Prolotherapy for the Treatment of Joint Pain

Noel Peterson, N.D.

What is Prolotherapy?
Prolotherapy is defined in Webster's New Collegiate Dictionary as "The rehabilitation of an incompetent structure such as a ligament or tendon, by the induced proliferation of new cells." It was developed over fifty years ago as a natural non-surgical method of assisting the body in healing injured tendons and ligaments. Prolotherapy helps your body make new cells, which strengthen lax or torn tendons and ligaments. (Ligaments are the tough tissues which connect bones to bones, and tendons are the tough tissue which connect muscles to bones) How can you strengthen tendons and ligaments?

Unlike muscle tissue, exercise cannot build, strengthen, or repair ligaments or tendons. Prolotherapy has been shown to increase the size of tendons and ligaments up to 40%. It has also been shown to increase their tensile strength by as much as 200%. Prolotherapy thickens knee cartilage and relieves the pain of degenerative joint diseases, and no scar tissue is formed (as would be the case in surgical procedures). The tissue formed from Prolotherapy is healthy, strong, flexible ligament or tendon tissue. Once Prolotherapy has repaired the ligament or tendon, the nerves are no longer stretched or irritated, the pain goes away, and normal function follows.

How is Prolotherapy performed?
Prolotherapy technique consists of using a fine needle to inject a proliferative solution into incompetent tendons, ligaments, and joints for the purpose of stimulating new growth and repair, thereby promoting joint stability and reduction of pain. The most common substance used is dextrose (a kind of sugar) diluted with procaine (a local anesthetic). When injected into the torn tendon or ligament, the dextrose and procaine solution induces a physiologic reaction that stimulates the healing processes to resume, and induces the migration of fibroblasts (the body's repair cells) to the site of injection. Fibroblasts lay down new connective tissue and in so doing, enlarge and strengthen the damaged tendons, ligaments, and cartilage.

Do Prolotherapy injections hurt?
Prolotherapy injections are performed with a lot of care and a little local anesthetic. The pain of treatment is minor and only temporary when compared to the chronic pain of tendon and ligament injuries.

What kinds of injuries respond to Prolotherapy?
Soft tissue injuries (strains, sprains and bruises of muscles, tendons, fascia, and ligaments) are the most common injuries encountered in sports, auto, household, and work accidents. These injuries produce chronic pain in the hands, elbows, shoulders, hips, knees, and feet, as well as neck, ribs, back, and sacrum. The majority of these injuries heal through the body's own internal mechanism of producing inflammation which triggers the proliferation of fibrous tissue that mends the damaged areas. The majority of these injuries heal, but many go on to chronic pain and dysfunction, and many common anti-inflammatory drugs used in these cases actually inhibit the repair of these damaged cells.

Which patients benefit from Prolotherapy?
Patients who will benefit from regenerative Prolotherapy are those who have pain referred from ligament, tendon or joint injuries. A history of prolonged pain, along with positive signs of pain on palpation of the tendon or ligament insertion (fibro-osseous junction pain), pain on movement of the joint, cases who are not responding to re-alignment treatments, and patients who have been unable to resume their pre-injury activity level all are appropriate candidates for Prolo. Because the normal healing cycle takes about 4-6 weeks, if pain persists beyond this time it is likely that the growth factors at the site of injury need to be re-stimulated. Prolotherapy injections provide a proliferative effect, raising growth factors, and re-starting the healing processes. Therefore, unresolved injuries with pain persisting for over 6 weeks are excellent candidates for Prolo injections.

Who is good candidate for regenerative Prolotherapy?
A good Prolotherapy case is one in which the patient has suffered either degeneration or accidental trauma to the connective tissue of a joint or the ligaments and/or tendons that stabilize the joint. This would include patients with:

Lateral epicondylitis, medial epicondylitis (tennis elbow or golfer's elbow);
Carple Tunnel syndrome
Rotator cuff syndromes, including supraspinatus tendinosis, rotator cuff impingement syndromes, and calcific tendinosis
Knee injuries, including lax or partially torn cruciate ligaments, chronic lateral and medial collateral ligament sprains, enthesopathies (origin and insertion injuries to tendons and ligaments), as in injuries to the tibio-fibular ligaments;
Osteoarthritic changes to the knees, including chondromalacia patellae and degenerative osteoarthritis of the cartilage and meniscus;
Sacroiliac jointchronic pain syndromes, including hypermobility syndromes, sciatica, and osteoarthritis;
Cervical and lumbar vertebrae osteoarthritis, causing chronic pain and dyskinesia;
TMJ syndrome, including referred pain patterns and bruxism;
Plantar fascitis and tarsal tunnel syndrome;
Arthritic changes to small joints of the fingers and toes;
Costochondritis, costovertebral ligament laxity and hypermobile ribs.

Prolotherapy stimulates injured connective tissue to heal. This healing response occurs because the injection of a Prolotherapy solution into the injured connective tissue stimulates the body's own fibroblasts to migrate into the affected area and re-build the damaged and frayed tissue. Prolotherapy solutions are made of “proliferant”, i.e., compounds, which cause proliferation of connective tissue at the fibro-osseous junction. The most common solution is a combination of dextrose and procaine. Ligaments and tendons have notoriously poor blood supply and are difficult to heal. Most trainers and doctors recommend the standard R.I.C.E. protocol: Rest, Immobilization and Ice, Compression, and Elevation, after injuries. This procedure can actually turn off the body's healing mechanisms. The addition of an anti-inflammatory like ibuprofen will further inhibit the body's healing response. With these treatments, athletic and accidental injuries often become chronic and lead to diminished function of the affected area, and further limitations to movement. We recommend the M.E.A.T protocol: Movement, Exercise, Analgesics, and Treatment.

What about conditions such as arthritis?
There are many forms of arthritis, the most common being Osteoarthritis. Osteoarthritis is the gradual degeneration of joint surfaces, caused by overuse and under repair. Overtime, this wear-and-tear of cartilage progresses to the point that the cartilage is worn thin and pain results. Degenerative joint disease can progress to the point where the patient needs a total hip or knee replacement. Prolotherapy has been proven to reverse the degeneration of joints when the condition is treated early enough. Other forms of arthritis are autoimmune mediated, such as Rheumatoid Arthritis, Lupus, and Ankylosing Spondylitis. Unfortunately, these forms of joint disease do not respond to Prolotherapy.

Why would you still have pain and weakness, even after a healing period of weeks or months?
The answer lies in the fact that both ligaments and tendons have very poor circulation, and it is this lack of circulation, which deprives them of the nutrients they need to heal properly. When ligaments become relaxed and weak, the nerves within and around the ligaments and tendons become stretched and irritated, and pain results.

What to expect from a course of Prolotherapy?
On your initial visit, you will be assessed for the appropriateness of regenerative therapy. We will learn your health history and perform a physical exam specific to your condition. Dr. Peterson will review your prior medical records, including X-rays, CAT scans, and MRI reports if available. The majority of patients will not require further tests. If necessary, additional tests may be discussed and ordered, and could range from X-ray films to metabolic profiles to nutritional and endocrine (hormonal) tests and evaluations. Using this information, in most cases, conclusive evaluation of the injury can be confirmed with hands-on palpation and range of motion testing in the office. Once the location and nature of the injury is confirmed, a course of regenerative therapy can be prescribed. The usual threshold for improvement is 4 sessions of Prolotherapy. In each session, a small needle will be used to inject the proliferative solution into the place where tendons and ligaments attach to bone, called the fibro-osseous junction. For every time the skin is pierced, several areas of the tendon or ligament will be injected and infused with the growth factor inducing proliferative solution. Most patients consider the pain of Prolo injections to be significantly less troubling than the chronic pain of their injuries. Since one of the ingredients of the proliferative solution is a local anesthetic, pain at the site of the injection is minimized.

Many of the conditions we treat have strong muscle spasm components where muscles have attempted to guard the injured tendon or ligament. These activated hypertonic muscles lower blood flow, inhibit healing, and cause referred pain in the injured areas. Most patients benefit significantly from the use of trigger point injections of Procaine into these areas of hypertonic and spastic muscle bundles. Procaine relaxes these muscle spasms, inhibits reflex spasm, and increases blood flow to the injured tissue.

All patients are encouraged to moderate their activities for 24 hours following each session, after which they can resume normal physical activity. Pain following the injections is usually of short term, and is controlled with the natural enzyme Bromelain. Occasionally, a few doses of Tylenol may be recommended to ease post injection pain, and rarely a narcotic pain reliever such as Vicodin is prescribed. The response to treatment is cumulative, with benefits compounding with each treatment. After the initial series of injections, patients will be given 4 -12 weeks to further accrue the benefits of therapy. Remember, the repair process lasts for 4-6 weeks, and further injections may be required to promote the healing of badly damaged ligaments. As the stabilizing effects of regenerative therapy accrues, and the supporting cast of nutritional support and muscle strengthening continues, pain free range of motion is enhanced.

How many Prolo injections are required?
The duration of treatment is dependent on the extent and location of injury, as well as the age, immune status, and nutritional reserves of the patient. Generally, athletes with good nutritional reserves heal the fastest, largely because they have greater circulation and muscle tone to assist the healing response. In these people, pain can be relieved and function restored in as little as 6 weeks. Depending on the region being treated, each Prolotherapy session can require up to 20 needle insertions, with up to 6 injections of proliferant per insertion. Sedentary men and women with poor diets, high stress lifestyles, and dysfunctional immune systems (autoimmune syndromes and inflammatory diseases such as colitis and fibromyalgia) are slow to regenerate their connective tissues. These patients should be identified during the initial workup and appropriate steps taken to address these underlying conditions. Nutritional support with dietary changes and supplementation, as well as a metered exercise program will speed the rate of repair. Aging joints are slower to heal. This is because circulation is compromised with older patients, and the joint capsule connective tissues desiccate over time. In elderly patients, shoulder injuries, such as rotator cuff syndromes, are especially slow to heal because circulation is compromised and the joint capsule is dried out. Typically they can take 6 to 12 months to restore function and relieve pain, with Prolotherapy sessions every 1 to 4 weeks.

What are the side effects of Prolotherapy?
Some patients experience pain and swelling at the injection sites for 1-3 days following the procedure. To counteract this, we recommend that patients take acetaminophen or hydrocodone with acetaminophen for pain, but not aspirin or anti-inflammatory medications like Advil, which can inhibit the healing response. Patients can also apply moist heat and ice alternately to the area 3-5 times a day for 10 to 20 minutes as needed, and perform moderate exercise such as walking, but should avoid strenuous exercise or work with heavy lifting. Often specific exercises are prescribed to follow-up the injections. The natural proteolytic enzyme Bromelain can also be taken for swelling if needed. Reports of more serious complications have been extremely rare, and are associated with the inadvertent injection into the spinal canal or the lining of the lung rather than into the affected ligament or tendon, causing spinal fluid leak, nerve damage, or pneumothorax.

Who performs Prolotherapy?
The injection technique involved in Prolotherapy requires skill and care. Dr. Peterson is certified in Prolotherapy techniques. You can schedule your appointment with him by calling 503-636-2734.