In human body 107 Marma are classified on the basis of structural, regional, dimensional and numerical classification. The knowledge of Marma was depicted in vedopanishads and puranas. It is advised not to injure these Marma points because on injury it may lead to deformity, pain or death as the vital energy (prana) is residing in the vicinity of these points. Hence it is said that the surgeon who is having the knowledge of Marma can operate well without complication.

In Ayurveda the role of Sushruta is most important, his description about Sharir is considered as best in all. Marma is unique concept of Ayurveda but the description present in Ayurvedic literature is based on the limited practical information present in that old era.

These ancient parameters cannot be applicable in today’s modern scientific word. Therefore it is important to understand the concept of Marma and prove it practically by showing its exact anatomical location and position on the body.

Keeping in mind aim and objectives, this research especially highlights about the The Gulpha Marma and study of its Rujakaratwa. To carry out this concept first the detail literature about Marma is reviewed. Simultaneously related modern literature is also studied in details. With the help of both the review, it is our attempt to corelate the Ayurvedic concepts with modern terminology.

Discussion on the basis of literature review

Study of Gulpha Marma and all related to it, has been carried out by collecting references from different Ayurvedic texts and modern Anatomy text books and studied critically and analysed.

The oldest reference about Marma is found in Rigveda. Along with Rigveda there are several references regarding Marma in Yajurveda, Ramayana, and Mahabharata etc. Sushruta being a surgeon described the Marma in detail with their numbers, type, sizes, locations, effects of injury etc. Whereas Charak gives the description about only three Marma Hridaya, Shir and Basti called as base of the body and other all Marma are dependent of these Marma.

Sushruta stated that Marma is a site in the body where Mamsa, Sira, Snayu, Asthi, and Sandhi are combined together and considered it as a location of prana that is life. Whereas Vagbhata stated that, Marma  is a point in the body when given pressure from outside causes pain, tenderness and show abnormal pulsation.

From these we can say that Marmas are related to the vital parts of body and has energies of the body. This connects the body, mind and prana. According to modern science vital organs or part of body is an organ that is essential function in the living such as heart, brain, and lungs etc. The concept of tripod of life given by modern science is similar to the trimarma concept of Acharya Charaka. Though Marma are uniquely described in Ayurveda, the vital organ or parts are most important in both the sciences.

The Marma composed of five structures or factors they are mamsa, sira, snayu, asthi and Sandhi, Laghu Vagbhata added a Dhamani factor to this group.

Gulpha Marma is one among Sandhi Marma and Rujakar Marma. Its size is mentioned as two angulas( Swa angula).
Discussion on Location of Marma

The Gulpha Marma lies in the Gulpha region, the detail discussion of this point is as follows:

The word Gulpha means where the Pada (foot) and Jangha meet together or the part of body where the foot is connected with the leg.

According to Dr. Ghanekar, Gulpha is ankle joint includes tibiofibular and talocrural articulation, when there is any injury on Gulpha there may be symptoms like: Ruja, stabdha padata, and khanjata.

According to Amarkosh Gulpha means Padasya granthi.

According to modern literature the ankle, or the talocrural region, is the region where the foot and the leg meet. The ankle includes three joints: The ankle joint, proper or Talocrural joint, Subtalar joint, and Inferior tibiofibular joint. The movements produced at this joint are dorsiflexion and plantar flexion of the foot. In common usage, the term ankle refers exclusively to the ankle region. In medical terminology, "ankle" can refer broadly to the region or specifically to the talocrural joint.

The main bones of the ankle region are the Talus (in the foot), and the Tibia and Fibula (in the leg). The talus is also called the ankle bone. The talocrural joint is a synovial hinge joint that connects the distal ends of the Tibia and Fibula in the lower limb with the proximal end of the Talus. The articulation between the Tibia and the Talus bears more weight than that between the smaller Fibula and the Talus.
My first aim of study is to determine the exact anatomical location of Gulpha Marma according to Ayurveda and modern science.

So after comparing the Ayurvedic and modern view & performing the dissection we concluded that the exact location of Gulpha Marma is nothing but the joint between tibia, fibula and talus and other structures related to lateral aspect of Ankle joint.

Structural study of Gulpha Marma shows 5 compositions as is correlated as:

Mamsa-  Fibularis (peroneus) longus, fibularis brevis, superior fibular (peroneal) retinaculum

Sira-  Perforating branch of Fibular (peroneal) Artery, Fibular nerve

Snayu- Lateral ligament of the ankle which consists of three separate ligaments:

     1. Anterior talofibular ligament, a flat weak band
     2. Calcaneofibular ligament
     3. Posterior talofibular ligament.

Asthi – Tibia, Lateral malleolus of Fibula and Talus.

Sandhi - Joint between Tibia, Fibula and Talus.

As we know Gulpha Marma is Rujakar Marma and after Aghat over Gulpha Marma symptoms appears Ruja (pain), Stabdhapadata (restrictedmovement) and Khanjata (functional deformity). According to Severity Khanjata is most severe symptom of aghata over Gulpha Marma.

The articulation between the tibia and the talus bears more weight than that between the smaller fibula and the talus. So after aghata over ankle joint maximum chances of injury in lateral side or fibulotaller joint as tibiotalur joint is more stable than fibuatalur joint .and lateral collateral ligament is weaker than medial collateral ligament. So the Ruja on the lateral side is more than medial side.

A sprained Ankle is nearly always an inversion injury involving twisting of the weight bearing planter flexed foot. The lateral ligament is injured because it is much weaker than the medial ligament that resists inversion at the Talocrural joint.

Sushrta as classified Gulpha Marma as Sandhi Marma and if any type of injury occurs over Gulpha Marma than maximum chances of joint injury and main symptom appears that is pain i.e Ruja so it is a Rujakar Marma.

Ankle sprain is the term used for ligament injuries of the ankle joint. And ligaments are making stable the joints. Commonly, it is an inversion injury, and the lateral collateral ligament is sprained. Sometimes, an eversion force may result in a sprain of the medial collateral ligament of the ankle. This condition gives rise to tremendous pain which is associated with all joints. But there is high prevalence in ankle Joint. So it is clear that ankle sprain is ligament injury and ligament is important part of Sandhi so if ligament is injured than the chances of Sandhi injury increases.

On the Basis of Composition of Marma

Aacharya Sushuruta has defined Marma as the site where “Mamsa, Sira, Snayu, Asthi, Sandhi sannipata, teshu svabhaavath eva Praanasthistanti.” It means Marma is a not individual structure actually Marma is a group of structure which contains Mamsa (muscles) Sira (vein, artery, nerve) Snayu (ligament) Asthi(bone) Sandhi (joint) and where they meet to together that can be said Marma.

According to the predominance of these structures the Marma also differs. As we know Gulpha Marma is a Sandhi Marma and Rujakar Marma so this Marma is a Sandhi predominant Marma, but other structures are also (Mamsa, Sira, Snayu and Asthi) involved in the Marma. Some experts are of the opinion that it does not mean that all the structure may be collectively present at the site.

After detail study of Ayurvedic and modern literature and dissection it  is concluded that Gulpha Marma which is a Sandhi Marma is situated at the junction of Pada (foot) and Jangha (leg) is called Gulpha or Ankle joint.

In my point of view Sandhi Marma means if there is any trauma (aghat) or injury at ankle region that directly affect the (Gulpha sandhi) Ankle joint,  in other words at ankle region any type of  injury causes easily injury to Sandi (ankle joint).

Discussion on Pramana:

Pramana of a Marma is so important that the surgical operations should be performed after considering the measurement of the marmas so as to avoid them. Even an injury to its borders may lead to deformity or loss of function. All Marmas have been explained in terms of definite pramana in samhitas it helps in the determination of location of the marma.

Among 107 Marma only 2 Marma having two angula (svanguli) pramana these are Gulpha and manibandha. Over these two Marma both are Sandhi Marma and Sushrut told that location of  manibandha in wrist joint same as Gulpha in adhosakha and both are rujakar Marma.

Angula pramana of Gulpha Marma means, that area where there is maximum chances of injury to the Gulpha Marma . And in ankle region maximum chances of injury is at the lateral side because of weaker lateral collateral ligament.
Discussion on the Basis of Observational Study

To study clinical aspects of Ankle sprain thirty (30) numbers of patients were examined according to criteria of assesment given in material and method.

The observation and findings are given below.

Study of patients according to Age wise distribution reveals that 10   (33.33%) patients belongs to age group of 10-20 years. In this study highest incidence of ankle sprain is in the 10 to 20 year age group.

Religion plays no role in ankle sprain

According to occupation more cases are registered from working group, most of them were having sedentary life style, sitting job in office, but over travelling also.

Marital status of patients plays no role in ankle sprain.

According to Prakruti vata kaphaj Prakruti is more prone for ankle sprain.

After examining the patient according to symptoms 30 (100%) patients are founded having symptoms of Ruja (pain), Stabhdhapadata (restricted movement), not any patients are observed having lakshana of Khanjata (functional deformity).

Most of the ankle sprain patient having ankle sprain due to forcefully inversion twisting of the ankle joint. And only 25% having eversion injury.

On the basis of symptoms most of the patients are found to have distressing and horrible type of pain according to VAS scale, as it is the most common symptom of ankle sprain.
It means most of the patients having sprain of the lateral side of ankle sprain and lateral collateral ligament got injured.

Study of patient according to site of pain (25) 83.33 % patient were having maximum tenderness at lateral side of the ankle region and (5) 16.66 % patient were having symptoms at medial aspect of the ankle region.

Result

Maximum pain intensity found in ankle sprain patient measured by vas scale was over lateral side of the ankle region.

After examining the patients, 20% were having mild pain, 30% were having moderate pain and 50% were having severe pain.

Discussion Based On Clinical Anatomy & Viddha Lakshana

Ankle sprains are one of the most common sports injuries, almost millions people are evaluated each year for ankle sprain and account for 25% of all sports related injuries. Over all, incidence of ankle sprain is 2.15 per 1000 person per year and is highest in the 15 to 19 years  age group. The ankle is usually injured by indirect violence. Although the mechanism is described as if the foot moved on a fixed tibia, but in practice ankle fracture always occur whilst the tibia moves along with the body.

Adduction (Inversion) Injuries

Adduction injuries are commoner than abduction injuries as the foot is more stable in aversion, when the foot is forcefully deducted.

1st degree –There is partial tear or rupture of the lateral ligament. This is a very common injury and is often called sprain of the ankle. The mortis is absolutely stable in this condition. Occasionally the tip of the fibula may also be avulsed.

2nd degree- With continued adduction or inversion upwards from the medial angle of the mortis the mortis is now unstable causing medial shift of the talus

3rd degree – Due to forward movement of the tibia with the momentum of the body, the posterior fragment of the tibia fractured leading to complete diastases.

Vidhhalakchana of Marma

If the Sandhimarma is injured the person feels as through the injury site is covered with full of thorns. There will be shortening of the limb even after healing the wound. It may also lead to marked decrease in mobility and strength. It may also cause emaciation, lameness and swelling in the joints.

Further Scope for The Study

The study can be taken as the clinical study. The injured cases related to Marma point can be taken from the trauma centres and military hospitals.

Practical importance of a particular Marma can only be experienced by taking guidance of Marma practitioner.

Ankle sprains are most common sports injuries in foot ball players. Almost million people are evaluated each year for ankle sprain and account for 25% of all sports related injuries. So this study can be used for the sports injury treatment.