Chronic pain is, unfortunately, a common and challenging condition for patients and physicians
alike. The generally accepted definition of chronic pain is pain that lasts greater than three
months or longer than expected for the injury or trauma that started the symptoms. Regarding
chronic muscle, tendon and ligament pain, this is one of the most difficult conditions to treat in
modern medicine. The accepted treatment has been use of nonsteroidal anti-inflammatory
medications, such as over-the-counter Aleve, Advil and Nuprin, physical therapy, steroid
injections such as corticosteroids, Depo-Medrol and Kenalog, etc, or surgery. None of these
treatments effectively change or promote the healing process. When an injury lasts longer than
expected, our bodies stop the healing process and change to a maintenance process. In simple
terms, this means the tendon, ligament or muscle no longer has inflammation, such as a
tendinitis, but rather a chronic thickening called tendinosis. This stage is where our body is no
longer trying to heal the process, but maintaining the painful condition. Nonsteroidal antiinflammatory
medications may actually inhibit the recovery process acutely by stopping our
body’s natural mechanism to heal. Corticosteroids may give short-term pain relief, but may
actually inhibit any healing. Surgery many times will cause a “re-injury” and jump-start the
healing process again so our body can repair itself.
More than 60 years ago, Dr. George S. Hackett, a general surgeon, began using injections with
an irritant solution to repair joints and hernias. Dr. Gustav Hemwall learned of this at a medical
meeting and began training with Dr. Hackett in his office to learn this technique called
“sclerotherapy.” The initial notion was that this caused scar tissue, which would tighten the
tendons and ligaments. Originally, they were toxic to tissue, and may have indeed caused
scarring. As this technique evolved, the preferred solution was a dextrose solution commonly
known as sugar. A solution between 15% and 25% was used and did not cause scarring, but
rather re-initiated the healing process of connective tissue, releasing chemicals that use our
body’s own natural method to heal.
The use of Prolotherapy is becoming much more accepted and popular. It has been used in a
variety of injuries, including ligament, tendon and muscle injuries. Recent use by professional
and college athletes has helped increase the popularity. Prolotherapy, though, is not limited to
competitive athletes. Individuals with common strains and sprains may benefit from this healing
technique. Unfortunately, most insurances do not pay for Prolotherapy injections. This is quite
odd, in that recent research shows that there is a significant improvement with Prolotherapy,
particularly for conditions such as tennis elbow. Corticosteroids are paid for, but there has been
no evidence that shows that they actually increase function or decrease pain long term.
Hopefully, this will change with the review of recent research.
What can someone expect with Prolotherapy? First, the physician needs to make an accurate
diagnosis and determine if the injury will respond to a technique such as Prolotherapy.
Additionally, an individual needs to refrain from any anti-inflammatory medications, aspirin or
aspirin-like products, blood-thinning medications, or immunosuppressant agents such as
prednisone or Imuran, which are used in conditions such as rheumatoid arthritis. Smoking
appears to inhibit the effectiveness of Prolotherapy, and if possible, this should be discontinued.
Additionally, nutritional support prior to any injection is very important. This includes the
building blocks that help restore injured tissue, such as protein, essential fatty acids, and vitamin
C to name a few.
Once the doctor has made the determination if an individual is a candidate for Prolotherapy after
obtaining a history and performing a thorough physical examination, the individual is again
briefed on the procedure. The technique usually entails cleaning the skin around the effected
area with a cleaning solution. Utilizing a small needle, the areas of injection will be anesthetized
with a small amount of numbing medicine, usually lidocaine. Then, the physician utilizes a
different needle to inject into specific sites of injury, injecting a small amount of dextrose
solution. These sites have been outlined by Doctors Hackett and Hemwall, and have proven to
be very effective over the years. Interestingly, the injection usually is with little pain. Following
the injection, it is advised to avoid anti-inflammatory medications and continue with nutritional
support. The joint or limb injected may require rest, so short-term use of a sling or crutches may
be needed. An individual can expect improvement in the next five to seven days. The entire
healing process may take as long as six weeks. Unfortunately, the injury may be such that more
than one Prolotherapy injection is required. On occasion, it may require up to five injections,
although this is rare. Areas that respond to such Prolotherapy injections include shoulder pain,
elbow pain, wrist pain, hip pain, knee pain, ankle pain, neck and back pain. There are
practitioners who utilize Prolotherapy for conditions such as temporomandibular joint, i.e., TMJ
syndrome, but this requires a high level of skill and should only be done by practitioners with
adequate training.
The complications of Prolotherapy include local irritation, and in rare cases, infection. A sterile
technique is used, so the risks for Prolotherapy are no greater than that of any other injection
through the skin. In the hands of a skilled practitioner, anatomical landmarks are used so the
chances of injuring structures such as an artery or vein are exceedingly rare. The dextrose is
absorbed by the body and does not increase blood sugar or worsen diabetes.
Follow-up after injection is usually at two- and six-week intervals. At the two-week interval, an
individual is re-evaluated to see if the Prolotherapy is indeed taking effect. At six weeks, if there
is inadequate symptom relief, repeat Prolotherapy may be considered.
Prolotherapy has been accepted and utilized throughout the world. In the United States,
institutions such as the Mayo Clinic and Harvard Medical School use this routinely. Dr. Joanne
Borg-Stein, medical director of the Spaulding-Wellesley Rehabilitation Center in Wellesley,
Massachusetts, part of the Harvard Medical School, routinely uses this technique and finds it
effective in carefully selected patients. The Hackett-Hemwall Institute at the University of
Wisconsin is the leading training center for Prolotherapy. They also sponsor several medical
mission trips to provide Prolotherapy to individuals who do not have access to medications or
surgery. I have trained at the Hackett-Hemwall Institute, and fortunate enough to be a part of a
medical mission trip to Honduras from February 22 to March 8, 2013. While there, I assisted in
providing Prolotherpy along with several of the world’s foremost Prolotherapy experts.
As mentioned, Prolotherapy is usually not covered by insurance. The cost of Prolotherapy
ranges from $200.00 to $1,500.00 depending upon the body part to be injected and the provider.
There has been recent evidence that intra-articular, i.e., in the joint injection of dextrose solution
can slow down or even reverse advanced degenerative changes. This is a promising application
of this technique that is currently being researched.
In summary, Prolotherapy is a safe technique that injects a sugar solution to help our bodies reinitiate
the natural healing process. It can be effective, but it is important that the patient and
clinician have realistic expectations and there is careful selection of patients for injection.
If you have further questions regarding Prolotherapy or other regenerative injection therapies,
please contact Donald A. Lakatosh, M.D., at (865)577-1914.