Approaching Enthesitis

Approaching Enthesitis

P.K.V.Anand

Vaidyaratnam Ayurveda College

E

nthesitis has emerged as one among the frequent complaints a Vaidya attends in his everyday practice.  In spite of the vast experience in managing such peri-arthritic manifestations successfully, each of them will be keen on acquiring new clinical tips for such cases. A thorough orthopedic clinical examination helps him to pinpoint the site & structure involved. On most occasions they fit into any common patterns of joint manifestations and named accordingly.

Conventionally they are treated by anti-inflammatory agents from either English or Ayurvedic pharmacopeia, and advised rest.  The only thing which differs according to site of lesion is the orthotic supports and physiotherapy which complements the treatment.  Still, in almost all cases, a positive response is always delayed, Irrespective of the severity of the manifestation.  Leave alone the painkillers; because a sustained mild relief to permanent complete relief without them can be expected somewhere during 3 months to 2 yrs only. There are spontaneous recoveries we frequently meet with; yet, we fail to differentiate it from results of intervention.

Common enthesitis

Deqerveins

T.Elbow

Golfers elbow

Carpel tunnel syndrome

Deltoid tendinitis

Supraspinatus tendinitis

Trapezious along scapular margin or along the vertibral spines

Mastoid tendinitis

Iliac spine margine

Patellar tendinits

Achellus tendinits

plantar facietis

The structure

The structure  involved is tendon, which is a kind  of snayu. It is derived from Medas. Medas offers  strength to the tendons by offering  unctuousness. The digestive fire in Asthidhatu and Snayu Upadhatu’s converts the refined  medas to build & nourish the tendons and its junction with bones.  This activity of building, repairing and nourishing is continous throughout  life and not limited to embriyonic or juvanile growth.  Its structural and functional integrity depend largely on availabilty of (sthayi) refined medas in the body. At times when refined Medas is not optimally available to get converted as Snayu or metabolic fire in Snayu and asthi are unsound, the strength of the tendons are at stake. In most occations this related with the stagnation of unfinished medas,  may b e co-existing with obesity, arthritic manifestations, hypothyroidism, perimenopausal features, etc.  When the most prevalant age for such diseases is considered, it reminds us about Susrutha’s insight on the age related liquefaction of adipose structures in the fourth decade of life.  Chakrapani  further clarifies at another context that,  the nourishing of minute Snayus is the responsibility of medas in the body, which opens up a way to relate with fine fibers of both ligumentous and neural structures. The summary of events here is, lesser conversion from crude medas to refined medas,  and the sequential reduction of strength of tendons, ligaments and peri-arthrus structures  derived from adipose substance, which makes it vulnerable for injury and inflammation, even with any insignificant activity such as using a screw driver, squeezing wet cloth, holding a vessel by hand, etc.

In fact Siraas themselves get converted to become the Snayus, by acquiring unctuousness from Medas. The tendon, which is one type of snayu, is also directly described as Upadhatus derived from Rakthadhatu. So when ever tendons are involved, the pathology should be traced down to Rakthadhatu also. This structural background of both Medas and Raktha dhatus has a substantial influence in the re-enactment of etiopathogenesis for deriving a treatment plan in a patient.

The event

Once this structure acquires or predisposes with the above settings, the manifestations gets switched on by any minor incident, such as an apparently insignificant strain at the site or a change of weather to cold. Patients frequently recollect incidences of excessive activity at that part of the body, keeping an unusual posture for long time, exposure to cold, sunshine or breeze some days prior to its start. It may also be during a routine activity like squeezing water out of a washed cloth, a badminton play or while using a screw driver for Tennis elbow. Similarly a skipping exercise, or walking without foot wear in uneven surface, etc, might be recollected in a case of plantar fasciitis.

Both a generalized pathology and a specific predisposition are needed for the disease to keep going.  Without the former, the local injury or inflammation can have normal healing in a few days. The manifestations are either different or deferred, without a local predisposition and trigger incident.  In other words, structural inferiority and the local strain tow the pathology to its own area, which could have located anywhere else. This explanation satisfies patients who shoot questions like, this was my routine job for years together, or I had such abrupt movements earlier also, but did not have any such intense pain. In such cases, a forceful or abrupt pull becomes a trauma at those tendon insertion areas, which has already a constitutional damage, triggering an inflammatory sequence. While trauma initiates, controls and results in gross Vatha & Raktha vitiation, an easy healing doesn’t happen due to the generalized pathology prevailing. As for any illness, the treatment of enthisitis also should follow a plan generated considering all those who took part in this event depiction.

Discussing treatment plan

The treatment is of special importance in diseases of vessels, ligament structures and joints are oil application, a forceful massage, sudations, poultice, bandage and burning the site with honey, oil etc.  In most cases, oil massage is very soothing.  The choice of oil should be deliberated to add specificity.  For example, a swelling prompts the use of kottamchukkadi oil, while a history of trauma, prompts for murivenna.

A forceful massage is suitable when there is hyper tonicity, tight ligaments & muscles, reduced flexibilty of joints etc. In most occasions this is done as oil massage. In general, a hard massage is advised only in Kapha kopa, kaphavatha kopa and kevala vatha kopa. On the other hand, for enthisitis is in the background of Vathasonitha, the massage should be gentle & soothing .

Selection of right techniques for sudation in the clinical condition, is often a matter of skill & experience. We have options of various bundle massages for Kaphavatha conditions like Patrapotala, Choornapinda, Valuka, Shashtikapinda etc, with gradients like unctuousness to dryness.  Other Ushmaswedas like a steam baths or sudation with liquids like Dhanyamla or oil are advised when prompted by any Pithanubandha feature. All these techniques can be applied either locally or in general considering the disease environment.

Among all these techniques, Upanaha has the distinction of being most prospective in neuro-musculo-skeltal conditions, at all times and irrespective of manifestations. The self generated heat of active fermentation here is not often identifiable being so close to body temperature. The richness of salt, the medicine used etc, collectively dissolves the edema & inflammation prevailing and relaxes the tight structures. Discomfort of a heavy bandage, unskilled therapists, and complication of hear rashes in sensitive skin, might be the only issues that may reduce its popularity.

A simple tight bandage is always a good option. It offers a therapeutic effect by soothing the commotion, pacifying Vatha, offering immobility and providing a false support in cases of sense of weakness etc.

Agnikarma offers Remarkable results in enthisitis

Agnikarma is another remarkable procedure in the context. The pain relief is often instantaneous here. The popular technique of administration is to make burns with a Salaka. As a partial destruction followed by repair of structures adjacent is effected, the cure is immediate and complete. It appears that the local steroid injections used in this context could be accepted as a kind of Agnikarma.

Internal medications 

If enthesitis is to be considered merely as a local pathology, a general healing agent would be sufficient for internal use. Instead, understanding this local pathology as a reflection of the systemic environment is the wise option. The treatment principles of Vathasonitha, Aamavatha, Sandhigathavatha and Kshathaj vidradhi are to be employed here. The Aama is so relevant here that, swedana and the medications of conventional practice does’nt appear fast responding. In most instances, the time period is the Aamapachana factor makes a surprising spontaneous recoveray after a time period, even without any intervention. By this charector of the disease, there is a say among orthopeditions about the patients shifting from one doctor to another, “always the last orthopedition bags the credit”. The most prescribed medicines are Guggulu preparations. But the currently prescribed doses are much below the textual advice of one Karsha. This may be due to various reasons like it is considered as just an adjunct, or Prakshepadravya for the medicine, Vaidya is not serious about the dose required, lack of accommodative space in a long list of medicines or It may not be just not suitable to situation. However Guggulu is the primary choice of internal medicatio n that it fits to a clinical condition where, medas, ama, vatha, kshatha, raktha snayu, kandara etc are involved.

Conclusion

An operational diagnosis, such as Tennis elbow, supra spinatus tendinitis, etc, does make the communications more precise. But when treatment options are discussed, every vaidya builds his treatment plan based on Ayurvedic diagnostic method.  For this purpose, he matches its features with a defined samprapthy.  Thus the enthesitic manifestations are usually discussed under Vathasonitham,  Amavatham or Sandhigatha Vaatha, or any other samprapthy which has this symptom potential, such as Apabahukam for a frozen shoulder or Vathakandakam for Plantar faciatis.   The key to treatment is generated from envisaging the construct of manifestations logically and de-constructing it.

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