Prolotherapy
A Regenerative Medicine Technique to Strengthen Tendons, Ligaments, and Joints to Improve Pain and Function
Early animal studies show that injections (usually hypertonic dextrose) result in inflammation and a subsequent increase in the side of ligament size and strength. Studies of tendons in both rabbits and rats injected with dextrose show a significantly larger cross-sectional area than saline-injected tendons. It is thought that dextrose may itself reduce pain through other mechanisms.
Prolotherapy treatment is thought to revitalize and reorganize tissue. It is considered regenerative therapy. The first book on prolotherapy was authored by Dr. Hackett in the 1950s. Later, Dr. Gustav Hemwall, a student of Dr. Hackett who practiced prolotherapy for many decades, began teaching this technique to physicians worldwide. Prolotherapy treatment is available worldwide in Canada, Australia, Europe, China and Taiwan, Mexico, Central and South America.
What is Prolotherapy?
Prolotherapy is a healing modality that involves injecting a solution, typically a hypertonic (15-25%) dextrose (sugar) solution, into weakened or damaged ligaments, tendons, or joints. By creating a controlled inflammatory response, prolotherapy stimulates the body to repair and strengthen the targeted tissues. Dextrose acts as an irritant, triggering local inflammation and promoting tissue repair. This inflammatory response recruits growth factors and stimulates the production of collagen, a key component of ligaments and tendons. This results in pain reduction and improved stability. The entire mechanism behind the treatment is not entirely understood. Dextrose itself is thought to decrease pain by a sensorineural mechanism.
The History of Prolotherapy
Prolotherapy has been used for over 75 years for the treatment of pain. The earliest report of its use is from the 1930’s for the treatment of temporal mandibular joint syndrome by Louis Schultz, DDS. During the 1950’s, Dr. George Hackett, a general surgeon, pioneered this non-surgical treatment for musculoskeletal conditions which emphasizes the body’s capacity to heal itself. It was originally called “sclerotherapy,” and was later changed to “prolotherapy” based on the observation that injections caused ligamentous tissues to proliferate or become larger.
Why Consider Prolotherapy?
The simple idea of injecting a dextrose solution into a ligament or joint to incite an inflammatory response may sound unconventional. We are conditioned to think that medications such as steroids or more invasive alternatives such as surgery are the only modalities that can be effective, but having seen many people who have received those treatments over the years, prolotherapy can provide a good alternative for people who are open to taking a different approach to joint rehabilitation. Physical therapy, steroid injections, arthroscopic surgery and joint replacement are all treatments that can be effective and have a place, however I think many people could benefit from prolotherapy and regenerative treatments such as PRP (platelet enriched plasma) to prevent or delay surgery and to restore function. It is a simple treatment with few risks and it may help people who either don't want to have surgery or cannot have surgery.
Consider degenerative changes in your knees, for example. As we age, we walk, run and exercise and we have injuries, our bones and ligaments are continually remodeling and adapt to stressors. Over time we accumulate those injuries, which often start with dysfunction in the tendons and ligaments that progress to changes in the bone. Tendons and ligaments are softer and more prone to injury than bone. Physical therapy can help us to improve our muscle strength and integrity of the joint which can be very effective. But what if we do not have improvement with PT. What are our alternatives?
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Steroids, often referred to as cortisone, are known to decrease inflammation quickly and can provide rapid relief of symptoms. Some people have very good results with steroids which can help with the process of physical therapy and restoration of function. However if injections with steroid and physical therapy do not work, repeated use of steroids can ultimately worsen joint function and thus, can only be done several times per year. Use of steroids is targeted at decreasing inflammation in the joint. The unfortunate problem is that repeated use can worsen the integrity of the joint, exacerbating problems. If you have tried steroid injections and they have not worked or have lasted for a few weeks or months what next?
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If physical therapy and steroid injections have not worked, an MRI or orthopedic evaluation may be warranted. At this time you may consider surgery or a procedure. But what if you are too young and would not qualify for surgery? What if you still have pain, but it's not severe enough that you would consider surgery, or what if you have a medical condition or life situation that would prevent you from having surgery? This is where prolotherapy can play a role. You might consider prolotherapy if you want to delay surgery or if your pain is not going away. It is a better choice, in my opinion, to choose a therapy that has the possibly to strengthen your joint and heal the tendons and ligaments, rather than repeatedly inject your joint with something that might worsen it's function. ​​​​​​​
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Another option would be PRP or platelet enriched plasma, which is often done by athletes to restore function. Prolotherapy is also a regenerative technique, but is less costly than PRP.
Indications
Knee Pain
Prolotherapy provides relief for chronic knee conditions such as knee osteoarthritis, patellar tendonitis, and ligament laxity, supporting joint stability and reducing pain. Two strong randomized controlled trials support use. Evidence level A.
Shoulder Pain
Prolotherapy can address tendinopathies and tendonitis, incomplete rotator cuff tears, loss of shoulder range of motion, and shoulder instability, allowing for improved range of motion and pain relief. Studies on rotator cuff syndrome with evidence rating A based on RCT and systematic review.
Elbow Pain
Medial epicondylitis (golfer’s elbow) and lateral epicondylitis (tennis elbow) may benefit from treatment with prolotherapy. There are two RCT on lateral epicondylitis showing benefit. Evidence rating A.
Back Pain & SI Joint
Prolotherapy is suitable for chronic back pain resulting from degenerative disc disease, or vertebral instability, promoting healing and enhancing spinal function. Nonspecific low back pain with evidence rating B. Prolotherapy may be helpful in reducing pain and instability in SI joint dysfuction. Evidence rating B.
Foot Pain
Plantar fasciitis, achilles tendonitis, and ligament sprains can be effectively treated with prolotherapy, enabling individuals to regain pain-free movement. Effective for plantar fasciitis evidence level B.
Hip Pain
Prolotherapy injections can address hip joint instability, tendonitis, facilitating pain reduction and improved hip function.
TMJ (Temporomandibular Joint Dysfunction)
Prolotherapy injections can address hip joint instability, tendonitis, facilitating pain reduction and improved hip function.
Safety
Prolotherapy is generally thought to be safe with few side effects and minimal risk. No serious adverse reactions were reported for peripheral joint injections. Adverse reactions for spine procedures were no more common than other spine procedures.
Treatment Course & Cost
The number of prolotherapy treatments required varies depending on several factors, including the severity of the condition and individual response. A typical course of prolotherapy involves 2 to 8 treatments, spaced 3 – 4 weeks apart. Cost for prolotherapy is more affordable than PRP (platelet enriched plasma). usually in the range of $175 - $500 per region.
Sources:
1. Ligament and Tendon Relaxation treated by Prolotherapy 5th Edition, 2008 George Stuart Hackett, MD, Gustav A Hemwall, MD and Gerald A Montgomery, MD
2. Regenerative Injections: The Art of Healing, Joel Baumgartner, MD
3. Integrative Medicine, 5th Edition 2023 David Rakel, MD and Vincet Minichiello, MD
Medical Organizations Providing Prolotherapy in the US:
1. American Association of Orthopedic Medicine www.aaomed.org
2. The American Osteopathic Association of Prolotherapy and Regenerative Medicine
3. Hackett Hemwall Founation www.hhpfoundation.org
4. International Association for Regenerative Medicine www.iart.org5.University of Wisconsin Prolotherapy Research www.fammed.wisc.edu/prolotherapy/