Prolotherapy is an innovative injection technique developed by Hackett in the US, effective in treating most soft tissue injuries. It is an elegant refinement of the centuries-old sclerotherapy which produced scar tissue to stabilise joints and relieve pain.
When an acute soft tissue injury fails to heal, the strain or sprain is usually at the enthesis (attachment to the bone) possibly due to poor blood supply. If laxity or tensile strength deficit is not corrected sufficiently to stop pain mechanoreceptor stimulation, chronic pain and muscle spasm result.
Prolotherapy involves injection of hyperosmolar glucose or other irritating solution to the enthesis. This produces tissue damage by 'osmotic shock' and needle trauma, initiating the wound healing cascade. Inflammatory mediators attract fibroblasts which secrete collagen. The new collagen matures, gradually restoring strength to the enthesis and relieving pain1. The tendency of collagen to contract as it matures, which is a disadvantage in burns, is of benefit in prolotherapy as it can correct the laxity of strained ligaments.
Light and electron microscopic studies of human posterior sacro-iliac ligaments have shown marked fibroblastic hyperplasia and increase in collagen fibril size2. The treated ligaments and entheses become 30-40% stronger when compared with saline controls.
This is used to treat low back pain, whiplash and other neck pain, headache and migraine, chronic upper thoracic pain, sports injuries to ankles, knees3, wrists, fingers, and elbows, tennis elbow, Osgood Schlatters knees in teenagers, temporo-mandibular joint dysfunction, calcaneal spur and many other problems.
It is an excellent addition to musculo-skeletal and orthopaedic practice4/5 and as a result of Yelland’s trial in Spine 20046, Bogduk recommends, in Management of chronic low back pain, in MJA 20047 that “Injections into tender attachment sites for ligaments are a simple treatment that GPs can perform. They can achieve complete relief of pain in 20% of patients and significantly reduce pain in 40%. These figures are no worse than those for the best alternatives, and better than most.” Cyriax described use of 'sclerosants' in his book, Orthopaedic Medicine in 1983.
1Banks AR: A rationale for prolotherapy. J Orthopaed Med 1993; 13:54-59
2Klein R, Dorman T, Johnson: Proliferant injections for low back pain: Histological changes of injected ligaments & objective measurements of lumbar spine mobility before & after treatment: J Neurol & Orthop Med & Surg 1989; 10:123-126
3Ongley M, Dorman T et al: Ligament instability of knees: A new approach to treatment. Manual Med 1988; 3
4Reeves KD, Prolotherapy: Basic science and technique: in Pain Procedures in Clinical Practice, 2nd edition, ed Lennard TA, pub. Hanley & Belfus
5Dorman TA and Ravin TM: Diagnosis and Injection Techniques in Orthopedic Medicine, 1991 pub Williams & Wilkins.
6Yelland M, Glaziou P, Bogduk N et al, Randomised controlled trial of prolotherapy injections, saline injections and exercise in the treatment of chronic low back pain. Spine 2004; 29: 9-16
6Bogduk N, Management of chronic low back pain. MJA 2004; 180: 79-83