This article will cover information on Prolotherapy including general questions on Prolotherapy treatments, side effects and research.
- Prolotherapy is a regenerative injection treatment used to repair incomplete healing of the ligament and tendons.
- Prolotherapy is considered a viable alternative to surgery, as an option to pain medications and anti-inflammatory injections such as cortisone and other steroidal injections in instances of joint instability and osteoarthritis.
- Prolotherapy is considered a safe, affordable option that allows the patient to keep working and/or training during treatment.
Most athletic injuries or work related wear and tear involve strains and sprains to tendons and ligaments, respectively. A tendon attaches a muscle to the bone and involves movement of the joint. A ligament connects two bones and is involved in the stability of the joint. A strain is defined as a stretched or injured tendon. A sprain is a stretched or injured ligament. Once a body structure is injured, the immune system is stimulated to repair the injured area. Because ligaments and tendons generally have a poor blood supply, incomplete healing is common after injury.
This incomplete healing results in decreased strength of the area. The ligaments and tendons are normally taut, strong bands of fibrous or connective tissue but, because of injury, become relaxed and weak. The injured ligament or tendon then becomes the source of chronic pain and weakness for the athlete.
Ligaments and tendons are also more prone to injury because of the natural aging process. The water content in our joints and connective tissues (ligaments and tendons) decreases with age, the articular cartilage (which lines the joints) gets brittle and shrinks.
Cartilage is so vital, especially in weight-bearing joints like the knee, because it causes an even force to be generated at the underlying bone. It also causes the force generated on the bone to be less. When cartilage is degenerated, the force to the bone is greater and uneven and arthritis develops. Since cartilage decreases the force inside the joint, it becomes obvious that as cartilage deteriorates as we age, other structures are going to have to bear this force. Since tendons move the joints and ligaments stabilize the joints, it is primarily these soft tissue structures that are involved. Because ligaments stabilize the joints, a weakening of these structures causes a further force to the bones of the joints. This increased force hastens the arthritic process.
Finding the source of your joint pain
The greatest stresses to the ligaments and tendons are where they attach to the bone, the fibro-osseous junction. The most sensitive structures that produce pain are the periosteum (covering of the bone) and the ligaments. It is important to note that in the scale of pain sensitivity (which part of the body hurts more when injured), Research notes that the periosteum ranks first, followed by ligaments, tendons, fascia (the connective tissue that surrounds muscle), and finally muscle.1
Articular cartilage contains no sensory nerve endings. If you are told that your cartilage is the cause of your pain, that is not possible and is, actually, quite ridiculous. The cartilage cannot hurt because there are no sensory nerves to sense pain located in the cartilage. If there is cartilage damage, what hurts? The ligaments are typically the structures that hurt. Ligaments are weakest where they attach to bone. The periosteum is the most sensitive area to pain and the ligaments second. It is now easy to understand why this area hurts so much. This is where the Prolotherapy injections occur and thus eliminate the chronic pain of many conditions including arthritis, mechanical low back pain, Degenerative Disc Disease, cartilage injury, and, of course, sports injuries.
The ideal Prolotherapy candidate has the following:
- Pain originating from a ligament or tendon
- Strong immune system
- Willingness to improve and receive follow-up visits
- Healthy diet
- Positive mental outlook
Prolotherapy as a Ligament and Tendon Tear Treatment
Prolotherapy technique involves the injection of a proliferant (a mild irritant solution) that causes an inflammatory response which “turns on” the healing process. The growth of new ligament and tendon tissue is then stimulated. The ligaments and tendons produced after Prolotherapy appear much the same as normal tissues, except that they are thicker, stronger, and contain fibers of varying thickness, testifying to the new and ongoing creation of tissue.
Because ligaments and tendons generally have a poor blood supply, incomplete healing is common after injury.
In our peer-reviewed research published in October 2014 - the scientific and clinic basis of the use of Prolotherapy in repairing ligaments and tendons are discussed with numerous citations – you can download this article as Free Access Prolotherapy Research Ligaments and Tendon Repair
This incomplete healing results in these normally taut, strong bands of fibrous or connective tissue becoming relaxed and weak. The relaxed and inefficient ligament or tendon then becomes the source of chronic pain and weakness.
Understanding your pain generators
- The greatest stresses to the ligaments and tendons are where they attach to the bone, the fibro-osseous junction.
- The most sensitive structures that produce pain are the periosteum (covering of the bone) and the ligaments. It is important to note that in the scale of pain sensitivity (which part of the body hurts more when injured), the periosteum ranks first, followed by ligaments, tendons, fascia (the connective tissue that surrounds muscle), and finally muscle.
- Cartilage contains no sensory nerve endings. If you are told that your cartilage is the cause of your pain, you have been misinformed; the cartilage cannot hurt because they contain no pain sensing nerves. If there is cartilage damage, the ligaments are typically the structures that hurt.
Prolotherapy Treatment Goals
- Function Is the patient’s ability to function in activities of daily living improved? Is the patient able to perform previously painful activities without pain? Is the person able to do things that he/she could not do prior to Prolotherapy?Patients are typically advised to continue to receive Prolotherapy treatments until able to stably perform that certain function pain and cracking-free. For example, if a patient can nowclimb two flights of stairs without knee pain after Prolotherapy, whereas prior to the Prolotherapy this would cause excruciating pain, then we know that Prolotherapy is helping improve function.
- Strength Ligament and tendon injury may cause muscle strength to decline. When a person receives Prolotherapy, one of the noticeable effects of the treatment is that strength improves in the injected areas.
- Pain Pain is one of the most common reasons patients receive Prolotherapy. Thus, a noticeable decrease in pain shows the benefit of successful Prolotherapy.
- Stiffness Patients commonly experience stiffness upon morning rising or after performing a certain activity. This stiffness is commonly felt in the lower back or neck, but could involve any area of the body. A great sign that Prolotherapy is working is that stiffness has subsided. Once Prolotherapy helps stabilize the area involved, the muscles no longer have to provide this stability so they relax. Once they relax, the stiffness subsides.
- Physical Examination An experienced Prolotherapy doctor should be able to assess whether the Prolotherapy is working by simple physical examination. The physician can also listen for crepitation or crunching in the joints which can often be audibly heard by moving the joint. The joint that doesn’t crunch is also improving. X-rays and MRIs are poor indicators that Prolotherapy is working, the reason being that most ligaments do not show up well on these tests. Some improvements from Prolotherapy can be seen with x-rays and MRI’s, but it isn’t always necessary or advantageous to rely solely on those indicators due to their high incidence of inaccuracies.
Are there times when Prolotherapy results are not satisfactory?
Just like with other medical procedures, Prolotherapy is a specialty. If you are looking into getting Prolotherapy, you first want to make sure that the Prolotherapy doctor in experienced in the Comprehensive Prolotherapy procedure and has successfully treated cases like yours. Someone who receives Prolotherapy does so with the hope of achieving complete pain relief. Most people are very happy that they received Prolotherapy. There are several options available to the person who has a less than optimal results with Prolotherapy. They could quit Prolotherapy – but what are the other options? Typically, the patients are offered a lifetime of pain, a lifetime of anti-inflammatories with all their side effects, cortisone shots, or various surgical operations. At Caring Medical, we work with patients to dig deeper into why they are not healing. It could be as simple as the prior Prolotherapy doctors’ technique was to give minimal injections and they did not receive enough Prolotherapy injections to the area. If that is the case, it may be worth coming to Caring Medical. The same goes for patients who did not receive a strong enough Prolotherapy solution. We know what typically works best to get a patient a better Prolotherapy response. If you are not happy with your Prolotherapy results, a better approach is to seek another Prolotherapy specialist and get another opinion on your case. Sometimes a fresh look and a slightly different approach is all that is needed. In our office, it is common for us to get various referrals from other Prolotherapy doctors and have some of their patients see us.
Prolotherapy for Knee Pain
In this study, Caring Medical doctors investigated Prolotherapy in patients with unresolved knee pain at a charity clinic in rural Illinois. Eighty patients, representing a total of 119 knees, were treated quarterly with Prolotherapy. On average, 15 months following their last Prolotherapy session, patients were contacted and asked numerous questions in regard to their levels of pain and a variety of physical and psychological symptoms, as well as activities of daily living, before and after their last Prolotherapy treatment. The results of this study showed that patients had:
- Statistically significant decline in their level of pain, stiffness, crunching sensation, and improvement in their range of motion with Prolotherapy.
- More than 82% showed improvements in walking ability, medication usage, athletic ability, anxiety, depression, and overall disability with Prolotherapy.
- Ninety-six percent of patients felt Prolotherapy improved their life overall. 3
Other researchers have shown that Prolotherapy injections resulted in safe and substantial improvement in quality of life in knee osteoarthritis patients.4 Prolotherapy resulted in clinically meaningful sustained improvement of pain, function, and stiffness scores for knee osteoarthritis compared with blinded saline injections and at-home exercises.5 In Caring Medical research, Dr. Hauser was able to document articular cartilage regeneration.6
In patients with symptoms of anterior cruciate ligament laxity and weakness, intermittent Prolotherapy injections resulted in clinically and statistically significant improvement in pain, swelling, and knee range of motion.7
Main page> Prolotherapy for knee pain Anterior Cruciate Ligament (ACL), Articular Cartilage Tears, Baker’s Cyst, Chondromalacia Patella, Collateral Ligament Injuries, Knee Tendon Bursitis, Meniscal Tears, Osteoarthritis, Osteochondritis Dissecans, Patellar Tendinitis, Patellar Tendon Tear, Patellofemoral Pain Syndrome, Runner’s Knee (Patellofemoral Pain)
Prolotherapy and PRP (Platelet Rich Plasma) Injections for Knee Pain
Comprehensive Prolotherapy is an injection technique utilizing many healing factors. They can include or be used in conjunction with Dextrose, Blood Platelets, and stem cell injection therapy. The stem cells and blood platelets are drawn from the patient. In research, PRP by itself has been shown to be a remarkable treatment for knee osteoarthritis. However, other research points out that PRP’s effects may not be long lasting or beyond six months.8 At Caring Medical we developed comprehensive Prolotherapy and inject the supportive structures of the knee with dextrose Prolotherapy and other growth factors. Simply, while PRP can address and repair damaged cartilage, it is not addressing the ligament and tendon weakness that contributed to the cartilage deterioration. Comprehensive Prolotherapy seeks to repair the entire knee.
Prolotherapy and Stem Cell Therapy for Knee Pain
In this study, Caring Medical doctors examined the use of a simple, cost-effective regenerative treatment using direct injection of bone marrow stem cells into osteoarthritic joints in combination with dextrose Prolotherapy. Seven patients with hip, knee or ankle osteoarthritis received two to seven treatments over a period of two to twelve months. All patients reported improvements with respect to pain, as well as gains in functionality and quality of life. Three patients, including two whose progress under other therapy had plateaued or reversed, achieved complete or near-complete symptomatic relief, and two additional patients achieved resumption of vigorous exercise.9
Prolotherapy for Back Pain
Caring Medical patients are often surprised to learn that Prolotherapy can heal most disc problems in neck and back. While we talk about Prolotherapy healing joint pain that results from ligament and tendon injuries, most people are unaware that disc problems results from ligament injuries or instability along the spine. Patients with degenerative disc disease,herniated discs, bulging discs, bone on bone, etc can all be healed with Prolotherapy. Prolotherapy works to stabilize the ligaments of the spine allowing discs to get back into position and can even create space to a person who has lost space due to one or more degenerated disc. In Prolotherapy research from the doctors of Caring Medical, patients with more than four years of unresolved low back pain were shown to have had their pain improved, stiffness, range of motion, and quality of life measures even 12 months subsequent to their last Prolotherapy session. 10
Prolotherapy for Shoulder Pain
In published research from Caring Medical doctors, The optimal long-term, symptomatic therapy for chronic shoulder pain has not been established. Accordingly, we investigated the outcomes of patients undergoing Hackett-Hemwall dextrose Prolotherapy treatment for unresolved shoulder pain at a charity clinic in rural Illinois. We studied a sample of 94 patients with an average of 53 months of unresolved shoulder pain that were treated quarterly with Prolotherapy. An average of 20 months following their last Prolotherapy session, patients were contacted and asked numerous questions in regard to their levels of pain and a variety of physical and psychological symptoms, as well as activities of daily living, before and after their last Prolotherapy treatment. The results of this study showed that patients had a statistically significant decline in their level of pain, stiffness, and crunching sensations (crepitation).
How many Prolotherapy injections are given at each treatment?
Most people do not want to receive a lot of injections. Injections hurt. However, if you want to achieve a curative result with Prolotherapy, your Prolotherapy doctor must take a comprehensive approach and give you alot of injections. Every area of your body must be treated that is causing pain. Thus, Comprehensive Prolotherapy involves
- Injecting all of the injured structures (IE not just the joint, but also the surrounding support structures)
- Using a strong enough proliferant (Prolotherapy solution)
If you go to a Prolotherapy doctor who only give you two or three shots, it is highly likely you will not get better. Most people understand conceptually that if you injure a structure in a joint that over time that injury will affect all the structures of the joint. Most patients come to see a Prolotherapy doctor after having pain for at least several years. What may have started out as a simple ligament sprain, after 3-6 years is now a total joint problem. All the structures of the joint and around the joint (or at least the majority of them) must be treated with Prolotherapy to completely alleviate the pain. Some Prolotherapy doctors only provide 1-3 injections. Often patients who receive this type of Prolotherapy will eventually seek out a doctor who provides Comprehensive Prolotherapy. While in the most technical sense, the patient did receive Prolotherapy, it may not be effective. To be effective, the Prolotherapy doctor must do the following:
- Stimulate all the structures that are injured to heal.
- Use enough solution per structure to induce a sufficient healing reaction.
- Use a strong enough solution per structure to induce a sufficient healing reaction.
- Help the person obtain maximum health if their health is not good.
- Assist the person in getting off medications, supplements, or traditional hormones (like birth control pills) that inhibit healing.
The effectiveness of Prolotherapy
The effectiveness of Prolotherapy does depend upon the technique of the individual doctor, as well as the overall health and dedication of the patient to encourage the healing process after each treatment. For the patient who has localized areas of pain or the person who has had a recent injury from an accident, Prolotherapy is a very effective treatment to strengthen those specific areas and eliminate the pain. Realize, however, that Prolotherapy starts the growth of new healthy, strong tissue. Your body–your own immune system–grows the tissue. For the person who has terrible digestion, chronic fatigue, irritable bowel; and a host of other chronic nutritional, hormonal, allergic problems, these deficiencies and illnesses should be corrected so the body will be able to respond to Prolotherapy.
Can Prolotherapy help you?
1. Kayfetz, D. Occipital-cervical (whiplash) Injuries treated by Prolotherapy. Medical Trial Technique Quarterly, June, 1963, p. 9-29.)
2. Low back pain research: Steindler A, Luck JV. Differential diagnosis of pain low in the back JAMA. 1938;110(2):106-113. doi:10.1001/jama.1938.02790020020007.
3. Hauser RA, Hauser MA. A Retrospective Study on Dextrose Prolotherapy for Unresolved Knee Pain at an Outpatient Charity Clinic in Rural Illinois Journal of Prolotherapy. 2009;1(1):11-21.
4. Rabago D et al. Association between disease-specific quality of life and magnetic resonance imaging outcomes in a clinical trial of prolotherapy for knee osteoarthritis. Arch Phys Med Rehabil. 2013 Nov;94(11):2075-82. doi: 10.1016/j.apmr.2013.06.025. Epub 2013 Jul 10.
5. Rabago D. et al. Dextrose prolotherapy for knee osteoarthritis: a randomized controlled trial. Ann Fam Med. 2013 May-Jun;11(3):229-37. doi: 10.1370/afm.1504.
6. Hauser RA. The Regeneration of Articular Cartilage with Prolotherapy. Journal of Prolotherapy. 2009;1:39-44.
7. Reeves KD, Hassanein KM. Long-term effects of dextrose prolotherapy for anterior cruciate ligament laxity. Altern Ther Health Med. 2003 May-Jun;9(3):58-62.
8. Khoshbin A, Leroux T, Wasserstein D, Marks P, Theodoropoulos J, Ogilvie-Harris D, Gandhi R, Takhar K, Lum G, Chahal J. The efficacy of platelet-rich plasma in the treatment of symptomatic knee osteoarthritis: a systematic review with quantitative synthesis. Arthroscopy. 2013 Dec;29(12):2037-48. doi: 10.1016/j.arthro.2013.09.006.
9. Stem Cell Therapy and Prolotherapy research Hauser RA, Orlofsky A. Regenerative injection therapy with whole bone marrow aspirate for degenerative joint disease: a case series. Clin Med Insights Arthritis Musculoskelet Disord. 2013 Sep 4;6:65-72. doi:
10.4137/CMAMD.S10951. eCollection 2013. 10. Hauser RA, Hauser MA Dextrose Prolotherapy for Unresolved Low Back Pain: A Retrospective Case Series Study Journal of Prolotherapy. 2009;3:145-155.