Prolotherapy… Is it as ‘sweet’ as it sounds???

Prolotherapy is a popular yet controversial injection therapy used widely in sports medicine and recently more in general practice, that involves the injection of a dextrose solution. Yes that’s right, sugar injected into the body to help treat a variety of ligament, tendon, muscle and joint pains. However despite lots passionate anecdotal evidence for its benefits, such as speeding up healing, quicker return to sport, and the ability to reduce chronic joint and ligament laxity, there is actually little robust research that supports it use, and even less on its long-term effects.

I have personally witnessed its growing popularity and widespread use in professional sport and in general practice, and I have even referred patients for these injections. But I have to question my motives for this, and in this article we will look at what are the benefits, the risks, the research and the future for prolotherapy?

When is prolotherapy used?

Prolotherapy can be traced back about a hundred years when doctors used to give irritants to help heal many things. But its modern use has really been going since the 1950’s. It was first called ‘sclerotherapy’ as it was thought to be a scar forming therapy, and has been growing in popularity, for the treatment of acute ligament injuries, where the ligament has undergone a mechanical failure leading to laxity but not rupture, these are commonly seen in sports with the ankle and the knee ligaments being the most commonly injured areas.

Ligament laxity after a injury can be present for a long time afterwards and in some cases can be permanent leading to chronic joint instability and cause long-term pain and loss of function. This often prevents a returning to activity long after the original injury has healed. So having a treatment that could speed up the healing rate, but also reduce ligament and joint laxity seems a very attractive prospect to any medical professional, especially those working in sport, where the speed of an injured player returning to play is often the main measure of your success.

So what does prolotherapy do?

Prolotherapy acts as a local irritant and so creates an increased inflammatory response, this increases protein synthesis and collagen formation and so increased cell proliferation. Prolotherapy is also thought to increase the infiltration of leukocyte (white blood cells) and macrophages (debris removers) as well as increase platelet-derived growth factor (PDGF) and interleukin-1β (IL-1β) (chemical building blocks) and so help improve a ligaments strength, mass, thickness and a trend toward an increase in cell number, glycosaminoglycan (protien), and water content. (source, source , source)

How is prolotherapy administered?

Injections of the irritant in solution are given in and around the injured ligament, joint or muscle over a course of a few weeks to a few months. The number, dosage and concentration of the solution used is not well described or explained. Many clinicians seem use their judgement and intuition dependent on the severity and size of the injury and the amount of laxity present. One of the major limitations of prolotherapy research is the lack of consensus or standardisation of dosages or protocols to administer the injections.

Three solutions are commonly used in prolotherapy D-glucose (dextrose), phenol-glucose-glycerin (P2G), and sodium morrhuate. D-glucose is thought to be the safest solution but with conflicting evidence on its effects, with studies showing increase cell proliferation (source) but others showing cell apoptosis (cell death) (source). P2G is thought to create a stronger inflammatory response, but phenol has been found to be toxic to some human cells (source) and can also block peripheral nerves in humans (source). Sodium Morrhuate is a an extract of cod liver oil and found to be toxic to red blood cells (source). All the prolotherapy injections I have seen used have been D-glucose, which seems not only to to be the safest with regards to toxicity, but also has the most conflicting effects.

How does prolotherapy feel?

Well the first thing to mention is that prolotherapy is painful, more so in some areas than others, I have seen grown sports men and women have injections in their lateral ankle ligaments, knee MCL’s and LCL’s, lumbar facet joints, SIJ’s, and even one poor soul having is symphisis pubis injected… three times… ouch! They ALL complained of increased pain and discomfort during, and after these injections.

Thats not really surprising as the irritant nature of the solution causes a local inflammation which obviously can cause pain and discomfort, in my experience this lasts anywhere from 24 hours, up to a week afterwards. Patients are advised to rest and take analgesia as required, but obviously not anti-inflammatory medications as this counter effects the work of the injections, they are also advised not to do any vigorous exercise or have any manual therapy during this reactive inflammatory stage. Once the pain and inflammation is settled the ligament or joint is reassessed for laxity and pain and either re injected or the rehab can begin

Are there any adverse effects to prolotherapy.

In the scant literature and in my clinical experience there are no significant side effects apart for a post injection flare of pain and some tenderness around the injection site. Rabago et al. 2010 did find some very rare effects such as allergic reactions and nerve damage but none classed as serious.

However I would like to add something here, about possible long-term detrimental side effect that prolotherapy may cause. It is purely anecdotal and based only on a single case, but it was observed in conjunction with a very senior and well-respected sports orthopaedic surgeon who regularly operates on many high-profile and professional sports men and women.

It was observed that during an operation on a chronic MCL injury in a professional footballer that had previously had four prolotherapy injections over two years ago, that the ligaments collagen structure was unusual and had changed. It was noted to be comprised mainly of soft stringy collagen, Type III, opposed to the normal stiffer more rigid collagen Type I. The orthopaedic surgeon doing the surgery also commented that this is not the first time he has witnessed this unusual collagen make up with other athletes who have had prolotherapy injections around ligaments, and then needed surgery.

The surgeon explained that he thought these prolotherapy injections may indeed help with protein synthesis and collagen formation, but he believes its of this softer less dense Type III collagen which is formed rapidly and quickly after the injections, which for a stabilising ligament isn’t the best type. He went on to explain that he thought this excessive Type III collagen produced by prolotherapy injections may well actually prevent the formation of normal Type I collagen from being laid down with normal natural healing mechanisms, and so could caused potential long term deficits.

Does prolotherapy work?

Well in my experience and from my own anecdotal evidence…

YES… and NO?

YES… There does seem to be a speedier rate of healing for acute ligament injuries, and ligament laxity does seem to improve very quickly. I have personally seen very lax MCL’s and ATFL ligaments with clear joint gapping on testing, have three to four of these injections over a 4-6 week period and the laxity reduces remarkably quickly and in some cases go completely. I have also seen players return to play a lot quicker than I would expect after ligament injuries, I would say around 30-40% quicker, so a six-week injury is back in four, not majorly important in general sport but a massive bonus in professional sport.

NO… However for those that I have seen go for prolotherapy for conditions such as chronic muscle, tendon or joint pains I would have to say I saw no major benefit. These injections for low back pain, possible facet joint pain and other joint issues such as osteitis pubis I would say didn’t achieve much?

But what about the research????

Well as mentioned there isn’t that much out there and most research has been done on animal models. Jenson et al. 2008 found that rat MCL’s did show ligament thickening after prolotherapy but no difference in its strength or any reduction in joint laxity.

Jenson et al. 2008 again in a different study found that prolotherpay did produce an increased inflammatory response in rats that could assist in cell proliferation, but this was not significantly different from injections of saline solution or just needle stick trauma.

Kim et al. 2011 showed prolotherapy helped reduce chronic SIJ pain better than corticosteriod injections but it was a small study and its results cannot be generalised to the wider population

Cusi et al. 2010 again showed good results in SIJ pain but again cannot be generalised as only individual case studies and no control group

A systematic review done by Dagenais et al. 2007 showed conflicting effects and no effect of prolotherpay when used alone in the treatment of low back pain

And finally another systematic review by Rabago et al. 2005 found limited results for use of prolotherapy in sport related soft tissue injuries and further high quality research with non injection controls is needed

Would I recommend prolotherapy???

Hmmm tricky one… possibly YES and definitely NO… confused… so am I

Possibly YES… in professional sport I think it has a role to play in getting an injured player back quicker with minimal risk. But this has to be used wisely, I think it should only be used for acute ligament injuries that show clear laxity, not just the strains. I also think the player should be fully informed of the lack or research and possible side effects, ie it will hurt like a bugger afterwards, and the possible effect it can have on the ligament in the long-term as mentioned earlier.

In my experience most athletes wont give a toss about the long term effects, most are focused on getting back as soon as they can. This is the ethical dilemma many healthcare professionals have, a duty to weigh up the pro’s and cons’s of an intervention, verses the desires, beliefs and expectations of a patient, and this can be extremely difficult in a professional sports environment.

And definitely NO… I don’t think there is any role for prolotherapy, at the moment, in general musculoskeletal medicine and other non professional sports therapy until the evidence and research can show greater clearer benefits of these injections and prove that there is little to no detrimental long-term side effects to the ligaments and joints injected.

What do you think, have you come across prolotherapy and would you use it or have you used it and what results did it get you.

Thanks for reading and as always enjoy your sport

Cheers

Adam

117 thoughts on “Prolotherapy… Is it as ‘sweet’ as it sounds???

  1. Hi Adam,
    I am a high school athlete. I play tennis but I have been struggling with shoulder instability for the past 2 years. I have popped my shoulder out of place 9 times most of which has been over the past five months as my instability has gotten worse. I have done intensive physical therapy, I have taken time off, I have seen a chiropractor, and nothing seems to be helping. My trainers have suggested that we find a more long term solution for my instability. One option being surgery, another option mentioned was prolotherapy. Do you think prolotherapy could potentially help me? Do you think surgery is my only option? Do you think I could wear a brace while playing and continue with PT until after my senior season (October 2016) or do you feel like something needs to be done now? I understand you may not be qualified to answer some of my questions especially via comment on a blog but I am asking for your OPINION (I understand this is a blog and that it is your opinion) and any advice would greatly be appreciated. Thank You!

    • Hi CW

      My opinion is no prolotherapy wont help significantly with a recurrent dislocation shoulder. The evidence and my opinion is that the younger you are the more times your shoulder has dislocated the more likely you will need surgery.

      I would advise an MR arthrogram to check for any structural defects from your dislocations

      Regards

      Adam

  2. too many incompetent doctors peform prolotherapy thats why im not surprised it doesnt work for so many people, first it has to be comprehensive,secondly the injections need to be precise using ultrasound and fluoroscopy,thirdly it should be stem cell using bone marrow in combination with PRP. thats the most effective way to make it work!

    • Agree with the comment about too many doctors use prolotherapy

      But disagree with everything else you say. There is now good robust and unbiased evidence to show PRP has no effect in improving healing of anything. Asd for stem cells I am not aware of much unbiased research that shows much effect either.

  3. Hi Adam,
    I am currently undergoing prolotherapy injections in my C2C3 neck vertebrae. I was in a vehicle accident in 2013 and have had ongoing health issues since. My physiotherapist has assessed that I have “a consistent block in left extention at C2C3.” I have had 6 prolo sessions and see no significant results. My doctor feels I need 9 more to know for sure. (15 all together). In fact the tingling sensations in hands seem worse and burning on back of hands and right arm is worse. This past weekend I called 911 as my right side face, arm, side of body and outer right leg went numb & tingly. They did CTC scan ..EKG..blood work. All came back normal. After recent assessment by my physio he feels I have trigeminal issues happening. ( the burning face..right side mainly..around right eye. .right ear & forehead & chin ) they r not ruling out the very slight possibility that I had a TIA mini stroke..possibly in my sleep. Which he felt may not have been revealed in the CTC scan. He said we will keep an eye on your symptoms ( play a waiting game) and in the mean time feels that it is safe to Continue with my prolotherapy injections. I need him on my side, as he believes me and knows my symptoms are real, as my doctor (I believe) is starting to feel that it is in my head, that I am turning into a hypochondriac. But I am scared and am worried that the prolotherapy has caused this issue with my trigeminal facial nerve and or the TIA. My physiotherapist strongly believes in prolo and feels it has absolutely no bearing on the other issues. I don’t know what the heck to do. If I refuse to go, and my physiotherapist is not happy and let’s me go so to speak, as his patient.. feel I may be in quite a delema! !
    Sincerely, Christina

    • I don’t know if you have giving up on prolo or not, but I started prolo 2/2016 in my neck as while. there is nothing regenerative about prolo; it delivered me to chronic, debilitating pain because I became so inflamed. I kept listening to the prolotherapist that I needed more prolo to help with my ever increasing pain/new symptoms, not realizing that my body had gone off the rails with inflammation. I finally spoke to my PCP and he said to “stop the madness” and don’t go again. I am still in a high degree of pain and will be seeing a pain specialist in a couple of days to see what can be done for the inflammation so I can get back to work. (I haven’t worked since March). I would listen to yourself and not your physiotherapist, it’s your body, not the physiogherapist’s.

    • Christina,
      I just received my first series of shots also to treat my neck from a car accident. He must have poked my herniated disc because intense pain shot down my leg at the time. But the following day i started noticing a burning sensation on the top of my forearms and now spreading to the tops of my hands. Clothing hurts by touching it. Im curious what you ended up deciding on doing, and how your symptoms are now. Is the burning/tingling temporary? If so how long did it last? I had one mild session to see how my body responded, but he recommended 5 more sessions on different areas of the neck. Not sure if I should continue, if the cost and pain out weigh the results or not.
      Fingers crossed,
      Abby

  4. I just had my 4th Prolo treatment over 8 weeks for a 63 year old knee that gets over 90 days of downhill skiing annually. I was barely walking after last season. The improvement has been remarkable, I am now able to get back to my brisk walking routine and increase my heart rate to the needed levels for short bursts. I heard about Prolo from a friend who had great results. Of coarse the issues are different for everyone, for me at this point as a very sceptical participant I am impressed. I will try and report again in another few months.

  5. Christina, Michelle, Abby…
    Just my opinion based upon my experiences:
    I had a work-related shoulder injury (torn rotator cuff) in April 2013. Workman’s Comp sent me to a DO for Prolotherapy treatment. With my perfect 20/20 hindsight I would now refuse Prolotheray. For me, it would have been FAR better to have just had the surgery as there would have been far LESS residual damage! The Prolotherapy has caused MORE damage than the initial injury due to buildup of scar-tissue at the injection sites.
    For my first Prolo session, the DO gave me 17 injections…then I returned every two weeks (from April – Sept) for the next set of injections (typically 9-12 each session). Three years later, I’m still dealing with scar-tissue buildup (around the injection sites) and have to have a physiotherapist and a massage therapist to help break it down…otherwise, my shoulder locks-up.
    Pure torture…I would NEVER recommend Prolotherapy…but, for some people it MIGHT have some success.
    But for those who must try Prolotherapy…”good luck”…and be SURE to “listen” to your body.

  6. I had it done for Ostitus Pubis and it worked amazing! I’ve also read a lot of scientific articles that said it was beneficial. So there is some scientific evidence. It was gone in 7 sessions after 2 years of pain. I’ve had really good luck with it but I have a great doctor and he finds the right spots. If you don’t find the right spots I have found there is little benefit

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