JR.A.S. Vol. XXX, No.2, April- June ·09 pp.

57-70

A PRELIMINARY STUDY ON EVALUATION OF

CLINICAL EFFECT OFAGNlKARMA CHIKITSA
ON PARSNISULA (PLANTAR FASCITIS)

G. Kusuma', A. Mitral, V. C. Deepl, P. Madhavi Kutty', P.K.S. Nair',

V. A. Prabhakaran- and N. Jaya'

(Received on 18-01-2006)

Females of late 30 S commonly hydrocortisone into the tender area is

suffer with a clinical condition called the alternate.
Parsnisula. In this condition the patient
Whereas in Ayurv e dic system of
experiences severe pain under the heel
medicine Agnikarma-an Ayurvedic para-
(parsni). The characteristic feature of
surgical procedure has been indicated
parsnisula is pain which will get
and practiced in this condition by
increased during walking or standing
ancient physicians of Ayurveda since
from sitting posture. After few steps the
centuries.
pain will get reduced.
In support of this, a preliminary
Not much description is available in
study has been carried out by Central
classical literature of Ayurveda
Research Institute, Cher uth uruthy.
regarding Parsnisula. It can be
Keral a and 30 patients in total have
compared with plantarfascitis of modern
accepted the trial procedure and
medicine based on the symptomatology.
Agnikarma therapy was performed over
Modern practitioners usually the affected heel. On the basis of
prescribe NSAID s and protect heel by clinical improvement by symptomatic
a resilient cushion on an insole. If pain observation encouraging results were
is not relieved then local injection of obtained by the study.

1. Research officer (Ayurveda), 2. Asst. Director (Ayurveda), 3. Asst. Director

Incharge. P.O.-Cheruthruthy, via shora nur, Thrissur Dist. Kerala

57
G. Kusuma, A. Mitra et a/.

Introduction prominent weight bearing part of the

Parsnisula is a common clinical calcaneus. In most cases mild inflammation
condition found especially among females of uncertain origin will be there but in some
in late 30's, In this condition .the patient cases the lesion is only a simple contusion,
experiences unbearable pain under the Pain beneath the heel extending medially
parsni (heel) (S,Sa,SI19) particularly during and into the sole on standing or walking is
walking or standing from sitting posture the only symptom. The disability is
when the weight of the body is carried by sometimes severe, On examination there
the heel and quite common during early is well marked local tenderness over the
morning after getting up from bed, site of attachment of the plantar fascia to
the calcaneus on firm palpation over the
Not much description is available in
heel pad. The site of tenderness is farther
classical literature of Ayurveda regarding
forward than it is in tender heel pad,
Parsnisula. As Vata is mainly responsible
Radiographs usually do not show any
for pain in the body, so Parsnisula can be
abnormality. There is a tendency to slow
considered as a Vata predominant disorder
spontaneous improvement. Recovery may
where characteristic pain is the cardinal
be hastened by providing a sponge-rubber
symptom.
heel cushion on an insole and by local
Parsnisula of Ayurveda can be injection of hydrocortisone or by a course
compared with plantar fascitis of modern of short-wave diathermy to the tender area,
medicine. Plantar fascitis is a common
Central Research Institute (tv.).
cause of heel pain in adults. It is otherwise
Cheruthuruthy is a reputed Institute o. the
popularly known as Policeman's heel or
area and popularly known as Institute of
tender heel pad and is characterized by pain
excellence in Panchakarma wherein
beneath the hind part ofthe heel (anterior
Panchakarma procedures are practiced
part of the calcaneus) (Fig. I0 & Fig.ll)
regularly with good results, Patients
on standing or walking from sitting posture.
suffering with Parsnisula visit to O,P,D
The cause may be a small tear in the
of this Institute very frequently,
attachment of plantar fascia to the os-
Agnikarma (a Para-surgical procedure)
calcis(Fig.9).Non specific infection from
has been indicated and practiced in
non specific urethritis or from specific
Parsnisul a by ancient physicians of
gonococcal infection may also develop in
Ayurveda since centuries, This has drawn
this condition. Sometimes a bony spur at
our attention towards the disease and made
the attachment of the plantar fascia may
us to carry out a pilot study of 6 weeks
be the cause. This mayor may not be the
treatment with Agnikarma over 36
cause of pain. The site of the tenderness is
selected patients at O,P.D level.
the tough fibro-fatty tissue beneath the

58
A PRELIMINARY STUDY ON .. ,.

Material and Methods (Sever's disease) and rupture and

paratendinitis of the tendo Achilis,
I. Selection of Patients
infracalcaneum bursitis, Rheumatism,
Those Patients were selected from local Cellulitis etc. Ski graphic views
OPD who have suffered from Parsnisula were taken for exclusion from the
(with special reference to Plantar fascitis) study.
having less than 2 years of history with all
cardinal features irrespective of age, sex, * Age below 12 years and above 60
years.
religion and occupation etc.
1.1 Inclusion criteria 1.3 Number of Patients
36 (Thirty Six)
* Age between 12-60 years.
1.4 Duration of therapy (Agnikarm«i
* Patients of either sex,
6 weeks
* With less than 2 years of history,
* With all cardinal features of the disease 2. Agnikarma Chikitsa is the method
(i.e , Tenderness, Pain, localized of producing Samyak Dagdh a
swelling, Pain increased during Vrana at diseased part of the patient.
walking from sitting posture/rest) It is a therapeutic burn, Th is
1.2 Exclusion criteria Upakrama (method of treatment) is
divided into three parts (S,Su.5/4)
* Any con com itant serious disorder of i.e. Purvakarma (pre-operative
the liver, kidneys, lungs, eye and/or preparation), Pr adhan akarma
multi-systemic involvement, i.e. (Operation proper) and
Diabetes mellitus, Chronic Renal Pasc atkarma (post-operative
failure, Bronchial asthma etc. management). Disease produced by
Vat a and Kaph a dosa may be
* Any other drug treatment being
treated successfully by this method
received simultaneously that influenced
of treatment.
the positive study outcome.
2.1 Purvakarm a (Pre-operative
* Without clear signs and symptoms,
proced ure/preparotions)
* Other related cases like fracture or
Collection of the materials required
diseases of Calcaneum (Osteomyelitis
or tumor or Paget's disease) ,arthritis for the Agnikarma therapy forms the
of the subtaloidjoint, Calcaneum Spur, prime pre-reqisite. Panchaloha
Tendo Achilis bursitis, retrocalcaneum Shalaka, Patra of Ghritakumari
bursitis, Apophysis of the Calcaneum (Aloe vera) and mixture of Ghrita

S9
G. Kusuma, A. Mitra et al.

and Madhu is kept ready prior to the The total procedure may be
actual procedure. continued for maximum 15 minutes
and the sittings of Agnikarma Chikitsa
Localized anti-septic dressing
(ASD) of affected part of the patient varies depending on the severity and
was done every time before principal chronicity of the disease and
procedure. Patients were allowed to patient's condition. Agnikarma was
take langhu ahara (light food) 30 done in 6 sittings. I sitting per week
minutes before the actual procedure i.e.6 sittings in 6 weeks.
to avoid fasting condition and
associated weakness. 2.3. Paschatkarma (Post-operative
procedure)
2.2.Pradltallak(lrma (Principal
procedure) As per guidelines of Susruta
(S.Su.12/13), mixture ofGhritaand
After anti septic dressing (ASD), the
Madhu (may be due to its soothing
proper procedure i.e.Agnikarma
effect) is anointed over the heel after
Cikitsa was done with Shalaka made
the principal procedure.
up of Panchaloha (Gupta P. D.,)
1993) as panchaloha Shalaka is said
2.3. Assessment criteria for evaluation
to be ideal produce Samyak
Dagdha Vrana (S.Su.12/8).
Panchaloha Shalaka was kept on The results were on before
fire and heated red hot and applied treatment, 14u1 day, 28 day and after
th

nd
over the affected area or diseased treatment (42 Day). The four
part i.e. hee I frequently to produce cardinal signs & symptoms were
Samyak Dagdha Vrana along with the taken for assessment Iike Pain in
application of the pulp of morning, tenderness of heel, typical
Ghritakumari (Aloe vera) in pain increased when standing/
between to prevent burns if excess walking/ running after getting up
heat is applied and to reducedagdha from sitting posture and localized
Vedana(burning pain). The type of swelling. The clinical improvement
Agnikarma adopted is of disease condition was evaluated
Twakdagdha S.Su.1217) and is done on the basis of signs and symptoms
in Bindu Akriti or dot pattern(S.Su.12/ by means of arbitral)' scoring index,
II). This method of Agnikarma where 04 indicated severe and 03
Chikitsa is result oriented having no indicated marked or fair, 02 indicated
complication and easy to carry out. moderate, 0 I for mild or poor and 0

60
A PRELIMINARY STUDY ON. .....

for nil or none. The results were
evaluated before treatment, 14thday,
28th day, and after treatment (42nd
Day).
Observation & Results
1. Demographic data
1.1. Age & sex ratio
Total 36 patients were selected for
this present study where 30 patients
have completed the 28 days trial. All
patients were female (J 00 %) and
no male patients have been seen.
Most of patients (J 4 cases) were
belongs to middle age group (31-40
years) in the pre-menopausal age
(fig. J).
1.2 Religion wise classification
From the present study it is observed
that 76.6 % patients belong to Hindu
community and 23.4% patients are
from Muslim community (fig.2).
2. Symptomatological assessment
of treatment. Pain in rest and
morning had been reduced
significantly after treatment (p<
0.00 I) when compared with 0 day
value (Table-I,fig.3). One of the
most common objective criteria of
(plantar fascitis) is tenderness of
heel. It was also scored oy armtrary
index and treated patients have got
highly signification response (p<
0.001) when compared with the
value of before treatment(Table-II
figA). It is also observed that treated
patients have got good response
from typical pain increased when
walking/ running after sitting or
resting posture. Treated patients
have got significant response (p <
0.001) when compared with 0 day
Value (Table-III, fig 5). Treated
patients also have got very good
response from local swelling or
edema (p<O.O1) when compared with
oday value (Table-Iv, fig.5 & 6).

The signs and symptoms were

assessed by the scoring index on 0
day, J 4th day, 28th day and 42nd day
Christian
12-20 Years 0%
51-60 Years 0% 21-30 Years Muslim Others
13'Y<~20%
23~

-:.:
41-50 Years
20"/0

31-40 Years
47% 77%

Fig 1: Age- Sex ratio of trial cases of Fig 2: Religion wise demographic data of
Parsnisula Parsnisulu cases
61
G. Kusuma, A. Mitra et al.

Table I : Clinical improvement of tenderness of heel in Parsnisula cases

o day 7th day 14th day 21st day

2.57 ± 0.160 1.83 ± 0.128* 1.03 ± 0.148* 0.5 ± 0.142*

* p<O.OOI, values are mean ± SEM, where n =30

3.5

3 287

2.5 -
2.13
2 -
1.5 - It';
" 1.5

~
-
0.63
0.5 -
I
o day 7th day 14th day 21st day

Fig 3 : Clinical improvement of Local 12ed-pain in heel of Parsnisula cases

257
2.5 -I·,

2 - ~-
.,,~
E
1.5 -
1.03
- I!l

0.5
0.5 --

o "'"
;w
i!!

I ~I
o day 14th day 28th day 42nd day

Fig 4 : Clinical improvement of tenderness of heel in Parsnisula cases

62
A PRELIMINARY STUDY ON.....

Table III : Clinical improvement of typical pain in standing/walking just after

sitting or laying in Parsnisula cases

o day 14thday st
21 day

2.1± 0.140 1.37 ± 0.l39* 0.90 ± 0.129* 0.40 ± 0.132*

* p<O.OO1, values are mean ± SEM, where n =30

2.5
2.1
2

1.5

09

0.4
0.5

o
o day 14th day 28th day
D
42nd day

Fig 5 : Clinical improvement of typical pain in standing/walking just after

sitting or laying in Parsnisula cases

Table IV : Clinical improvement of localized swelling in heel of Parsnisula cases

o day 14thday st
21 day

0.47 ± 0.120 0.26 ± 0.095* 0.13 ± 0.079* 0.10 ± 0.073*

* p<O.OO1, values are mean ± SEM, where n =30

0.47
0.5
0.45 -
0.4 -
113
0.35 -
0.3 -
0.26
0.25 -
0.2 -
-
tA 0.11
0.15
0.1
0.1 -
0.05 -
I
o I ~
o day 14th day 28th day 42nd day

Fig 6 : Clinical improvement of localized swelling in heel of Parsnisula cases

63
G. Kusuma, A. Mitra et al.

3.5

3
~Pain
2.5
___ Tenderness
2

1.5 ~ Typical pain

during walking
.....~....Local swelling
0.5

o
o day 14th 28th 42nd
day day day

Fig 7 : Global assessment on symptomatic in improvement in Parsnisula cases

16
-
14 -

.•... 12 -
'"
c -
CoI
.•... 10 -
C'iI
Q.,
8 -
'-
<:>
6 I---
Q
Z 4 I---

2 I---
-
0
Good Fair Response Poor No Response
Response Response
Result of the study

Fig 8: Individual assessment as per subjective scoring of Parsnisula cases

64
A PRELIMINARY STUDY ON .....

Fig 9 : Showing Plantar fascia

Fig 10 : Showing most common site (Ieteral view) of in Parsnisula

Pain
Lateral Side
often
here

() Plantar Fascia

Medial Side

Fig 11: Showing most common site (Inferior-superior view) of pain in Parsnisula

65
G. Kusuma, A. Mitra et a/.
Discussion calcanean spur, the clinician cannot infer
Plantar fascitis is an inflammation of that the calcanean spur is the cause of pain.
the plantar fascia. "Plantar" means the Very often inflammation of the soft tissue
bottom of the foot; "fascia" is a type of or a bursa beneath the spur gives rise to
connective tissue, and "it is" means pam.
"inflammation".
Heel spurs are soft, bendable deposits
Pain in the heel may be subdivided into of calcium that are the result of tension and
3 types. inflammation in the Plantar fascia
(a) Pain within the heel attachment to the heel. The plantar fascia
encapsulates muscles in the sole of the
(b) Pain behind the heel
foot. It supports the arch of the foot by
(c) Pain beneath the heel acting as a bowstring to connect the ball of
the foot to the heel. When walking and at
In conditions like fracture or disease
the moment the heel of the trailing leg
of the calcaneus (osteomyelitis or tumor
begins to lift off the ground, the plantar
or Paget's disease) and arthritis of the
fascia endures tension that is approximately
subtaloidjoint there will be pain within the
two times body weight. This moment of
heel and in tendo Achilis Bursitis,
maximum tension is increased and
retrocalcaneum bursitis, apophysitis of the
"sharpened" (it increases suddenly) ifthere
calcaneum (Sever's disease) and rupture
is lack of flexibi Iity in the calf muscles. A
and paratendinitis of the tendo achillis pain
percentage increase in body weight causes
will be behind the heel.
the same percentage increase in tension in
Whereas in infra-calcaneum bursitis the fascia. Due to the repetitive nature of
and plantar fascitis (Policeman's heel) pain walking, plantar fascitis may be a repetitive
will be beneath the heel. stress disorder (RSD). Moreover, the lesion
affects the soft tissues at the site of
Sometimes parsnisula is wrongly
attachment of the plantar aponeurosis to
correlated with Calcaneal spur. Calcaneal
the inferior aspect of the tuberosity of the
spur is a bony projection forwards from
calcaneus.
undersurface of the calcaneal tuberosity
and is usually revealed in X-Ray. It's nothing From this present study it has been
but ossification of the plantar fascia at its observed thatParsnisula or Plantar fascitis
calcaneal end. This has very little is commonly seen in female subjects
significance so far as the pain in the heel is specifically in pre-menopausal age (3 1-40
concerned. That means if a patient yrs.).Plantar fascitis is a common cause
complains of pain in the heel and on X- of heel pain in adults. The pain is usually
Ray one can find the presence of caused by collagen degeneration at the

66
A PRELIMINARY STUDY ON .....

caused by collagen degeneration at the is also revealed from this study that 15
origin of the plantar fascia at the medial patients have got excellent response, 11
tubercle of the calcaneus. This patients have got fair response whereas 4
degeneration is similar to the chronic patients have got no response on the basis
necrosis oftendonosis, which features loss of individual assessment of symptoms.
of collagen continuity, increases in ground Moreover. it is also very much cost
substance (matrix of connective tissue) and effective and cost benefited treatment and
vascularity and the presence of fibroblasts no adjuvant therapy or drugs required.
rather than the inflammatory cells usually
The probable mode of action of
seen with the acute inflammation of
Agnikarma Chiki ts a is by doing
tendonitis.
Agnikarma the Agni from the stove/gas
Conclusion flames is taken by Shalaka and it becomes
red hot. Then thisAgni(heat) is transferred
Agnikarma Chikitsa as heat therapy from the Shalaka to the Dushya-Dhatu
is practiced in parsnisula since ancient era (skin). The time taken for this transfer of
by Ayurvedic scholarsParsnisula is mostly heat is two to three seconds. The Dhatu-
simi lar to the conditions of plantar fascitis Agni in the skin becomes Utkl esita
as per clinical features. The classical sign (activated) and the disease producing Dosa
of Plantar fascitis or Parsnisula is that the becomes neutral byDosha-pachana acnon
worst pain occurs with the first few steps of the Utklesita Dhatu-Agni.
in the morning. Patients often notice pain
at the beginning of activity that lessens or So it can be concluded that local
resolves as they warm up. The pain may disorders produced by Vata dosha or
also occur with prolonged standing and is Kapha dosha are beneficially treated by
sometimes accompanied by stiffness and this result oriented method of Agnikarma
tenderness by examination associated with Chikitsa.
slight swell ing ofhee!' In the present study
Acknowledgement
it was seen that female were mostly
affected those who were belongs to pre- Authors are grateful to the Director,
menopausal may due to sudden weight gain CCRAS, New Delhi for providing
and less movement or activities. From this necessary facilities and his continuous
study it was observed that all patients have support & encouragement for innovative
got highly significant clinical improvement research. Authors are also thankful to Adm.
on the basis of subjective scoring and it may Officer & all staff of this institute and the
be concluded that Agnikarma is the right patients who have cooperated through out
solution for the treatment of Parsnisula. It the study period.
is also revealed from this study that 15

67
G. Kusuma, A. Mitra at a/.

REFERENCES
D. Singh et al. 1997 Plantar fascitis. BMJ; 315: 175-5.

D.Ojha 1993 Panchakarma therapy in Ayurveda.

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M. Wolgin et al. 1994 Conservative treatment of plantar heel

pain: long-term follow-up. Foot Ankle
Int; 15:97-102.

M. Powell et al. 1998 Effective treatment of chronic plantar

fasciitis with dorsiflexion night splints:
a crossover prospective randomized
outcome study. FootAnkle Int; 19: 10-8.

MS Mizel et al. 1996 Treatment of plantar fascitis with a night

splint and shoe modification consisting
of a steel shank and anterior rocker
bottom. Foot & Ankle International
17:12,732-735.

E. C. Huskission & Hart. F. Dubly 1978 Joint Diseases; all the Orthopedics', 3rd
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Ltd.

S. Das 2000 Manual of clinical Surgery. 5th Edition,

Calcutta, India.

B. K. Mahajan 1995 Methods in Biostatics. Japee brothers.

New Delhi, India.

Astangahri day Edited by Taraduttapanth, Chow-

khamba Sanskrit Series Office,
Varanasi, Vatavyadhi Nidanam, 15:53
2036 (B. S.)

68
 A PRELIMINARY STUDY ON .....

GuptaP. D. 1993 Agnik arma Chikitsa- Technological

Innovations Regarding Agnikarma
Salaka, Samyak Dagdha Vrana and
Useful Method of Agnikarma Chikitsa,
l.R.A.S. Vol. XIV, No.3-4, pp. 125-136,
Sept-Dec. 1993.

Susruta Samhita 2004 Translated by K. R. Srikantha Murthy,

2nd edition, Chaukhambha Orientalia,
Varanasi, Sutra Sthana 5th and 12th
Chapter.

~I;C,< ~ (Plantar Fascitis) 1R 31P"1Cf)q ~ - ~

'fHPll @Of Cf) ~ rf> ftrf¢ct1 c6h, ~ C5T
1f\t""Q jCf)"1 ~ ~~ 3T~

~. ~, ~. fl1:5rr, cfr. xt. ~, 1fi. l1tJ)fq ~R:<, 1fi. cfJ. "Cfff. -;::n<R,

cfr. ~. Wi Icp'F"I ~ ~. \jJ<IT

LITfWf ~ "CfCP ~ ~ Rlfmffll 3TCR~ t vfr ~ ~ ~ ~

~ ~ ~ gl'"lcllc1) iiffiC'll3lT -B ~ \JlTffi tI~ 3lCR~ em ~ cfJ ~
e5C'l'"l "lIT~ ~ m -B \JXlro ~.~ -B ii5fl\'H men t I cgt9 ~ ~
cfi ~ Gcf Q)1l m \JlTffi tI

~ ~ ~1I'bI'j -q ~ ~ Cf>T~ \i~~ ~ f?tC'idl I ~

~cm-"C'1T~ ~ ~ ~ WR=?f ~ ~I~'< cbffiR:fi (Plantar
Fascitis) xl gc;RT CfR ~ ~ I

69
G. Kusuma, A. Mitra et at.

~ ~ flIJiI;;q("j: NSAID's cpr f.1c{~I'1 qmf t Jftx ~ em

C"Ii?tC"llq'1~ (Resillient cushionjvl ~e:rr~ t I Gcf Cf)ll m m tR
~'RlenlR:'<fl'1 (Hydrocortisone) cfi x~ ~~~1'1 -gr fclenC'G t I
~ ~ cfi ~Fchctil ~ l) ~fT.1en4 (~ fI~~I~en ~) em
~ ~ ~ ~ -9" ~ ~ l) \3q~'PI cpr ~ ~ ~ I

~ ~ il, ~ ~ 3l~ $rs;~~ ~ ~ (~,

ih>g'Q~, ~, ~ il f$<:n lTm 3m- ~ ,<lfTltll· ~ ~ WafUT ~ em
tell enl '< fclRrr I ~ tR tR ~ fT.1en4 em f$<:n 7fm 3TR ~ 3lUfl.T'1" il
"C'1T~ -Q-afUT&RT ~fchcticB)~ XJ'tlR cfi ~ tR 3f1ctilf@en qRul(J"I ~

~I

70