Prolotherapy & Platelet Rich Plasma (PRP)

Regenerative Injection Therapy (RIT) includes prolotherapy, platelet rich plasma (PRP) injection and injection of stem cells. RIT incites the body to manufacture growth factors, platelets already have growth factors within them and stem cells can potentially lead to more specific tissue regeneration. All of these treatment techniques share a completely different paradigm for treating musculoskeletal disorders than what we are used to today. Its use is intended to strengthen or even, at least, partially heal, damaged tissue. The word prolotherapy is derived from the word, proliferate. Conditions that can be treated with regenerative injection therapy include:
  • Osteoarthritis
  • Partial Rotator Cuff Tears
  • Sports Injuries
  • Ankle and knee Injuries,including sprains and post fracture pain
  • Low back pain
  • Neck pain and whiplash injuries

Cortisone injections have become the panacea treatment of almost all musculoskeletal injuries; cortisone is injected to injured tendons and ligaments, as well as to arthritic joints with the purpose of reducing the inflammation resulting from the injury. Cortisone has beneficial effects if injected in absolute minute quantities into a joint or around a tendon, a dose of 3mg of methylprednisolone. The average dose of a cortisone injection given to joints, bursae and tendons is between 40- 80mg, which is likely to cause damage! Cortisone has well known side effects which can be categorised into local and systemic. Cortisone is ‘catabolic’, that is, it breaks down proteins, thereby weakening collagen tissue. This may well interfere with the body’s response to healing, and increases the risk of a rupture of the ligament or tendon. When injected into joints repeatedly, a ‘steroid arthropathy’ results, which is further degeneration of the cartilage. When absorbed into the bloodstream, cortisone causes significant increase in appetite and weight gain, increases blood pressure, reduces the immune response, and may even lead to depression.

In contrast, the proliferant solution, usually dextrose, injected in prolotherapy stimulates the synthesis of more collagen tissue in the ligament or tendon, as well as cartilage. This enables the ligaments or tendons to withstand the forces applied to them and makes them more resistant to further wear and tear. Various growth factors are manufactured, including platelet derived growth factor, transforming growth factors, insulin growth factor and more.

I am including the discussion of Platelet Rich Plasma (PRP) in this section because both share common mechanisms of action. For more details on how the platelet rich plasma method works and is used, please refer to the section on PRP. Generally, PRP and prolotherapy can be used interchangeably. It must be stressed that no-one has tested prolotherapy head-to-head with PRP, so neither has been proven to be more effective. Prolotherapy has an added advantage, due to its low cost, in that it addresses and strengthens the whole functional unit, and not just the injured tissue.

For prolotherapy and PRP to have maximal effect an environment conducive for tissue regeneration should be maintained. The patient should be active, though not excessively, in order to encourage motion, mechanical loading, and increased blood supply to the treated tissues. Recommendations for an active life, proper exercise and good ergonomic advice go hand in hand with promoting, maintaining and maximizing the effect of these treatment methods.

Injections can be performed with and without ultrasound. They are not usually performed under fluoroscopy, because a few points are injected in every treatment and this would entail unnecessary radiation exposure. Dextrose is injected together with local anaesthetic. Within 5-8 minutes after the treatment, the pain should start to clear if the right points were injected, and this gives one an indication if a) the right diagnosis was made and b) the right points were injected.

There are many substances that were once used in prolotherapy but it has become more common practice in recent years to simply inject dextrose with local anaesthetic. Dextrose is the exact same sugar molecule that exists within the body so that nothing foreign to the body (except for local anaesthetic) is being introduced. The volume injected into each point is minimal: between 0.2 and 0.5 cc, and will therefore does not affect the blood sugar level, even in diabetics. In fact, intense pain causes the body to release more glucose into the bloodstream, so that diabetic patients with unresolved pain will have high levels of circulating glucose in their bloodstream anyway. If the treatment works in reducing pain, the sugar levels should fall!

See section on sacroiliac pain) The sacroiliac ligaments play a central role in providing stability during stance and gait. Because they are constantly engaged in shock-absorbing with every step that we take they often suffer from dysfunction. They also suffer from tremendous stress when the lumbar spine is limited in range of motion due to spinal stenosis and especially after a spine fusion. These ligaments take more of the load when the hip has pathology such as osteoarthritis or fracture. The whole SI region is pivotal to normal bio-mechanic functioning of the musculoskeletal system; therefore, it is important to treat it as a whole system even if it is not the direct cause of the pain. The sacroiliac (SI) ligaments are capable of referring pain locally as well as all the way down the leg (figure 1). If there are positive clinical signs on the physical examination of SI dysfunction, then prolotherapy to these ligaments can lead to lasting relief of severe pain. Patients usually feel that they function better and often note that they are more stable than they used to be. Overall, there are about 12 points at least to be injected over the course of treatment sessions. In each session, several are injected, however, different ligaments are usually injected in each session. At some point in time, the hips and lumbar spine may have to be treated as well to give lasting relief.

As we age and the disc height decreases, the ligaments become slack, which can lead to vertebrae slipping one on the other- a condition called “spondylolisthesis”. The direction of slipping can be from side to side or front to back (see figure 3). Often CTs and MRIs do not pick up very mild cases as this is a functional dynamic phenomenon which is not always detected when we lie still on our backs, unless the situation is more pronounced. The extra traction caused by the slipping movement can add to the pressure or traction on nerve roots. These ligaments are targeted during prolotherapy treatments.

Stabilising the lumbar spine through prolotherapy often relieves pain from disc lesions and from spinal stenosis; the method by which this occurs is unclear. Cortisone injections, on the other hand, will likely mostly have a very temporary effect. Although epidural injections will relieve inflammation around an irritated nerve root that has arisen from mechanical traction described above, in the long term they are unlikely to achieve improvement in function of the structure.

Prolotherapy and platelet rich plasma can be used to strengthen a weakened shoulder girdle due to tendon tears, and possibly even lead to some healing of partial tears. Even in the case of full thickness tears, even though the tear is unlikely to be repaired, the supporting ligaments and shoulder capsule can be strengthened in order to improve shoulder function, and prevent further deterioration.

Biologically young patients with full thickness tears are generally advised to have surgical repair but this depends on several factors. Although surgical repair of partial thickness tears is becoming more prevalent, it is not recommended to operate on tears smaller than 1cm. One must take into account that surgical repair must be followed by a prolonged rehabilitation period of several months, the arm must be immobilized for some time, and there are serious surgical risks such as damage to the brachial plexus. And after all that, retear is a considerable risk.

This is in contrast to cortisone injections which have been found, at best, to bring about short-term relief only. A review in The Lancet has shown that if cortisone injections are repeated over and over, whether in the shoulder or other areas such as the elbow, the condition ends up worse than what it was prior to the beginning of the treatment.

Though there are no studies on the prevention of shoulder dislocation, it is the experience of many that strengthening of the shoulder capsule with prolotherapy can prevent further dislocations.

Treatment of the acromioclavicular joints and sternoclavicular joints are important as well. Osteoarthritic symptoms improve; ligament laxity may be reduced somewhat, however gross dislocations may need surgery.

For either prolotherapy or PRP to work in the long term, one has to treat the whole functional unit in order that it will be able to withstand the same forces that have been acting on it until now. Therefore, not only the injured tendon is treated but also the supporting ligaments and often other tendons of the rotator cuff which would otherwise be at risk of the tear involving them as well. Both prolotherapy and PRP can be combined very effectively with dry needling in order to bring the whole of the shoulder girdle to normal alignment and function. Injections are best performed under ultrasound, so that the exact location of the tear can be targeted, and the exact attachments of supporting ligaments can be injected.

Because the structures in the ankle are mostly very superficial, treatment is relatively easy to perform, and can usually be done without ultrasound. The main purpose for using ultrasound are to a) inject straight into a joint and b) to inject the solution within a partial tear. Treatment improves quite dramatically the level of stability, thereby reducing recurrent sprains, as well as pain levels.

Often there are also entrapped nerves from previous injuries and surgeries. These can also be treated with hydrodissection. These injections should be performed under ultrasound guidance in order to be exact in locating the entrapped nerve and also avoiding further damage.

Knee Injuries often result from car accidents and sports injuries. Common findings are torn collateral ligaments and meniscal tears. The menisci are attached to a ligament called the “coronary ligaments”. The injection of prolotherapy solutions into the knee is not intended to heal the tear within the meniscus. However, in the case of a mild tear, when prolotherapy solutions are injected into the coronary ligaments, it is thought that the coronary ligaments tighten up, preventing the loose section of the meniscus being thrown around within the knee joint during movement. Prolotherapy can also be used to treat patella tendonitis.

Surprisingly enough, according to several studies, injection of dextrose into a mildly to moderately arthritic joint has been found to be of benefit. This is in contrast to injection of cortisone which leads eventually to a steroid arthropathy in which case the cartilage is more degenerated than to begin with. Most studies on prolotherapy for osteoarthritis have been targeted to the knee (Rabago, Slattengren, and Zgierska 2010; Rabago et al. 2012), however, dextrose can be injected intra-articularly to most joints such as the hip, shoulder, hand joints and even the temporo-mandibular (jaw) joint. Much more literature is available on the treatment of OA with PRP, however prolotherapy can definitely help in mild to moderate cases of osteoarthritis. The mechanism by which this works is unclear, however it is clear that the induction of growth factors plays a factor in the response, theoretically much more so with PRP.

Whiplash injury can cause chronic neck pain in which muscles and ligaments in the neck are sprained leading to muscle spasm which limits movement. The IMS technique discussed in a separate section addresses the muscle spasm and asymmetries. Prolotherapy is targeted to ligaments which may have been damaged and sprained, bringing lasting relief. Both of these techniques work wonderfully together to achieve good results. However, in order to achieve lasting relief, it is imperative to adopt healthy sitting, working and sleeping postures and avoid the “head forward position” so rampantly adopted in our modern society.

Prolotherapy and PRP has been compared to cortisone in several research studies and has been found to be superior to cortisone injections for the treatment of golfers and tennis elbow. The IMS technique combines well with prolotherapy in the treatment of these conditions. However, in order for these treatments to be effective, the ergonomic issues leading to the problem must also be addressed and treated.

A very methodical review of 41 research studies on injections for treating tendinoses was published in The Lancet in 2010 (Coombes, Bisset, and Vicenzino 2010b). Corticosteroids were found on the whole to be beneficial in the short term only; repeated injections not only had no beneficial effect but actually worsened the patient’s condition relative to pre-treatment state. This finding must be internalized by practitioners, considering that until today, steroids are still the mainstay treatment of tendinoses. In contrast, the studies cited using prolotherapy solutions and PRP showed positive long term results. Both prolotherapy and PRP have been found to improve long term function and structure of the tendons (quote). PRP is perceived by many orthopedists as having more healing power than prolotherapy but it has never been compared head to head with prolotherapy.

Pain arising from the TMJ can be due to various factors; trigger points, loose ligaments, a disrupted disc, or a combination of these. A previous whiplash injury can precipitate TMJ pain. Treatment involves a combination of dry needling and prolotherapy injections as well as addressing posture and ergonomics.