Prolotherapy is a Musculoskeletal Medicine intervention that is supported by many studies. Prolotherapy is used for the same indications as steroid injections. Unlike steroids however, prolotherapy helps regeneration and repair following ligament and tendon injuries and arthritis.
If the ligaments or tendon is lax and weak, no amount of exercise, massage, or medication can strengthen them. The pain may be temporarily reduced with medications or with physical modalities but until the ligament is strengthened, the same problem will reoccur. Ligamentous and tendon laxity is a very common problem that can be treated with Prolotherapy.
Prolotherapy involves the injection of mildly irritating solutions into lax ligaments. This irritation triggers the wound healing cascade in which fibroblasts secrete collagen. This collagen results in the creation of new, stronger, flexible ligaments and tendons.
Shortly following injection of the proliferant, there is a localized inflammation which diminishes gradually over several days. Patients should not take aspirin or other anti-inflammatory agents to relieve the discomfort as they would interfere with the treatment. Following a course of prolotherapy which generally ranges from 3-6 treatments, the pain often recedes and there is often improvement in function. Some published studies using prolotherapy have shown an 80-90% success rate.
Prolotherapy involves the injection of proliferants which cause local inflammation. The inflammation triggers the wound healing cascade resulting in the deposition of new collagen and a hypertrophied ligament. Rabbit studies have shown ligament mass increased by 44%, the thickness by 27% and the strength of the ligament bone junction increased by 28%.
Prolotherapy can not only help with treatment, it can also help with diagnosis. By using lignocaine along with the prolotherapy solution, when the cause of the pain is treated and the pain resolves the diagnosis can become more clear.
As you know, diagnosis of the cause of chronic pain can be very confusing. Although MRIs scanning can be very helpful, it can also lead to confusion knowing that over 60% of people who are asymptomatic have abnormal lumbar MRI scans.1 Some patients who have pain and have either a normal MRI, or lesions on their MRI scan which are not consistent with their history and physical examination. The other confusion may come from knowing what to do with patients who have a psychological cause for their illness.
We now know that partial ligamentous injuries account for more than 85% of sprains observed in athletes.2 Incomplete healing is common3,4 and can lead to chronic pain5 and joint laxity and instability, and can possibly contribute to osteoarthritis 6-8. These injuries are often invisible on MRI.
The other confusion comes when we see patients with "radicular type pain" and and assume there is nerve root involvement. The fact is, ligaments that are injured often refer pain in specific sclerotomal patterns and a numb-like sensation called "nulliness" is often referred from both ligamentous and muscular lesions, as well as from nervous structures.
Prolotherapy using Platelet Rich Plasma (PRP) is also available. Platelets found in the Platelet rich plasma can help tissue regeneration and repair because they growth factors and bioactive proteins. By increasing stem cell production these proteins help to initiate tissue repair. Dr. Crane wrote an excellent article about platelet rich plasma: Crane D, Everts PAM. Platelet Rich Plasma (PRP) Matrix Grafts. Pract Pain Mgmnt 08(1):12-26
Arthritis
Prolotherapy can help joint strengthening and promote cartilage repair. A study performed by Dr. Dean Reeves has shown that prolotherapy performed in arthritic joints resulted in a significant reduction in pain, swelling, knee buckling and improved x-ray findings including a reduction in bone spurs and increased cartilage regeneration.
1. Jensen MC, et al. “MRI imaging of the lumbar spine in people without back pain.” N Engl J Med – 1994; 331:369-373
2. Andriachi T, Sabiston P, DeHaven K, et al. Ligament: injury and repair. In: Injury and Repair of the Musculoskeletal Soft Tissues, edited byWoo SY, Buckwalter JA. Park Ridge, IL: AAOS; 1987.
3. Frank CB, McDonald D, Shrive N. Collagen fibril diameters in the rabbit medial collateral ligament scar: a longer term assessment. Connect Tissue Res. 1997;13:261-269.
4. Frank CB, Amiel D, Woo SL, Akeson WH. Normal ligament properties and ligament healing. Clin Orthop Rel Res. 1985:15-25.
5. Palesy PD. Tendon and ligament insertions-a possible source of musculoskeletal pain. Cranio. 1997;15:194-202.
6. Felson DT. Osteoarthritis: new insights, part 1: the disease and its risk factors. Ann Intern Med. 2000;133:635-646.
7. Sharma L, Lou C, Felson DT, et al. Laxity in healthy and osteoarthritic knees. Arthritis Rheum. 1999;42:861-870.
8. Wada M, Imura S, Baba H, et al. Knee laxity in patients with osteoarthritis and rheumatoid arthritis. Br J Rheumatol. 1996;35:360-363.