Anterior Cruciate Ligament (ACL) tears are frequently managed surgically in conventional medicine; however, some patients seek alternative treatments due to personal preferences or contraindications. This case presents a 55-year-old male who suffered a high-grade complete ACL tear following a road traffic accident and fall. Despite recommendations for surgical intervention from multiple allopathic surgeons based on Magnetic Resonance Imaging (MRI) findings, the patient opted for an integrative approach combining Ayurvedic herbal and Panchakarma therapies with physiotherapy. The Ayurvedic treatment aimed to reduce inflammation, promote tissue regeneration, and enhance joint stability, utilising herbal medicines and therapeutic procedures such as snehana (oleation), basti (therapeutic enema), alepa (external application), and upanahaswedana (poultice). Concurrently, physiotherapy focused on strengthening the surrounding musculature, improving Range of Motion (ROM), and enhancing functional mobility. Over the treatment period, the patient experienced substantial pain relief, reduced knee swelling, and significant improvement in functional ability, enabling a return to daily activities without surgical intervention. This case underscores the efficacy and feasibility of an integrative approach in managing ACL tears, providing a holistic non surgical option for patients who are reluctant or unsuitable for conventional surgical interventions.
Joint stability,Oleation,Physiotherapy,Therapeutic enema
Case Report
A 55-year-old male patient came to the Outpatient Department (OPD) of Kayachikitsa with the chief complaint of chronic pain and swelling in his right knee joint, along with difficulty in walking, standing, sitting, and climbing stairs since seven months. The patient gave the history of road accident and fall in two feet deep trench seven months back. Patient told he stood up immediately after the fall and twisted his right knee. He immediately took the allopathic surgeon, consultancy and have been suggested MRI investigation. On investigation, MRI showed high-grade complete tear involving the proximal segment of the ACL, along with other abnormalities. The patient took advice of various surgeons, all of whom suggested that surgery was the only option. However, the patient was not willing to undergo surgery, so he approached Ayurvedic treatment and visited the OPD.
An examination of the patient was done [Table/Fig-1,2].
Ashtavidha pariksha (eight fold examination).
| S. No. | Pariksha | Findings |
|---|
| 1. | Nadi (pulse) | 80/min (slightly elevated due to pain) |
| 2. | Mala (stool) | Once in a day, regular, Nirama (no mucous) |
| 3. | Mutra (urine) | 5-6 times/day |
| 4. | Jivha (tongue) | Nirama (not coated) |
| 5. | Shabda (voice, speech) | Spasta (clear) |
| 6. | Sparsha (skin/touch) | Anushnasheeta (normal) |
| 7. | Drika (eyes) | Prakrita (No pallor/Icterus present) |
| 8. | Akriti (physical appearance) | Madhyam (medium) |
Dashvidha pariksha (ten-fold examination).
| S. No. | Pariksha | Findings |
|---|
| 1. | Prakriti (Constitution) | Vata-pitta |
| 2. | Vikriti (Pathological state) | Vata-dosha, Asthi-Majja-dhatuACL tear, Swelling, and pain in the knee |
| 3. | Sara (Excellence of tissues) | Mamsa Sara (Good muscle tone, but injured due to tear) |
| 4. | Samhanana (Compactness) | Medium built, good muscle mass but currently impaired by injury |
| 5. | Pramana (Measurement) | Height: 162 cm, Weight: 64 kg |
| 6. | Satmya (Adaptability) | Adapted to a pure vegetarian diet, moderate exercise routine |
| 7. | Satva (Mental strength) | Good, cooperative, motivated for recovery |
| 8. | Ahara Shakti (Digestive power) | Good appetite, regular bowel movements |
| 9. | Vyayama Shakti (Exercise capacity) | Limited due to injury, previously moderate activity level |
| 10. | Vaya (Age) | Madhyamavastha (55 years) |
Upon knee examination, swelling (grade III) and tenderness (grade III) around the knee were present, with limited ROM due to diffuse pain and injury. The Lachman test, anterior drawer test, and pivot shift test [1] were positive, indicating an ACL tear.
Investigation/radiological examination: Standard tests, such as Complete Blood Cont (CBC) and blood sugar measurements, were within normal ranges.
An X-ray showed no significant abnormalities. An MRI confirmed a high-grade complete tear involving proximal segment of ACL with retraction of torn end, associated with mild bulking of PCL. Mild anterior tibial translation for the distance of 6 mm was also observed, along with moderate soft-tissue oedema involving the proximal 2/3rd of the right leg. Additionally, there was mild to moderate joint effusion with periarticular soft-tissue oedema.
Diagnosis: The MRI confirmed the case of an ACL tear.
After completion of total of 21 days of treatment protocol [Table/Fig-3,4,5], patient achieved full ROM in the knee and was able to walk without pain or instability [Table/Fig-6,7] [2].
| Bahiya Chikitsa (External treatment) |
| 1. | Local Snehan, swedana | Murivienna oil | 15 days |
| 2. | Janu Basti | Murivienna oil | 15 days |
| 3. | Upanaha sweda | Kottamchukadi churna | 21 days |
| Abhyantara Chikitsa (Internal medicine) |
| 1. | Lakshadi Guggul with mustamarmani kashay | 500 mg with 30 mL kashay BD after meal | 21 days |
| 2. | Asthisamhruta (Hadjod) tablet | 500 mg with milk BD | 21 days |
| 3. | Gandha Taila | 10 mL with milk at bed time | 21 days |
| Physiotherapy |
| Open chain ROM (leg extension, ankle, hip exercise) | 10 days |
| Leg press, lunges, static cycling, leg curl, strengthening exercises | 10 days |
Upanaha Sweda and Janu Basti.
| Criteria | Grade-0 | Grade-I | Grade-II | Grade-III |
|---|
| Pain | No pain | Mild pain | Moderate pain | Severe pain |
| Tenderness | No tenderness | Mild-patient complains pain | Moderate- winces with pain | Severe-don’t allow to touch |
| Swelling | No swelling | Mild swelling | Moderate swelling | Severe swelling |
| Limitation of flexion | No limitation of flexion (flexion ≥135°) | Mild limitation flexion (flexion <135° but ≥90° | Moderate limitation of flexion (flexion <90° but ≥45°) | Severe limitation of flexion (flexion <45°) |
| Crepitus | No crepitus | Mild crepitus | Moderate crepitus | Severe-even with slight joint movement |
| Joint instability | No instability | Mild instability (appreciable by patient but not elicited on clinically) | Moderate instability (elicited clinically) | - |
| Limitation of extension |
| Full extension to 0° possible- Normal | Full extension to 0° not possible- Restricted |
| Assessment criteria | Before treatment | After treatment |
|---|
| Pain grade | III | 0 |
| Tenderness grade | III | 0 |
| Swelling grade | III | 0 |
| Flexion limit grade | III (40 degree) | I (130 degree) |
| Extension limit grade | Restricted | Normal |
| Joint stability grade | II | I |
| Crepitus grade | II | 0 |
| Lachman test | + | - |
| Anterior drawer test | + | - |
| Pivot shift test | + | - |
During both 1st and 2nd follow-ups, the patient was able to walk without pain and instability, with noticeable improvement in the movement of the knee joint. 1st follow-up of the patient was taken on 30 days after treatment, and last follow-up was taken 60 days after treatment.
Discussion
Ligaments, tendons, and corresponding muscles keep the knee joint stable. Between 25% and 50% of knee injuries are caused by ACL damage [3]. It is believed that the main passive restriction on tibial anterior translation with respect to the femur is the ACL. The ACL, due to its specific position, enhances knee rotational stability in the frontal and transverse planes [4]. A pop is frequently heard, followed by pain; the knee becomes oedematous due to blood from the cruciate ligament haemorrhage and effusion, and knee pain develops. The diagnosis is confirmed by computed tomography, MRI, or X-rays [5]. Management of ACL injury mainly suggests ligament repair by invasive surgical procedures. In this case, the patient was not willing for surgery so he approached for Ayurveda treatment.
According to the signs and symptoms, an Ayurveda treatment protocol for Snayugatavata can be followed, as described under vatavyadhi. The first detailed description of Sanyugata Vata is provided by Vāgbhata and Acharya Sushruta. They establish a number of therapeutic procedures, including Snehana (oleation), Upanaha (poultice), Agnikarma (therapeutic heat), Bandhana, and Unmardana [6]. Janubasti (knee oil pooling) with Murivenna oil, followed by local oleation and steam, is adopted to give stability to the knee joint by its potential effects. Murivenna oil has shown its potential in promoting healing and tissue repair by alleviating pain, reducing inflammation, and improved joint mobility [7]. Kottamchukadi churna Upanaha Sweda, the application of a warm herbal poultice directly on the affected area, is a combination of herbs like Musta, Eranda, and Rasna, which are known for their anti-inflammatory, analgesic, rejuvenating properties, and promotion of tissue repair. These herbs penetrate the skin and exert therapeutic effects on the injured tissues [8].
Lakshadi Guggul is a traditional Ayurvedic formulation known for its potential benefits in treating joint disorders. This herbal compound is primarily composed of Laksha (Purified Leadwort), Guggul (Commiphora mukul), and other medicinal plants [9]. It is reputed for its anti-inflammatory and analgesic properties, which help alleviate pain and improve joint function. Mustamarmani Kashay is used as Anupana with Lakshadi Guggul and is believed to reduce inflammation, alleviate pain, and promote healing of the ligament. Musta (Cyperus rotundus) and Marmani (various Ayurvedic herbs used in joint and tissue health) are the key components known for their anti-inflammatory and analgesic properties [10]. The Tablet Hadjod possesses significant anti-inflammatory and analgesic effects. It is known to promote bone healing and regeneration, enhancing the recovery process of bone tissues, which can be beneficial for ligament repair and strengthening [11]. Ingredients in Gandha taila, ingredients like Ashwagandha (Withania somnifera) and Bala (Sida cordifolia), help reduce inflammation and alleviate pain and swelling associated with ACL tears. where as Shatavari (Asparagus racemosus) and Laksha (Laccifer lacca) promote bone health and support the repair and strengthening of ligaments [12]. Additionally, milk enhances the absorption of the active compounds in Gandha taila and provides essential nutrients like calcium and vitamin D, which are crucial for bone health and recovery [13].
Physiotherapy done for its potential benefits by focusing on reducing pain and swelling, maintaining ROM, and preventing muscle atrophy through open-chain exercises such as leg extensions, ankle pumps, and hip abduction/adduction. Transition to strengthening exercises, including closed-chain activities like leg press, lunges, static cycling, and leg curls. Incorporate quadriceps setting, hamstring curls, and hip bridges to improve muscle strength and joint stability [14,15].
The combination of Ayurvedic oral and external therapy with physiotherapy has provided significant improvement in this ACL injury. Similar cases showing the results and improvements observed in the patient’s condition following the treatment [Table/Fig-8] [7,16,17].
Comparison of previously reported cases with present case [7,16,17].
| Author’s name and year (Reference no.) | Case presentation | Treatment | Outcome |
|---|
| Suryawanshi DP and Pawar DA 2023 [7] | A 26-year-old male, complaining of pain and swelling in his left knee joint with occasional instability for the past two weeks | Ayurvedic treatment plan includes, Nagaradi lepa, Janu basti, Bandhan, Pat rapotali sweda, Sastik shali lepa and oral ayurvedic medication for 31 days | The patient was able to walk without instability and pain and attained improvement in range of movements of the knee. |
| Ruparel SJ et al., 2017 [16] | A 38-year-old female patient, housewife, suffering from knee joint ligament tear for five years | Ayurvedic treatment plan includes, Janu basti with murivenna oil and shaman chikitsa including Rasa ausadhi | Anabolic effect on muscle and ligaments and promotes early repair and strength in knee joint. |
| Tharesa AJ, Masalekar S 2022 [17] | A 22-year-old female with complaints of pain, occasional swelling and painful flexion of the right knee joint since two years | Treatment includes, external therapy-Abhyanga with Murivenna, Visha Garbha Taila Pichu, Haridra Pottali Pinda Sweda and internal ayurvedic medication for 21 days | Improves joint stability, reduces the symptoms of pain, swelling, stiffness and rehabilitates the individual towards his daily activities. |
| Present study, 2024 | A 55-year-old-male patient complaining of chronic pain and swelling in his right knee joint with difficulty in walking, standing, sitting, and climbing stairs since seven months | Treatment plan included, local snehan, Swedan with murivenna oil, Janubasti, Upanaha sweda with kottamchukadi oil, oral ayurvedic medication and physiotherapy. Total duration of treatment was 21 days | Patient achieved noticeable improvement in grades of pain, tenderness, swelling and achieved complete strength of knee joint with full Range of Motion (ROM) and was able to perform daily activities of strenuous/non strenuous origin without pain or instability. |
Conclusion(s)
The inference from the case study on the integrated management of ACL tears is that a comprehensive approach, combining Ayurveda intervention and physical therapy, significantly improves functional recovery and long-term joint stability. Emphasising early diagnosis and tailored treatment plans, the study highlights the importance of a multidisciplinary Ayurveda approach in minimising complications and enhancing overall outcomes for ACL injury patients. Thus further research is needed to confirm these results with greater accuracy.
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