallucis longus tendinopathy isrelatively common in ballet dancers who spend significant time rising onto their toes.Signs and symptoms of flexor hallucis longus tendinopathy Patients with flexor hallucislongus tendinopathy typically experience pain in the region of the inner ankle. In less severe cases, patients may experience pain with rest following activitiesrequiring contraction of the flexor hallucis longus muscle such as standing on the balls ofthe feet, running, jumping etc. they may also experience pain and stiffness upon walkingthe following morning. As the condition progresses, patients may also experience painduring these activities. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  57. 57. Review of Literature 56FOOTBALLERS ANKLE116 Footballer’s ankle is a pinching or impingement of the ligaments or tendons of theankle between bones, particularly the talus and tibia. This results in pain, inflammation,and swelling.Causes A common cause of anterior impingement is a bone spur on anklebone(talus) or theshinbone(tibia). Repeated kicking actions can cause the anklebone to hit the bottom of theshinbone, which can lead to a lump of bone (or bone spur) developing. This bone spurmay then begin to impact on soft tissue at the front of the ankle causing inflammation andswelling. The condition is most common in athletes who repeatedly bend the ankleupward (dorsiflexion) ,such as footballers. Hence the name is given. Symptoms • Pain and tenderness when pressing in with fingers over the front of the ankle joint. • Pain when foot is bended up or down • A band of pain across the front of the ankle joint when kicking a ball • A bony lump at the front if the ankle. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  58. 58. Review of Literature 57PERONEAL TENDONITIS117 Peroneal tendonitis is an inflammatory condition of the peroneal tendon whichruns behind the ankle and under the foot. This condition is commonly seen in runners asan overuse condition.Causes • Running along slopes causing excessive eversion (rolling out) of the foot. • Tight calf muscles. • Overuse particularly in dancers or basket ball players. • Over pronation of the foot or excess eversion of the foot. Symptoms • Pain and swelling on the outside of the ankle or heel. • Pain is worse during activity and gets better with rest. • Pain when pressing in on the peroneal tendons. • Pain when the foot is passively inverted (stretching the peroneal muscles) and with resisted eversion. • Calf muscles may be tight. Contributing factors to the development of peroneal tendinitis There are several factors which can predispose patients to developing a peroneal tendinopathy.these need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:- • Poor flexibility • Inappropriate training • Poor foot biomechanics • Inappropriate footwear A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  59. 59. Review of Literature 58 PERONEAL TENDON DISLOCATION118 The peroneal are the two muscles and their tendons that attach along the outer edge of the lower leg. The peroneal tendons are enclosed in a fibrous tunnel that runs behind the lateral malleolus. Damage or injury to the structures that form and support this tunnel may lead to a condition in which the peroneal tendons snap out of the place. This is known as peroneal tendon dislocation. Causes The injury is common in athletes with unstable ankles. Often a contributing factor to this is tension in the muscle belly of peroneal tendon. Deep tissue massage is an excellent way of identifying this. Symptoms • Pain when the soles of feet is turned upwards(pronation) • Pain or tenderness behind the lateral malleolus • Swelling and bruisingSINUS TARSI SYNDROME119 The sinus tarsi is a small osseous canal which runs into the ankle under the talusbone. Damage to the sinus tarsi can be caused from overuse in conjunction with overpronation or poor foot biomechanics; however the majority of patients have suffered aninversion ankle sprain at some point in the past. The sinus tarsi have a lot of synovialfluid/ tissue which becomes inflamed. It may also occur with inflammatory conditionssuch as gout or osteoarthritis.Etiology Cause can be due to an inversion (rolling out)ankle sprain(70-80% of the time) orcan be due to a pinching or impingement of the soft tissues in the sinus tarsi due to a verypronated (rolling in) foot(20-30% of the time ). A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  60. 60. Review of Literature 59Clinical presentation Poorly localized pain, just in front of the lateral malleolus (bony bit on the outsideof the ankle). Tenderness at the opening of the sinus tarsi on the outside of the ankle .Pain ordifficulty running on a curve on the side of the painful ankle for example running round aleft hand bend running track if the left foot is painful. Passive inversion of the subtalarjoint. An anesthetic injection into the painful sinus tarsi will confirm the diagnosis byrelieving pain and allowing normal function.TARSAL TUNNEL SYNDROME120 The tarsals are the long bones of the foot. Just below the bony bit on the inside ofthe ankle (medial malleolus) is a passage where two nerves run. These nerves are calledthe medial and lateral plantar nerves. If over pronated then pressure is put on these nerveswhich can become inflamed causing tunnel syndrome.Cause Anything that creates pressure in the tarsal tunnel can cause TTS. This wouldinclude benign tumours or cysts, bone spurs, inflammation of tendon sheath, nerveganglions, or swelling from a broken or sprained ankle. varicose veins (that may or maynot be visible) can also cause compression of nerve. is more common in athletes, activepeople or individuals who stand a lot. Those people put more stress on tarsal tunnel area.flat feet may cause an increase in pressure in the tunnel region and this can causecompression.Symptoms • Pain (possibly sharp) radiating into the arch of the foot ,heal and sometimes the toes. • Pins and needles or numbness may be felt in the sole of the foot. • Pain when running. • Pain when standing for long periods of time. Poor foot biomechanics (flat feet) or inappropriate footwear may contribute to the development of tarsal tunnel syndrome and can prolong recovery if not addressed. These need to be assessed and corrected with directions from the physiotherapist. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  61. 61. Review of Literature 60INFERIOR TIBIOFIBULAR INJURY121 The tibia and fibula are the two long bones of the lower leg .Together these bonesform a joint known as the inferior tibiofibular joint which lies just above the ankle. Herethe tibia and fibula are connected by strong connective tissue and ligaments. Thisconnective tissue helps to keep the tibia and fibula together. When this connective tissueis placed under too much stress, tearing of the connective tissue can occur. This is knownas inferior tibiofibular joint injury and can range from a small tear resulting in minimalpain, to a complete tear resulting in significant pain and disability.Cause Inferior tibiofibular joint injuries typically occur during more severe ankle sprains.Signs and symptoms • Pain during weight bearing activity and on rotation or twisting of the ankle.Prognosis Depends on the severity of injury. Most patients with minor inferiortibiofibularjoint injuries heal well with an appropriate physiotherapy program. Patientswith severe inferior tibiofibular joint injuries whereby the tibia and fibular are separatedon X-ray may require surgery. It is important that this is detected early as untreatedsevere injuries may rapidly lead to ankle joint arthritis. It is therefore recommended thatall patients see their physiotherapist as soon as possible for accurate assessment anddiagnosis. A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries
  62. 62. Review of Literature 61 RADIOLGICAL INVESTIGATIONS A complete, standard radiograph examination of the ankle should include 3 views(AP, lateral, and a mortise).AP view: There are several findings that can be observed on the AP view. The tip of thelateral malleolus normally extends more distally than the tip of the medial malleolus.The syndesmosis of the ankle joint normally causes an overlap of the medial aspect of thedistal fibula and the lateral aspect of the distal tibia on this AP view. Therefore, subtlefractures involving either the lateral aspect of the distal tibia or the medial aspect of thedistal fibula (i.e., between the tibia andfibula) may be difficult to visualize on this APview alone because of the overlap. It is a common pitfall to miss a Salter Harris Type IIIfracture of the distal lateral tibia because it is obscured by the overlapping fibula.b) Lateral view: On a true lateral view, the malleoli should be superimposed upon one another. The lateralview provides a better view of the posterior aspect of the distal tibia and fibula, the talus, calcaneus and the base of the 5th metatarsal.c) Mortise view: To obtain a better view of the ankle mortise, the patients leg must be internally rotated just enough so that the lateral malleolus (which is normally posterior to the medial malleolus), is on the same horizontal plane as the medial malleolus, and aline drawn through both malleoli would be parallel to the tabletop. Usually this only requires approximately 10 -20 degrees of internal rotation. In other words, when viewing the mortise view, the tibia and fibula must be viewed without superimposition on each other. This mortise view represents a true AP projection of the ankle mortise and also provides a good visualization of the talar dome (to rule-out osteochondral talar domefractures).The clear joint space [formed by thetalofibular joint, the superior space between the domeof the talus & the tibial plafond (the inferior articulatingsurface of the tibia) and the tibiotalar joint] should all uniformely measure 3-4 mm.A difference of greater than 2 mm (i.e., the joint space width varies by more than 2 mm. Eg., Joint space measures 2 mm at lateral part of joint and 5 mm at medial side of joint.) is suggestive of mortise instability. If all of the above 3 views appear normal in a patient with a high clinical suspicion of a fracture, one should then obtain internal and external oblique views of the ankle to obtain additional views of A Comprehensive Study on Gulpha Sandhi Shareera w.s.r to Sports Injuries

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