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“ A Study On Prushtha Marma W.S.R. To Stabdha Bahuta In Amsa Marmabhighata ”
By
Dr.Shivasharanayya M.Swamy A dissertation submitted to the
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In partial fulfillment of the requirements for the degree of
AYURVEDA VACHASPATHI - M.D (AYURVEDA)
In
RACHANA SHAREERA
Guide Dr.N.G.Mulimani
MD (SR)
Co-Guide Dr.Shelly Divya M.D.(SR)
darshan
Post Graduate Department Of Rachana Shareera N.K.J. Ayurvedic Medical College & PG Centre, Bidar.
2010
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KKK aaa rrr nnn aaa ttt aaa kkk aaa ,,, BBB aaa nnn ggg aaa lll ooo rrr eee .
Declaration by the candidate
I, hereby declare that this dissertation/thesis entitled “A
study on Prushtha marma W.S.R. to Stabdha bahuta in Amsa
marmabhighata” Is a bonafide and genuine research work carried
out by me under the guidance of Dr.N.G.Mulimani,M.D.(SR)
Professor Department of Rachana Shareera.
Date: Signature of the candidate Dr.Shivasharanayya M.Swamy Place: Bidar
RRR aaa jjj iii vvv GGG aaa nnn ddd hhh iii UUU nnn iii vvv eee rrr sss iii ttt yyy ooo fff HHH eee aaa lll ttt hhh SSS ccc iii eee nnn ccc eee sss ,,, KKK aaa rrr nnn aaa ttt aaa kkk aaa ,,, BBB aaa nnn ggg aaa lll ooo rrr eee .
Copyright
Declaration by the candidate
I here by declare that the Rajiv Gandhi University of Health
Sciences, Karnataka shall declare the rights to preserve, use and
disseminate this dissertation/thesis in print or electronic format for
academic/research purpose.
Date:
Place: Bidar
© Rajiv Gandhi University of Health Sciences, Karnataka
Signature of the candidate Dr.Shivasharanayya M.Swamy
RRR aaa jjj iii vvv GGG aaa nnn ddd hhh iii UUU nnn iii vvv eee rrr sss iii ttt yyy ooo fff HHH eee aaa lll ttt hhh SSS ccc iii eee nnn ccc eee sss ,,, KKK aaa rrr nnn aaa ttt aaa kkk aaa ,,, BBB aaa nnn ggg aaa lll ooo rrr eee .
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation entitled “A study on
Prushtha marma W.S.R. to Stabdha bahuta in Amsa
marmabhighata” is a bonafide research work done by Dr.
Shivasharanayya M.Swamy, in partial fulfillment of the
requirement for the degree of Ayurveda Vachaspathi - M.D.
(Ayurveda).
Signature of the Co-Guide Dr.Shelly Divyadarshan
M.D.(SR) Lecturer,
Department of Rachana Shareera NKJ Ayurvedic Medical College & P G Centre
Bidar – 585403
Signature of the Guide Dr. N.G.Mulimani
MD (SR) Professor,
Department of Rachana Shareera NKJ Ayurvedic Medical College & P G
Centre Bidar – 585403
Date: Date: Place: Bidar Place: Bidar
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This is to certify that the dissertation entitled “A study on
Prushtha marma W.S.R. to Stabdha bahuta in Amsa
marmabhighata” is a bonafide research work done by Dr.
Shivasharanayya M.Swamy under the guidance of
Dr.N.G.Mulimani. Prof department of Rachana Shareera.
Seal and signature of the Principal/Dean
Dr.K.V.L.N Acharyulu. M.D. (Ayu)
Principal & Dean N.K.J. A.M.C. & PG Centre, Bidar – 585403 Karnataka.
Seal and signature of H.O.D. Dr .N.G.Mulimani MD (SR) Prof & H.O.D Dept. Of Post Graduate Studies In Rachana Shareera N.K.J. A.M.C. & PG Centre, Bidar – 585403 Karnataka.
Date: Date: Place: Bidar. Place: Bidar.
Acknowledgements
This is the greatest moment to me to acknowledge the respected personalities who
has given this opportunity and helped in doing my dream work of dissertation.
First and foremost I have to acknowledge to my parents Sri Mallayya Swamy and Smt
Mallamma swamy& my brother in law Sri Shivmurthy G & my brother Shivamurthy .Swamy.
I am very much indebted to my esteemed and cherished Guide Prof
Dr.N.G.Mulimani MD (SR) H.O.D P.G.Department of Rachana Shareera for
providing an opportunity to carry out this work under his proficient guidance. I will be ever
grateful for his invaluable guidance, constructive suggestions, thought provoking ideas in
every stage of this work to achieve this milestone.
It is a great privilege to record my esteemed & deepest sense of gratitude to my
Co‐guide Dr.Shelly Divyadarshan MD (SR) P.G.Department of Rachana Shareera for
his able guidance, all time support, generous help & affection throughout my work.
I consider it a great privilege to record my deepest sense of gratefulness to our
Professor. Dr.S.B. Kotur M.D (SR) for his all time support, during this work.
I also express my sincere gratitude to and offer my sincere thankfulness to my
mentor Professor Dr Ashwinikumar. M.D (SR) who is my well wisher and generous help during
my dissertation work.
I wish to extend my heartiest thanks to the Principal Prof Dr.K.V.L.N Acharyulu.
N.K.J Ayurvedic Medical College & P.G. Centre for providing the necessary facilities in
the college for conducting research work.
I
Any amount of thankfulness will be inadequate for all the department teachers
namely Sanjeevkumar jyoteppa for providing all possible guidance and support. I am highly
indebted to my beloved senior and lecturer Dr.Anup. B for his constant enthusiastic and
affectionate pushes in my thoughts in time and again. I take an opportunity to be grateful to my
teacher Dr.vijay Biradar. M.S (shalya) for his cooperation in his service.
On this occasion I give my deepest gratitude to my teacher Dr.Brahmanand. Swamy
. M.S (shalya). I take this opportunity to convey my thanks to Vidwan P.G.Bhatt for his proper
guidance during my dissertation work.
I also express my sincere gratitude to and offer my sincere thankfulness to
Dr.Manik kulkarni M.D (Panchakarma) and all Panchakarma dept staff.
I wish to extend my heartiest thanks to the vice‐ Principal Dr. Prasanna V. Savanur for
his active guidance during my dissertation work.
Sri. Vinod Bagali office supdt. , Sri. Lakshmikanth Reddy accountant, Shri Vidyanand
kulkarni, Mr.Ramesh Chidre, Mr Chandrakant, Mr Kaddi, Sri. R.J. Kadam Librarian,Mr
Rajkumar and Smt. Sakubai. Department assistant Mr. Sabeer, Mr. Abdul and all the other
technical and non technical staff of the college for their cooperation and help.
In addition this I am also very grateful to my batch mates Dr Vivek Kulkarni Dr
Sukhesh, Dr.Rajshekhar Tokare, Dr.Satyamma, Dr.Geeta Dolli, Dr.Satish Jalihal , Dr
Pradeepraju,Dr Sameer, Dr Jyoti Hullale, Dr Jyoti Rajole.,Dr Sanjeev Trivedi
,Dr.Baslingappa,Dr Omprakash, And I Extend My Regards To My Seniors Dr Santosh
Dixit, Dr Bapu Desai,Dr.Praveen Shegedar And, All My Seniors & Juniors Dr.Mohan.G,Dr
Mallikarjun,Dr.Nagendra,Dr.Sujit.
I pick up this precious moment for appreciation of my Friend Dr Vijay Bulgundi
Orthopedic Surgeon who helped me in modern aspect of my dissertation.
Lastly I acknowledge my thanks to those who have directly or indirectly extended
their support for completion of my work.
Date: Signature of the candidate
II
Place: Bidar Dr.Shivasharanayya. M.swamy
ABBREVIATIONS
LIST OF ABBREVIATIONS
ACCORDING TO REFERENCE BOOKS (AYURVEDIC)
A.H › Ashtanga Hridaya.
A.S › Ashtanga Samgraha.
Ch.S › Charaka Samhita.
K.S › Kashyapa Samhita.
Su.S › Sushruta Samhita.
ACCORDING TO STHANA OF SAMHITA
Chi › Chikitsa Sthana.
Sha › Shareera Sthana.
Su › Sutra Sthana.
U › Uttar Sthana.
VI › Vimana Sthana.
A study on Prushtha marma W.S.R.to Stabdhabahuta in Amsamarmabhighata Page III
ABBREVIATIONS
LIST OF ABBREVIATIONS (MODERN)
F › Female
Fig. › Figure
G › Grade
Gr. › Group
M › Male
Min › minute
No › Number
O.P.D. › Outdoor patient department
Sl. › Serial
Yr › year
A study on Prushtha marma W.S.R.to Stabdhabahuta in Amsamarmabhighata Page IV
ABSTRACT
“A study on Prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata” Page 1
ABSTRACT:-
Marma is described as the vital spots in our body, injury to which ends in
various dangerous crises. The marma are 107, they are classified in various groups based
on their location like-: Shakhagata, udara uarahgata, Prushthagata & Jatrudwagata.
Prushtha marma are 14 in number those are katikataruna, Kukundara, Nitamba,
parshvasandhi, Brahati, Amsaphalaka and Amsamarma each two in number.
Although the gross regional and the viddha laxanas are available in samhitas, but
detail description of particular structures present in Prusthamarma region are lacking in
ancient texts.
Objectives of the study were complete literary review on prushtha marma and
applied anatomy of prushtha marma with special reference to clinical & structural
assessment of Amsamarmabhighata.
METHODS:-
The subject of this dissertation is both literal and observational study, data related
to Prushtha marma were collected from various classics, objective and subjective
parameters and observations of 30 patients of stabdhabahuta (Amsamarmabhighata) were
collected and anatomical variations were noted.
All patients had the structural changes in Amsa pradesha in the form of fracture,
dislocation, rupture of the ligaments, rotator cuff tear, frozen shoulder etc... But we have
ABSTRACT
“A study on Prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata” Page 2
only included the soft tissue injuries which hold all the structure together and supports
the shoulder.
OBSERVATIONS:-
Subjective and objective parameters were taken to analyze the severity of the
trauma and range of signs & symptoms in each patient. As it is an observational study
based on clinical diagnosis, the student’s t-test was not used. Only the percentage of each
finding was mentioned.
INTERPRETATION & CONCLUSION:-
Interpretation will be done on controversial points and conclusion drawn after
completion of observations.
Key words:-
Prishtha marma, Amsa marma & Stabdhabahuta.
Index
Sl. No. Contents Page No.
1 Introduction 1-2
2 Aims & Objectives 3
3 Review of literature
1. Historical review:
2. Ayurvedic review:
a) Concept of marma shareera
b) Classification of marma
c) Prushtha marma
3. MODERN REVIEW:
a)Katikataruna,Kukundara &Nitamba b)Parshwasandhi marma c)Brahati marma d)Amsaphalaka marma e)Amsa marma f)Modern review of amsa marmabhighata g)Sports medicine & Biomechanics
4-6
7-60
7-11
12-13
14-60
61-86
61-65
65
66
67
68-76
76-83
83-86
4 Photo plates 86-98
5 Methodology 99-104
6 Observations 105-116
7 Discussion 117-134
8 Conclusion 135-137
9 Summery 138-139
10 Reference Shlokas 140-149
11 Bibliography 150-164
12 Annexure 1-5
13 Master chart 1
LIST OF TABLES
S.No Name of the table
Page no
1. Classification of marma based on the structure 12
2. Classification of marma based on effect of injury 12
3. Classification of marma on location 13
4. Classification of marma based on numbers 13
5. Classification of prushtha marma 14
6. Bones of Nitamba marma 25
7. Muscles acting on shoulder girdle 75
8. The distribution of patients based on age 105
9. The distribution of patients based on sex 106
10. The distribution of patients based on occupation 107
11. The distribution of patients based on diet 108
12. The distribution of patients based on shoulder pain 109
13. The distribution of patients based on restricted movement 110
14. The distribution of patients based on Tenderness 111
15. The distribution of patients based on visible deformity 112
16. The distribution of patients based on numbness 113
17. The distribution of patients based on Arm drop sign 114
LIST OF FIGURES
S.No Name of figure Page No
1
Limitations of amsa marma
59
2
Assesment for the joint mobility 102
3
Prushtha marma Photo plate 86
4
Bones & Joints of pelvic cavity Photo plate 86
5
Muscles of the gluteal region Photo plate 87
6
Nerves of pelvic cavity Photo plate 88
7
Ligaments of pelvic cavity Photo plate88
8
vessels of pelvic cavity Photo plate88
9
Viscera of pelvic cavity Photo plate88
10
Scapula & Ribs Photo plate89
11
Muscles of the scapular region
Photo plate89
12 Brachial plexus
Photo plate89
13 Vessels of the axilla Photo plate89 14
Shoulder girdle articular surfaces Photo plate89
15 Muscles & bursae
Photo plate90
16 Ligaments
Photo plate90
17 Bursae & Rotator cuff muscles
Photo plate91
18 Movements of the shoulder joint
Photo plate91
19 Muscles acting on shoulder girdle
Photo plate92
20 Causes of Supraspinatus
Photo plate93
21 Painful arch syndrome Photo plate93
22 Rotator cuff Muscles Photo plate93
23 Shoulder joint diagram Photo plate94
24 USG of Shoulder Normal
Photo plate94
25 Shoulder Diagram transeverse view Photo plate95
26 USG of Shoulder Normal transeverse view Photo plate95
27 Supraspinatus tendon full tear Photo plate96
28 Supraspinatus tendon full tear & Bursitis Photo plate96
29 Complete tear of Supraspinatus Photo plate97
30 Radiological Finding of Shoulder Photo plate98
31 Shoulder MRI;Rotator cuff injuries Photo plate98
LIST OF GRAPHS
Graph
No.
Description Page No.
01 Incidence of Age 106
02 Incidence of Sex 107
03 Incidence of Occupation 108
04 Incidence of Diet 109
05 Incidence of Shoulder pain 110
06 Incidence of Restricted movement on abduction 111
07 Incidence of Tenderness 112
08 Incidence of visible deformity 113
09 Incidence of Numbness 114
10 Incidence of Arm drop sign 115
11 Incidence of modern diagnosis 116
LIST OF FLOW CHARTS
Flow
chart
No.
Description Page no.
1 General Patho-physiology of marma 9
2 Mechanism 11 3 Structure of Katikataruna marma 16 4 Patho-physiology of katikataruna marma 18 5 Structure of Kukundara marma 23 6 Patho-physiology of Kukundara marma 24 7 Structure of Nitamba marma 27
8 Patho-physiology of Nitamba marma 30 9 Structure of Parshvasandhi marma 32 10 Patho-physiology of Parshvasandhi marma 36 11 Structure of Brahati marma 38 12 Patho-physiology of Brahati marma 40 13 Structure of Amsaphalaka marma 43 14 Patho-physiology of Amsaphalaka marma 45 15 Structure of Amsa marma 47 16 Patho-physiology of Amsa marma 50
INTRODUCTION
“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ” Page 1
INTRODUCTION
The human anatomy (shareera rachana) is an important for allied health sciences. It is one
of the fundamental subject to the health science.
The ayurvedic life science is also based on the human anatomy and physiology (rachana
& kriya), without the knowledge of shareera rachana and kriya, the physician cannot become
perfect in the profession.
So the ancient Acharyas like Sushruta, Charaka and Vagbhata were given importance to
the knowledge of rachana shareera. The acharya sushruta was mentioned in the shareera sthana
of sushruta samhita, other acharyas are also explained about the human anatomy in their
samhitas. The human body dissection was described in sushruta samhita.
Even though no descriptive anatomy of organ or structure is available in any samhita
granthas but our ancient have treated various diseases and performed the surgery perfectly and
precisely.
If we gone through the marma shareera, These are vital points of the body. They
are situated at various regions of the body. If any injury to the Marma points that leads to
deformity of the structures, produces the severe pain, loss of movements, and even some times
there may be a death. The Marma are still holding the power of anatomists and surgeons in high
amount. It seems that Acharyas have described the regional anatomy in relation to the surface
anatomy of Marma. Every Marma holds its own clinical importance and significant scientific
values, while on research none can ignore this.
INTRODUCTION
“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ” Page 2
Marma are vital areas regarded as conglomeration of mamsa, sira, snayu, asthi, and
sandhi and named after their individual predominant structure.
Prushtha Marma are 14 in number those are Katikataruna, Kukundara, Nitamba,
Parshwasandhi, Brahati, Amsaphalaka and Amsa and the structures related to shoulder
region are the most exposed area to common injuries. The activities like weight lifting,
swimming, cricket, fall on the outstretched arm causes the rupture of ligaments and muscles of
shoulder joint, leads to disability of the Amsa sandhi and bahu. Therefore selecting out this topic
for study will be a needful exercise for the subject Shareera Rachana.
Symptomology like stabdhabahuta or bahukriyahara is almost an uncovered area of
study. Hence the surgical and anatomical evaluation of stabdhabahuta symptom under Amsa
Marma will be need for research.
Looking into the above feature though no study has yet been conducted on the vital
points of back especially on Amsa Marma with its degenerative process following on injuries,
hence it is understood that still critical study is needed.
Aims & Objectives
“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ” Page 3
Aims and objectives of the study:
1. Conceptual study of Prushtha Marma Shareera.
2. To study the underlying structures of Amsa marma and to fix its limitations.
3. To study the Stabdhabahuta in Amsa marmabhighata on modern parameters.
HISTORICAL REVIEW
“A Study on prushtha Marma W.S.R. to Stabdhabahuta in Amsa Marmabhighata ” Page 4
HISTORICAL REVIEW
In Vedic Literature:
In Rigveda, a word Marma is found in connection with sharp weapon called
vajra,used by lord ‘Indra’ for the purpose of killing the demon ‘Virata’ by attacking the
Marma sthanas.1
In Atharveda, references to Marma sthanas can be found in connection with the
killing of ‘skanda’ by lord ‘Indra’ and lord ‘Agni’.2
Upanishads:
In, ‘Garbhopanishad’we can find the word Marma reference to a quality of
knife which is capable of cutting the Marma of jaghana pradesha, 107 Marma are referred
along with anatomical structures of the body, 18 sensitive or vital parts or Marma
distributed at various places of the body are described for the practice of dharana, which
is achieved by concentration and withdrawal of mind from one spot to other spot of the
body.3
Epic Literature:
In Ramayana, The king Dasharatha while hunting used shabdabhedhi arrow
capable of hitting the objector a person without even looking at which pierced the Marma
sthana of shravanakumar resulting in death soon after the removal of arrow from the
body.4
HISTORICAL REVIEW
“A Study on prushtha Marma W.S.R. to Stabdhabahuta in Amsa Marmabhighata ” Page 5
During the fight between the ‘Vali’ and ‘Sugreeva’ Sri Rama hits at the Marma
sthana of Vali and he falls down with agonizing pain and died after arrow was removed.
These references points to vishalyagna Marma described in ayurvedic texts.5
Hanuman, while entering into Lanka, happened to confront with a very dreadful
and peculiar rakshasi ‘sinhika’ He carefully observed the Marma of the body and killed
the rakshasi by piercing his sharp and long nails into the Marma sthalas.6
The Meghanatha hits the Marma sthana of Lakshmana and falls down with
agony.7
During the fight, Meghanada hits the Marma sthala of the Rama and Lakshamana
and captivated them and tied them tightly With Nag pasha.7
In Mahabharata also, the use of word Marma can be traced out in
Sauptikaparva and Bhishma parva.During the battle between the Kaurava and pandava,
the Ashwathhama inflicted strong blow with his lion like heels on the vitapa Marma of
the elephant.8
In another place, king Duryodhana cries due to torn and broken thigh, which
pierced the Marma sthana.9
On the above narrations if a close observation is made, it can clearly be pointed
out that the knowledge of Marma vigyana was extensively well known since Vedic
period (4000BC) Later on its progression can be observed in the samhita granthas
especially in sushruta samhita shareer sthana.10
HISTORICAL REVIEW
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But later, during Sushruta’s period the knowledge was acquired based on
the dissection of cadavers.
Later the Aristotle never dissected the human body but had a rough idea about the
vessels. Celsius (20BC) though wrote work on medicine but gave too little glimpse of
anatomy. Thus modern anatomy is only four hundred years old. The first public
dissection took place at Vienna on 12 February 1404. In 1565, queen Elizabeth of
England permitted dissection on executed criminals. Thus, the ancient Indian knowledge
on anatomy and dissection was considered superior to any of the anatomy in the world up
to 15th century. But afterwards, no efforts were made to improve the knowledge and
remained dormant and stagnated. However,after 19th century again devoped and made the
branches like Surface antomy, radiological Anatomy,Embryology etc ….
AYURVEDIC REVIEW
“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ” Page 7
AYURVEDIC REVIEW
CONCEPT OF MARMA SHAREERA
Vyutpatti of word Marma
Mru maneen jeevasthaane, Sandhisthaane taatparye cha10”
Word meaning of Marma is jeevasthaana sandhisthana.
Nirukti of Marma
That which causes death on injury is called Marma or painful condition in which
the patient experiences pain same as death.11
Definition of Marma
“Marmaani naama maamsa siraa snaayu asthi sandhi sannipatah;
teshu svabhaavata eva praanatishtanti”12
Marma consists of aggregate of Mamsa, Sira, Snayu, Asthi, Sandhi in which
particularly Prana by nature stays. That which leads to death or which gives misery to
individual similar to death when injured is called Marma.13
Marma are that part of the body which exhibits a peculiar sensation or unusual
throbbing and causing pain on pressure.14
Marma are so called because they cause death when they are injured and they are
meeting place of Mamsa, Asthi, Snayu, Dhamani, Sira, Sandhi and life entirely resides in
them.15
The place where Mamsa, Sira, Snaayu, Asthi, and Sandhi present as Marma in
which specifically Prana is situated.16,17,18
AYURVEDIC REVIEW
“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ” Page 8
Marma are jeeva darana places in the body.19
Marma are called a jeevaagaara, that is jeeva takes shelter in Marma.20 The point
of the body which leads to death when injured called Marma.21
Prana
In persons generally Soma (Kapha), Maruta (Vaayu), and Tejas ( Pitta), and
Rajas, Satva, and Tamas along with Atma stays in Marmas, that is why they do not
survive if injury takes place on Marma.22,23 These are said to be Prana according to
Sushruta.
There are said to be 10 seats of Prana that is Dasha Pranayatanas by Acharya
Charaka. Those are two Shankha, Three Marma (Shira, Hrudaya and Basti), Kantha,
Rakta, Shukra, Ojas, and Guda.24 Acharya Charaka again mentioned Pranayatanas in
Shareera sthana as Murdha, Kantha, Hrudaya, Nabhi, Guda, Basti, Oja, Shukra, Shonita,
and Mamsa.25Acharya Vagbhata in both Hrudaya and Sangraha mentioned same as
Acharya Charaka.26 Acharya Kashyapa told Dasha Pranayatana’s as Murdha, Hrudaya,
Basti, Kantha, Shukra, Shonita, two Shankha, Guda, among these he called first three are
MahaMarma.27
General structure of Marma
Marma consists of aggregate of Mamsa, Sira, Snayu, Asthi, Sandhi in which particularly
Prana by nature stays.28 In persons generally Soma(Kapha), Maruta (Vaayu), Tejas
( Pitta), Rajas, Satva, and Tamas along with Atma stays in Marmas, that is why they do
AYURVEDIC REVIEW
“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ” Page 9
not survive if injury takes place on Marma. By injury Shareerika and Manasika dosha are
aggravated which destroy body and mind and finally Atma leaves the body.29
Flow Chart No.1
AYURVEDIC REVIEW
“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ” Page 10
General symptoms of Marma Viddha lakshana30
Vishama spandana- Variation in pulsation of vessels in pulsatory places of
particular Marma pradesha is due to Viddha and structural impairment. Vishama ruk-
Deferent type of pain will be felt on putting pressure on Marma Viddha pradesha.
Antah (peripheral region) Viddha and Madhya Viddha lakshana
The structure of the Marma generally includes 2 parts, Madhya and Antah
(peripheral region) parts.
Madhya Viddha (central region) –
Injury to the Madhya (central part) of the Marma occurs, and then cardinal
symptoms related to particular Marma appears.
Example- Shankha Marma Madhya Viddha leads to Marana.
Antah (peripheral region) Viddha-
Injury to the Antah (peripheral region) pradesha of the Marma occurred then
instead of showing cardinal signs; it converted in to successive Marma lakshana
So many times patient came with Marma Viddha lakshana will not exhibit
cardinal symptoms. This is because in injury to peripheral part of Marma Rachana
involved.On observation it is clinically very difficult to demark peripheral and central
part of Marma. But on the basis of symptomatology and also Acharya Sushruta’s concept
of Antah (peripheral region) and Madhya Viddha, will guide us to determine the
prognosis. Example- sometimes Shankha Marma Viddha will not lead to Sadhyo Marana,
AYURVEDIC REVIEW
“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ” Page 11
patient may die after a month. It means in this condition, only peripheral part of Shankha
Marma injuries
Flow Chart No.231
AYURVEDIC REVIEW
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CLASSIFICATION OF MARMA
Classification of Marma is done depending upon structures involved, effect of Marma
injury, place of situation, measurement of Marma, and number of Marma.
Table No 1: Classification of Marma based on structure32,33,34
Marma Sushruta Vagbhata Bhavaprakasha
Mamsa 11 10 11
Sira 41 37 47
Snayu 27 - 21
Asthi 8 8 8
Sandhi 20 20 20
Dhamani - 9 -
Total 107 107 107
Table No 2: Classification of Marma based on effect of injury35
Sadyopranahara 19
Kalantara pranahara 33
Vaikalyakara 44
Rujakara 8
Vishalyaghna 3
Total 107
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Table No 3: Classification of Marma on location36
Shakhagata 44
Udara uraha gata 12
Prushtha gata 14
Jatrurdhvagata 37
Total 107
Table No 4: Classification of Marma based on numbers37
One in number
vitapa, kakshadhara, guda, basti, hrudaya, nabhi, sthapani,
adhipati
Two in number
gulpha, janu, stana moola, stana rohita, apalapa, apasthambha,
Katika taruna, kukundara, nitamba, parshva Sandhi, bruhati,
amsaphalaka, amsa, krukatika, viduara, phana, apanga, aavarta,
Utkshepa, shankha
Four in number
kshipra, talahrudaya, koorcha, koorcha shira, indra basti, ani,
oorvi, lohitaksha, srungataka
Five in number
Seemanta
Eight in number
matruka,
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PRUSHTHA MARMA38
Prushtha marma are situated at the back of the trunk. Those are 14 in number are
kateekataruna, kukundara, nitamba, parshwasandhi, brahati, amsaphalaka and amsa, each
2 in number.
Table No 5: Classification of prushtha marma (figure no-1)
MARMA NUMBER SIZE STRUCTURE TRAUMA
EFFECT
Kateekataruna 2 ½ anguli Asthi Vaikalyakara
Kukundara 2 ½ anguli Sandhi Vaikalyakara
Nitamba 2 ½ anguli Asthi Kalantarapranahara
Parswasandhi 2 ½ anguli Sira Kalantarapranahara
Brahati 2 ½ anguli Sira Kalantarapranahara
Amsaphalaka 2 ½ anguli Asthi Vaikalyakara
Amsa 2 ½ anguli Snayu Vaikalyakara
1.KATIKA TARUNA:-
Kati – low back region,39 Taruna – young, Trauma here it refers as it may be the
cartilaginous bone or ossification process is going on. In the low back region the five
small bones are ossified and forms single bone called “Katikpalasthi” (Sacrum). That
region is called “Kati” pradesha
On both sides of the prushtha vamsha (vertebral column) in each shroni kanda
(hip bone), there are kateekataruna marma situated. Injury to them gives rise to pallor,
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discoloration of the skin, due to hemorrhage or blood flows, disfiguration of the body and
ultimately leads to death. 40
According to Dalhana, kateekataruna marma are asthi marma structurally, having
kalantara pranahara consequences and covers an area half angula and bilateral.41
It is situated on either side of the vertebral column, on the ear like bones of the
pelvis are the two kateekataruna marma injury to these causes pallor due to loss of blood,
emaciation and death.42
Location
On the both sides of the vertebral column where kati kapaala Asthi meet with
Shroniphalaka Asthi. It means sacro-iliac joint. In this region “Katika taruna is present”.
Pramana
Half Anguli Pramana on both sides of sacro-iliac joint of pelvic cavity. It is
approximately 1cm in diameter circular area on the pelvic cavity.
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Flow Chart No.3
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Viddha Laxanas:-
1. Samanya lakshana
a. After injury to this Asthi marma leads to rupture of major blood vessels because in this
region Asthi protecting major blood vessels of pelvic cavity with main nerves.
b. Severe bleeding.
2. Vishesha lakshana43
a. Shonita kshaya- loss of blood, this is due to rupture of major blood vessels in pelvic
cavity near to the sacro-iliac joint.
b. Pandu- due to blood loss, pallor is the main symptom. This is the first stage of
bleeding.
c. Vividha varna – this is due to moderate blood loss, means other than pale yellow, little
bit bluish coloration starts to occur. Sometimes it exhibits mixed colour, this is second
stage of bleeding.
d. Heena roopata – this is the third stage of bleeding due to excessive blood loss
&distortion of pelvic girdle, leads to heena roopata.
e. Marana – this is last stage of bleeding, means it leads to death hypovolemia.
f. For this process it may take a month, so Marana may occur in a month.
3. Madhya and Antah (peripheral region) Viddha lakshana.
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a. Madhya Viddha lakshana – cardinal signs and symptoms- Kalantara pranahara
b. Antah (peripheral region) Viddha lakshana – It is converted in to Vaikalyakara
Marma.
Flow Chart No.4
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It is situated on the back of the body on the both sides of the lower spine. The area
of the hip on both the sides of the sacrum can be included in this and since it is asthi
marma, it may be related bone or bony joint. And because it produces loss of blood,
anaemia, distortion of hip & giving ugly look to the person (i.e deformity of pelvic
girdle).
The possibility of rupture of blood vessels along with the fracture, dislocation of
particularly sacro-iliac joint can be thought of.
In compression injury fracture dislocation of sacro-iliac joint and distortion of
pelvic takes place, accompanied by injury to blood vessels especially common iliac
vessels at its bifurcation giving.we can give the another openion that superior glutial
artery it is direct branch from the internel iliac artery injury to this gives rise to
hemorrhage, leading to panduta, etc.
According to the classics this marma is included under the asthi marma. Injury to
this marma leads posterior weight transmitting segment injury which is important from
the locomotion point of view are more disabling. Katikataruna injury, which produces
fracture and dislocation with severe hemorrhage and distortion of normal shape of pelvis,
suggests the following possibilities. The signs and symptoms of trauma over this marma
point to a possibility of joint involvement which produces instability of a pelvis and
produce sever hemorrhage and result in change of normal shape of pelvis. All these three
symptom complexes are possible if the sacro-iliac joint is taken as kateeka taruna. The
internal iliac vessels which lies in the vicinity, will produce intra pelvic hemorrhage on
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trauma and produce obvious distortion of normal contour of pelvis, resulting in ‘HEENA
RUPA’ and ultimately death due to hemorrhage or sepsis & shock.
Based on these the kateeka taruna marma seems to be anatomically situated on
the back adjacent to the both the sides of the lower spine where both the hip bone joints
with the sacrum. Dalhana mentioned this marma as asthi marma, satisfies the bony
structures or joints found in the area concerned. But while considering the loss of blood,
pale and distortion of hip arises ugly look to the person, the possibility of rupture or
dislocation of the bony structures usually caused by crush injury, inturn blood vessels and
nerves are damaged producing loss of blood (anaemia) and ultimately leading to death.
The important anatomical structures lie in the sroni pradesha are inferior &
superior gluteal arteries and nerves, internal pudendal artery & the sciatic nerve. If in
case any damage to any arteries may leads to excess bleeding and consenquently death
takes place after some time. Any injury to the sciatic nerve produces loss of sensation and
the movements of the muscles innervated with the nerve.
According to the Vd RR Pathak, the posterior aspect of the ilium, bifurcation of
common iliac artery opposite lumbosacral articulation, in to the external iliac and the
hypogastric arteries the corresponding iliac veins and sacroiliac ligaments should be
taken as the anatomical structures involved in the kateek taruna marma, Dr. V.S Patil also
stands with the same view.
Dr. B.G Ghanekar enumerated the anatomical structures involved in the area of
this marma as sciatic notch, but the description does not justify because the sciatic notch
is deeply situated.
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Dr Avinash Lele, in the secrets of marma accounted the anatomical structures
involved in this marma as posterior aspect of the ileum, sacro-iliac ligament, superior
gluteal artery, and vein draining common iliac lymph gland, sacral plexus, gluteus
maximus muscle, and as per their view this marma is not accepted as asthi marma.
According to P.V. krishnarao the important anatomical structures corresponding
to kateekataruna marma are the posterior aspect of the ileum, bifurcation of the common
ilac artery, opposite to the lumbo-sacral articulation.
Astthi marma viddha laxana:
When asthi marma are injured there is discharge of thin fluid mixed with bone
marrow and intermittent pain.44
The learned surgeon well versed in the scripture should diagnose the patient who
has severe pain day and night and who gets no relief in any posture as suffering from an
injury to bone.
2. KUKUNDARA MARMA
Kukundara marma is situated on both sides of prushtha vamsha and the lateral
sides of the outer part of the jaghana asthi and an injury to this marma causes loss of
sensation and movements in lower part of the body.45
It is a sandhi marma in nature, vaikalyakara in consequence and extends over an
half angula area (Dalhana)46
According to chakrapani there are two deviated parts over the sphik47
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According to Haranachandra the word kati means jaghana, the marma are situated on the
both sides of vertebral column and they are in whirl in shape.48
Location:
On the two flanks, outside the buttocks and on either sides of the vertebral column
are the two kukundara, injury to this leads to loss of sensation and the movements of the
lower parts of the body.
Pramana:
½ Angula Pramana, outside the buttocks and on either sides of the vertebral column. It is
approximately 1cm in diameter circular area on the pelvic cavity.
According to the Gananathsen , the kukundara marma counted as ischial
tuberosity .Vd.R R pathak counted this marma as to the sacro-iliac articulation over
which the sacral nerves arising from the sacral plexus and passes and emerges out the
pelvis through the greater sciatic foramen.
As per the openion of Dr.Avinash Lele the anatomical structures under the
marma as ischial bone, inferior gluteal artery and vein, inferior pudendal artery and vein,
gluteus maximus muscle and levator ani muscles.
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Flow Chart No.5
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Flow Chart No.6
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Sandhi marma viddha laxana:
Progressive (muscular) atrophy, severe pain, decrease of strength, oedema all
around and a loss of all movements are the features of an injury to the movable and the
immovable joints49. Injury to the sandhi marma the site injury feels as though full of
thorns, even after healing of wound there is a shortening of the arm, lameness, decrease
of strength, movements and emaciation of the body and swelling of the joints.50
.. 3.NITAMBA MARMA:
Nitamba marma is situated above the sroni kanda (hip bone), which covers the
ashaya and connects the lateral part of the vertebral column. An injury to this marma
leads to shosha (atrophy) in the lower extremity and weakness, which ultimately causes
death.51
Table No:6 Shroni phalakasthi
Nitambasthi Hip bone 2
Bhagasthi Pubic symphysis (both together)
1
Trikasthi Sacrum 1
Gudasthi Coccyx 1
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According to Acharya Dalhana it is an asthi marma in nature,in consequences cause
kalantara pranahara marma.52
According to vagbhata this marma is located above the ear like bones of the
pelvis, concealing the visceral organs and composed of cartilages. Any injury to this
marma leads to swelling and debility of the lower part, and and lastly leads to death.53
Dr . R. R Pathak has accounted floating ribs, the lumbar plexus along with the
other important structures as the anatomical contents of the nitamba marma.
In the context of Shroni panchaka, Acharya Sushruta told two Nitambasthi. So the
shroni panchaka is nothing but the union of five bones in pelvic region.
So hip bone, specifically ilium and ischium are considered as Nitambasthi, and
the region is called “Shroniphalaka” region.
Location
Above the Jaghana karna of pelvic bone is covering pelvic organ. It is located interior to
the pelvic cavity on the both sides of lateral aspect of the iliac bone. This is nothing but
location of lumbo- sacral plexus and its branches in interior of the pelvic cavity.
Pramana
Half Anguli Pramana on both sides of the interior of the pelvic cavity. It is
approximately one cm diameter circular area of the pelvic cavity.
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Flow Chart No.7
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Viddha lakshana
1. Samanya lakshana
a. After injury, Sthanika dhatu kshaya; due to dhatu kshaya, Vata prakopa, it may leads to
sarva Shareera dhatu kshaya or specific rakta dhatu kshaya.
b. Vividha vedana – due to involvement of sensory nerves.
2. Vishesha lakshana54
a. Adhah kaaya shosha – Adhah kaya shosha means loss of sensory and motor activity or
atrophy of lower limb.
b. Daurbalya - General debility or lower limb debility. Due to rakta dhatu kshaya and
Vata prakopa, general debility may occur otherwise involvement of the motor and
sensory nerve leads to debility in lower limb only.
c. Marana – involvement of the major blood vessels severe bleeding may occur that leads
to hypovalemia, it may be end up with Marana.
3. Antah (peripheral region) and Madhya Viddha lakhana
a. Madhya viddh lakshana – cardinal signs and symptoms (Adhah kaya shosha,
Daurbalya and Marana).
b. Antah (peripheral region) Viddha lakshana – it is converted in to Vaikalyakara Marma,
it means if the Marana not occur, it may end up with deformity of the lower limbs.
Daurbalya due to general Dhatu kshaya or Rakta dhatu kshaya. After injury the
person may die after a month. This depends on the nature of the patho-physiology.
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Within this period if Chikitsa Chatushpada’s are available, the person may survive or end
up with sensory and motor loss of lower limb as a deformity.
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Flow Chart No.8
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4. PARSWA SANDHI MARMA:
Location:55
It is situated inferior to and in the middle of the lateral flanks being attached to it.
They are obliquely placed of conjoined together in order and attached to the lateral sides
of bony part hidden by it.
Pramana:56
Half anguli Pramana on both sides of the Poster-interior part of the Abdomino-
pelvic cavity. It is approximately one cm diameter circular area of the Abdomino-pelvic
cavity. Injury at this site fills up koshta with blood leading to death.57 It is kalantara
pranahara, sira marma structurally.
Dr.sharma has considered iliac artery and its branches regarding this marma. He
has reached this idea by considering filling of koshta (pelvic cavity) with hemorrhage.
Dr. Pathak has given his own comments, The structures responsible for this marma are
renal arteries and veins. Dr patil has located the site of marma between the highest point
of kati and the subcostal region. The possibility of probable structures involved in the
injury could be the lower part of liver on right side or spleen on the left side inferior
venacava and descending aorta, it is ardhangula in pramana measured by all classical
books. Dr.pathak has measured half an inch. This marma is situated in pelvic
region(shroni guha).
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Flow Chart No.9
.
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Regarding its surface anatomy, it is situated in between the jaghana parswa
obliquely and superiorly,It is sira marma and injury to this causes delayed death(kalantara
pranahara). Due to bleeding filling up the pelvis with blood. Sharma and Ghanekar have
suggested common iliac arteries responsible for this marma. It is to be recalled here that
Vagbhata has confirmed about the marma lying inside the pelvis placed obliquely from
below upwards at the joint where the five pieces of parshuka conjoined together in an
order and attached to the lateral side where the bony part is situated .This vascular marma
lying in the iliac fossa near the sacroiliac joint in the pelvis. The iliac vessels rarely
present isolated uncomplicated wounds. Such wounds are usually complicated by
fracture of the pelvis or by a perforating wound of the abdominopelvic cavity. In other
words they are observed only in connection with extensive traumatic lesions such as
usually in death on the battle field. The immediate and formidable hemorrhage followed
by death.
The external iliac and its companion vein have been injured by bullet traversing the iliac
fossa either obliquely or front to back or by spent shell fragments arrested by contact
with the vessels. Tuffier has reported a case of this description to the “The societe De
chirurgic” which was observed by Letoux. A fragment of a bomb extend at the level of
anterior superior iliac spine, the opening wound did not reveal the vascular injury which
was manifested 15 days later by the appearance of the secondary diffuse hematoma .The
external iliac artery was ligated ,death followed ,however as the result of secondary
hemorrhage. Soubbotitch has reported two cases of hematoma resulted from a wound of
external iliac, one recovered and other died after double ligature of the vessels.
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Wounds of the gluteal region leading to injury of gluteal vessels and nerves are
more frequently observed at field ambulences then wounds of external iliac .They usually
result from shell wounds, rarely bullet wounds of the buttock. On one occasion it was
seen that shell fish traversed the buttock and penetrated the iliac fossa into the pelvis.
These extensive injuries are extremely serious and their gravity is enhanced by the
presence of co-existing vascular lesions.
Wounds of the gluteal and pudendal arteries rarely give rise to serious external
hemorrhage therefore they are more attractive to trauma surgeons. The external iliac
artery and vein may together be severed in gunshot wound or may be intermittently or
accidentally divided during pelvic operation. A challenging problem facing the trauma is
the gunshot wound to the pelvis which may generate secondary missiles of bomb and
cause multiple injuries to branches of the venous plexus; The mortality of 50% has been
reported. Attempts at suture, ligation, cautery and clipping are all made difficult by the
rapidity with which the relatively small pelvic cavity of male fills with blood, despite the
employment of multiple suction units. Ligation of major vessels rarely helps.
The discussion suggests that there are two regions, which seems to be responsible
for this marma they are pelvic cavity and gluteal region. The vessels of extremities are
iliac vessels and their external branches.The bleeding from gluteal region also not
apparent but manegable.However ligation or control of bleeding of pelvic vessels are
very difficult rather unmanegable.Therefore these vessels are suggestive for
parswasandhi marma.
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The common iliac artery bifurcates into external and internal iliac artery at the
point superior 1/3rd (2 inch) of the imaging line drawn on the surface of the abdomen
joining the point of aortic bifurcation (3/4th inch below the umbilicus ) and mid inguinal
point.the diameter of the aorta and inferior venacava are approximately 1 inch each.The
course of these vessels are also comparable with the description of sushruta’s
parswasandhi marma. The gunshot wound to the pelvis involving the pelvic vessels by
missiles of bone or pallets is a challenging problem for the trauma surgeon even though
the fatality is quite high.
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Flow Chart No.10
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5.BRAHATI MARMA:
Location:58
Just opposite the stanamula bilaterally on the back are brahati marmas. The injuries of the
region has high tendency of severe bleeding resulting to complications and terminates
into death.It is kalantara pranahara, sira marma structurally.
This word derived from the Sanskrit root Brahat means huge. The region of this
marma is back of the thorax. Its surface anatomy is the area on the surface of the back
corresponding to nipples. The anatomical structure responsible for the traumatic result is
sira (vessels)and the delayed death (kalantara pranahara).
Pramana:59
Half Anguli Pramana on both sides of the Poster-interior part of the Thoraco-
abdominal cavity. It is approximately 1cm diameter circular area of the Thoraco-
abdominal cavity.
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Flow Chart No.11
Dr. H.P Sharma has translated this marma into anastomoses around the scapula. Dr.R.R
pathak has discussed for the vessels at the hilum of the liver at right side and vessels at
the hilum of spleen at left side.
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Etymologically the word brahati denotes symbolic number 36, or part of the body
between the breast and back. Hence the base of the lungs, diaphragm and the bare area at
the inferior angle of scapula with sub scapular artery or intercostals vessels behind the
pleura in the intercostals space may be included in this marma. An injury to this marma
may produce the excessive bleeding leading to serious complications. It has been
measured ardhangula in pramana by all classical books. Dr Pathak has mentioned it is
half an inch.
Dr Sharma and Ghanekar opines that anastomosis around the scapula. May
correlated to this marma. Dr. V.S Patil has included base of the lungs, bare area at the
inferior angle of the scapula, diaphragm or intercostals muscles behind the scapula are
responsible for this marma.
The triangle of auscultation lies behind the scapula bounded above by trapezius,
below by latissimus dorsi and laterally by the vertebral border of scapula and the exposed
part of the rhomboideus muscle, However the triangle of auscultation is the area of
choice where sixth inter costal artery lies in the sixth intercostal space within the triangle
of auscultation in its approach from below upwards oblique to run in the sixth costal
groove at the angle of the rib. If this artery ruptures leads to intrathoracic hemorrhage
complications leading to death. The penetrating injury on the back of the chest usually
complicates due to uncontrollable bleeding. The fracture of the lower part of the scapula,
bullet or fractured rib usually produces complications.
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Flow Chart No.12
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6.AMSA PHALAKA MARMA:
On the dorsal aspect of the body the marma is associated with trika.60It is asthi
marma . Injury to this leads to muscular atrophy and loss of sensation or numbness to
related area.
Location:61
It is located in prushtha ( posterior aspect of thorax) on both sides of the prushtha
vamsha(vertebral column) related to the “Trik”.
Pramana 62
Half Anguli Pramana near to the superior angle of the scapula, a circular area is
made with 1cm diameter. Below this cervical enlargement of spinal cord is situated.
According to Prof. J.N Mishra this marma considered,The amsaphalaka marma is
somewhere in the superior part of the back, It lies in both lateral sides of the vertebral
column, This marma is in the close relationship with scapula.
The nerve supplying the upper extremity is an essential part of the marma,
because any injury to this marma may cause atrophy of muscles those are attached to the
amsaphalaka and numbness of the upper extremity. Therefore this can be taken as the
site of the suprascapular notch is the anatomical site where all the above said conditions
can be found with this fact.
According to sushruta the marma is an asthi marma. This statement is doubtful
because traumatological effect of this marma cannot be correlate with this. The wasting
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and numbness is possible only after the involvement of nerve supplying to the upper
extremity. Probably the above said version of sushruta was based on the presence of the
scapula in the close relationship with this marma. Sushruta has said that any injury to this
marma causes numbness (swapa) and wasting (shosha ) of the upper extremity.63This is
reliable because an injury to this marma may damage to the branches of the brachial
plexus along with the damage of supraclavicular nerve and artery the damage may
follow-
If foreign body penetrates the deeper parts severe damage of the brachial plexus is
possible this will lead to paralysis of the upper extremity.
If foreign body penetrates the deeper parts leaving light impact, moderate damage
of brachial plexus is possible.
If foreign body penetrates to the superficial part damage to the suprascapular
nerve and artery will be resulted. This will cause paralysis of abductor muscles of the
shoulder joint along with wasting of the same.
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Flow Chart No.13
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Viddha lakshana
1. Samanya lakshana64
a. Patient will not die after injury to the Amsaphalaka Marma, but leads to vikalata.
b. Pain due to increased Vata.
2. Vishesha lakshana65
a. Bahu shosha – Bahu means arm region, but Dalhana commentary gives the idea as
upper limb. This is because depend on the involvement of Brachial plexus branches.
b. Bahu shopha – As arm atrophy. This is due to involvement of all the upper limb motor
nerves ( Radial, Ulnar, Median, Musculo cutanious nerves).
3. Antah (peripheral region) and Madhya Viddha lakshana.
a. Madhya Viddha lakshana – cardinal symptoms, means bahu shosha as a deformity.
b. Anth Viddha lakshana- converted in to Rujakara Marma, the person feels pain for
long duration. This will cause numbness and wasting due to partial loss of functions.
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Flow Chart No.14
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7. AMSA MARMA:-
It is situated between the root of the arm on one side and the neck on the other.
This ties shoulder and amsapeetha together. Here there are ligaments binding the scapula
with the clavicle. Injury to this marma, results in stiffness of the limb with loss of
function66. It includes all the soft tissues like muscles, tendons,ligaments etc, which take
part in the formation of shoulder joint with scapula. An injury to these structures may
cause rupture of the muscles, ligaments resulting in dislocation of joint,that leads to loss
of function of the shoulder joint.
According to vagbhata the injury to Amsa marma leads to bahukriyahara i.e loss
of function of upper limb.67 Amsa marma includes the structures related to shoulder
region are the most exposed area to common injuries. The activities like weight lifting,
swimming, cricket, fall on the outstretched arm causes the rupture of ligaments and
muscles of the shoulder joint, leads to the disability of the amsa sandhi and
bahustabdhata.
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Flow Chart No.15
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Definition of Stabdhabahuta:
This term is mentioned in Su.Sa. Sha.6/35, while explaining about the
Amsamarmabhighata, he says injury to the Amsa marma leads to the Stabdhabahuta,Here
the broad meaning of stabdhabahuta is “Bahukriyanasha”according to Ayurveda
Shabdakosha,that means loss of functions of the upper limb.Accoding to A.Hru. Sha
traumatological effect of Amsa marma is ‘Bahukriyahara’ means same as that of the
meaning of stabdhabahuta. Lastly we can consider the Stabdhabahuta is the impairment
of the upper limb.
Causes for the stabdhabahuta:
Mainly due to the abhighata to the Amsa pradesha, in modern era the injuries
like,
1. Sports injuries
2. Heavy weight lifting
3. RTA (Road traffic accidents)
4. Fall on the outsretched arm
5. Over exertion
Samprapti of Stabdhabahuta:
Here the Stabdhabahuta is not a disease, it is a symptom where the
Amsamarmabhighata takes place.According to Gayadas in Nyayachandrika of Su.sa Ni
1/82 The major structural impairment in the conjoined structure of shoulder or Amsa is
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due to Amsastha shleshma or shleshaka kapha. Vitiation of the shleshma leads to the
dryness of the Amsabandhana and lastly emaciation of Amsa pradesha takes place-
ultimately it leads to deformity of the shoulder, However the samprapti of stabdhabahuta
is shown in the flow chart 16.
Clinical features of Stabdhabahuta:
Samanya marmabhighata laxana are:67(1)
1. Vicheshtana
2. Urdhvavata
3. Vayukruta tivra ruja
4. Stabdhata
5. Kriyanasha
Amsa marma is a snayu marma structurally, it measures about half anguli, if injury to the
Snayu marma leads to the following laxanas-67(2)
1. Koubjyam (Shortening)
2. Shareeravayavasaada (svakarmanyaasamrthyam)-loss of functions
3. Kriyasvashaktiriti (Loss of movements like Abduction, Adduction, Flexion
extension etc,)
4. Ruja (Pain)
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Flow Chart No.16
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AMSA PRADESHA:-
Before dealing with the Amsa marma let us know the shoulder & scapular region
according to Ayurvedic scholors.
In amsa pradesha includes nine structural complexes are present. Those are as
followes–Amsa,amsakuta,
amsadesha,amsapinda,amsapeetha,amsaphalaka,amsabandhana,Amsamul & amsasandhi.
These are described according to different Ayurvedic scholors. These terms has been
explained in the sushruta samhita-sutra, shareera, nidana,chikitsasthana, charaka vimana
sthana,vagbhata shareera & nidana sthana.
The dictionary meaning of amsa term is Bhuja,shira,and skandha, “Asyate
samahanyate bharadina”functionally this region is responsible for the weight bearing
part.
This site consists of certain important structures-bones, ligaments, vessels and
nerves.
Bones: Parts of the scapula,clavicle,and upper part of the humerus.
Joints: Shoulder joint
Acromioclavicular joint
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Ligaments & muscles:
(1) Coracoacromial ligament
(2) Capsular ligament
(3) Glenoid labrum
(4) Transverse humeral ligament
(5) Bursae-8
(6) Rotator cuff muscles & associated muscles
By observing these structures we can consider that this site is vital one, because injury to
this leads to loss or deformity of the upper limb i.e nothing but the stabdhabahuta or
Bahukriyahara. Based on their references we will come to know that Amsa marma is the
complex structure.
Let us discuss one by one, among the nine terms as according to ayurvedic
scholors.
1. Amsa
Amsa is included under the prushtha marma 68
Among them amsaphalaka is an Asthimarma, but the amsa marma is snayu marma. 69
Amsa marma is a snayu marma structurally, If we discuss about snayu based on
many references (shastracharchaparishad) we can call it as ligament, somewhere it is
considered as nerve or tendon. But depending upon the situations we can name it to
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different structures as above said, traumatic effect on amsa marma (snayu) leads to the
functional deformity so, it is known as VAIKALYAKARA MARMA.
Vaikalyakaramarma kalantaram kleshayati rujaam cha karoti.70
All the vaikalyakara marma are later converted into rujakara one. By this reason
this marma can neigther be considered as nerve or tendon,but this may be considered as
complex structures like ligaments, muscles, tendons, bursae & nerves, Hence amsa
marma is the CORACOACROMIAL ARCH or ACROMIOCLAVICULAR JOINT or
SUBACROMIAL BURSA. Based on these observations without any disputs, we can
confine it to SHOULDER REGION, ACROMIAL REGION & SCAPULAR
REGION(PRATYKSHA SHARIR).
According to Kashyapa samhita sutrasthana laxanadhyaya, The amsa term is
mentioned, as -“shushkamsah daridra….. snigdhamsah krushaka,peenamsa adhya,
kathinamsah shura, shithilamsoashakta, unnatamsah puman prashasyate, brashtamsa
kanya.”71
Based on this explaination of Kashyapa we can consider it as shoulder and
acromial region.
According to Charaka vimana sthana while explaining the pramana sharira he
mentioned “ ashthangulou skandhou shadangulou amsou.”72
8 Angula-skandha
6 Angula-amsa
Based on this anthropometry
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Skandha kshetra is scapular region
Amsa kshetra is Acromial region.
2. Amsakuta
This term can be seen in the sushruta shareera 6 chapter
In A. Hru.sha-4/16
Apalapa is one of the sira marma, traumatic effect of this marma fills the blood in
the thoracic cavity later is converted into pus formation lastly leads to death. Here,
Anatomically the Apalapa is the beginning part of lungs or pleural sac, Exactly above the
apalapa is the AMSA KUTA or ACROMION REGION73,74.
The kuta is considered as Acromion process of the scapula which is very
prominent structure in the shoulder region.
3. Amsadesha
Here Desha means place or region.“Amsa desha” is that area where the amsa has
spreaded its vicinity.This term has been mentioned in the sushruta Nidanasthana 1st
chapter.Here in Amsa desha – emaciation of structure which bind the amsa i.e
AMSABANDHANA takes place.and constriction of the siras related to Amsa takes
place.This clinical feature is known as Avabahuka.75According to Dalhana the definition
of amsadesa is
“Amsasameepopalakshito deshoamsadesha”76
The area which is superior to Amsa is Amsadesha. Due to the effect of aggravated
vata over conjoined structures of Amsa and related vessels and nerves has been said to be
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the cause for the manifestation of Avabahuka. We can compare to the brachial plexus
palsy to the Avabahuka. Where the compression of brachial plexus and related blood
vessels takes place.
Here the amsabandhana is the conjoined structures of shoulder joint (Amsasandhi)
related ligaments and muscles of the shoulder region i.e Rotator cuff.
Hence area occupied by the Rotator cuff muscles, axillary vessels and ligaments
related to the shoulder joint and injury to this leads to loss of functions of Bahu is known
as Avabahuka or were the amsa marma is also present. Overall that area is Amsa desha or
shoulder region.
4. Amsapinda
In Sushruta shareera 5th chapter,whIle explaining “SHODASHA KANDARA” he
described the praroha and he named Amsapinda as Agrapraroha, and Dalhanacharya
clearly explained this term as77
“Hastagatanaam chatusrunamuparigatanamamsapindo bahushiro agrapraroha iti.”78 Here
Bahushira is the synonyme of amsa. No doubt here amsa panda is rounded structural
area and above that area kandaras or prarohas are converged,Bahushira (Part of Amsa) is
the spherical shaped structure containing muscles.
The area over the greater tuberosity of humerus which is attached with the deltoid
muscle is called deltoid prominency. So it bears spherical shape i.e Amsapindika.
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5. Amsapitha
According to Gananathsen saraswati,glenoid cavity is compared to the Amsapeetha.
Again this term has been explained in Sushruta sutrasthana and sharir sthana-
(1) While explaining the Anga-pratyanga measurement, Sushruta has quated.
(2) While explaining the types of sandhi-he quated “Amsapeethagudabhaganitambeshu
saamudgah.” 79
By observing these quotations the anthropometry inbetween Amsa peetha and
kurpara is 16 angula,and here we can consider amsapeetha as a exterior border of the
scapular and shoulder region.80 We can give another openion; Inbetween Amsapeetha
sandhi and kurpara sandhi 16 angula length. But Dalhanacharya commentated Amsa
peetha as Bahushira i.e
“Amsapeetho Baahushirah;” and amsapeetha sandhi as one of the type of ‘Saamudga
sandhi’ But the dictionary meaning of peetha is Aasanam & Saamudga is Samputaka, 81
However the area of amsapeetha is accomodates in the area of Amsa.
Hence, By observing above said explaination we can consider Amsapeetha as
scapula and Amsapeetha sandhi as Acromioclavicular joint, because it is one of the
Saamudga sandhi and it is situated just above the shoulder joint.
By discussing all these points based on the quotation of AMSA MARMA in Su.Sa. sha-
6th chapter and A.Hru.Sha 4th chapter we will come to know that all above said structures
like Amsa peetha,bahushira etc…are included under the Amsa marma.
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6. Amsaphalaka
In Kashyapa Samhita sharira sthana while explaining the Asthi sankhya,he
mentioned Amsaphalakas are Asthi they are two in number.
“Dwaamsavamsaphalakaavapi dwaveva chakshakou.”82
According to him amsa-2
Amsaphalaka-2
Akshakasthi-2
Here,we should think about the Amsa because he considered these are also asthi and 2 in
number. But these structures or parts we can include under the spines of scapula,
according to sushruta a mass are included under the kapalasthi.
Finally we can consider Amsa as acromion process and Amsaphalaka as scapula.
7. Amsabandhana
This term already we discussed in the Amsadesha topic.
Sushruta nidana vatavyadhi chapter while explaining the Avabahuka vatavyadhi,he
mentioned the term Amsabandhana-
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In the area of the Amsa-underground structures impaired by the aggravation of
vata and rakta due to injury to the amsabandhana that leads to the compression of siras
lastly the disease Avabahuka.83
Here the structures which bind the BAHUSHIRA,AMSAPEETHA, GREEVA
inbetween these the amsa marma is present.the amsa which is bounded by the SNAYU &
PESHI i.e the ligaments of the shoulder joint & Rotator cuff muscles, if injury to these
structures that leads to ‘BAHUKRIYAHARA’ 84or STABDHABAHUTA and lastly
vitiation of the vata and rakta takes place that leads to AVABAHUKA.
According to Gayadas-in Nyayachandrika,
By this quotation we will come to know that the major structural impairment in the
conjoined structure of shoulder or Amsa is due to Amsastha shleshma or shleshaka
kapha. Vitiation of the shleshma leads to the dryness of the Amsabandhana and lastly
emaciation of Amsa pradesha takes place-ultimately it leads to deformity of the
shoulder.85 But according to modern science wasting of muscles are due to the injury of
motor nerve paralysis.
By this explaination we can consider that structures underlying the shoulder and
scapular region are effected, mainly due to the trauma, like Rotator cuff injuries, frozen
shoulder,tearing of ligaments etc….these are resulted into the dislocation of shoulder
joint, ultimately that leads to Bahukriyahara or STABDHABAHUTA.
8. Amsamula
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According to Shastracharcha parishad, the amsa mula is correlated into apex of
the axilla.where the brachial vessels and brachial plexus are situated. If injury to this
leads to the paralysis of the upper limb takes place i.e STABDHABAHUTA.
By observing this discussion we can approach that apex of the axilla is included in
the area of the AMSA MARMA
9. Amsasandhi
Amsa sandhi rachana shareera vivechana:
This is a major joint of the upper limb. This is one type of chala and ulookhala
sandhi. This joint is formed by the articulation of Pragandasthi, Akshakasthi and
Amsaphalakasthi.
Pratanavati type of Snayu covers this Sandhi. Acharya Sushruta states that
Snayu is binding material of Mamsa, Asthi and Medha. Like a boat made up of planks
and timber, tightened together by means of large number of bindings is enabled to float
on the water and to carry cargo. Similarly in the body all the Sandhis are tightened up by
large number of Snayus, which enables the body to bear the weight.
Sheshmadhara Kala is present in this joint and seceretes shleshaka kapha. this
act as a lubricant for the joint and helps in protection and movements of the Sandhi.
Acharaya Sushruta has described that the rachana of Sandhi as like a wheel having an
axis. When the axis is lubricated by putting oil on it, the wheel can move freely and
friction does not occur. In the same way the bones or joints can move freely in the
presence of Shleshma.
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The word Amsa denotes the shoulder; the Amsa Marma is situated within the
line of the area joining head (murdha). Neck (Greeva) and the arm (bahu). This is a
Snayu Marma to a length of half fingers width (1 cm).
The physical matrixes that are present in amsa marma are Mamsa, Sira, Snayu,
Sandhi and Asthi. It is one of Vaikalyakara marma, and trauma to this will produce
disability of the shoulder joint.
Location & Pramana of Amsa marma87
To make the limitations of Amsa marma, we should know about the classical
definition of amsa marma which correlates with the modern science.
• Bahumurdha (Amsapindika)- Deltoid prominency-1st point
• Amsapitha- Upper 1/4th of .Exterior border of the scapular and shoulder
region-2nd point
• Skandha-shoulder joint-3rd point
• Greeva -Root of the Neck-4th point
• Amsabandhana-Soft tissues of shoulder & scapular region which hold the
above said points.
Joining of all these points one by one and make the half angula point at the
centre of all above said structure,that forms the Amsa marma.
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Figure No: 1 Limitations of Amsa marma
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MODERN REVIEW
Modern review of katikataruna, kukundara and Nitamba marma:
ANATOMICAL REVIEW OF GLUTEAL REGION:
The Gluteal region forms the prominence at the upper posterior parts of lower
limb.Gluteal maximus is the largest muscle of the region which indirectly extends till the
tibia bone, so that it can act simultaneously on both the hip and knee joints.
The ischial tuberosity on which one sits underlies this muscle. The gateway to the
gluteal region, the greater sciatic notch; the thickest nerve of the body, the sciatic nerve,
also lie beneath this huge antigravity postural muscle. One neurovascular bundle formed
by pudendal nerve and vessels just appear into the gluteal region from the sciatic notch to
disappear fast through the lesser sciatic notch to supply anything and everything in the
region of the perineum.
INTRODUCTION:
The gluteal region overlies the side and back of the pelvis,extending from the iliac
crest above to the gluteal fold below. The lower part of the gluteal region which presents
a rounded bulge due to the excessive amount of subcutaneous fat is known as buttock or
natis. The anterosuperior part of the region seen in a side view is called the hip. The
muscles, nerves and vessels emerging from pelvis are covered by gluteus maximus and
buttock.
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SUPERFICIAL FASCIA:
It is heavily laden with fat, more so in females, and is tough and stringy over the
ischial tuberosity where it forms an efficient cushion for supporting the body weight in
the sitting posture, It contains cutaneous nerves, vessels and lymphatics.
DEEP FASCIA:
The deep fascia above, and in front of the gluteus maximus i.e over the gluteus
medius, is thick, dense, opaque and pearly white over the gluteus maximus, however, it is
thin and transparent, the deep fascia splits and encloses the gluteus maximus muscle.
MUSCLES OF THE GLUTEAL REGION (Figure no-4)
These muscles are the gluteus maximus, the gluteus minimus, the gluteus
medius,the piriformis, the superior and inferior gemilli, the obturator internus and
externus and the quadrates femoris, the tensor fasciae latae which lies on the lateral side
of the thigh.
ACTIONS OF THE GLUTEAL REGION:
The muscles of the gluteal region form only three functional groups
The gluteus maximus is the chief extensor of the thigh at the hip joint.
The gluteus medius and the gluteus minimus are powerful abductors of the thigh.
Remaining are the lateral rotators of the thigh.
The tensor fasciae latae is an abductor and medial rotator of the thigh and extensor of
knee.
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STRUCTURES DEEP TO THE GUTEUS MAXIMUS:-
Muscles:-
(1) Remaining all gluteal muscles.
(2) Origin of the four hamstring muscles from the ischial tuberosity.
(3) Insertion of the pubic fibres of the adductor magnus.
(B) VESSELS (Figure no-6)
(1)Superior gluteal vessels
(2)Inferior gluteal vessels
(3)internel pudendal vessels
(4)Ascending branch of the medial circumflex femoral artery.
(5)Trochenteric anastomoses,formed by the descending branches of the superior
gluteal artery
The ascending branches of the medial and lateral circumflex femoral artery.
(C)NERVES:-(Figure no-5)
Superior gluteal(L4,5, S1)
Inferior gluteal (L5, S1, S2)
Sciatic (L4,5,Si,2,3)
Posterior cutaneus nerve of the thigh(S1,2,3 )
Nerve to the quadrates femoris (L4,5,S1)
Pudendal nerve (S2,3,4)
Nerve to the obturator internus(L5,S1,S2)
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(D)BONES & JOINTS (Figure no-2,3)
(1)Ilium (2)Ischium with ischial tuberosity;
(2) Upper end of femur with the greater trochanter;
(3) Sacrum and coccyx
(4) Hip joint and sacroiliac joint
(E)LIGAMENTS:- (Figure no-7)
(1) Sacrotuberous
(2)Sacrospinous and
(3)Ischiofemoral
CLINICAL APPLICATION OF THE GLUTEAL MUSCLES:-
Intermuscular injections are given in the anterosuperior quadrant of the gluteal
region,i.e in the glutei medius and minimus, to avoid injury to large blood vessels and
nerves which pass through the lower part of this region.
When gluteus maximus is paralysed as in muscular atrophy, the patient cannot
stand up from a sitting posture without support. Such patients, while trying to stand up,
rise gradually, supporting their hands first on the legs and then on the thighs; they climb
on themselves.
When the glutei medius and minimus are paralyzed, the patient cannot walk
normally, He sways or waddles on the paralysed side to clear the opposite foot off the
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ground, this is known as LURCHING GAIT; when bilateral it is called WADDLING
GAIT.
These all are we can apply to the traumatological effect of lower three paired
marmas of the back i.e kukundara, kateekataruna & nitamba marma
MODERN REVIEW OF PARSHWASANDHI MARMA
The parshwasandhi marma is the area lying inside the abdomino-pelvic cavity at
posterior wall. It is placed obliquely from below upwards at the joint where the five
lumbar vertebrae are arranged together in an order and further sacralized, attached to the
lateral side where the bony part is situated. This marma deeply reaches to the posterior
abdomino-pelvic cavity.
By observing this explanation, the parshwasandhi marma may be considered as
the vessels related to the posterior abdomino-pelvic cavity i.e major vessels are the
common iliac artery which bifurcates into external & internal iliac artery and inferior
vena cava.
The associated structures involved in this marma are:
MUSCLES:
(1) Psoas major
(2) Psoas minor
(3) Iliacus
(4) Quadratus lumborum
NERVES:
(l) Lumbo-sacral plexus
(2) Lumbar sympathetic chain
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VESSELS:
(1) Abdominal aorta & its branches
(2) Bifurcation of common iliac artery
(3) Inferior vena cava & its tributaries
Organs of urinary system (Ureter, urinary bladder, etc)
MODERN REVIEW OF BRAHATI MARMA
The brahati marma is the area lying in the triangle of auscultation which lies
behind the scapula, bounded above by trapezius, below by latissimus dorsi and laterally
by the vertebral border of scapula and the exposed part of rhomboideus muscle.
The vessels of this area may be directly correlates to the brahati marma i.e 6th
intercostal vessels,deeply related to the branches of celiac trunk i.e hepatic artery, splenic
artery and portal vein.
The associated structures involved in this marma are:
MUSCLES: (Figure-4)
1. Trapezius
2. Latissimus dorsi
3. Levator scapulae
4. Rhomboideus major
5. Rhomboideus minor
6. Erector spinae
NERVES:
1. Intercostal nerves (6 & 7th )
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2. Sympathetic chain
VESSELS ( Figure no-12)
1. Intercostal vessels(6 & 7th )
2. Anastomotic branches of scapula
3. Branches of coeliac trunk
VISCERA:
1. Base of the lungs
2. Liver at right side
3. Spleen at left side.
MODERN REVIEW OF AMSAPHALAKA MARMA
In the posterior part of the thoracic cavity on both sides of the vertebral column,
near to the shoulder joint, flat type of bone is present which is called by the name
“Scapula” and the region is called “Scapular region”.
In the scapular region, predominantly scapula along with the ribs and vertebral
bones forms one Asthi marma, which is by name “Amsaphalaka marma”(Figure no-9)
It extends from C6 vertebral body to T12 vertebral body. In this region- vertebrae,
ribs and angle of the scapula come together. So the location of Amsaphalaka on both
sides of vertebral column is related to the “Trika”.
Structures associated with the Amsaphalaka marma:
MUSCLES: (Figure no-10)
1. Rhomboideus major
2. Rhomboideus minor
3. Serratus anterior
4. Serratus posterior inferior
MODERN REVIEW
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5. Teres major
6. Teres minor
7. Trapezius
8. Infraspinatus
NERVES (Figure no-11)
Brachial plexus
ARTERIES (Figure no-12)
1. Axillary artery
2. Scapular, circumflex artery
3. Scapular, dorsal artery
MODERN REVIEW OF AMSA MARMA (SHOULDER REGION)
JOINTS OF THE SHOULDER GIRDLE:- (Figure no-13)
The shoulder or pectoral girdle connects the bones of the upper limb with axial
skeleton. The girdle consists of clavicle and scapula. The clavicle meets the sternum at
the sternoclavicular joint,and unites with the scapula at the acromioclavicular joint. The
scapula has no direct connection with axial skeleton, but is attached to the latter only by
the muscles. The glenoid cavity of the scapula articulates with the head of the head of the
humerous to form the shoulder joint.
The joints of the shoulder girdle, strenoclavicular and acromioclavicular, always
permit the movements of the clavicle and scapula. Moreover, they facilitate the
movements of the shoulder joint in raising the arm above the head.
STERNOCLAVICULAR JOINT:-
It is a saddle type of synovial joint.
Bones forming the joint:-
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1. Sternal end of the clavicle, which is covered by a fibrocartilagenous; the articular
surface is convex from above downwards and slightly concave from before
backwards.
2. Clavicular notch of manubrium sterni and upper surface of the first costal cartilage
from a continuous articutar surface covered by fibrocartilage.
LIGAMENTS:-
1. The capsular ligament:Envelops the joint and is attached to the peripheral margins of
the articulating bones.The capsule is thickened infront and behind by the anterior and
posterior sternoclavicular ligament;below it is composed of loose areolar membrane.
2. The fibres of anterior and posterior sternoclavicular ligaments slope downwards and
medially and resist medial displacement of clavicle.
3. The articular disc,made of fibrocartilage,intervenes between the clavicle and the
sterna notch. It is attached above to the posterosuperior part of the sterna and of the
clavicle below to the first costal cartilage, and at the periphery blends with the fibrous
capsule.
The disc divides the joint into a supero lateral or meniscoclavicular compartment,and
an infero medial or meniscosternal ciompartment,the around the lateral compartment is
more lax than that of medial compartment.The articular disc prevents medial
displacement of clavicle when a force is applied to the shoulder region.
1. Interclavicular ligament:-stretches across the suprasternal notch and connects the non-
articular upper part of sterna ends of both clavicles. Some fibres gain attachment to
the suprasternal notch of manubrium.
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2. Costo-clavicular ligament:- It is attached below to the first costal cartilage and its
rib,and above to a rough impression on the inferior surface close to the sternal end of
clavicle, the ligaments consists of anterior and posterior laminae which fuse laterally;
medially they are separated by a bursa and merge with the capsule.The fibres of the
anterior lamella are directed upwards and laterally,and those of the posterior lamella
upwards and medially. The costoclavicular ligament acts as a fulcrum for the
translator and rotator moements of the scapula.
ARTERIAL SUPPLY:-
From internal thoracic and suprascapular arteries;
NERVE SUPPLY:-
From medial supraclavicular nerve and nerve to the subclavius.
ACROMIOCLAVICULAR JOINT:-
It is a plane synovial joint. Bones forming the joint are the lateral end of the clavicle,and
clavicular facet on the medial margin of the acromial process of scapula.
Both bones possess small, oval articular surfaces which are covered with fibrocartilage.
The clavicular facet laterally and downward to meet the acromial facet which inclined in
opposite direction. Therefore in dislocation of the joint the acromial process is driven
below the lateral end of the clavicle. Sometimes the joint cavity is divided by an
incomplete articular disc(meniscus) which projects from the upper part of the fibrous
capsule.
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LIGAMENTS:-
The joint posseses fibrous capsule and coraco-clavicular ligament.
The fibrous capsule envelops the joint and is attached to the periphery of the articular
surfaces of both bones. The capsule is thickened above to form the acromio-clavicular
ligament.
Coraco clavicular ligament:-
The ligament consists of two parts-conoid and trapezoid,
The trapezoid part is attached, below to the upper surface of the coracoid process; and
above to the trapezoid line on the inferior surface of the lateral part of the clavicle.
The conoid part is inverted cone, Its apex is attached to the root of the coracoids process
above the supra-clavicular notch and its base is attached to the conoid tubercle of the
medial 2/3rd and lateral 1/3rd of the bone.
BLOOD SUPPLY:-Suprascapular & Thoraco-acromial arteries.
NERVE SUPPLY:- Lateral supraclavicular nerve.
MOVEMENTS OF THE SHOULDER GIRDLE:-
Movements at the two joints of the girdle are always associated with the movements of
the scapula.The movements of the scapula may or may not be associated with the
movements of the shoulder joint.
The various movements are
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(1) Elevation of the scapula
(2) Depression of the scapula(Drooping of the shoulder )
(3) Protraction of the shoulder(as in pushing and punching movements)
(4) Retraction of the shoulder(squaring the shoulders)
(5) Backward movement of the scapula.
Anatomy of the Shoulder Joint:
This is a synovial joint of ball and socket variety.
Articular Surface: The joint is formed by articulation of scapula and head of the
humerus. Therefore, it is also known as Gleno Humeral articulation.
Structurally it is a weak joint; because Glenoid cavity is too small and shallow to hold the
head of the humorous in the place (the head is four times larger than the size of the
glenoid cavity). However this arrangement permits great mobility, stability of the joint is
maintained by the following factors.
1. The coracoacromial arch or secondary socket for the head of the humorous.
2. The musculotendinous cuff of the shoulder
3. The Glenoid labrum helps in deepening the Glenoid fossa. Stability is also provided
by the muscle attaching the humorous to the pectoral Girdle, the long head of the
biceps, the long head of the triceps and atmospheric pressure.
Ligaments of the Joint: Fig No 15
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1. The capsular ligament: It is very loose and permits free movements. It is least
supported inferiorly where dislocation may damage the closely related axillary nerve.
2. The Glenoidal Labrum: It is a fibro cartilaginous rim, which covers the margins of
the glenoid cavity, thus increasing the depth of the cavity.
3. The Coracohurmeral Ligament: It extends from the root of the coracoid process to
the neck of the humerus opposite to the greater tubercle. It gives strength to the
capsule.
4. Transverse humeral ligament: It bridges the upper part of the bicipital groove of the
humerus (between the greater and lesser tubercle). The tendon of the long head of the
biceps brachi, passes deep to the ligament.
Bursae Related to the Shoulder Joint: (Figure no-14,16)
1) The sub acromial (sub deltoid) bursa.
2) The Sub Scapularis bursa, communicates with the joint cavity.
3) The infraspinatus bursa, may communicate with joint cavity.
4) Several other bursae related to the coroco brachialis, teres major, long head of the
triceps, latissimus dorsi, and the coracoid process are persent.
Relations:
Superiorly: Coracoarcomial arch, sub acromial bursa, supraspinatus and deltoid.
Inferiorly: Long head of the triceps.
Anteriorly: Sub Scapularis, corcao brachialis, short head of biceps and deltoid.
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Posteriorly: Infraspinatus, teres minor and deltoid within the joint tendon of the long
head of biceps brachii.
Blood Supply:
Anterior circumflex humeral artery
Posterior circumflex humeral artery
Subscapular artery
Suprascapular artery.
Nerve Supply:
Axillary Nerve
Musculocutaneous Nerve
Suprascapular Nerve
Movements at the Shoulder Joint (Figure no-17)
The shoulder joint enjoys great freedom of mobility at the cost of stability. There
is no other joint in the body which is more mobile than the shoulder. This wide range of
mobility is due to laxity of its fibrous capsule, and large size of the head of the humorous
as compared with the shallow glenoid cavity. The range of movements is further
increased by concurrent movements of the shoulder girdle.
Movements of shoulder joint are analyzed as follows.
1. Flexion and Extension: During flexion the arm moves forwards and medially and
during extension the arm moves backwards and laterally. The flexion and extension
take place in a plane parallel to the surface of the Glenoid cavity.
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2. Abduction and Adduction: This takes place at right angles to the plane of flexion
and extension (i.e.-approximately midway between the saggital and coronal plane).
In Abduction, the arm moves antero-laterally away from the trunk. This movement
is in the same plane as that of the body of scapula.
3. Medial and lateral Rotation are best demonstrated with mid-flexed elbow. In this
position the hand is moved laterally in lateral rotation of the shoulder joint. And
hand moved medially is medial rotation.
4. Circumduction is the combination of different movements as a result of which the
hand moves along the circle.
5. Elevation: Elevation is an upward movement of a part of the body. Here arm is
taken upwards.
The Range of any movement depends on the availability of an area of free articular
surface on the head of the humerous. It may be noted that the articular area on the head
of the humerous is four times larger than that of the Glenoid cavity.
Table No 7: Muscles acting on Shoulder Girdle. (Figure no-18)
Muscles Origin Insertion Action on Shoulder
Pectoralis major Clavicle medial 2/3, sternum and costal
cartilages 1-6.
Humorous, crest of greater tubercle
Flexion & medial rotation. Adduction & medial rotation.
Lattisimus dorsi Lower ribs, iliac crest.
Humorous inter tubercular groove.
Adduction, medial rotation, extension
if flexed.
Deltoid Clavicle lat.1/3,
acromion spine of scapula.
Deltoid tuberosity of humerous.
Abduction, extension, & lat.
Rotation. Biceps brachii
Short head Long head
Coracoid process Supraglenoid
tubercle
Radius Radius
Flexion Stabilization
Coracobrachialis Coracoid process Humerous middle body Flexion
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Teres major Inf. 1/3 margin of scapula
Crest of lesser tubercle humerous
Adduction, medial rotation.
Teres minor
Scapula, superior 2/3 lat. margin
Humerous greater tubercle post. surf.
Lateral rotation, stabilization
Supraspinatus
Scapula, supra spinous fossa
Humerous greater tubercle sup.
Surface
Abduction, stabilization
Infraspinatus
Scapula, infra spinous fossa
Humerous greater tubercle
post.surface
Lat.rotation, stabilization
Subscapularis Scapula, subscapularis fossa
Humerous lesser tubercle.
Med.rotation, stabilization
Analysis of abduction at the shoulder occurs through 90 degrees. The movement
takes place partly at the shoulder joint and partly at the shoulder girdle (forward rotation
of scapula round the chest wall). The humerous and scapula move in the ratio 2:1
throughout abduction, for every 15 degree of elevation, 10 degrees occur at the shoulder
joint and 5 degrees are due to movement of the scapula is facilitated by movements at the
sterno-clavicular and acromio-clavicular joint.
The articular surface of the head of the humerous permits abduction of the arm only
up to 90 degrees. At the limit of this movement there is lateral rotation of the humerous
and the head of the bone comes to lie deep to the coraco-acromial arch. Abduction is
initiated by the supraspinatus, but the deltoid is the main abductor. The scapula is rotated
by combined action of the trapezium and serratus anterior.
MODERN REVIEW OF AMSA MARMABHIGHATA:- (injuries around the
shoulder)
(1) Fracture of the clavicle
(2) Injury to the Acromioclavicular joint
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(3) Injury to the Sternoclavicular joint
(4) Proximal humerus fractures
(5) Dislocation of shoulder
(6) Fracture of the scapula
(7) Rotator cuff tear
(8) Frozen shoulder
Here we are not including the Fracture and dislocation as the
Amsamarmabhighata, because the predominant structure of Amsa marma is Snayu
marma,but we can consider these are the complications of Amsamarmabhighata,
remaining are the traumatological effect of amsa marmabhighata as above mentioned.
Soft Tissue injuries Around the shoulder joint:-
The painful shoulder:
Shoulder pain is the second most common musculoskeletal problem (Back pain is
the most common) seen by primary care physicians the most common causes of painful
shoulder in adults are disorders of the rotator cuff, particularly the supraspinatus tendon.
Although conditions such as painful arch syndrome, impingement, rotator cuff tears and
cuff tear arithritis are often considered as separate conditions, in reality they are part of a
spectrum of disorders of the supraspinatus tendon. Other causes of shoulder pain include
calcified tendinitis, frozen shoulder and degenerative disease.
SUPRASPINATUS SYNDROME (Figure no-19)
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CAUSES:-
(1) Minor tear of supraspinatus tendon
Trauma due to fall
Small strain where a predisposed degenerative tendon.
(2) Supraspinatus tendinitis
Inflammatory reaction due to a trauma with a history of degeneration or not.
(3) Calcified deposite in supraspinatus tendon.
(4) Subacromial Bursitis
Due to mechanical irritation, but bursal wall inflamed and thickened.
(5) Injury of greater tuberosity
Undisplaced fracture of greater tuberosity.
CLINICAL FEATURES:-
Usually young adults between the ages of 25 to45 years are affected.Occasionally older
individuals may be affected.
Symptoms:-
Pain is most important symptom of this condition. Pain is sever in young adults, whereas
pain is dull aching character in old people.
Physical signs:-
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The patient holds the arm by the side of the chest in almost immobile position,as
slight movement is painful. Movement of the shoulder joint is very much restricted and is
almost impossible due to pain. Particularly active abduction is very painful.
X-ray shows calcification within the supraspinatus tendon.
The chronicity of the supraspinatus tendinitis, the typical symptom is that patients
get pain in the middle range of abduction, that means in the beginning of abduction there
is no pain,similarly extreme abduction is also painless but the middle of the arc(70 to 120
degree) of abduction is painful and that is why this condition is also called ‘painful
arc’syndrome. (Figure no-20).
SUPRASPINATUS TEAR:-
Supraspinatus tendon may rupture spontaneously or following trivial injury when
this is degenerated with interruption of its blood supply.This usually occurs in the middle
aged or elderly individuals. In case of complete tear, no repair occurs.In case of partial
tear,fibrous repair is possible.Partial tear may ultimately (a) either recover fully or (b)
partly recover with a persistent painful arc of abduction or (c) gradually develop a frozen
shoulder.
Clinical Features: The patients are usually above 45 years of age.
Symptoms:- Following insignificant violence like lifting a weight or even as part of
normal daily activities, such rupture may occur. The patient first complains of sudden
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pain in the shoulder, the severity of which varies. After a while pain is relieved
automatically and later on the patient realizes his inability to start abduction of the
shoulder.
Physical signs:-The shoulder looks normal with slight or no tenderness below the tip of
the acromion process.
In case of movement, after some weeks of disappearance of pain, disability varies
according to type of the tear-either complete or partial. With a complete tear the patient is
unable to start active abduction. To rectify this defect the often shrugs his shoulder and
then abducts it. By shrugging the shoulder he creats an angle of 20 degree at the shoulder
joint, after which the deltoid muscle abducts shoulder to its full range. Supraspinatus
muscle is concerned with first 15 degree to 20 degree abduction and the patient is unable
to abduct the shoulder for these initial degrees. Passive abduction of the shoulder, so no
problem and the range is also full and painless. When he lowers the arm, it suddenly
drops-the ‘drop sign’ of complete tear of supraspinatus tendon.
FROZEN SHOULDER:-
This is also known as ‘peri-arthritis’or adhesive capsulitis.
Frozen shoulder is the degenerative process of the supraspinatus tendon following
injury or overuse. The vascular response if this degenerative process gradually involves
the entire tendinous rotator cuff. The cuff becomes thick, vascular and infiltrated with
lymphocytes and plasma cells. Gradually the infra-articular gusset of the capsule
becomes obliterated by adhesion leading to frozen shoulder.
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Clinical features:-
This condition affects slightly older individuals than the supraspinatus
tendinitis.Males are more often affected than the females.
Symptoms:-
The patients usually give history of trauma which is often trivial. This is followed
by pain around the shoulder joint.The pain is felt just above the greater tuberosity and
gradually radiates along the outer side of the arm to the back of the forearm and hand.
Gradually the pain increases in severity. Night pain is considerable and often awakes the
patients from fast sleep. Patient also realises stiffness of the shoulder along with the
pain.As the pain gradually subsides after a few months, stiffness increases in severity.
This stiffness continues for a few months and then the movements gradually return
almost to normal. So three phases can be distinguished in the clinical feature-(1)
Increasing pain with slight stiffness;(2) Decreasing pain with increasing stiffness; (3)
Gradual reduction of stiffness to almost normal movement of the joint. Each phase lasts
for about 6 months.
ROTATOR CUFF INJURIES :-
Rotator cuff muscles:- (Figure no-21)
The capsule of the shoulder joint is reinforced by the 4 tendons which form
expansions and blend with the capsule of the shoulder joint.This is known as Rotator cuff
it is called ‘rotator’as these tendons are concerned with rotation of the shoulder joint and
it is called ‘cuff’ as it is like cuff of the shirt covering the capsule of the shoulder
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joint.The tendon of the supraspinatus superiorly,tendons of the infraspinatus and teres
minor posteriorly and tendon of the subscapularis anteriorly take part in the rotator cuff.
Cause:-
Sudden strain due to trauma
Even mild to moderate injury in an age degenerated tendon.
It is complete tear of tendinous cuff.
Clinical features
Passive movement possible
Men over 60 age
Rarely young patients when trauma is strong
Pain at the tip of shoulder Upper arm
Unable to abduct
Tenderness below the lateral margin of acromion
No initial abduction with supraspinatus
Abduction about 45-60 degree
Able to sustain abduction beyond 90 degree by deltoid action
By all above these conditions we can consider, shoulder pain with immediate trauma or
with a history of trauma.
Many shoulder related post trauma problems are degenerative origin.
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Such problems are similar to that of post traumatic AMSA MARMA signs.
So This marma correlates to the Snayu marma viddha laxana as mentioned in the Su.Sa.su 25/38
by Dalhanacharya.
Ayama, akshepa, Sthambha, ativedana, bahukriyahara are the signs
NERVE INJURIES RELATED TO SHOULDER REGION:-
The nerves of the shoulder region are mainly the brachial plexus,the lesion of the
brachial plexus may be either complete or partial.
Complete lesion is rare and occurs only after severe injury. It damages all the roots of the
plexus and is often fatal. In this case, there will be anaesthesia of the whole upper limb
except the upper part of the arm which is supplied by C3,4 & 5 and by the
intercostobrachial nerve. There will be complete paralysis of the arm and scapular
muscles.
Incomplete lesion may be due to stabs or cuts and may affect any of the roots. But
the common injury is due to traction or pressure, which affect either the upper or lower
portion of the plexus.
ERB’S PARALYSIS:
Erb’s point is the segment where C5 and C6 roots join to form upper
trunk,suprascapular and nerve to subclaveus are given and ventral and dorsal divisions of
upper trunk start. In injury to this point the abductors and lateral rotators of
shoulder,flexors of elbow and supinators are paralysed.Arm hangs by the side.It is rotated
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medially extended at elbow joint, pronated at forearm, cutaneous loss on lateral side of
arm and forearm.
KLUMKE’S PARALYSIS:
Damage to C8 and T1 segments is called Klumpke’s paralysis. Small intrinsic
muscles of hand are affected. It leads to ‘complete claw hand’. i.e extension of
metacarpophalangeal joints and flexion of interphalangeal joints, loss of sensation on
medial side of forearm. If T1 is injured proximal to the white ramus communicans to
first thoracic sympathetic ganglion .
SPORTS MEDICINE & BIOMECHANICS:-
Definitions:-
Sports medicine focuses on the physical problems experienced by people whose
tissues are healthy but in whom the level of activity has exceeded the strength of those
tissues.Biomechanics is the study of the physical limits of the human body and is
therefore the basic science underlying sports medicine.
DIAGNOSIS OF SPORTS INJURIES:-
History (onset):
From the history, sports injuries can be grouped according to the type of onset.
• Acute extrinsic injuries are those caused by a direct blow and are commonly cuts
and bruises.
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• Acute intrinsic injuries are a failure of the human body in response to the ultimate
load of that structue being exceeded. These are commonly ligament strains or
disruptions, dislocations, and fractures with a very different pattern to those seen in
acute extrinsic injuries.
• Chronic injuries have no single moment of onset and are more likely to relate to
fatigue failure of tissues or injury in an area where a previous injury has not yet
completely settled.
Investigations:
The careful clinical assessment of the fuctional stability of an injured muscles
,ligament, tendon etc is far more valuable than expansive imaging techniques, such as
MRI,CT which can be very misleading.
Some disorders related to the sports injuries:
TENDON
Tendons attach muscle to bone and are composed of dense, regularle arranged
fascicle, or groups of collagen bundles.Disorders are:
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• Paratendinitis
• Paratendinits with tendinosis
LIGAMENTS
Ligaments transmit tensile forces across the joint, define the motion limits of the
bones with respect to each other and guide the relative movements of bones within the
motion limits.The principles of examination of an injured ligament can be applied to any
joint that is readily palpable by direct comparison with the uninjured limb:
• Grade 0: normal ligament , normal joint stability;
• Grade1: tenderness at the site of ligament injury, no detectable increase in joint
laxity while loading the ligament;
• Grade2: Increase in joint laxity but with a solid end point;
• Grade3: significant increase in joint laxity with no end piont.
The stability of joints varies enormously from one individual to the next.women’s joints
tend to be more lax than men’s and all joints become stiffer as we grow older.
BURSAE
Sandwitched between tissues that slide past each other, bursae decrease the
frictional forces present. They are endothelium lined cushions and normally contain little
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fluid. If they are overloaded they can become inflammed, swollen and very
painful.Althogh the appearance can mimic sepsis,a pathogenic organism is rarely
isolatedin cases of closed injury.
PHOTO PLATE NO 86
Figure no 3 : PRUSHTHA MARMA
Figure no 4 (BONES & JOINTS)
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PHOTO PLATE NO 87
Figure no 5 : MUSCLES OF THE GLUTEAL REGION
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PHOTO PLATE NO 88
Pelvic cavity structures
Figure no 6: NERVES
Figure no 8: VESSELS
Figure no 7: LIGAMENTS
Figure no 9: VISCERA
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PHOTO PLATE NO 89
Figure no 10: SCAPULA & RIBS
Figure no 11: MUSCLES OF SCAPULAR REGION
Figure no 12: NERVES
Figure no 13: VESSELS
Figure no 14: SHOULDER GIRDLE‐ ARTICULAR SURFACES
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Figure no 15: MUSCLES & BURSAE
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PHOTO PLATE NO 90
Figure no 16: LIGAMENTS
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PHOTO PLATE NO 91
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Figure no‐17: BURSAE & ROTATOR CUFF MUSCLES
Figure no 18: MOVEMENTS OF SHOULDER
JOINT
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PHOTO PLATE NO 92
Figure no: 19‐MUSCLES ACTING ON SHOULDER GIRDLE
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PHOTO PLATE NO 93
Figure no 20: CAUSES OF SUPRASPINATUS TEAR
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PHOTO PLATE NO 94
Figure no 21: PAINFUL ARCH SYNDROME
Figure no 22: ROTATOR CUFF MUSCLES
Figure no 23: SHOULDER JOINT DIAGRAM:‐
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PHOTO PLATE NO 95
Figure no 24: USG OF SHOULDER NORMAL:‐
Figure no 25 : SHOULDER DIAGRAM TRANSVERSE VIEW:‐
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PHOTO PLATE NO 96
Figure no 26: USG OF SHOULDER NORMAL TRANSVERSE VIEW:‐
Figure no 27: SUPRASPINATUS TENDON FULL TEAR:‐
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PHOTO PLATE NO 97
Figure no 28: SUPRASPINATUS TENDON FULL TEAR & BURSITIS:‐
.
Figure no 29: COMPLETE TEAR OF SUPRASPINATUS
“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”
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PHOTO PLATE NO 98
Figure no 30 : RADIOLOGICAL FINDINGS
“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”
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PHOTO PLATE NO 99
Figure no 31: SHOULDER MRI: ROTATOR CUFF INJURIES
“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”
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MATERIALS AND METHODS
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METHODOLOGY
MATERIALS & METHODS:-
(1) Literary study was undertaken by the data, compiled from Brihatrayis, Laghutrayis and
other classical texts including journals, presented papers.previous thesis work done and
correlated,analyzed with the knowledge of contemporary science on the subject.
(2) Observations are analyzed and correlated in the view of ancient description of
structures and traumatological effects of Amsa marma.
(3) A special case proforma was prepared with all the points of Amsamarmabhighata
(stabdhabahuta). Observation of minimum 30 patients will be selected for
study.structural abnormality will be observed with the help of clinical examination of
ARM DROP SIGN.
METHOD OF COLLECTION OF DATA:-
Literary study:-The data for the present work was collected from the samhitas, the text
books of the recent author’s scientific journals and internate. The data obtained was
arranged in the systematic manner.
Clinical study:-Present study is observational study where in the 30 patients diagnosed
as stabdhabahuta are taken from N.K.J Ayurvedic medical college & PG centre teaching
hospital randomly. The patients were subjected for screening of the symptoms, clinical
examination, and data obtained was analysed.
MATERIALS AND METHODS
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STUDY DESIGN:-
(a) Clinically diagnosed 30 patients of stabdhabahuta due to the injury to Amsa
marma (Snayu marma) was selected.
HISTORY TAKING AND PHYSICAL EXAMINATION:
Complete history regarding age, sex, occupation, socio-economic status,history of
present illness, family history etc was recorded. Physical examination from general
routine examination to local shoulder joint examination was done.
INCLUSION CRITERIA:-
(1) The patients of either sex irrespective of all ages.
(2) Diagnosed patients of stabdhabahuta due to the injuries to amsapradesha,the
clinical features correlated with snayu marmabhighata laxana and samanya
marmabhighata laxana were taken.
EXCLUSIVE CRITERIA:-
(1) Fracture with dislocation
(2) Tuberculosis of shoulder joint
(3) Sprengel’s shoulder (congenital elevation of the scapula).
(4) Non-traumatic conditions and systemic disorders.
ASSESSMENT CRITERIA:-
MATERIALS AND METHODS
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Subjective parameters:
(1) Shoulder pain (Amsa ruja)
(2) Restricted movement. (Chestopaghata).
(3) Motor weakness (kriyahani).
(4) Tenderness (sparshaasahatva)
OBJECTIVE PARAMETERS:
Clinical parameters
Arm drop sign
This test is mainly for the complete tear of rotator cuff muscles.
Stabilising the scapula with one hand, the examiner passively abducts the patient’s
affected shoulder to 90 degree and asks him to sustain it .In case of complete tear, the
patient cannot sustain the abducted arm and it drops by the side of the trunk.
ASSESSMENT OF PAIN:
Measurement of intensity of pain was assessed by medical research council (MRC)
grading recommendation by W.H.O... Patient’s subjective experience of pain is measured
& the grades with numbers show the features of pain such as its intensity & severity.
MRC grading:
G0 : absence of pain.
MATERIALS AND METHODS
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G1 : Mild pain – pain that can be easily ignored (those who are having pain &
able to bear it without any drug or medication)
G2 : Moderate pain – pain that cannot be ignored, interferes with daily
activities & needs treatment from time to time (pain which the patients were able to bear
with difficulty & relieved with the use of analgesic drugs.)
G3 : Severe pain – Demanding constant attention (In which the patients were
unable to bear and use of analgesic drugs was essential.)
G4 : Totally incapacitating pain or most excruciating pain.
ASSESSMENT FOR LOCAL TENDERNESS:
The grading for assessment of local tenderness was taken as:
Go : No tenderness
G1 : Patient complains of pain
G2 : Patient complains of pain and winces
G3 : Patient complains of pain and withdraws the joint
G4 : Patient does not allow to touch the joint
ASSESSMENT FOR JOINT MOBILITY OR RANGE OF MOTION -
RESTRICTED MOVEMENT (CHESTOPAGHATA):Figure No:2
MATERIALS AND METHODS
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The grading for assessment of restricted movement was taken as in degrees,
For abduction
Go : 80‐90
G1 : 61‐80
G2 : 41‐60
G3 : 21‐40
G4 : 0‐20
ASSESSMENT OF MOTOR WEAKNESS:
Here, two things we should remember, muscle power and nerve supply, While
investigating for muscle power, one must have a clear conception about the anatomy as to
which nerve which nerve supplies which muscle. It may so happen that the muscle
MATERIALS AND METHODS
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concerned is supplied by more than one nerve. In that case, the clinician will not be able
to assess the severity of the nerve injury by investing the muscle power. To test whether a
particular nerve is injured or not, the muscle which is exclusively supplied by the same
nerve should be examined for muscle power. The patient is asked to carry out the
movement of the joint against resistance which is performed by the same muscle supplied
exclusively by the nerve concerned. Following are the gradations of the muscle power
which has been quoted according to MRC, London.
Gradation of muscle power:
G0 - Complete paralysis
G1 - Flicker of contraction
G2 – contraction with gravity eliminated alone
G3 – contraction against gravity and some resistance
G4 – contraction against opposed force .
OBSERVATIONS
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OBSERVATIONS
1. Age:
Table No 8: Table showing the distribution of patients based on Age (N=30)
Sl no Age No of Patients %
1. Below 20 0 0
2. 21-30 4 13.33
3. 31-40 7 23.33
4. 41-50 6 20
5. 51-60 6 20
6. 61-70 4 13.33
7. 70 above 3 10
(N = total number of patients, % = Percentage)
Out of the 30 patients, the above observation shows that a maximum number of patients i.e. 7
patients (23.33%) fall in the age group 31-40. Followed by 6 (20%) patients in the age groups
41-50 & 51-60, 4 patients (13.33%) in the age groups 21-30 & 61-70, 3 patients (10%) in the age
group 70 and above.
OBSERVATIONS
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2. Sex
Table No 9: Table showing the distribution of patients based on Sex (N=30)
Sl no Sex No of Patients %
1. Male 20 66.67
2. Female 10 33.33
(N = total number of patients, % = Percentage)
Out of the 30 patients, 20 patients (66.67%) were male and 10 patients 33.33% were
female. The ratio of male to female was 2:1.
OBSERVATIONS
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3. Occupation
Table No 10: Table showing the distribution of patients based on Occupation (N=30)
Sl no Occupation No of Patients %
1. Farmer 8 26.67
2. Housewife 5 16.67
3. Teacher 2 6.67
4. Driver 4 13.33
5. Sports 7 23.33
6. Other 4 13.33
(N = total number of patients, % = Percentage)
Out of the 30 patients, maximum no of patients- 8 patients (26.67%) were farmers by occupation
and sportsmen- 7 patients (23.33%), 5 patients (16.67%) were housewife, 4 patients (13.33%)
were drivers and other occupations, 2 patients (6.67%) were teachers.
OBSERVATIONS
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4. Diet
Table No 11: Table showing the distribution of patients based on Diet (N=30)
Sl no Diet No of Patients %
1. Mixed 17 56.67
2. Vegetarian 13 43.33
(N = total number of patients, % = Percentage)
Out of 30 patients, 13 patients (43.33%) were vegetarian, 17 patients (56.67%) had mixed diet.
OBSERVATIONS
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5. Shoulder Pain
Table No 12: Table showing the distribution of patients based on Shoulder pain
(N=30)
Sl no Shoulder pain No of Patients %
1. Unbearable 5 16.67
2. Severe 11 36.67
3. Moderate 6 20
4. Mild 2 6.67
5. Absent 6 20
(N = total number of patients, % = Percentage)
Out of the 30 patients, maximum- 11 patients (36.67%) presented with severe shoulder
pain, 6 patients (20%) had moderate pain, 6 patients (20%) had no pain, 5 patients
(16.67%) had unbearable pain and only 2 patients (6.67%) had mild pain.
OBSERVATIONS
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6. Restricted movement on abduction (in degrees)
Table No 13: Table showing the distribution of patients based on restricted
movement (N=30)
Sl no Restricted movement
(in degrees)
No of Patients %
1. 80-90 0 0
2. 60-80 0 0
3. 40-60 5 16.67
4. 20-40 17 56.67
5. 0-20 8 26.67
(N = total number of patients, % = Percentage)
OBSERVATIONS
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Out of the 30 patients, maximum patients- 17 (56.67%) had restricted movement of the
shoulder joint on abduction, limited from 20-40 0. 8 patients had restricted movement of
0-20 0 and 5 patients had restricted movement of 40-60 0.
7. Tenderness
Table No 14: Table showing the distribution of patients based on Tenderness (N=30)
Sl no Tenderness No of Patients %
1. Absent 19 63.33
2. Pain 9 30
3. Pain + winces 2 6.67
4. Pain with withdrawal 0 0
5. Does not allow to touch 0 0
(N = total number of patients, % = Percentage)
OBSERVATIONS
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Out of 30 patients, maximum patients- 19 (63.33%) didn’t have any tenderness over the
shoulder joint. 9 patients (30%) had only pain and 2 patients (6.67%) had pain and
winced.
8. Visible deformity
Table No 15: Table showing the distribution of patients based on Visible deformity
(N=30)
Sl no Visible deformity No of Patients %
1. Visible 0 0
OBSERVATIONS
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2. Palpable 5 16.67
3. Absent 25 83.33
(N = total number of patients, % = Percentage)
Out of 30 patients, maximum 25 patients (83.33%) had no visible deformity and only 5
patients (16.67%) had palpable deformity. No patients had any visible deformity.
9. Numbness
Table No:16 Table showing the distribution of patients based on Numbness (N=30)
Sl no Numbness No of Patients %
1. Positive 5 16.67
2. Negative 25 83.33
(N = total number of patients, % = Percentage)
OBSERVATIONS
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Out of 30 patients, maximum 25 patients (83.33%) had numbness and 5 patients
(16.67%) did not have numbness.
10. Arm drop sign
Table No:17 Table showing the distribution of patients based on arm drop sign
(N=30)
Sl no Arm drop sign No of Patients %
1. Positive 17 56.67
2. Negative 13 43.33
(N = total number of patients, % = Percentage)
Out of 30 patients, maximum 17 patients (56.67%) had positive Arm drop sign and 13
patients (43.33%) had negative Arm drop sign.
OBSERVATIONS
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11. Modern diagnosis
Table No: 18 Table showing the distribution of patients based on Modern diagnosis
(N=30)
Sl no Modern diagnosis No of Patients %
1. Frozen shoulder 19 63.33
2. Erb’s paralysis 2 6.67
3. Klumpke’s paralysis 3 10
4. Rotator cuff injuries 6 20
(N = total number of patients, % = Percentage)
Out of 30 patients, maximum 19 patients (63.33%) were diagnosed suffering from frozen
shoulder, 6 patients (20%) were suffering from rotator cuff injuries, 3 patients (10%) were
suffering from klumpke’s paralysis and 2 patients (6.67%) suffered from erb’s paralysis. All
these conditions fall under the term –“Stabdhabahuta”.
OBSERVATIONS
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DISCUSSION
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DISCUSSION:
After going through the conceptual literature in detail, the present study entitled as “A
study on Prushtha marma W.S.R to Stabdhabahuta in amsamarmabhighata.” Reveals
some interesting points which are discussed thoroughly to draw the probable conclusions
at various levels.
Discussion on History and concept of Marma:
The origin of marma can be traced back to the vedic period.Its references were
also found in Upanishads, epics like Ramayana, Mahabharata, and as well as the ancient
medical science.The word marma derived from the Sanskrit root ‘mru’ and applies to a
part or a spot of vital importance in the body, which if injured results in serious
consequences it also denotes vital force of life.
The ancient surgery in India primarily associated with warfare. Though the
knowledge of anatomy was not too accurate and was deficit about many important
structures but it is surprising to find the phenomenon growth and excellence of Indian
surgery during the period of sushruta. Surgical operations demanded the accurate
knowledge of anatomy but it seems, the concept of marma has supplied them with the
knowledge of regional anatomy and the structures involved in the region and considered
the knowledge of marma as half the knowledge of surgery and it was the mastery of
knowledge of these marma that might have helped for the growth of surgery in ancient
age.
It is noteworthy that up to 15th century Greek, Roman and Arabians did not
posses much anatomical knowledge. If peep into the history of modern anatomy even the
Aristotle not never dissected the human body but had rough idea about vessels.’ Celsius’
DISCUSSION
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though wrote book on medicine but we little glimpse of anatomy in it.
Discussion on pathophysiology of marmabhighata
The four types of siras carrying the doshas and Rakta separately are connected
with all the marma as well. In case of trauma, blunt or piercing over the marma there will
be an bleeding leading to dhatukshaya there by resulting into vata prakopa in turn
mobilization of pitta and its vitiation. Thus causing severe pain accompanied by trishna,
shosha, bhrama and later death preceded by excessive sweating. Sushruta emphasis more
on vata prakopa and its role destroying normal physiological function or haemostasis.It is
a reflex vasodilatation and fall in blood pressure, loss of consciousness. And some time
leading to death, if it is irreversible type of shock. It is a systemic effect of mechanical
injury.
In view of modern pathology also the death in marmabhighata is the result of
shock.shock is defined as disparity between volume and space and it is the sudden
derangement of the physiological functions. A mechanical injury at any part of the
produce reflex vaso-dilatation, fallen blood pressure and loss of consciousness and
death.Hence marmabhighata will definitely produce reflex vaso-dilatation unbelievable
amount of blood flows from vascular system to the interstitial spaces.
So it may be considered that after the abhighata siras of affected marma may
produce vasovagal reflexes due to vata prakopa and raktasrava. Thus it is obvious that
marma are susceptible points to traumatic shock especially, which are located in head &
neck,chest and abdomen including pelvis.
Discussion on role of prana
As we understand, marma is reservoir of prana. The prana pervades every cell of the
DISCUSSION
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body through the innumerable nadis in which it moves or flows. There are Dasha
Pranayatanas told in Ayurvedic Classics, generally Soma (Kapha), Maruta (Vaayu), and
Tejas ( Pitta), and Rajas, Satva, and Tamas along with Atma stays in Marmas, that is why
they do not survive if injury takes place on Marma. That is why named as Prana.
Discussion on Prushtha marma
Prushtha marma are fourteen in number,and let us discuss one by one.
Discussion on katika taruna Marma
It is Asthi Marma Varity which is delayed fatal on injury, it present on the both
sides of the vertebral column where sacrum meet with pelvic bone which is Ardha anguli
in measurement. It means sacro-iliac joint. In this region “Katika taruna is present”.
General symptoms of Katikatruna Marma injury are loss of blood (shonita kshaya ),
Pandu (anemia ) discoloration or produces different colours (vivarna ), disfigure ( heena
roopata) and death (Marma).
After injury to this bone leads to rupture of major blood vessels because in this
region pelvic bone in front of the sacroiliac joint protecting major blood vessels of pelvic
cavity with main nerves.
In front of the sacroiliac joint the terminal branches of common iliac artery
divides in to external and internal iliac artery. Sacroiliac joint is a synovial joint; the
fibrous articular capsule is thickened dorsally and ventrally to form the sacroiliac
ligaments; because of the interlocking nature of the joint surfaces and the strong
sacroiliac ligaments, only limited movement is permitted at the sacroiliac joint. Fracture
of this sacroiliac joint leads to rupture of major vessels inside i.e. iliac vessels, leads to
bleeding. Traumalogist explains injury to internal vessels is always hazardous because
DISCUSSION
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due to lack of coagulation causes chronic internal bleeding and needs emergency surgical
intervention. Acharya Sushruta explained the stages of internal blood loss very
beautifully as follows.
1. Shonita kshaya- loss of blood, this is due to rupture of major blood vessels in
pelvic cavity near to the sacroiliac joint.
2. Pandu- due to blood loss, pallor is main symptom. This is first stage of
bleeding.
Discussion on Kukundara marma
It is sandhi marma varity which is vaikalyakara on injury, it present on the both
sides of vertebral column and the lateral sides of the outer part of the jaghana asthi and
which is Ardha angula in measurement. Gananathsen counted the kukundara marma as
ischial tuberosity, Vd R.R. Pathak counted this marma as to the sacroiliac articulation
over which the sacral plexus and pass out the pelvis through the greater sciatic
foramen.Injury to this marma leads to loss of sensation and the movements of the lower
limbs.
But on discussion we can confine that the Anatomical structures under the marma
as Ischial bone, inferior gluteal artery and vein, inferior pudendal artery and vein,roots of
the sacral plexus, gluteus maximus muscle and levator ani muscle.
Discussion on Nitamba Marma
Nitamba Marma is Asthi Marma, which lies above the ear like bone (ischium) of
pelvis, covering pelvic organ. It is located interior to the pelvic cavity on the both sides of
lateral aspect of the ishchial bone. This is nothing but location of lumbo sacral plexus,
sciatic notch is present for sciatic nerve, and the Marma is Ardhanguli in pramana, injury
DISCUSSION
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to which leads to Adhah kaya shosha, Daurbalya and it is vaikalyakara in nature. Context
of Shroni panchaka, Acharya Sushruta told 2 Nitambhasthi. So the shroni panchaka is
nothing but the union of 5 bones in pelvic region. So hip bone, specifically ilium is
considered as Nitambhasthi, and the region is called “Shroniphalaka” region. To cause
Shosha (wasting) and numbness is possible only after involvement of nerves supply to
the extremity. Probably above said version of Sushruta i.e. katikataruna is Asthi Marma
was based on the presence of ischium in the close relationship with Marma. Here the
nerves ashrayee and ischium gives ashraya. Sushruta has said that any injury to this
Marma cause wasting ( Shosha) and debility ( Daurbalya ) of the lower extremity. This is
reliable because an injury at this Marma may damage to the sciatic nerve along with the
superior gluteal, internal pudendal artery.
Adhah kaaya shosha means loss of sensory and motor activity or atrophy of lower
limb. Daurbalya - General debility or lower limb debility. Due to rakta dhatu kshaya and
Vata prakopa, general debility may occurs otherwise involvement of the motor and
sensory nerve leads to debility in lower limb only. Marana is not common but the severity
of injury if involve major blood vessels severe bleeding may occur that leads to
hypovolemia the it may be end up with death.
Discussion on Parshwasandhi marma
It is situated inferior to and in the middle of the lateral flanks being attached to it,
they are obliquely placed of conjoined together in order and attached to the lateral sides
of bony part hidden by it. It is sira marma and injury to this leads to delayed death, this
vascular marma lying inside the pelvis placed obliquely from below upward,and some
modern Ayurvedic authors have suggested common iliac arteries responsible for this
DISCUSSION
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marma.
The discussion suggests that there are two regions which seems to be responsible
for this marma they are pelvic cavity and gluteal region,the vessels of extremities are iliac
vessels and their exrernal branches.If injury to these regions leads to priorly bleeding,
these are not apperent but manegable.then also very difficult rather unmanegable.
Therefore these vessels may correlate to the Parshwasandhi marma.
The common iliac artery bifurcates into external and internal iliac artery at the
point superior 1/3rd (2 inch) of the imaging line drawn on the surface of the abdomen
joining the point of aortic bifurcation (3/4th inch below the umbilicus) and mid inguinal
point. The diameter of the aorta and inferior venacava are approximately 1inch each, the
course of these vessels are also comparable with the description of Sushruta’s
parshwasandhi marma.The gunshot wound to the pelvis involving the pelvic vessels by
missiles of bone or pallets is a challenging problem for the trauma surgeon even though
the fatality is quite high
Discussion on Brahati marma
The brahati marmas are situated just opposite the stanamula bilaterally on the
back. Structurally this marma is a sira marma injury to this region has high tendency of
severe bleeding resulting into complications and terminates into delayed death.Few
authors says that structures involved in this marma are anastomoses around the scapula,
and R.R Pathak has discussed for the vessels at the hilum of the liver at right side,vessels
at the hilum of spleen at left side.
Dr. V.S Patil has included the base of the lungs,bare area at the inferior angle of
the scapula,diaphragm or intercostals muscles behind the scapulaare responsible for the
DISCUSSION
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marma.
Lastly the area of triangle of auscultationis the choice where sixth intercostals
artery lies in the sixth intercostal space within this area.If this artey ruptures leads to
intrathoracic hemorrhage,complications leading to death.The penetrating injury on the
back of the chestusually complicates deu to uncontrollable bleeding.bullet or fractured rib
usually produces complications.
Discussion on Amsa phalaka Marma
On the dorsal aspect of the body Marma is associated with Trika (scapula). It is
Asthi Marma and post traumatic condition is muscular atrophy and anesthesia. Following
facts should be essentially may be considered in Amsa phalaka Marma.
1. That Marma is somewhere in the superior part of the back.
2. That Marma is in both lateral sides of the vertebral column.
3. That Marma is close relationship with scapula.
4. That Marma includes the nerve supply to the upper extremity, because an injury to this
Marma may cause wasting and numbness of the upper extremity.
There fore this can be concluded that the site of supra scapular notch is the
anatomical site where all the above said conditions can be found with this fact fertion of
Acharya Sushruta is reliable. According to Acharya Sushruta this Marma is Asthi Marma.
This statement is not acceptable because wasting and numbness is possible only after
involvement of nerves supply to the extremity. Probably above said version of Sushruta
was based on the presence of scapula in the close relationship with Marma. Here the
nerves ashrayee and scapula gives ashraya. Sushruta has said that any injury to this
Marma cause numbness (Swapa) and wasting ( Shosha) of the upper extremity. This is
DISCUSSION
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reliable because an injury at this Marma may damage to the brachial plexus along with
the damage of suprascapular nerve and artery. The damage may follow as under:
1. If foreign body penetrate the deeper parts- severe damage to the brachial plexus is
possible. This will lead to paralysis of the upper extremity.
2. If foreign body penetrates the deeper parts leaving light impact, moderate damage of
brachial plexus is possible. This will cause numbness and wasting due to partial loss
of function.
If foreign body penetrates to the superficial part – damage to the suprascapular nerve and
artery will be resulted. This will cause paralysis of abductor muscles of the shoulder joint
along with the wasting of the same.
Discussion on Amsa marma
The word Amsa denotes the shoulder; the Ama marma is situated within the line
of the area joining head (murdha),Neck (Greeva), and the arm (Bahu).This is the snayu
marma to a length of half finger width.
The physical metrixes that are present in Amsa marma are
mamsa,sira,snayu,sandhi and Asthi.It is one of the vaikalyakara marma, and trauma to
this will produce disability of the shoulder joint.
By observing the above said quotation,we can make it as the basement for the
modern establishment of Ams marma, In modern science there are the muscles and
ligaments binding the scapula with the clavicle,an injury to these structures may cause
rupture of the ligaments resulting in disability of shoulder joint and arm.
The Amsa marma that includes the structures related to shoulder region are the most
exposed area to common injuries.The activities like weight lifting, swimming, cricket ,
DISCUSSION
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fall on outstretched arm causes the rupture of ligaments and muscles of the shoulder
region leads to the disability of the amsa sandhi and bahustabdhata.
Let us discuss the amsa pradesha where the amsa marma is present,we will try to
approach the underlying structures of amsa marma and fixing its limitations. Based on the
anguli pramana marma vargeekarana, the amsa marma is half angula,we cannot say the
actual limitations of amsa marma, structurally.
Before discussing the anthropometry of Amsa marma, we will discuss the
underlying structures of Amsa pradesha.
Underlying structures of Amsa marma:
According to parishabdartha sharira,there are nine structural complexes are
presentthoseare;Amsa,Amsakuta,Amsadesha,Amsapinda,Amsapitha,Amsaphalaka,amsab
andhana & Amsandhi.
Let us correlate the classical quotation of Amsa marma with modern science.
Bones:(Bahumurdha & Amsaphalaka):
Parts of the scapula,clavicle and upper part of the humerus.
Joints :(Amsa sandhi & Amsapeetha sandhi):
Shoulder joint and acromioclavicular joint.
Soft tissues: (The snayu binding the Amsa sandhi):
Ligaments of the shoulder joint and muscles of the shoulder joint.
Underlying structure of Amsa marma as to Ayurvedic scholors, correlating with the
modern science:
Amsa
Amsa marma is a snayu marma structurally,If we discussed about snayu,based on many
DISCUSSION
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 126
openion,we can call it as ligament,somewhere it is considered as nerve or tendon.But
depending upon the situations we can name it to different structures as above
said,traumatic effect on Amsa marma (snayu) leads to the functional deformity, so it is
known as Vaikalyakara marma.
Pratanavati type of snayu covers this sandhi,Acharya sushruta states that snayu is
the binding material of mamsa, Asthi and medha.Like a boat made up of planks and
timber, tightened together by means of large number of binding is enabled to float on the
water and to carry cargo.similarly in the body all the sandhis are tightened up by large
number of snayus, which enables the body to bear the weight.
All vaikalyakara marma are later converted into rujakara one.by this
reason this can neigther be considered as nerve or tendon ,but this may be considered as
complex structures like ligaments, muscles, tendons,bursae and nerves. Hence,based on
these observations without any disputs, we can confine it to Shoulder region
(Amsa),Acromion region (Amsa kuta)& scapular region (Amsapitha) and these binds
together by the soft tissues is known as Amsa marma.
Amsakuta
Amsakuta is situated exactly above the Apalapa marma.The kuta is considered as
Acromion process of the scapula which is very prominent structure in the shoulder
region.
Amsa desha:-
The area occupied by the Rotator cuff muscles,axillary vessels,ligaments &
bursae related to the shoulder joint and injury to this leads to loss of functions of Bahu is
known as Avabahuka and where the Amsa marma is also present.Overall that area is
DISCUSSION
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known as Amsa desha or shoulder region.
Amsa pinda:-
The area over the greater tuberosity of humerus which is attached with the deltoid
muscle is called deltoid prominency.So it bears spherical shape i.e Amsapindika.
Amsapitha:-
According to Gananathsen saraswati,glenoid cavity is compared to the Amsapeetha.
Again this term has been explained in Sushruta sutrasthana and sharir sthana-
1. While explaining Anga-pratyanga measurement, Sushruta has quoted-Su.sa.su-35/12
2. While explaining the types of sandhi-he quated “Amsapeethagudabhaganitambeshu
saamudgah.” (Su.Sa.Sha-5/27)
By observing these quotations the anthropometry inbetween Amsa peetha and
kurpara is 16 angula,and here we can consider amsapeetha as a exterior border of the
scapular and shoulder region.We can give another openion; Inbetween Amsapeetha
sandhi and kurpara sandhi 16 angula length. But Dalhanacharya commentated Amsa
peetha as Bahushira i.e “Amsapeetho Baahushirah;” and amsapeetha sandhi as one of
the type of ‘Saamudga sandhi’. But the dictionary meaning of peetha is Aasanam &
Saamudga is Samputaka, However the area of amsapeetha is accomodates in the area of
Amsa.
Hence, by observing above said explaination we can consider Amsapeetha as
scapula and Amsapeetha sandhi as Acromioclavicular joint, because it is one of the
Saamudga sandhi and it is situated just above the shoulder joint.
DISCUSSION
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By discussing all these points based on the quotation of AMSA MARMA in
Su.Sa. sha-6th chapter and A.Hru.Sha 4th chapter we will come to know that all above said
structures like Amsa peetha,bahushira etc…are included under the Amsa marma.
Amsaphalaka:-
In Kashyapa Samhita sharira sthana while explaining the Asthi sankhya,he
mentioned Amsaphalakas are Asthi they are two in number.
“dwaamsavamsaphalakaavapi dwaveva chakshakou.”
According to him amsa-2 Amsaphalaka-2 Akshakasthi-2
Here, we should think about the Amsa because he considered these are also asthi
and 2 in number. But these structures or parts we can include under the spines of scapula,
according to sushruta a flat mass are included under the kapalasthi.
Finally we can consider Amsa as acromion process and Amsaphalaka as scapula.
Amsabandhana
In the area of amsa-underground structures impaired by the aggravation of the
vata and rakta due to injury to the amsa bandhana that leads to the compression of siras
i.e blood vessels and nerves, lastly the disease avabahuka.
Here the structures which bind the bahushira,Amsapitha and greeva in between
these the amsa marma is present.The amsa is bounded by the snayu & peshi i.e soft
tissues.if injury to these structures that leads to disability of upper limb.
By this explaination we can consider that structures underlying the shoulder and
scapular region are affected, mainly due to trauma,like rotator cuff injuries,frozen
shoulder,tearing of lagaments etc….these are complicated into disability of the shoulder.
Amsamula:-
DISCUSSION
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 129
According to Shastracharcha parishad, the amsa mula is correlated into apex of
the axilla.where the brachial vessels and brachial plexus are situated. If injury to this
leads to the paralysis of the upper limb takes place i.e STABDHABAHUTA.
By observing this discussion we can approach that apex of the axilla is included in
the area of the AMSA MARMA.
Amsasandhi:-
This is a major joint of the upper limb. This is one type of chala and ulookhala
sandhi. This joint is formed by the articulation of Pragandasthi, Akshakasthi and
Amsaphalakasthi.
Pratanavati type of Snayu covers this Sandhi. Acharya Sushruta states that
Snayu is binding material of Mamsa, Asthi and Medha. Like a boat made up of planks
and timber, tightened together by means of large number of bindings is enabled to float
on the water and to carry cargo. Similarly in the body all the Sandhis are tightened up by
large number of Snayus, which enables the body to bear the weight.
Sheshmadhara Kala is present in this joint and seceretes shleshaka kapha. this act
as a lubricant for the joint and helps in protection and movements of the Sandhi.
Acharaya Sushruta has described that the rachana of Sandhi as like a wheel having an
axis. When the axis is lubricated by putting oil on it, the wheel can move freely and
friction does not occur. In the same way the bones or joints can move freely in the
presence of Shleshma.
Discussion on limitations of Amsa marma & Amsamarmabhighata:
To make the limitations of Amsa marma, we should know about the classical
definition of amsa marma which correlates with the modern science.
DISCUSSION
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 130
• Bahumurdha (Amsapindika)- Deltoid prominency-1st point
• Amsapitha- Upper 1/4th of .Exterior border of the scapular and shoulder
region-2nd point
• Skandha-shoulder joint-3rd point
• Greeva -Root of the Neck-4th point
• Amsabandhana-Soft tissues of shoulder & scapular region which hold the
above said points .
Joining of all these points one by one and make the half angula point at the
centre of all above said structure, that form the Amsa marma. Injury to this leads
to Stabdhabahuta, this symptom we can consider in the aghata to the
Amasapradesha, like Rotator cuff injuries, Frozen shoulder, Bursitis, ligament
tear, Erb’s palsy, Klumpke’s paralysis etc..as we know the Amsa marma is a
Snayu marma injury to this, we can correlate to the Samanya maramabhighata &
snayu marma viddha laxanas.
Samanya marmabhighata laxana are:
1. Vicheshtana
2. Urdhvavata
3. Vayukruta tivra ruja
4. Stabdhata
5. Kriyanasha
Snayu marma viddha laxanas are:
1. Koubjyam (Shortening)
DISCUSSION
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 131
2. Shareeravayavasaada (svakarmanyaasamrthyam)-loss of functions
3. Kriyasvashaktiriti (Loss of movements like Abduction, Adduction, Flexion
extension etc).
4. Ruja (Pain)
By observing all these clinical features we will come to know that all are
comes under the Stabdhabahuta symptom of Amsamarmabhighata,and injuries
according modern science viz Rotator cuff injuries,frozen shoulder, nerve
injuries related to shoulder, ligament tear,etc are also correlates to the samanya
marmabhighata and snayu marmaviddha laxana.
Discussion on clinical observations:
1. Age:
Out of the 30 patients, the above observation shows that a maximum number of
patients i.e. 7 patients (23.33%) fall in the age group 31-40. Followed by 6 (20%) patients
in the age groups 41-50 & 51-60, 4 patients (13.33%) in the age groups 21-30 & 61-70, 3
patients (10%) in the age group 70 and above. So, more number of patients were found in
of 31-40 years (adult age group). This is due to continued exposure to strenuous physical
work and also due to repeated stress over the joints in case of sportsmen.
2. Sex:
Out of the 30 patients, 20 patients (66.67%) were male and 10 patients 33.33% were
female. The ratio of male to female was 2:1. This is obvious because of males in India
being outdoors most of the time span for work.
DISCUSSION
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 132
3. Occupation:
Out of the 30 patients, maximum no of patients- 8 patients (26.67%) were farmers by
occupation and sportsmen- 7 patients (23.33%), 5 patients (16.67%) were housewife, 4
patients (13.33%) were drivers and other occupations, 2 patients (6.67%) were teachers.
More incidences in farmers may be due to excessive work in the farms and in case of
sportsmen might be due to repeated stress over the joints.
4. Diet:
Out of 30 patients, 13 patients (43.33%) were vegetarian, 17 patients (56.67%) had
mixed diet. Incidences over dietary habits are not convincing to say that the diet plays a
role in the particular clinical study.
5. Shoulder pain:
Out of the 30 patients, maximum- 11 patients (36.67%) presented with severe
shoulder pain, 6 patients (20%) had moderate pain, 6 patients (20%) had no pain, 5
patients (16.67%) had unbearable pain and only 2 patients (6.67%) had mild pain. Most
of the patients in the study presented with muscle inflammation leading to intense pain.
This was found to vary according to the different structural involvement viz. muscle
tendons (increased severity), nerve (numbness), etc. and also upon the friction involved
in between the associated structures.
6. Restricted movement on abduction: (in degrees)
Out of the 30 patients, maximum patients- 17 (56.67%) had restricted movement of
the shoulder joint on abduction, limited from 20-40 0. 8 patients had restricted movement
of 0-20 0 and 5 patients had restricted movement of 40-60 0. Since the patients had much
DISCUSSION
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pain or limitations of function (in nerve injury), restricted movement might have been
observed on abduction, in this study.
7. Tenderness:
Out of 30 patients, maximum patients- 19 (63.33%) didn’t have any tenderness over
the shoulder joint. 9 patients (30%) had only pain and 2 patients (6.67%) had pain and
winced. This might be due to the involment of softer structures involved in the shoulder
joint as compared to the other traumatic pathologies of bone.
8. Visible deformity:
Out of 30 patients, maximum 25 patients (83.33%) had no visible deformity and only
5 patients (16.67%) had palpable deformity. No patients had any visible deformity. As
the inclusion criteria for the study included only of the injuries of the soft tissues, no
patients were included with conditions like fractures, dislocations, etc. which often
present with visible deformity. As compared to those conditions, it was found in this
study that there was no visible deformity in maximum number of patients.
9. Numbness:
Out of 30 patients, maximum 25 patients (83.33%) had numbness and 5 patients
(16.67%) did not have numbness. This might be due to less nerve involvement cases
being observed in this particular study.
10. Arm drop sign:
Out of 30 patients, maximum 17 patients (56.67%) had positive Arm drop sign and 13
patients (43.33%) had negative Arm drop sign. Upon the assessment parameters being
observed in the study, the patients obviously had difficulty in normal functioning of the
DISCUSSION
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 134
upper limb. So, the Arm drop sign was found to be positive in most of the shoulder soft
tissue injuries.
11. Modern diagnosis:
Out of 30 patients, maximum 19 patients (63.33%) were diagnosed suffering from
frozen shoulder, 6 patients (20%) were suffering from rotator cuff injuries, 3 patients
(10%) were suffering from klumpke’s paralysis and 2 patients (6.67%) suffered from
erb’s paralysis. All these conditions fall under the term –“Stabdhabahuta”. The incidence
of Frozen shoulder is found to be maximum in the study, than other conditions. This
might be due to involvement of only capsular ligament of the shoulder joint. Whereas in
case of the other conditions observed (rotator cuff injuries/ erb’s paralysis/ klumpke’s
paralysis), there is involvement of other structures along with the capsular ligament
which may or may not have preceded with Frozen shoulder.
CONCLUSION
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 135
Conclusion:
1. If a close observation is made, we will come to know that the knowledge of
marma vijnana was extensively well known since vedic period (4000BC). Later
on its progression can be observed in the Samhita granthas especially Sushruta
samhita shareera sthana.
2. The various classical texts of Ayurveda have defined marma as a reservoir of
prana, the seat of tridosha and triguna, atma, chetana, a conglomeration of mamsa,
sira, snayu, asthi, sandhi making the place vulnerable to injury.
3. The marma of the back are studied in relation to anatomical locations, structures
involved and their patho-physiology as shown in the flow charts.
4. Symptoms produced after marmabhighata are to that of traumatic complications
viz shock, Functional deformity, if not treated properly lastly leads to death.
5. The Prushtha marma are the physio-anatomical vital areas on the back of the body
surface. Injury to these vital areas leads to vata vyadhi, associated with rakta
dosha, sometimes kalantara pranahara and vaikalyakara effect on the body.
6. The Prushtha marma are 14 in number they are lower three marma are situated in
the gluteal region, structural correlation of these marma are:
i. Katikataruna marma can be correlated as the cartilaginous bone or
ossification process is going on. In the low back region the five small
CONCLUSION
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 136
bones are ossified and forms single bone called “Katikpalasthi” (Sacrum).
That region is called “Kati” pradesha.
ii. Kukundara marma can be correlated as sacro-iliac articulation over
which the sacral nerves arising from the sacral plexus and passes and
emerges out the pelvis through the greater sciatic foramen.
iii. Nitamba marma can be correlated as hip bone, specifically ischeal
tuberosity, considered as Nitambasthi,
7. Parshwasandhi marma can be correlated as the iliac vessels and its branches.
8. Brahati marma can be correlated as the triangle of auscultation is the area of
choice where sixth inter costal artery, and deeply the branches of coeliac trunk is
present.
9. Amsaphalaka marma can be correlated as the Scapular region where the muscles,
vessels and nerves are related to the scapula bone.
10. The Amsa marma limitations can be concluded by joining the following points as
the root of the neck, deltoid prominancy, Shoulder joint and upper 1/4th of exterior
border of scapular region and make the half anguli point at the centre of all above.
11. The underlying structures of Amsa marma are the muscles, ligaments, bursae,
vessels and nerves related to shoulder region.
12. The Amsamarmabhighata leads to Stabdhabahuta,this symptom can be seen in
following diseases:
A. Rotator cuff injuries
CONCLUSION
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 137
B. Frozen shoulder
C. Bursitis
D. Ligament tear
E. Erb’s paralysis
F. Klumpk’s paralysis
The observational study helps us to take the traumatological cases based on
the marma shareera illustrated as per Ayurvedic literature. The specific ill effects
produced due to the injury caused over a precise location of the body, explained
as viddha laxanas in classics is tried to be justified hypothetically on the basis of
modern anatomy, Physiology & surgery in the present study.
As I have taken observational study on the living subjects, the study is
more precise and effective. On the basis of this observational study we can better
study the radiological findings on the particular marma sthana in the form of
surgical anatomy and traumatology in future, as per Ayurveda.
SUMMERY
“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ” Page 138
SUMMARY
The dissertation entitled “A STUDY ON PRUSHTHA MARMA W.S.R.TO
STABDHABAHUTA IN AMSAMARMABHITA” comprises of 8 chapters namely
Introduction, Objectives, Review of literature, Methodology, observation, Discussion,
Conclusion and Summary.
Chapter 1:
general idea regarding Rachana shareera, Marma and Prushtha Marma along
with the needs of the study has been covered in the introduction part of dissertation
along with need of this study in the present scenario is been highlighted.
Chapter 2:
Gives an idea about aims and objectives of the study.
Chapter 3:
Review of literature is subdivided into Historical review, Ayurvedic review,
Aghata laxana and Modern review Historical review section comprises of references
pertaining to Marma. In Ayurvedic review, location, measurement, classification, effect
of injury of Marma Pradesha explained in detail. In the first part of modern review detail
regional and correlative anatomy of Gluteal region, upper back region, shoulder region
and injuries related shoulder region has been explained.
SUMMERY
“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ” Page 139
Chapter 4:
Methodology chapter explains about method of data collection, and study Pattern and
modern parameters for the observational study has been taken.
Chapter 5:
Observational study reveals that, 30 patients has been taken and complaining of
Symptoms under the marmabhighata laxana presents the stabdhabahuta laxana correlated
with the injuries of shoulder region according to modern science.
Chapter 6:
In the discussion part, discussed in detail on Prana, definition,
classification and detail discussion has been done on individual Prushtha marma and
on their Viddhalakshanas. Special observational study has been taken on
Amsamarmabhighata, correlates with the modern conditions.
Chapter 7:
Conclusions drawn from various sections of the work are given.
Chapter 8:
Summarizes the entire work.
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“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 140
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qÉÔkÉÉï,MühPûÈ,¾ÒûSrÉÇ,lÉÉÍpÉ,aÉÑSÇ,
SHLOKA REFERENCE
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 143
oÉÎxiÉÈ AÉåeÉÈ,zÉÑ¢Çü,zÉÉåÍhÉiÉÇ, qÉÉÇxÉÍqÉÌiÉ |
iÉåwÉÑ wÉOèû mÉÔuÉÉïÍhÉ qÉqÉïxÉÇZrÉiÉÉÌlÉ || (cÉ.xÉ.zÉÉ.7/9)
24. SzÉ eÉÏÌuÉiÉkÉÉqÉÉÌlÉ ÍzÉUÉåUxÉlÉoÉÇkÉlÉqÉç |
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(A.WØû.zÉÉ.3/13)
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qÉqÉïxÉÑ mÉëÉrÉzÉÈmÉÑÇxÉÉÇ pÉÔiÉÉiqÉÉ cÉÉuÉÌiɸiÉå || (xÉÑ.
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28. qÉqÉï xuÉÍpÉWûiÉÉxiÉxqÉÉ³É ÎeÉuÉÎliÉ zÉUÏËUhÉÈ || (xÉÑ. xÉ. zÉÉ
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29. xÉÉåqÉqÉÉÂiÉiÉåeÉÉÇÍxÉ UeÉÈxÉiuÉiÉqÉÉÇÍxÉ cÉ ||
qÉqÉïxÉÑ mÉëÉrÉzÉÈmÉÑÇxÉÉÇ pÉÔiÉÉiqÉÉ cÉÉuÉÌiɸiÉå ||
qÉqÉï xuÉÍpÉWûiÉÉxiÉxqÉÉ³É ÎeÉuÉÎliÉ zÉUÏËUhÉÈ || (xÉÑ. xÉ. zÉÉ
6/35)
30. ÌuÉwÉqÉÇ xmÉlSlÉÇ rÉ§É mÉÏÌQûiÉå ÂMçü cÉ qÉqÉï iÉiÉç ||
(A.WØû.zÉÉ.4/37)
SHLOKA REFERENCE
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 144
31. iÉ§É xÉkrÉ:mÉëÉhÉWûUqÉliÉå ÌuÉ®Ç MüÉsÉliÉUåhÉ
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SHLOKA REFERENCE
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 145
MüÉsÉÉliÉUmÉëÉhÉWûUÉÍhÉ,̲ÌWûlÉÉlÉÉÇ
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SHLOKA REFERENCE
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 146
40. iÉ§É mÉ׸uÉÇzÉqÉÑpÉrÉiÉÈ mÉëÌiÉ´ÉÉåÍhÉMüÉlQûqÉÎxjÉlÉÏ
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xÉ. zÉÉ 6/26-QûsWûhÉ)
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SHLOKA REFERENCE
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 147
47. MÑüMÑülSUÉæ ÎxTücÉÉåÂmÉËU E³ÉiÉpÉaÉÉæ | (cÉ.xÉ.zÉÉ.7/11
cÉ¢ümÉÉÍhÉ)
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SHLOKA REFERENCE
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 148
54. iɧÉÉkÉ:MüÉrÉzÉÉåwÉÉå SÉæoÉïsrÉÉŠ qÉUhÉÇ; (xÉÑ. xÉ. zÉÉ
6/26)
55. AkÉÈmÉɵÉÉïliÉUmÉëÌiÉoÉ®Éæ
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56. ÍxÉUÉqÉqÉïÍhÉ AkÉÉïÇaÉÑsÉå MüÉsÉÉliÉUqÉ×irÉÑmÉëSå cÉ |
(xÉÑ. xÉ. zÉÉ 6/26 QûsWûhÉ)
57. iÉ§É sÉÉåÌWûiÉmÉÔhÉïMüÉå¸iÉrÉÉ ÍqÉërÉiÉå; (xÉÑ. xÉ. zÉÉ 6/26)
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61. mÉ׸ÉåmÉËU mÉ׸uÉÇzÉqÉÑpÉrÉiȨ́ÉMüxÉqoÉ®å AÇxÉTüsÉMåü |
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63. iÉ§É oÉÉÀûÉæÈxuÉÉmÉzÉÉåwÉÉæ;| (xÉÑ. xÉ. zÉÉ 6/26 QûsWûhÉ)
SHLOKA REFERENCE
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 149
64. qÉ‹ÉÎluÉiÉÉåAcNûÉå ÌuÉÎcNû³ÉÈxÉëÉuÉÉå ÂMçü
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“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 150
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“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 151
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“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 152
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SHLOKA REFERENCE
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 153
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SHLOKA REFERENCE
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 154
(A.WØû.zÉÉ.4/25 AÂhÉS¨É, WåûqÉÉÌSì
OûÏMüÉ)
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ANNEXURE
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 1
SHRI SIDDHARUDHA CHARITABLE HOSPITAL
TEACHING HOSPITAL ATTACHED TO
N.K.J. AYURVEDIC MEDICAL COLLEGE AND P.G. CENTRE
BIDAR – 585403
P.G. DEPARTMENT OF RACHANA SHAREER
TITLE ‐ “A study on prushtha marma w.s.r to stabdhabahuta in amsa marmabhighata.”
Name of the P.G. Scholar – Dr. shivasharanayya M. swamy
O.P.D No – Bed No –
I.P.D No – Ward –
Diagnosis – Duration –
Date –
Name – Age / Sex –
Address –
Occupation – Religion –
Date of Admission –
Date of Discharge –
ANNEXURE
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 2
1. Chief complaint with Associated Sign & Symptom with duration :
a. Pain(Ruja)
b. Swelling(shotha)
c. Tenderness
d. Loss of function (Bahu kriyahara)
e. Morning stiffness(stabdhata)
f. Inability to move the upper limb
g. Others
2. History of present illness :
a. Fall from a height
b. Accident
c. Strike by a hard object
d. Twisted
e. Crushing injury
f. Others
3. History of past illness :
a. H/O – related to operation
b. H/O – Diabetes
c. H/O – Tuberculosis
d. H/O – Rheumatic/ Rheumatoid diseases
e. Others
ANNEXURE
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 3
4. Family History :
5. General Examination :
Body built – Temp. – 0 F
Nutrition – Pulse –
Appearance – B.P. –
Pallor – Respiration –
Lymphadenopathy – Weight –
Oedema –
6. Local / Regional examination :
a. Deformity – Visible ⃞ / Palpable ⃞ / No Deformity ⃞
Specification: __________
b. Swelling – Yes ⃞ / No ⃞ in Cm ________
c. Visible bruising – Yes ⃞ / No ⃞ area in measurement ________
d. Tenderness over the shoulder areas – mild ⃞ / moderate ⃞ / severe ⃞ / absent ⃞
e. Function of the upper limb – impaired ⃞ / limitation ⃞ / intact ⃞
f. Movement of the upper limb – abnormal movements ⃞ / crepitus ⃞
Specification :__________
ANNEXURE
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 4
7. Additional Clinical Examination :
a. Skin wound : Communicated with fracture
i. Position –
ii. Nature of wound –
b. State of circulation in distal part :
i. Colour – Pink ⃞ / Blue ⃞ / Gray ⃞ / White ⃞
ii. Warmth – Warm ⃞ / Cold ⃞
iii. Arterial Pulsation –
iv. Capillary return – on digital pulp –
Pink flush / Sluggish / Absent
c. State of spinal cord and peripheral nerve :
d. Involved joint :
i. Joint mobility in degree –
ii. Extension ⃞ / Flexion ⃞ / Lateral rotation ⃞ / Medial
rotation ⃞ / Adduction ⃞ / Abduction ⃞ / Circumduction
⃞ / Protraction ⃞ / Retraction ⃞
8. Radiological examination :
a. Type of Dislocation – Traumatic ⃞ / Fatigue ⃞ / Pathological ⃞
Specification :__________
ANNEXURE
“A study on Prushtha marma W.S.R. to stabdhabahuta in Amsa marmabhighata” Page 5
b. No. of fragments ________ : Displaced ⃞ / Undisplaced ⃞
c. Direction of displacement _____________
d. Alignment – _______________
e. Evidence of union – _______________
f. Evidence of adjacent joint injury –_______________
g. Joint condition –_______________
h. Condition of the articulating surface –_______________
i. Joint space –________________
j. Others –________________
9. Pathological investigation :
a. Blood – DC TLC Hb% ESR Fbs
b. Urine – Routine Microscopic
Signature of the Guide –
Signature of the Co-guide – Signature of the Scholar –
Sr No
OPD/IPD No. of
Patient Age Sex Occupation Diet
Habit
Chief complaints
Shoulder pain (Amsa ruja)
Restricted movements
(cheshtopaghata)
Tenderness (sparshaasahatva)
Motor weakness
(Kriyahaani) 1 29545 62 M farmer mixed 3 3 1 32 30476 46 M farmer veg 2 2 0 33 29497 28 F housewife veg 1 3 0 44 31573 95 M other veg 0 4 0 35 31774 59 M farmer veg 3 2 1 46 31735 44 M driver mixed 4 3 2 37 32009 32 F sports mixed 2 3 0 38 32557 32 F other mixed 3 2 1 39 36339 35 M teacher veg 0 3 0 4
10 37204 59 M other mixed 3 3 1 311 82 F housewife veg 0 4 0 012 76 M other veg 3 2 1 213 65 M farmer veg 2 3 0 314 34 M sports mixed 4 3 1 315 56 F housewife mixed 0 4 0 116 67 M farmer veg 3 3 0 317 33 M sports mixed 3 3 0 318 43 F housewife mixed 2 3 0 419 56 M farmer mixed 1 3 0 420 34 F sports mixed 3 4 1 221 42 M driver mixed 4 3 0 322 55 M driver veg 3 2 0 323 32 F teacher veg 2 3 0 424 28 F sports mixed 4 4 1 225 61 M farmer mixed 0 4 0 026 27 M sports mixed 4 3 1 227 23 M sports veg 3 3 0 4
28 45 M driver mixed 3 4 2 229 49 F housewife mixed 2 3 0 430 55 M farmer veg 0 4 0 0
history of present illness clinical examination
Modern diagnosis Ayurvedic diagnosisVisible
Deformity numbness
(Stabdhata) trauma pathology arm drop sign
absent negative yes no positve Frozen Shoulder Stabdhabahutaabsent negative yes no negative Frozen Shoulder Stabdhabahutaabsent negative yes no positve Frozen Shoulder Stabdhabahuta
palpable positve yes no positve Erb's Paralysis Stabdhabahutaabsent negative yes no negative Frozen Shoulder Stabdhabahutaabsent negative yes no positve Rotator cuff injury Stabdhabahutaabsent negative yes no positve Frozen Shoulder Stabdhabahutaabsent negative yes no negative Frozen Shoulder Stabdhabahutaabsent negative yes no negative Frozen Shoulder Stabdhabahutaabsent negative yes no negative Frozen Shoulder Stabdhabahuta
palpable positve yes no positve Klumpke's Paralysis Stabdhabahutaabsent negative yes no negative Frozen Shoulder Stabdhabahutaabsent negative yes no negative Frozen Shoulder Stabdhabahutaabsent negative yes no positve Rotator cuff injury Stabdhabahuta
palpable positve yes no positve Klumpke's Paralysis Stabdhabahutaabsent negative yes no positve Frozen Shoulder Stabdhabahutaabsent negative yes no negative Frozen Shoulder Stabdhabahutaabsent negative yes no positve Frozen Shoulder Stabdhabahutaabsent negative yes no positve Frozen Shoulder Stabdhabahutaabsent negative yes no positve Rotator cuff injury Stabdhabahutaabsent negative yes no negative Frozen Shoulder Stabdhabahutaabsent negative yes no negative Frozen Shoulder Stabdhabahutaabsent negative yes no negative Frozen Shoulder Stabdhabahutaabsent negative yes no positve Rotator cuff injury Stabdhabahuta
palpable positve yes no positve Klumpke's Paralysis Stabdhabahutaabsent negative yes no positve Rotator cuff injury Stabdhabahutaabsent negative yes no negative Frozen Shoulder Stabdhabahuta
absent negative yes no positve Rotator cuff injury Stabdhabahutaabsent negative yes no negative Frozen Shoulder Stabdhabahuta
palpable positve yes no positve Erb's Paralysis Stabdhabahuta