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Ross Hauser, MD

This article will cover information on Prolotherapy including general questions on Prolotherapy treatments, side effects, research, reviews, and medical studies.

Prolotherapy has been utilized in clinical practices for over 80 years. Standardized and reviewed in clinical application by Dr. George Hackett in the 1950s, prolotherapy has been shown to be an effective treatment in patients who suffer from joint instability due to ligament damage and overuse and related musculoskeletal and osteoarthritis.

Prolotherapy’s popularity as a treatment for chronic pain has intensified over the past two decades among both physicians and patients as clinical and anecdotal observations has proved in many cases its reliance as a non-surgical option for joint and back pain.

What is Prolotherapy?

Prolotherapy is a nonsurgical regenerative injection technique that introduces small amounts of an irritant solution to the site of painful and degenerated tendon insertions (entheses), joints, ligaments, and in adjacent joint spaces during several treatment sessions to promote growth of normal cells and tissues.

Irritant solutions most often contain dextrose (d-glucose), a natural form of glucose normally found in the body, but may also contain combinations of polidocanol, manganese, zinc, pumice, ozone, glycerin, or phenol.

In severe cases, autologous cellular solutions may also be needed, such as platelet-rich plasma (PRP), bone marrow, or adipose tissue.

For the patient, the goal of Prolotherapy in chronic musculoskeletal pain and instability is the stimulation of body’s natural healing and regenerative processes in the joint that will facilitate the repair and regrowth of connective tissue, ligaments, tendons for tensile strength, and cartilage and other joint stabilizing structures such as labral tissue.

Prolotherapy works by the same process that the human body naturally uses to stimulate the body’s healing system, a process called inflammation. The 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. This is documented in the research below.

Learning points

• Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments.
• In our opinion, based on extensive research and clinical results, Prolotherapy can be superior to many other treatments in relieving the problems of chronic joint and spine pain and, most importantly, in getting people back to a happy and active lifestyle.
• At our center, we offer our method of Prolotherapy. We call this method H3 Prolotherapy. We consider it the evolution of the traditional Hackett-Hemwall type Prolotherapy into Hackett-Hemwall-Hauser Prolotherapy.  The Hauser Prolotherapy technique has developed over 28+ years of continual service. For those of you first exploring the treatment and not sure what these names are or mean, consider H3 Prolotherapy as the evolution of Prolotherapy protocols based on 80 years of research and clinical observation and based on tens of thousands of treatments.

While we treat with H3 Prolotherapy methods we will refer to these treatments simply as Prolotherapy for the remainder of this article.

Is Prolotherapy like cortisone? 

• The difference between Prolotherapy and Cortisone is extensive.
• Cortisone when injected into the joint can successfully mask pain. Many people have very successful treatments with Cortisone. We typically see patients who have a long history of Cortisone injection and these injections are no longer effective for them.
• Cortisone has been shown, in many studies, to accelerate degenerative osteoarthritis through cartilage breakdown.
• Over the years we have seen many patients who have received corticosteroid (cortisone) injections for joint pain. Unfortunately for many, excessive cortisone treatments lead to a worsening of chronic pain. Again, while some people do benefit from cortisone in the short-term – the evidence however points to cortisone causing more problems than it helps.

Prolotherapy is a regenerative injection treatment used to treat joint and spine pain by repairing damaged and weakened ligaments and tendons.

• Prolotherapy is considered a viable alternative to surgery, and as an option to pain medications, cortisone and other steroidal injections.
• The Prolotherapy procedure is considered a safe, affordable option that allows the patient to keep working and/or training during treatment.
• H3 Prolotherapy difference: It is typically best to treat all or most of the ligaments of an unstable joint if that joint or its surrounding structures are painful. Multiple joints and structures can be treated with each visit.

Principle findings reveal that dextrose prolotherapy has a clear and positive effect on chronic musculoskeletal pain ranging from 6 months to 1 year.

A December 2020 study in the journal Anesthesia and Pain Medicine (1) made these observations on prolotherapy treatment:

• The researchers principle findings revealed that dextrose prolotherapy has a clear and positive effect on chronic musculoskeletal pain ranging from 6 months to 1 year.
• In comparison with saline injection or exercise, treatment with prolotherapy showed a moderately superior therapeutic effect. In particular, prolotherapy was found to be more effective than exercise from one month after treatment.
• Prolotherapy was also found to have a similar effect to steroids or PRP (Platelet Rich Plasma injections) one month after treatment.
• In a comparison of the effects of corticosteroid injection and prolotherapy in patients with first carpometacarpal (thumb) osteoarthritis, one study reported that the corticosteroid injection group had better results of pain score at 1 month. However, after 2 months, prolotherapy had a more favorable outcome than corticosteroid injection. Another concern of corticosteroids is adverse effects, in contrast, prolotherapy has no serious side effects and is effective, safe, and sustainable.
• In conclusion, dextrose-based prolotherapy has been shown to have a positive and significantly beneficial effect for patients with chronic musculoskeletal pain, ranging from 6 months to 1 year. There is evidence that dextrose-based prolotherapy has a better therapeutic effect than exercise, and that it has a similar effect compared to PRP and steroid injection.

Prolotherapy Treatment Goals

What are the goals of Prolotherapy treatments?

• 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 now climb 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.

What do we use in our Prolotherapy injections?

The Prolotherapy technique we use at Caring Medical is called Comprehensive Prolotherapy or Hackett-Hemwall-Hauser (H3) Prolotherapy. This type of Prolotherapy incorporates the teaching and techniques of doctors George S. Hackett, MD, and Gustav A. Hemwall, MD, two of the pioneers in the field, as well as developments made in our 3 decades of clinical experience and analysis of results.

The primary ingredient in Prolotherapy injections used at Caring Medical is dextrose. How does dextrose accelerate healing?

This technique involves using the simple and safe base solution dextrose as the primary proliferant, along with an anesthetic (such as procaine or lidocaine), that is given into and around the entire painful/injured area(s). Many injections are given during each treatment, versus just a few injections. Most treatments are provided every 4 to 6 weeks to allow time for the growth of new connective tissues.

In these basic Prolotherapy injection solutions, we also use an alkaline extract of the pitcher plant called Sarapin. Almost all pain issues have some kind of nerve component, which Sarapin helps to relieve. In our experience, Sarapin enhances the healing effects of injection treatments and has an excellent safety profile. It is one of the few materials found in the Physicians’ Desk Reference that has no known side effect. Also in the basic solution, to help ease the pain of the injection procedure, as well as provide pain relief to the area, procaine or lidocaine is added in very small quantities. Often, this helps to ease the pain right away after the procedure, but is used in such a small amount to not cause any adverse effect to the joint repair/wound healing cascade.

With a comprehensive approach, we utilize many different types of Prolotherapy solutions, individualizing each treatment according to the patients’ unique needs. The solutions are changed depending on the individual patient and the amount of inflammatory reaction required to produce sufficient healing and new collagen growth. We also use cellular proliferants such as blood, PRP (platelet rich plasma), bone marrow, and stem cells.

As with other medical procedures, Prolotherapy is a specialty. If you are looking into Prolotherapy, you first want to make sure that the Prolotherapy doctor or Prolotherapist experienced in the Comprehensive Prolotherapy procedure and has successfully treated cases like yours.

PRP and Prolotherapy

A January 2021 study in the journal Anesthesia and pain medicine (2) “found that PRP and dextrose prolotherapy were shown to be effective for treating degenerative conditions and injuries. Both PRP therapy and prolotherapy commonly have regenerative therapeutic properties, but the central mechanisms of prolotherapy and PRP are different.

In prolotherapy, hyperosmolar dextrose triggers an inflammatory response, increases platelet-derived growth factor expression, and upregulates several mitogenic factors that may act as signaling mechanisms in tendon repair. In PRP therapy, it aims to augment the natural healing process of tendon repair and regeneration by delivering high concentrations of growth factors directly to a lesion.”

In other words, Prolotherapy does not act directly as a patch on a tear but rather is initiates a new and natural healing response to injury. PRP does act in a “patch-like” method to repair a tear. It is this understanding of these two treatments which leads us to use both treatments to help the patients.

For more information on these treatments please see our articles:

• The use of Stem Cells in Stem Cell Prolotherapy
• The use of Platelet Rich Plasma as part of Prolotherapy

Video: What type of treatment do I need?

In this video, Danielle R. Steilen-Matias, MMS, PA-C, offers a brief introduction to treatments. Explanatory and summary notes are below:

A major factor in determining which treatment to get is the extent of your injury and whether this is a recent injury or a problem with degenerative joint disease or degenerative arthritis.

• General patient type 1: Younger patient, athlete, active, or with a physically demanding job. Recent injury, such as a sprain that has not healed all the way.
  • Injury is still causing pain and discomfort.
  • This is the type of injury that does very well with dextrose Prolotherapy injections.
  • Dextrose is a sugar water that when injected into the injured joint attracts you own healing repair cells into the area to fix damaged soft tissue such as ligaments and tendons.
• General patient type 2: Chronic problems from an “old” injury, such as a sprain that happened a few years ago,
  • Injury “never really healed,” has progressively worsened. Causing pain, discomfort.
  • Injury has not responded long-term to more conservative care options such as NSAIDs, medications, cortisone, physical therapy
  • Soft tissue damage continues, joint instability has become more permanent.
  • In this patient, it may not be enough to attract your own cells to this damaged area with Prolotherapy, in this type case we may have to put cells there by injection. Our first option would be Platelet Rich Plasma Therapy (PRP). This would put the healing factors found in your blood platelets into the damaged joint.
  • WE DO NOT offer PRP as a stand-alone treatment or injection. While PRP brings healing cells into the joint, it acts to repair degenerative damage. In our experience, while PRP addresses damage deep in the joint, we must still address the joint instability problem created around the joint. We do this with Prolotherapy. Here damaged or weakened ligaments that are simply “stretched,” can be strengthened with treatment to help restore and maintain normal joint mobility.
  • Simple PRP on the inside, Prolotherapy on the outside of the joint.
• General patient type 3: Chronic long-term degenerative problems. Possibly in need of a joint replacement
  • This is a patient who may have had degenerative joint disease for many years even decades. These are the “bone on bone people.” They have exhausted all means of conservative care, they may have had short-term success with PRP treatments, hyaluronic acid treatments, cortisone injections, but none of these are helpful anymore.
  • It is important to realize and it will be explained in this article, that it is rare that we would need to go to stem cell therapy in many of these patients. When we do recommend stem cells it would be from your own stem cell sources and mostly taken from bone marrow. We do not offer “stem cell therapy,” from donated source material.

What is the evidence for Prolotherapy?

For patients who are looking into Prolotherapy, please understand that this is a specialty procedure with technique and experience being a key component. What we present on our website is based on our experience and research and does not apply to all practitioners or injection therapies.

In July 2016, our doctors at Caring Medical published findings on the effectiveness of Prolotherapy treatments in the medical journal: Clinical Insights: Arthritis and Musculoskeletal Disorders, (3) here are the summary highlights:

Our doctors reviewed 32 studies on dextrose prolotherapy for chronic musculoskeletal pain. The following conclusions are made:

• Prolotherapy is supported in the treatment of tendinopathies in patients who fail conservative therapies;
• Prolotherapy is supported in the treatment of knee osteoarthritis
• Prolotherapy is supported in the treatment of finger joint osteoarthritis in patients who do not respond to conservative therapies;
• Prolotherapy is supported in the treatment of back pain and
• Prolotherapy is supported in the treatment of pelvic pain in patients who fail to respond to conservative therapies. .  .

Overall, Prolotherapy has been demonstrated to be efficacious and should be considered as a treatment for pain and dysfunction associated with chronic musculoskeletal conditions, particularly tendinopathies and osteoarthritis.

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Prolotherapy for Knee Pain

In this image of a patient being prepped for receiving Prolotherapy injections into their knee, the dots on the skin represent those areas of the knee that should receive an injection. In this particular patient, there are 50 dots on their knee. Each dot would represent where each injection would be given. This is one comprehensive Prolotherapy treatment to the knee. 

Published research papers from our doctors at Caring Medical on Knee Disorders

• Prolotherapy knee cartilage regeneration: Standard Clinical X-ray Studies Document Cartilage Regeneration in Five Degenerated Knees
  • This paper was published in the Journal of Prolotherapy.
  • Hauser R, Cukla J. Standard Clinical X-ray Studies Document Cartilage Regeneration in Five Degenerated Knees After Prolotherapy. Journal of Prolotherapy. 2009;1(1):22-28. [Google Scholar]
• Outcomes of Prolotherapy in Chondromalacia Patella Patients: Improvements in Pain Level and Function
  • This paper was published in the journal Clinical medicine insights. Arthritis and musculoskeletal disorders.
  • Hauser RA, Sprague IS. Outcomes of prolotherapy in chondromalacia patella patients: improvements in pain level and function. Clin Med Insights Arthritis Musculoskelet Disord. 2014 Feb 17;7:13-20. doi: 10.4137/CMAMD.S13098. PMID: 24596471; PMCID: PMC3937178. [Google Scholar] [Pubmed]
• Prolotherapy as an Alternative Treatment for Osteochondritis Dissecans: Two Cases of Young Baseball Players
  • Hauser RA. Prolotherapy as an Alternative Treatment for Osteochondritis Dissecans: Two Cases of Young Baseball Players. Journal of Prolotherapy. 2011;3(1):568-71. [Google Scholar]
• Bone Marrow Prolotherapy for Degenerative Joint Disease
  • This paper was published in the journal Clinical medicine insights. Arthritis and musculoskeletal disorders.
  • 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. PMID: 24046512; PMCID: PMC3771705.  [Google Scholar] [Pubmed]
• A Retrospective Study on Dextrose Prolotherapy for Unresolved Knee Pain at an Outpatient Charity Clinic in Rural Illinois
  • This paper was published in the Journal of Prolotherapy.
  • 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. [Google Scholar]
• Platelet Rich Plasma Prolotherapy as First-line Treatment for Meniscal Pathology
  • This paper was published in the medical journal Practical Pain Management
  • Hauser RA, Phillips HJ, Maddela H. Platelet rich plasma Prolotherapy as first-line treatment for meniscal pathology. Pract Pain Manag. 2010 Jul;10(6):53-64. [Google Scholar]

Recent Prolotherapy knee research

Lead by researchers at the University of California at Los Angeles (UCLA) and the Department of Biological Sciences, at the University of Southern California (USC) a June 2021 paper in the medical journal Cartilage (4) offered these observations:

“Hypertonic dextrose injections (prolotherapy) for osteoarthritis are reported to (be able to) reduce pain. Cartilage regeneration is hypothesized as a mechanism. This in vitro study identifies an prolotherapy concentration that stimulates chondrogenic cells to increase metabolic activity and assesses whether this concentration affects collagen deposition and proliferation.”

What the researchers are doing is taking hypertonic dextrose (a concentrate simple sugar, the main ingredient in the Prolotherapy solution) to see if in a lab setting, they can grow cartilage cells with it. This was their observation.

(Prolotherapy)  “solution appears to be associated with increased metabolic activity of chondrocytes (reproduction of the cells that make cartilage), increased collagen deposition, and increased chondrocyte proliferation. These results support clinical prolotherapy research suggesting that intra-articular Hypertonic dextrosejoint injections reduce knee pain. Further study of Hypertonic dextrose injections and cellular processes is warranted.”

A May 2020 study in the Annals of Family Medicine (5) made this simple statement at the conclusion of the research findings:

• “Intra-articular dextrose prolotherapy injections reduced pain, improved function and quality of life in patients with knee osteoarthritis compared with blinded saline injections. The procedure is straightforward and safe; the adherence and satisfaction were high.”

Another study from May 2020 published in The Journal of Alternative and Complementary Medicine (6) made these observations:

• “These findings suggest that dextrose prolotherapy is effective at reducing pain and improving the functional status and quality of life in patients with knee osteoarthritis.

In January 2019, David Rabago, MD, of the University of Wisconsin School of Medicine and Public Health, published research on Dextrose Prolotherapy for Symptomatic Knee Osteoarthritis in the Journal of Alternative and Complementary Medicine.(7) The study concluded:

• “(suggested) that Prolotherapy in this primary care clinic is feasible and acceptable.” In other words, it is beneficial to patients.

A May 2021 study in the Journal of clinical orthopaedics and trauma (8) suggests while Prolotherapy researchers may be biased or overlyentusiastic about the treatment, Prolotherapy does offer safe benefit for knee pain. This is what these researchers wrote:

• “Prolotherapy in knee osteoarthritis confers potential benefits for pain but the studies are at high risk of bias. Based on two well-designed studies, dextrose prolotherapy may be considered in knee osteoarthritis (strength of recommendation B). This treatment is safe and may be considered in patients with limited alternative options (strength of recommendation C).”

Basically, Prolotherapy appears to be helpful, it would be better if these researchers had more research to review.

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 cells. The stem cells and blood platelets are drawn from you the patient. We typically DO NOT offer stem cell therapy for knee pain as a first option. We may offer PRP treatments in conjunction with Prolotherapy at initial treatment visits.

WE OFFER PRP with PROLOTHERAPY. We do not offer PRP as a single injection treatment.

Articles:

• Platelet rich plasma injections for meniscus tears
• Platelet Rich Plasma for Knee Osteoarthritis When it works When it will not work and When is it better than other treatments

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Prolotherapy for Back Pain

Published research papers from our doctors at Caring Medical on low back pain

• Dextrose Prolotherapy for Unresolved Low Back Pain: A Retrospective Case Series Study
  • This paper was published in the Journal of Prolotherapy.
  • Hauser RA, Hauser MA. Dextrose prolotherapy for unresolved low back pain: a retrospective case series study. Journal of Prolotherapy. 2009;3:145-55.[Google Scholar]

Lumbar instability as an etiology of low back pain and its treatment by prolotherapy

In December 2021, our peer review paper Lumbar instability as an etiology of low back pain and its treatment by prolotherapy: A review was published in the Journal of Back and Musculoskeletal Rehabilitation (1) was published. For the full version or abbreviated lay version please see our article Prolotherapy treatments for lumbar instability and low back pain.

The main theme of this article is treating low back pain with Prolotherapy. These are some of the previously published papers we used as source information.

• Although facet joint pain can account for up to 45% of low back pain, there are few randomized controlled studies in the literature on the use of comprehensive or cellular prolotherapy for treating this type of pain. Narrative review studies (where the authors interpret previously published medical works) and systemic reviews (where the authors combine data and empirical evidence from previously published medical works) as well as meta-analysis (authors rely on data outcomes) noted overall positive results especially with cellular (PRP and/or Mesenchymal stem cells prolotherapy but mixed with dextrose prolotherapy for chronic low back pain.

Research:

• A single-blind, randomized, crossover study evaluated the effectiveness of injection therapy in 35 patients diagnosed as having painful enthesopathies (these are painful conditions caused by the ligament or tendon attachment to the bone).
  • In this study 86% patients had prior spinal surgery and continued pain.
  •  Thirty-five patients diagnosed as having painful enthesopathies as a major pain generator were studied.
  • Among the study’s participants, 86% had undergone prior spinal surgery, and all had been referred to a neurosurgeon to see if more surgery was needed.
  • Patients were injected with either anesthetics alone or with anesthetics combined with a phenol-glycerol proliferant (prolotherapy).
• Clinical assessment revealed 80% of patients had excellent to good relief of pain and tenderness when prolotherapy injections were given, but only 47% of patients given anesthetics alone had the same amount of pain relief.
• Of the questionnaire responses, 66% reported excellent to good pain relief after prolotherapy vs. 34% after anesthetics alone.

Research:

Sustained pain reduction has been demonstrated in a prospective consecutive patient series in which the effects of disc space injections of hypertonic dextrose were assessed in patients with chronic advanced degenerative discogenic leg pain, with or without low back pain, including those with moderate to severe disc degeneration. In this 2006 study published in the journal Pain Medicine patients underwent bi-weekly disc space injections of a solution consisting of 50% dextrose and 0.25% bupivacaine in the affected disc(s). Each patient was injected an average of 3.5 times. Overall, 43.4% of patients achieved sustained improvement as shown by average changes in numeric pain scores of 71% between pretreatment and 18-month measurements. The authors concluded that intradiscal injection of hypertonic dextrose has promise as a treatment for managing the pain of advanced lumbar disc degeneration.

Research:

In a retrospective case series of 21 patients with MRI-confirmed lumbar disc degeneration and refractory low back pain/non-radicular low back pain, 18 (86%) of patients experienced 70% or greater improvements in pain and function at 1-year follow up. Patients underwent 3 prolotherapy treatment sessions at 1–3 weeks apart, which included injections at the ligamento-periosteal junctions at the origin and insertion of the posterior sacroiliac ligaments, iliolumbar ligaments, facet joint capsules, and supraspinous and interspinous ligaments (all bilaterally). Injections were done under fluoroscopic guidance.

Research:

A small case series of 4 patients with low back pain also proved successful in treating those with disc herniations with prolotherapy. Patients underwent 3–9 prolotherapy sessions to the ligaments of the low back (almost all 1 month apart) with all patients experiencing 95–100% pain relief and increase in function, including the ability to return to work.

Sacroiliac joint-mediated pain

Research:

A study published in the British Journal of Sports Medicine, doctors found positive clinical outcomes for 76% of patients treated with prolotherapy suffering from with sacroiliac joint problems.  In this study, 3 injections at 6-week intervals of a hypertonic dextrose solution were given into the dorsal interosseous ligament of the affected sacroiliac joint of each patient.

A 2010 paper published in The journal of alternative and complementary medicine compared the pain relief effects of prolotherapy to corticosteroid injection. At 15 months, 58% of the patients treated with prolotherapy reported that more than half of their pain was relieved, which was statistically significant compared with only 10% in the corticosteroid group who reported that same level of pain relief. The researchers here concluded: “Intra-articular prolotherapy provided significant relief of sacroiliac joint pain, and its effects lasted longer than those of steroid injections. Further studies are needed to confirm the safety of the procedure and to validate an appropriate injection protocol.”

Prolotherapy for failed back surgery syndrome

A July 2019 study in the European spine journal (10) suggested that “dextrose (Prolotherapy) is one of the regenerative methods that has gained popularity in the treatment of many musculoskeletal problems, and (the researchers)  aimed to present and evaluate the outcomes of 5% dextrose (Prolotherapy) for the treatment of failed back surgery syndrome.”

Study summary:

• A total of 79 patients with failed back surgery syndrome, who had minimum 6 months of symptoms and did not respond to 3 months of conservative methods between May 2014 and March 2016, participated in the study. Prolotherapy injections were applied in posterior (back) and lateral (side) approaches. Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were used for the pre- and post-treatment evaluations. Patient satisfaction was assessed with using a 5-point Likert scale by phone contacting.

Results: There was statistically significant difference between repeated VAS and ODI measurements.

Conclusions: These results may be the first step giving a lead to an undiscovered field. This treatment method should be kept in mind for failed back surgery syndrome patients before giving a decision of revision surgery. ”

Prolotherapy for Shoulder Pain

A November 2020 study in the Journal of back and musculoskeletal rehabilitation accessed the effectiveness of Prolotherapy in shoulder disorders. To do this the researchers evaluated existing studies to see if they could form a consensus on how effective, or not effective prolotherapy can be.

Here are the summary learning points:

• “Wide variation exists regarding usage patterns of prolotherapy.”
  • Explanatory note: These variations included the number of injections given within a treatment (some of studies these researchers assessed were a single injection treatment. Similar to the way cortisone is given. In our 28 years experience we never offer a single shot of Prolotherapy as “the treatment.” It is not effective. Read more you will see these researchers came to this conclusion as well.)
• “Interestingly, amongst the prolotherapy studies evaluated in this review, the two in which significant pain relief was sustained long-term both utilized multiple injections and the three with either non-significant or non-sustained pain relief used a single injection.”
  • Explanatory note: Multiple injection at treatment is superior to single injection at treatment. This is what we have been saying for three decades.

The researchers suggested: “Prolotherapy (appears) to be a safe treatment option with perhaps greater efficacy for shoulder pathology when provided through a series of injections using higher concentrations of dextrose.”

Robinson DM, Eng C, Makovitch S, Rothenberg JB, DeLuca S, Douglas S, Civitarese D, Borg-Stein J. Non-operative orthobiologic use for rotator cuff disorders and glenohumeral osteoarthritis: A systematic review. Journal of Back and Musculoskeletal Rehabilitation. 2020(Preprint):1-6. [Google Scholar]

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Published research papers from our doctors at Caring Medical on Shoulder Disorders

• Prolotherapy: A Non-Invasive Approach to Lesions of the Glenoid Labrum; A Non-Controlled Questionnaire Based Study
  • This paper was published in The Open Rehabilitation Journal.
  • Hauser RA, Dolan E, Orlofsky A. Prolotherapy: a non-invasive approach to lesions of the glenoid labrum; a non-controlled questionnaire-based study. The Open Rehabilitation Journal. 2013 Dec 27;6(1).[Google Scholar]
• A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Shoulder Pain at an Outpatient Charity Clinic in Rural Illinois
  • This paper was published in the Journal of Prolotherapy.
  • Hauser RA, Hauser MA. A retrospective study on Hackett-Hemwall dextrose prolotherapy for chronic shoulder pain at an outpatient charity clinic in rural Illinois. J Prolotherapy. 2009;4:205-16. [Google Scholar]

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In this video, a general demonstration of Prolotherapy and PRP treatment is given for a patient with repeated shoulder dislocations

Danielle R. Steilen-Matias, MMS, PA-C narrates the video and is the practitioner giving the treatment:

• PRP or Platelet Rich Plasma treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets and growth and healing factors from your blood into the shoulder. The treatment is explained further below.
• In the shoulder treatment, I treat all aspects of the shoulder including the ligament and tendon injections to cover the whole shoulder.
• The patient in this video is not sedated in any way. Most patients tolerate the injections very well. The treatment goes quickly. However, we do make all patients comfortable including sedation if needed.
• This patient in particular comes to us with a history of repeated shoulder dislocations. His MRI findings showed multiple labral tears and rotator cuff problems.
• The patient complained of shoulder instability typical of the ligament and tendon damage multiple dislocations can do.
• With the patient laying down, treatment continues to the anterior or front of the shoulder. The rotator cuff insertions, the anterior joint capsule and the glenohumeral ligaments are treated.
• PRP is introduced into the treatment and injected into the front of the shoulder. PRP is a form of Prolotherapy where we take concentrate cells and platelets from the patient’s blood and inject that back into the joint. It is a more aggressive form of Prolotherapy and we typically use it for someone that has had a labral tear, shoulder osteoarthritis, and cartilage lesions.
• PRP is injected into the shoulder joint and the remaining solution is injected into the surrounding ligaments in this case it was in his anterior shoulder attachments to address the chronic dislocations.

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Prolotherapy for Cervical Spine Instability and related symptoms

This section will also provide information on the following symptoms as they relate to neck pain and cervical spine instability

• Headache and Migraine
• TMJ
• Whiplash Associated Disorder
• Hearing problems
• Vision problems
• Swallowing difficulties
• Dizziness
• Drop Attacks
• Vagus Nerve disorders

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability. Cervical instability is a progressive disorder causing a normal lordotic curve to end up as an “S” or “Snake” curve with crippling degeneration.

Since 1993, Ross Hauser, MD and Marion Hauser, MS, RD have developed Caring Medical into one of the world’s leading clinics for Prolotherapy (including dextrose, PRP, and stem cells) with a commitment to helping the toughest chronic pain cases. ​Today, our work is heavily focused on the cervical spine.

Published research papers from our doctors at Caring Medical on Cervical Spine Instability and related symptoms

• Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability
  • This paper was published in the European Journal of Preventive Medicine
  • Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The Open Orthopaedics Journal. 2014;8:326-345. [Google Scholar]
• The Biology of Prolotherapy and Its Application in Clinical Cervical Spine Instability and Chronic Neck Pain: A Retrospective Study
  • This paper was published in the European Journal of Preventive Medicine
  • Ross Hauser, MD, Steilen-Matias D, Gordin K. The biology of prolotherapy and its application in clinical cervical spine instability and chronic neck pain: a retrospective study. European Journal of Preventive Medicine. 2015;3(4):85-102. [Google Scholar]
• Non-Operative Treatment of Cervical Radiculopathy: A Three Part Article from the Approach of a Physiatrist, Chiropractor, and Physical Therapists
  • This paper was published in the Journal of Prolotherapy
  • Ross Hauser, MD, Batson G, Ferrigno C. Non-operative treatment of cervical radiculopathy: a three part article from the approach of a physiatrist, chiropractor, and physical therapists. Journal of Prolotherapy. 2009;1(4):217-231.
• Dextrose Prolotherapy for Unresolved Neck Pain
  • This paper was published in Practical Pain Management
  • Hauser R, Hauser M, Blakemore K. Dextrose prolotherapy for unresolved neck pain. Practical Pain Management. 2007;7(8):58-69.
• Cervical Instability as a Cause of Barré-Liéou Syndrome and Definitive Treatment with Prolotherapy: A Case Series
  • This paper was published in the European Journal of Preventive Medicine
  • Hauser R, Steilen-Matias D, Sprague IS. Cervical instability as a cause of Barré-Liéou syndrome and definitive treatment with prolotherapy: a case series. European Journal of Preventive Medicine. 2015;3(5):155-166. [Google Scholar]

Degenerative Disc Disease in the Cervical Spine

• Treatment of Cervical Spondylosis
• Cervical neck instability | Regenerative medicine and Prolotherapy for chronic neck pain

Ross Hauser, MD. Cause of occipital neuralgia and migraines as seen on DMX and resolved with Prolotherapy

In this video, Ross Hauser, MD offers a brief introduction to causes of occipital neuralgia and migraines and treated with the aid of DMX (Digital Motion X-Ray and simple dextrose Prolotherapy cervical spine injections.

Prolotherapy for hip pain

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Published research papers from our doctor at Caring Medical on Hip Disorders

• Regenerative Injection Therapy (Prolotherapy) for Hip Labrum Lesions: Rationale and Retrospective Study
  • This paper was published in The Open Rehabilitation Journal.
  • Hauser R, Orlofsky A. Regenerative injection therapy (prolotherapy) for hip labrum lesions: rationale and retrospective study. The Open Rehabilitation Journal. 2013 Oct 18;6(1). [Google Scholar]

In the Journal of Prolotherapy, we sought to show how Prolotherapy could provide high levels of patient outcome satisfaction while avoiding hip surgery. Here is what we reported:

• We examined Sixty-one patients, representing 94 hips, who had been in pain an average of 63 months We treated these patients quarterly with Hackett-Hemwall dextrose Prolotherapy.
• This included a subset of 20 patients who were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of eight patients who were told by their doctor(s) that surgery was their only option.

Patients were contacted an average of 19 months following their last Prolotherapy session and asked questions regarding their levels of pain, physical and psychological symptoms and activities of daily living, before and after their last Prolotherapy treatment.

Results: In these 94 hips,

• pain levels decreased from 7.0 to 2.4 after Prolotherapy;
• 89% experienced more than 50% of pain relief with Prolotherapy;
• more than 84% showed improvements in walking and exercise ability, anxiety, depression and overall disability;
• 54% were able to completely stop taking pain medications.

The results confirm that Prolotherapy is a treatment that should be highly considered for people suffering from chronic hip pain.

Published research on Prolotherapy:

Dr. Ross Hauser and our team have published a number of research papers, case studies, and scientific editorials in the Journal of Prolotherapy, including articles on Prolotherapy as an alternative to surgery; Prolotherapy for chronic back pain; cartilage regeneration in knees; Stem cell therapy for degenerative joint disease; Prolotherapy as for meniscus tears, and many, many more.

Prolotherapy for Medial tibial stress syndrome – shin splints

A study published in the Journal of foot and ankle research (1) examined the effectiveness of Prolotherapy injections in difficult to treat and chronic Medial tibial stress syndrome. In this study sports active people were treated and followed to see how many returned to sports and at what level.

Conclusions: “Ultrasound-guided 15% dextrose prolotherapy injection has a significant medium-term effect on pain in Medial tibial stress syndrome. This benefit may be maintained long-term; however, more robust trials are required to validate these findings. . . Clinicians should consider the use of ultrasound-guided injection of 15% dextrose as a viable treatment option to reduce pain and aid return to activity for patients with recalcitrant Medial tibial stress syndrome.”

More research on possible patient outcomes using Prolotherapy for shin splints can be found here: When you have chronic and painful shin splints and nothing helped

1 Padhiar N, Curtin M, Aweid O, Aweid B, Morrissey D, Chan O, Malliaras P, Crisp T. The effectiveness of PROLOTHERAPY for recalcitrant Medial TIBIAL Stress Syndrome: a prospective consecutive CASE series. Journal of Foot and Ankle Research. 2021 Dec;14(1):1-2. [Google Scholar]

Adductor-related groin pain syndrome

A March 2021 review study (1) looked at research outcomes for the treatment of Adductor-related groin pain. They found that the intervention(s) showing the greater level of strength of evidence, and the greater grade of recommendation are compression clothing therapy, manual therapy and strengthening exercise, and prolotherapy.”

1 Bisciotti GN, Chamari K, Cena E, Rodriguez Garcia G, Vuckovic Z, Bisciotti A, Bisciotti A, Zini R, Corsini A, Volpi P. The conservative treatment of longstanding adductor-related groin pain syndrome: a critical and systematic review. Biology of Sport. 2021;38(1). [Google Scholar]

Prolotherapy for TMJ related pain

The research on Prolotherapy for Temporomandibular Joint Pain and Dysfunction

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Comprehensive Prolotherapy for TMJ. 

In this section, we will discuss how to turn a degenerative TMJ environment into a healing environment through the use of Comprehensive Prolotherapy.

“Dextrose prolotherapy is one of the most promising approaches in the management of TMD”

A March 2021 study in the Journal of Maxillofacial and Oral Surgery (11) writes: (This) study concluded that prolotherapy is an effective therapeutic modality that reduces TMJ pain, improves joint stability and range of motion in a majority of patients. It can be a first-line treatment option as it is safe, economical and an easy procedure associated with minimal morbidity.”

In March 2019, publishing in the journal Mayo Clinic Proceedings (12)  doctors from the University of British Columbia, University of Missouri-Kansas City, School of Medicine, the University of Wisconsin School of Medicine and Public Health, and the Chinese University of Hong Kong announced these findings in their study to assess the LONG-TERM effectiveness of dextrose prolotherapy injections in study participants with temporomandibular dysfunction. Their results: “Intraarticular (Prolotherapy) resulted in clinically important and statistically significant improvement in pain and dysfunction at 12 months compared to lidocaine injection.”

Indian doctors writing in the Journal of Maxillofacial and Oral Surgery (13) found positive results utilizing Prolotherapy injections for TMJ in recent research (June 2017). Here is what they said: In their study, the researchers examined 23 patients suffering from either chronic recurrent dislocation or subluxation of the TMJ who were treated with the single-injection technique prolotherapy with 25 % dextrose into the pericapsular tissues along with auriculotemporal nerve block.

• The overall success rate in the study was 91.3 % (21/23) with a minimum follow-up period of 13.9 months.
• The number of successfully treated patients requiring one injection was 7 (30.4 %), two injections were 8 (34.7 %), and requiring three injections was 6 (26.1 %). There were no permanent complications.

Prolotherapy reports on TMJ disc dislocation

In Prolotherapy research, doctors say that they see appreciable improvements in the number of episodes of dislocation and clicking after Prolotherapy treatment.

• Doctors writing in the British Journal of Oral and Maxillofacial Surgery found that Prolotherapy injections were curative in preventing recurrent TMJ dislocations. In fact, nearly 2 of 3 of these patients achieved this result with a single treatment. (14)

Prolotherapy and aspiration (arthrocentesis) provided significant relief for TMJ patients.

Doctors at Ordu University in Turkey published in The Journal of Alternative and Complementary Medicine (15) suggesting that Prolotherapy and aspiration (Arthrocentesis) provided significant relief for TMJ patients.

A December 2020 study in the medical journal Cranio, Journal of Craniomandibular Practice (16) also compared the effectiveness of dextrose Prolotherapy in conjunction with arthrocentesis (fluid draining of the TMJ) and dextrose prolotherapy alone in the management of symptomatic TMJ hypermobility. The study concluded Prolotherapy is effective in the management of TMJ hypermobility. However, Prolotherapy with arthrocentesis may be superior to Prolotherapy alone in the management of TMJ hypermobility.

Our Prolotherapy research papers, case studies, & scientific editorials:

• Articular Cartilage Regeneration
• Avascular Necrosis Case Report
• Big Toe and Bunion Pain
• Bone Marrow Prolotherapy for Degenerative Joint Disease
• Cartilage Degeneration with NSAIDs
• Chronic Ankle Pain
• Chronic Hip Pain
• Complex Regional Pain Syndrome
• Consensus Statement on Prolotherapy for Musculoskeletal Pain
• Corticosteroid Injections
• Dextrose Prolotherapy for Musculoskeletal Pain
• Prolotherapy for Headache and Migraine Pain
• Direct Bone Marrow Aspirate Therapy
• Elbow Pain
• Foot & Toe Pain
• Hand & Finger Pain
• Hip Labrum Lesions
• Joint Hypermobility Syndrome
• Joint Instability Treatment with Prolotherapy
• Ligament Injury and Healing
• Morton’s Neuroma Pain
• Osteoarthritis Pain: Can Prolotherapy Help?
• Osteochondritis Dissecans
• Over-manipulation Syndrome
• PRP Injection Technique
• Prolotherapy as an Alternative to Surgery
• Rationale for Direct Bone Marrow Aspirate
• Systematic Review of Dextrose Prolotherapy
• Thumb Arthritis
• TMJ Dysfunction Pain
• Upper Cervical Instability
• Wrist Pain

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Prolotherapy Side effects and risks

Prolotherapy Side effects and risks

• Bleeding in the area
• Bruising in the area
• Increased pain
• Infection
• Joint effusion
• Nerve injury
• Puncture of a lung
• Spinal headache
• Stiffness
• Swelling
• Tendon/ligament injury

Because Prolotherapy causes inflammation, the person will often note some bruising, pain, stiffness and swelling in the area after receiving Prolotherapy. Typically this lasts 1 to 7 days. On rare occasions, it lasts longer. Lasting longer is not necessarily bad, some people just inflame more easily. Since the treatment works by inflammation, lingering pain after Prolotherapy can be a sign of healing. If the pain is severe after Prolotherapy, then call the office where the Prolotherapy was done. Prolotherapy should not cause excessive, severe pain. Severe pain after Prolotherapy, especially accompanied by a fever, could indicate an infection. Infection after Prolotherapy is the most serious risk that we have seen.

The risk of infection after Prolotherapy is between 1 and 1000 to 1 and 10,000 procedures. The most common infection with Prolotherapy is an infection in the skin. This type of infection typically responds to an antibiotic taken by mouth. If a joint or blood infection results, then intravenous antibiotics will typically be needed for six weeks.

Since some of the risks with Prolotherapy relate to the actual technique or solutions used, it is important to go to a clinic with a lot of experience and one who has researched the best options for various types of pain, versus just utilizing the same ingredients for every patient.

References

1 Bae G, Kim S, Lee S, Lee WY, Lim Y. Prolotherapy for the patients with chronic musculoskeletal pain: systematic review and meta-analysis. Anesthesia and Pain Medicine. 2020 Dec 16. [Google Scholar]
2 Bae G, Kim S, Lee S, Lee WY, Lim Y. Prolotherapy for the patients with chronic musculoskeletal pain: systematic review and meta-analysis. Anesthesia and Pain Medicine. 2021 Jan 31;16(1):81. [Google Scholar]
3 Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain. Clinical Medicine Insights Arthritis and Musculoskeletal Disorders. [Google Scholar]
4 Johnston E, Kou Y, Junge J, Chen L, Kochan A, Johnston M, Rabago D. Hypertonic Dextrose Stimulates Chondrogenic Cells to Deposit Collagen and Proliferate. Cartilage. 2021 Jun 10:19476035211014572. [Google Scholar]
5 Shan Sit RW, Keung Wu RW, Rabago D, et al. Efficacy of Intra-Articular Hypertonic Dextrose (Prolotherapy) for Knee Osteoarthritis: A Randomized Controlled Trial. Ann Fam Med. 2020;18(3):235‐242. doi:10.1370/afm.2520 [Google Scholar]
6 Sert AT, Sen EI, Esmaeilzadeh S, Ozcan E. The Effects of Dextrose Prolotherapy in Symptomatic Knee Osteoarthritis: A Randomized Controlled Study. J Altern Complement Med. 2020;26(5):409‐417. doi:10.1089/acm.2019.0335 [Google Scholar]
7 Rabago D, Kansariwala I, Marshall D, Nourani B, Stiffler-Joachim M, Heiderscheit B. Dextrose Prolotherapy for Symptomatic Knee Osteoarthritis: Feasibility, Acceptability, and Patient-Oriented Outcomes in a Pilot-Level Quality Improvement Project. The Journal of Alternative and Complementary Medicine. 2019 Jan 28. [Google Scholar]
8 Wee TC, Neo EJ, Tan YL. Dextrose prolotherapy in knee osteoarthritis: A systematic review and meta-analysis. Journal of Clinical Orthopaedics and Trauma. 2021 May 20. [Google Scholar]
9 Giordano L, Murrell WD, Maffulli N. Prolotherapy for chronic low back pain: a review of literature. Br Med Bull. 2021 Apr 21:ldab004. doi: 10.1093/bmb/ldab004. Epub ahead of print. PMID: 33884404. [Google Scholar]
10 Solmaz İ, Akpancar S, Örsçelik A, Yener-Karasimav Ö, Gül D. Dextrose injections for failed back surgery syndrome: a consecutive case series. European Spine Journal. 2019 Jul;28(7):1610-7. [Google Scholar]
11 Dasukil S, Arora G, Shetty SK, Degala S. Impact of Prolotherapy in TMDs: a quality of life assessment. British Journal of Oral and Maxillofacial Surgery. 2020 Oct 27. [Google Scholar]
12 Louw WF, Reeves KD, Lam SK, Cheng AL, Rabago D. Treatment of temporomandibular dysfunction with hypertonic dextrose injection (prolotherapy): A randomized controlled trial with long-term partial crossover. InMayo Clinic Proceedings 2019 May 1 (Vol. 94, No. 5, pp. 820-832). Elsevier. [Google Scholar]
13 Majumdar SK, Krishna S, Chatterjee A, Chakraborty R, Ansari N. Single Injection Technique Prolotherapy for Hypermobility Disorders of TMJ Using 25 % Dextrose: A Clinical Study. J Maxillofac Oral Surg. 2017 Jun;16(2):226-230. [Google Scholar]
14  Zhou H, Hu K, Ding Y. Modified dextrose prolotherapy for recurrent temporomandibular joint dislocation. Br J Oral Maxillofac Surg. 2014 Jan;52(1):63-6. doi: 10.1016/j.bjoms.2013.08.018. [Google Scholar]
15 Cezairli B, Sivrikaya EC, Omezli MM, Ayranci F, Cezairli NS. Results of Combined, Single-Session Arthrocentesis and Dextrose Prolotherapy for Symptomatic Temporomandibular Joint Syndrome: A Case Series. The Journal of Alternative and Complementary Medicine. 2017 Oct 10. [Google Scholar]
16 Taşkesen F, Cezairli B. Efficacy of prolotherapy and arthrocentesis in management of temporomandibular joint hypermobility. CRANIO®. 2020 Dec 18:1-9. [Google Scholar]

This page was updated January 1, 2022

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