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A Regenerative Medicine Technique to Strengthen Tendons, Ligaments, and Joints to Improve Pain and Function

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 from1930s 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.

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.

Medical Organizations Providing Prolotherapy in the US:

1.  American Association of Orthopedic Medicine

2. The American Osteopathic Association of Prolotherapy and Regenerative Medicine

3. Hackett Hemwall Founation

4. International Association for Regenerative Medicine www.iart.org5.University of Wisconsin Prolotherapy Research


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.


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 $200 - $500 per region.


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

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