Article by Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
There is a condition called as ‘Janu Vishlesha’ mentioned amongst Vata Nanatmaja Rogas – specific and special disorders caused by aggravation of ‘only vata’. Totally there are eighty nanatmaja rogas of vata. Janu Vishlesha is one among them.
Word Meaning
The word Janu Vishlesha is made up of two terms – Janu and Vishlesha
Janu = Knee joint
Vishlesha means feeling of looseness, which also means instability. Other meanings of the term vishlesha are –
– Separation, separate from
– Falling asunder / apart
– Dissolution – Destruction by breaking down
– Disjunction – lack of consistency
– Cause to be disunited
Causes for Janu Vishlesha
1. Abhyantara Nidana: Intrinsic Causes
Kapha factor: Sandhi Bandha – binding the joints and keeping them integrated is one of the chief functions of balanced kapha. Kapha lubricates the bony joints and keeps them moist and flexible. This is brought about by the unctuous, stable and smooth qualities of kapha. The movements are easy at the joints due to the presence of shleshaka kapha – subtype of kapha, in balanced proportions. The joints give way and become loose when this kapha decreases. Kapha depleting foods and activities will hit hard on the integrity of joints. On the other hand, kapha depletion will lead to an increase of vata. This will further damage the joints by depleting the lubricating substances which are natural to those joints and bring about instability therein. When these events happen in knee joints, it may lead to janu vishlesha.
Vata factor: Vata, in its balanced and serene state is responsible for proper movements at the joints and locomotion. When vata gets aggravated in the joints it destroys kapha – the protective buffer, moistness and lubrication of those joints, due to its dry and rough qualities. The causes include vata aggravating foods and activities. Sandhi vishlesha is caused by vata aggravation in the knee joints.
Note: Vata and kapha are antagonistic doshas. Increase of one dosha would decrease the other. The other way is also true. So, vata increasing foods and activities by default would deplete kapha. Similarly, kapha depleting foods and activities would increase vata.
Pathogenesis of Janu Vishlesha, Kapha Kshaya and Vata Vriddhi link
Integrity and lubrication of any joint including Janu Sandhi – knee joint is brought about by balanced kapha located in the joints, mainly shleshaka kapha – joint specific subtype of kapha. The movements and flexibility and involvement of joints in locomotion is brought about by balanced vata. As long as the relationship of kapha and vata involved in joint integrity and functioning is balanced, the joints are stable and healthy. When there is a proportional imbalance of these two doshas, especially kapha decrease followed by vata increase or vice versa, there occurs laxity or feeling of looseness in the joints and a feel of ‘joints giving way’. This is called ‘Janu Vishlesha’.
Medo Upadhatu factor
Snayu – ligaments (and tendons) and Sandhi (joints) are the upadhatus – sub-tissues of medo dhatu (fat tissue). Both these components are affected by knee instability. So, one should keep a check on the body weight. Being overweight or obese may be a risk factor and may cause severe pressure on the ligaments around the knee joint and the joint itself so as to cause instability and painful conditions of knee joint.
2. Bahya Nidana – External Causes
Injury factor – vata and rakta aggravation
Tears and injury to the ligaments in and around the knee joint is the main cause for janu vishlesha vis-à-vis instability of the knee. Injury is an extrinsic factor which later leads to aggravation of vata. Injury also causes aggravation of rakta.
Ati Vyayama – as nidana
Ati Vyayama – excessive exercises and physical activities beyond one’s capacity is the chief cause of trauma, compression and vata aggravation in the knee joint which may in turn lead to janu vishlesha.
3. Bahya-Abhyantara Nidana – External and Internal Causes
Majjavaha Srotas factor
Asthi – bones and Sandhi – joints are the roots of the majjavaha srotas – channels transporting / or responsible for formation and maintenance of bone marrow. Utpesha – crushing injuries, abhighata – accident, trauma and prapeedana – compression are the important causes for contamination of majjavaha srotas. These are also the chief causative factors for knee instability. Viruddha Ahara – consumption in excess of mutually incompatible foods and Ati Abhishyandana – being filled with wet components / kapha are the intrinsic causes for contamination of majjavaha srotaas. A combination of both these factors involved in the pathogenesis occurring in the bones and joints involving the knee joint may cause pain and instability related to janu vishlesha vis-à-vis knee joint / joints.
Vatarakta Link
In the disease vatarakta, vata and rakta are individually aggravated due to their individual aggravating factors. In the later part of pathogenesis, vata and rakta mutually afflict each other and cause the disease vatarakta. This condition is caused by a mixture of intrinsic and extrinsic factors as explained in the nidana of the disease. Injury is the common extrinsic factor for aggravation of both vata and rakta. When injury is the common factor aggravating vata and rakta along with their individual aggravating factors, they may come into the way of each other and cause a condition called vatarakta. This condition can cause painful conditions of the joints. When this pathogenesis occurs in the knee joint / joints, it may cause joint instability along with pain and other symptoms of vatarakta. In this condition, knee joint will not be the only joint afflicted.
Sandhi Vikriti: Joint diseases and deformities
Many joint disorders, mainly those which are chronic, would cause janu vishlesha – knee instability in the long run. They include –
Janu Sandhigata Vata – popularly compared to osteoarthritis, also affects the knee joints and is one of the disorders which might cause knee instability i.e. janu vishlesha in the long run. This is a vata disorder wherein aggravated vata localized in the knee joint causes sandhi nasha – destruction of the joint including the destruction of ligaments, tendons, sinews and the entire joint causing janu vishlesha. Shula – pain and Atopa – sounds / swelling in the joint are the other symptoms. There is also difficulty in movements at the knee joint, mainly prasarana – extension and akunchana – flexion of the knee joint.
Amavata – often correlated with rheumatoid arthritis, is a disease caused by a vicious combination of ama and vata. It is a systemic disease which starts from the gut and ends by affecting the musculoskeletal system. Among the multiple joints it affects, the knee joint is also the one. Apart from pain and swelling of the joint, it may also cause janu vishlesha.
Vatarakta – often correlated with gouty arthritis, is also a systemic disorder which in due course of time afflicts the joints. The pathogenesis of vatarakta has been explained above. It is one of the causes for Janu Vishlesha.
Though ‘janu vishlesha’ has not been directly mentioned among the symptoms of any of these conditions, the condition occurring in the process of these diseases can be inferred through their pathogenesis and also from the perspective that vata is involved in all these diseases and all of them do affect the knee joint.
Modern Perspective of Janu Vishlesha
Signs and symptoms of knee instability v/s Janu Vishlesha
Instability of the knee joint is the main symptom of ‘knee instability’. Janu Vishlesha too means the same.
Signs and symptoms of ‘knee instability’ are relatable to the symptoms of vata aggravation.
Popping sound, sudden and severe pain, swelling, inability to bear weight and sensation of joint looseness or instability – which are the signs and symptoms of ‘knee instability’, which are also the signs and symptoms of ‘vata aggravation’. All these symptoms are also part and parcel of janu vishlesha.
The same are also the symptoms of ‘sandhigata vata’.
‘Janu Vishlesha’ can be correlated with a condition called ‘Knee Instability’ explained in modern medicine. The symptoms of knee instability which follow injury are caused by aggravated vata.
Treatment Principles of Janu Vishlesha
Nidana Parivarjana – Since Janu Vishlesha is mainly caused by vata aggravation, all etiological factors leading to it shall be kept away. Mainly, one should be cautious about their nature of work especially if it is ‘injury prone’ work and also excessive and vigorous physical activities, including sporting. Any injury or insult happening to the knee joint should be immediately addressed with suitable interventions.
Vata and Kapha balancing – The key to treat Janu Vishlesha will be to bring vata and / or kapha to a state of balance and also to bring about their relative balance.
Since vata is the chief dosha involved in the causation of this condition and is also a vata nanatmaja roga, the medicines, therapies and dietetic protocols meant to treat vata rogas are also applicable here.
Dealing with Medo Vriddhi – Fat increase, obesity or being overweight would impart extreme pressure on the knee joint as it is an important weight bearing joint and cause damage to the joint, and related structures i.e. muscles, bones, ligaments, tendons and blood vessels get injured and consequently damaged. Weight management is the key strategy in this condition.
Dealing with sandhi vikriti
Diseases like vatarakta, sandhigata vata or amavata afflicting the knee joint shall be effectively handled with suitable interventions. This will check the further damage to the joint. Further the knee joint may be strengthened by balya and brimhana treatments and medicines.
Dealing with asthivha and majjavaha sroto dushti and gata vata
Contamination or damage to channels related to asthi – bones and majja – bone marrow can cause janu vishlesha. Similarly, it may also be caused by conditions like asthigata vata or majjagata vata – aggravated vata localized in bones or bone marrow respectively and shall be dealt accordingly.
Balya, Brimhana and Rasayana Chikitsa
To strengthen the knee joint and to enhance stability therein, balya – strengthening, brimhana – bulk promoting and rasayana – anti-ageing / rejuvenation medicines and foods should be administered.
1. Bahya Chikitsa – External therapies
Below mentioned external treatments will be helpful in strengthening the knee joint and also in reducing the symptoms of sandhi vishlesha and also would balance the vitiated vata.
– Abhyanga – massage with herbal / vata mitigating oils
– Swedana – sudation – patra pinda sweda, shashtika shali pinda sweda
– Swedana – sudation – patra pinda sweda, shashtika shali pinda sweda
– Janu Vasti – oil pooling around the afflicted knee joint / joints
2. Abhyantara Chikitsa – Internal medicines
The internal interventions for janu vishlesha are as below mentioned –
– Sneha pana / Snehana – oral consumption of medicated fats, mainly ghee or ghee and oil – like Guggulutiktaka Ghrta, Ashwagandha Ghrta etc.
– Vasti – enema with medicated ghee / oil or both – using the same medicines mentioned in Sneha pana
Beneficial formulations
– Maharasnadi Kashayam
– Sahacharadi Kashayam
– Dhanwantaram Kashayam
– Rasnasaptaka Kashayam
– Guggulutiktakam Ghrtam
– Ksheerabala Taila
– Yogaraja Guggulu
Beneficial Yoga Postures
– Utkatasana – Chair pose
– Virabhadrasana II – Warrior II Pose
– Ardhachandrasana – Half moon pose
– Utkata Konasana – Goddess Pose
– Prapadasana – Tip Toe Pose
– Ardha Purvottanasana – Reverse Table Top
– Balasana – Child’s Pose
– Dandasana – Staff / Stiff Pose
– Sethu Bandhasana – Bridge Pose
– Janu Shirsasanan – Head to knee forward bend
– Utthitha Parsvakonasanan – Extended side angle
– Malasana – Garland Pose
– Paschimottanasana – Seated Forward Bend
Modern Correlation
Janu Vishlesha can be correlated with a condition explained in modern medicine named ‘Instability of Knee Joint’, by meaning and also by similar clinical presentation.
Knee instability is mostly caused by injuries or complications affecting the ligaments within the knee joint. It presents as a sensation of ‘giving out’ or ‘buckling’ of the knee joint, mainly when the joint is subjected to pressure. It happens when the ligaments around the knee joint fail to hold the bones making the knee joint in place securely. This eventually results in a wobbly feeling while bearing weight on the knees. Tears of ACL, MCL and PCL majorly contribute to the knee instability. Apart from tears and injuries, it may also be caused by various activities related to lifestyle – like twisting, jumping or sudden stops etc. Knee osteoarthritis, patellar instability, knee strains and sprains, gout, infection of knee joint, meniscus tear or bursitis may also cause knee instability.
The chief symptoms of knee instability include loud popping or snapping sounds in the joint, sudden and severe pain manifestation, feeling of looseness of the knee joint, inability to bear the weight on the affected joint and swelling.
Related Reading – Knee Instability
