Prolotherapy vs. Cortisone
Why Prolotherapy Is a Better Treatment Option Than Cortisone
Injuries and chronic pain are a common occurrence in our increasingly active lives, whether as a result of playing sports, a repetitive task at work or slipping and falling on a patch of ice. The healing process that follows has three characteristic phases: inflammatory, proliferative and remodeling. The first phase, the inflammatory-reparative phase, sets the stage for the others, and is critically affected by the treatment options chosen. These options can either block or stimulate the process…can either heal the affected area or make it worse.
So what are the treatment options? Traditional modern medical uses cortisone as well as other anti-inflammatories, in addition to the RICE (rest, ice, compression and elevation) protocol, all of which provide temporary pain relief but hinder healing. Natural medicine uses Prolotherapy as well as nutritional and other supplements to promote healing. The difference can determine one’s ultimate path to either chronic pain, tissue degeneration and possibly eventual surgery, or pain relief, healing and often a strengthening of the areas involved. A seemingly easy choice: pain relief and healing versus chronic pain management. Read on for details.
Corticosteroids are the main hormone secreted by the adrenal gland, the small gland located on top of the kidneys. The typical corticosteroid is cortisol, also called hydrocortisone. Its many effects allow us to live in an ever-changing environment. For example, our bodies normally produces cortisol in response to an allergic reaction, or to keep our blood sugar high when we haven’t eaten for quite a long time. They are especially necessary for normal bodily functions during times of stress.
Corticosteroids are used to provide anti-inflammatory relief in affected areas of the body. However, the synthetic analogues used are many times stronger than our naturally occurring forms. They lessen swelling, redness, itching and allergic reactions, and, in addition to their use for acute and chronic pain, are often used as part of the treatment for a number of different diseases, such as severe allergies or skin problems, asthma, or arthritis. The discovery that they could be injected was received with enthusiasm, and led to widespread use. However, shortly after doctors started injecting cortisone and other steroids into knee joints in the 1950s, reports of terrible arthropathies, or joint diseases, began to surface, an indication that all was not well with this treatment choice. Nevertheless, cortisone shots are still considered the standard care for the injured athlete.
How cortisone hinders injury repair
Let’s say you like to play tennis—a lot. Over time you notice a painful elbow, which your doctor diagnoses as golfer’s elbow. Maybe you’ve taken anti-inflammatories, such as aspirin, or non-steroidal anti-inflammatories, such as ibuprofen, Motrin or Naproxen for a while, but with only temporary relief. Your doctor may recommend a cortisone shot in the elbow next. You get temporary relief, but the pain doesn’t go away—it may even be getting worse. In the case of an acute athletic injury, such as a knee sprain, a cortisone shot is sometimes given on the spot in order to check the edema, relieve the pain and allow the athlete to return to the sport either immediately or in a very short period of time. So while the goal of the cortisone shot is to decrease the painful inflammation of the injury, the goal of the normal inflammatory-reparative healing cascade is to do its work regenerating the collagen and extracellular matrix (called proteoglycans) that give the connective tissues their strength and characteristic ability to handle great strain forces. Unfortunately for many individuals, corticosteroids block this normal healing process.
How corticosteroid injections suppress inflammation and healing
- They decrease collagenase and prostaglandin formation. Prostoglandins help recruit immune cells to the injured area to clean up the damaged tissue and start the repair process. Prostaglandins also help increase circulation to the injured area.
- They decrease the formation of granulation tissue, which is needed to heal the area.
- They block glucose uptake in the tissues, enhance protein breakdown and decrease new protein synthesis in muscle, skin, bone, connective tissue and lymphoid tissue. Muscle, ligament and tendon tissue is 70 to 90 percent collagen, which is a protein. Corticosteroids are catabolic promoters, which means they are involved in processes that break down tissue.
- They inactivate vitamin D, limiting calcium absorption by the gastrointestinal tract, and increasing the urinary secretion of calcium. Bone also shows a decrease in calcium uptake with cortisone use, ultimately leading to weakness at the fibro-osseous junction.
- They inhibit the release of growth hormone, which further decreases soft tissue and bone repair.
- They can lead to painful tendon and ligament ruptures.
- They compromise tendon and ligament strength, a scary finding considering that many athletes return to the game or the sport shortly after an injection.
- They can predispose a joint to infection.
In the case of our knee sprain example, the result of a cortisone shot is weakened synovial joints, supporting structures, articular cartilage, ligaments and tendons. In fact, one study showed that even 16 weeks after a single joint injection, the cartilage remained biochemically and metabolically impaired or weakened. This weakness ultimately increases the pain and, guess what. The increased pain leads to more steroid injections. Cortisone fools many athletes by providing pain relief instead of tissue repair and healing.
The effect of cortisone on popular sports injuries
- Plantar “fasciitis”: cortisone shots further degenerate the already degenerating tissue; this condition should really be called plantar “fasciosis” because the fascia is degenerated (-iosis), not inflamed (-itis)
- Achilles “tendonitis”: cortisone shots enhance the degeneration of the tendons, which are usually degenerated as the result of an injury, and not inflamed
- Stress fractures and shin splints: cortisone shots further degenerate the tissue, which is actually suffering from localized connective tissue deficiency
- Chronic shoulder pain or elbow pain: cortisone further degenerates the already degenerating ligament or tendon
- Chondromalacia patella, also referred to as patellofemoral pain syndrome (PFPS): cortisone shots exacerbate the deterioration of the articular cartilage beneath the patella, or the kneecap
- Acromioclavicular joint pain due to sprain: cortisone shots cause a marked increase in the amount of long-term degeneration of first-degree sprains
- Jumper’s knee: cortisone leads to progressive tendon degeneration
- Disc degeneration and disc herniation: cortisone, as well as surgery and NSAIDs, speed up the process of tissue degeneration
In a nutshell: Local inflammation of injured ligaments or tendons is necessary to heal injuries, whether acute or chronic. Cortisone interferes with this process. And here’s where Prolotherapy comes in.
How Prolotherapy promotes healing
Prolotherapy stimulates, rather than interferes with, the normal healing process of inflammation. While corticosteroids inhibit the enzymes that block the production of prostaglandins and leukotrienes, which mediate the inflammatory process, Prolotherapy stimulates them. By blocking the production of these enzymes, cortisone has a deleterious effect on soft tissue healing by inhibiting blood flow to the injured area, new blood vessel formation, immune cells like leukocytes and macrophages, protein synthesis, fibroblast proliferation and ultimately collagen formation. Prolotherapy doesn’t. In addition, the collagen that forms in ligaments and tendons treated with cortisone is disrupted and weaker, while that treated with Prolotherapy is—you guessed it—stronger. Prolotherapy provides the stimulus that is needed to bring in healing fibroblasts and allow them to proliferate and lay down new collagen fibers. This causes the connective tissues, ligaments and tendons to become thicker and stronger. Prolotherapy stimulates the normal inflammatory-reparative mechanisms of the body, encouraging normal collagen and extracellular matrix growth.
Prolotherapy is almost always given in conjunction with supplements such as MSM, glucosamine, hydrolyzed collagen, bromelain and chondroitin. Growth hormone may also be prescribed to aid soft tissue healing, and if non-steroidal anti-inflammatiories were part of the individual’s initial modern medical treatment, EPA, an essential fatty acid, will help wean individuals off them. As a result, not only do nutritional therapies and Prolotherapy strengthen and repair the weakened and degenerated structures, but, in the case of athletic injuries, it will enhance athletic performance as the injured structures become stronger instead of weaker. The end result is a stronger joint and athletes who are back playing their sport instead of on the operating table getting their arthritis scraped or, even worse, getting a joint replacement.
In summary, while cortisone shots weaken an injured area even further, Prolotherapy stimulates the body to repair it. Prolotherapy stimulates blood flow to the area, protein synthesis, fibroblast proliferation and ultimately collagen formation. The choice is simple: cortisone shots that lead to proliferative arthritis of joints or proliferative injections (Prolotherapy) that stimulate the repair of the injured tissue.