Jan 29, 2015
Vaulting Over Pain

More and more athletes are interested in trying prolotherapy treatments for their injuries. But does it work?

By R.J. Anderson

R.J. Anderson is an Assistant Editor at Training & Conditioning. He can be reached at: [email protected]

Two years ago, while treating one of his men’s ice hockey players for extreme pubic symphysis pain, Boston University Senior Associate Head Athletic Trainer Larry Venis, MEd, LAT, ATC, came to a standstill. It was late November, and while the athlete had been practicing lightly, he had yet to play in a game for the Terriers. Venis consulted with a specialist in treating athletic pubalgia and one who specialized in osteitis pubis. Both physicians said the player needed surgery, but they couldn’t agree on what part of his anatomy required an operation.

Frustrated by the conflicting diagnoses and wanting to avoid surgery, the athlete came to Venis to talk about another option he had read about online: proliferation therapy. More commonly known as prolotherapy, this alternative medicine technique involves injecting a patient with an irritant solution to further inflame a connective tissue injury. The goal is for the inflammation to generate blood flow to that area, usually a tendon or ligament, and thereby jump-start the healing process.

While Venis had heard of prolotherapy, he didn’t know much about it, and neither did his colleagues. “I couldn’t find anybody who had experience with it,” says Venis, who has been at BU for 13 years. “Our team orthopods simply said, ‘It might be painful for him, but I don’t think it’s going to set him back any. Whether it will help, we just don’t know.'”

A senior who had been drafted by an NHL team in 2002, the player decided to pursue the unconventional treatment and sought out a Boston-area physician who specializes in prolotherapy. Venis accompanied the player to each of his three treatment sessions, which stretched out over a month-long period beginning in late November. During the sessions, the player received about 14 injections of a dextrose-based solution in his pelvic region.

“The physician stuck a needle into the pelvic area in various locations where the bone attaches to the ligaments and tendons,” says Venis, who describes the player’s pain level before the procedure between seven and nine on a scale of one to 10. “During and immediately following the procedure, the athlete had increased localized pain where the injections went in, but at the same time he thought his pubic region was generally feeling better.”

Even though the athlete made it through each session without wincing, Venis said the injections looked extremely painful. “This athlete has an unbelievably high pain tolerance and was able to handle it without any complaints,” says Venis. “But for someone who’s more sensitive, I’m not sure this would be a great treatment just because of the amount of pain that’s involved. To get through it three times, you have to be pretty tough.”

A day after the first treatment, the player was back at practice, and Venis says about four weeks after completing the treatments, the athlete’s pain level dropped to a six and continued to decrease from there. In mid-January, he played in his first game and went on to lead the team in scoring over the last 25 games of the season. Venis says the player has now completely overcome the pelvic injury and has a very good chance to make his NHL team’s roster this season.

Despite the player’s improvement, Venis is still on the fence about prolotherapy. “I don’t know if his recovery was a long-term effect of the treatments or a placebo effect,” he says. “At that point we were also doing a lot of other things in his rehab, such as some manual therapy treatments, so I can’t isolate the prolotherapy as the reason he got better.”

Venis’s experience is an appropriate anecdote for illustrating the uncertainty surrounding prolotherapy. Due to a limited amount of science-based research, many medical professionals are skeptical about its effectiveness and its use remains clinically driven.

There is, however, a growing body of anecdotal evidence from Web sites and locker room conversations singing its praises. Recently, mainstream media outlets have published articles describing prolotherapy, with some detailing the experiences of professional athletes who have used the technique, including members of the U.S. Ski Team, U.S. Track and Field Team, Terrell Owens of the Dallas Cowboys, and a number of other NFL and Major League Baseball players.

PROVIDING STABILITY

Prolotherapy is most commonly used to treat athletes with tendinopathy and ligament strains that result from soft tissue instability caused by chronic stretching and degeneration. Those who choose the technique generally do so as an alternative to surgery. The therapy involves injecting a sugar-based solution, of which there are many varieties, into the site where a tendon or ligament connects with a bone to inflame the injured area and initiate a rebuilding of the tissue’s collagen strains.

There’s no consensus as to what the exact healing mechanism for prolotherapy is, but the most generally accepted theory is that the inflammation expedites blood flow to the affected area, which brings more white blood cells to aid the healing process. This is important because blood flow in and around connective tissue is normally very slow.

The next important step in the healing process is the work of construction cells called fibroblasts, which start rebuilding collagen in the affected area several days after an injection. Collagen reconstruction usually lasts for several weeks, depending on the severity and location of the injury. The rebuilding of the collagen is what stabilizes connective tissue and joints.

Ronald Glick, MD, Medical Director at the Center for Integrative Medicine at the University of Pittsburgh School of Medicine Shadyside and Assistant Professor of Psychiatry and Physical Medicine and Rehabilitation at the school, says the fibroblasts help build collagen in a very organized fashion–which flies in the face of a common misconception he hears from patients and even some physicians. “A lot of people think prolotherapy causes scar tissue,” he says. “It doesn’t. A scar is connective tissue, or collagen, that’s laid down haphazardly. With prolotherapy, collagen fibers are laid down in a very organized, linear manner along the force lines of the tendon or ligament, so there’s no scarring at all.”

ART OF THE INJECTION

A wide variety of medicinal solutions can be injected for prolotherapy. They contain different combinations of ingredients with varying concentrations depending on the athlete’s needs and each individual practitioner’s knowledge. Most clinicians choose combinations and concentrations on a case-by-case basis to target specific pain levels and injury areas.

One of the most common prolotherapy injections is a concentrated sugar solution, often dextrose, used along with a local anesthetic such as lidocaine. Ross Hauser, MD, Medical Director and co-founder of Caring Medical & Rehabilitation Services in Oak Park, Ill., works with professional and Olympic athletes and says for most isolated tendon and ligament injuries, he uses a solution that contains 15 percent hypertonic dextrose and 10 percent sarapin (an extract of the pitcher plant) as an anesthetic.

“Then, depending on how much inflammation or healing a person needs, we’ll add things like an extract of cod liver oil or vitamins and minerals like zinc, manganese, magnesium, and B12,” says Hauser. “For athletes, we tend to use strong solutions right away so we can get them back into action as quickly as possible.

“For instance, if a Chicago Bears football player came here during training camp with an ankle sprain and we had to get it healed very quickly, I might see him once a week and use a really strong solution that’s high in dextrose or another irritant,” Hauser continues. “The stronger the solution, the more inflammation it’s going to cause and the faster the healing process will be. However, a stronger solution is also more painful in the days immediately after the injections.”

Glick’s primary solution also contains dextrose as the main proliferant. He likes dextrose because it is very safe. “If you’re in the hospital getting an IV, the IV fluid is five percent dextrose,” says Glick. “So I use 15 percent, which is concentrated enough to act as a mild irritant. But because dextrose is so benign, if the medicine were to mistakenly hit a blood vessel or be in the vicinity of a nerve, it wouldn’t cause any severe problems.”

If an injury doesn’t respond to the traditional formula, Glick switches to Plan B. “If somebody has partial or zero response after a series of injections, I’ll inject them with a more aggressive solution containing P2G–a combination of phenol, glycerin, and glucose,” says Glick. “That’s my ace in the hole.

“A lot of practitioners use P2G as their main agent and the benefit is that it’s stronger,” he adds. “The downside is that if the solution spills into an area where there’s a nerve, there’s a small possibility of numbness or weakness that can last three to six months. Obviously we take a lot of care when injecting the medicine to avoid overlapping with nerves, but I tend to be even more cautious when using the stronger agent. Since I’ve had good success with my standard dextrose solution, I use it 90 percent of the time.”

When he is unable to isolate a specific tendon or ligament injury, a more global approach to treating the joint is needed, so Glick does a series of injections around the injured area–sometimes with a stronger solution. “Let’s say a patient comes to me with medial knee pain,” says Glick. “There are three or four different structures we can treat. We’ll target the usual suspects and make multiple injections around the knee.”

For injections meant to heal intra-joint injuries such as meniscus damage, Glick uses a solution containing a higher concentration of dextrose–typically 25 percent. “There’s already some fluid in a joint, so the dextrose gets diluted,” he says. “When injected inside the knee, the medicine coats the sack surrounding the joint and you get some benefit for all the soft tissue structures contacting the femur, the tibia, and the patella.”

No matter what type of tissue or area he’s treating, Glick says his approach to injecting is always the same. “Whether it’s a tendon or a ligament, we always inject where tissue meets the bone,” he says. “We do that for two reasons. One is that tendons and ligaments don’t have much of a blood supply, so we go to the junction of the bone where the blood supply comes from. The second reason is safety–if the needle is resting on the bone when you inject, then you know you’re not in the middle of an artery or a nerve.”

Hauser says most injection sessions take less than five minutes to administer, and there’s no limit to how many parts can be injected. “Some people get their whole body done in one sitting,” he says. “But most athletes get one or two joints or their lower back injected.”

RESEARCH NEEDED

Because of the lack of placebo-controlled studies to substantiate prolotherapy’s effectiveness, most physicians, athletic trainers, and physical therapists are not currently recommending the technique to their patients. “As with every treatment we render, whether it’s a medicine or an injection or a surgery, it’s important that we have some good scientific evidence to support it,” says Orr Limpisvasti, MD, Orthopedic Surgeon at the Kerlan-Jobe Orthopaedic Clinic in Los Angeles and an orthopedic consultant for the Los Angeles Angels, Los Angeles Kings, Anaheim Ducks, and Los Angeles Galaxy. “Anecdotally, I’ve had patients who report having done well with it and others who say they did quite poorly with it.

“We need to have some well controlled studies with thorough reviews so we know what the true effect–or lack of effect–is,” he continues. “I haven’t seen anything in mainstream sports medicine, orthopedic, or sports science literature that supports it. If practitioners of prolotherapy want greater acceptance of the practice, they need to get more data behind it.”

David Rabago, MD, Assistant Professor at the University of Wisconsin School of Medicine and Public Health, agrees with Limpisvasti and is working hard to fill the data gap. Rabago is conducting a randomized, controlled study to evaluate prolotherapy’s effectiveness for knee osteoarthritis pain. He also recently completed a controlled, double-blind trial looking at the effects of prolotherapy on tennis elbow injuries. The study, which is soon to be published in a peer-reviewed journal, measured the recovery of prolotherapy-injected arm injuries versus a control group of saline-injected arms. Because the study has yet to be published, Rabago cannot divulge all the details about his results just yet, although he can say he saw strong results from the prolotherapy-injected arms compared to the control group.

Rabago also co-authored “A Systematic Review of Prolotherapy for Chronic Musculoskeletal Pain,” which appeared in the September 2005 edition of the Clinical Journal of Sport Medicine. The article examined 34 case reports and two nonrandomized controlled trials suggesting prolotherapy is also effective for treating many musculoskeletal conditions. However, the authors also found six randomized, controlled trials that had conflicting results and wrote that the studies had “significant methodological limitations.”

The article concluded: “There are limited high-quality data supporting the use of prolotherapy in the treatment of musculoskeletal pain or sport-related soft tissue injuries. Further investigation with high-quality randomized controlled trials with noninjection control arms in studies specific to sport-related and musculoskeletal conditions is necessary to determine the efficacy of prolotherapy.”

“Obviously, I think it’s okay that people want to see more data before they support it,” says Rabago. “However, it’s unfair to say ‘there’s not strong evidence that this works, so therefore it doesn’t work’–that’s flawed reasoning.”

There are many takes on why research has lagged so far behind prolotherapy’s clinical practice. One theory is that pharmaceutical manufacturers–who fund much of today’s medical research–aren’t interested in contributing to a therapy that’s centered around dextrose. “Nobody will make any money if dextrose turns out to be a winner,” says Rabago. “It’s a very inexpensive solution–fundamentally, you’re talking about sugar in a syringe.”

PROLO CANDIDATES

What types of injuries is prolotherapy ideal for? Hauser says most of the injuries he treats are chronic–usually tendinopathy, ligament damage, and cartilage issues. However, he is using the technique more and more on acute injuries.

“We treat everything from Achilles tears to rotator cuff injuries, and even athletes who have meniscus tears and don’t want to have arthroscopy because they don’t want the meniscus removed,” says Hauser, who has been practicing prolotherapy for 15 years and provides about 18 patients with treatments every day. “We see athletes with sprained ankles who have been told they’re out for six to eight weeks–they come in for prolo and we can get them back to playing in half that time.”

Author of the books,Prolo Your Sports Injuries Away! and Prolotherapy: an Alternative to Knee Surgery, Hauser says that last year during the NFL season, he had a starting linebacker with a glenoid labral tear visit his office. “They wanted to operate on his shoulder, but he didn’t want to have surgery,” says Hauser. “So we did prolotherapy and he got through the season and had a great year. He wasn’t 100 percent, but I’d say he was 90 percent healed thanks to the injections.”

Glick says prolotherapy is also an option for multi-faceted problems. But, he cautions, the results may not be as easy to gauge as they are for localized, single-tendon or ligament injuries.

“It works for broader injuries such as hip pain, where there can be a lot of things going on like arthritis, iliotibial band tightness, and hip and pelvic dysfunction,” says Glick, who estimates that about 75 percent of his patients experience a positive outcome after prolotherapy treatments. “The injections may help only some of those problems and the global response may not be as dramatic as if you were targeting one tendon. If someone has hip or low back pain, there are a lot of structures to treat, so it’s hard to get a complete response.”

When treating an athlete, Glick says it’s important to carefully schedule the timing of their injection sessions in order to minimize negative effects on performance. “I try to see athletes when they have some type of break,” he says. “I do this because if you overlap the prolotherapy injections with normal athletic activity, they’re going to have more pain and more limitations. Even though you’re strengthening the structure in the long run, you are creating inflammation, which in the short term will probably impact their performance. Therefore, I try to treat athletes before their season, some time in the middle when they have a lull, and then at the end of the season.”

Despite a lack of support from the mainstream medical community, Hauser says prolotherapy practices around the country are packed with patients–including athletes. “We see more and more athletes every year,” he says. “Even though you won’t find many, if any, college or professional team physicians willing to recommend prolotherapy yet, athletes are finding out about it on their own through the Internet and word of mouth.”

Hauser also feels that prolotherapy is better for an athlete’s long-term health. “These days, we’re so focused on getting athletes back into the game that we forget to ask whether these actions are in their best interests a month, a year, or even 10 years down the road,” he says. “To me, it’s clear that anti-inflammatories inhibit the healing process after you’ve had an injury. For instance, should an athlete get a cortisone shot in his shoulder so he can play in the game this week? I would say no, because that shot is going to inhibit the repair of cartilage in his shoulder. It’s more important to allow it to get repaired through prolo and other therapies, even if that means missing a game or two.

“It’s also very cost-effective,” Hauser continues. “Prolotherapy of the knee costs about the same as one session of physical therapy and is obviously much less expensive than surgery. Why would an athlete want surgery when they can get the same results, if not better, from prolotherapy–and without the risks?”

SIDEBAR: WHO CAN PROLO?

Because prolotherapy involves injections, those who administer the treatments must be licensed medical doctors. Beyond that, there is no special certification, though a number of institutions, including the University of Wisconsin, the American Academy of Osteopathy, and the American Academy of Orthopedic Medicine, offer prolotherapy training courses.

“There seems to be a broad range of practitioners,” says Orr Limpisvasti, MD, Orthopaedic Surgeon at the Kerlan-Jobe Orthopaedic Clinic in Los Angeles and an orthopedic consultant for the Los Angeles Angels, Los Angeles Kings, Anaheim Ducks, and Los Angeles Galaxy. “And it’s tough to judge which practitioners are best. You might have a practitioner who is good at injections, but maybe isn’t doing it when it’s the best indication for that procedure.”

Ronald Glick, MD, Medical Director at the Center for Integrative Medicine at the University of Pittsburgh School of Medicine Shadyside and Assistant Professor of Psychiatry and Physical Medicine and Rehabilitation at the school, agrees with Limpisvasti and says it’s important to find out how experienced a prolotherapy physician is and what they specialize in. Glick also notes that prolotherapy isn’t the right answer for every patient.

“I try to be really selective as to who I think prolotherapy will help. If it’s not structural and tendon and/or ligament related, I’ll point them in another direction,” says Glick, who has practiced prolotherapy for 10 years. “There aren’t many contraindications, but I generally won’t treat people during pregnancy because there haven’t been any studies about prolotherapy during pregnancy. The other main contraindication is if a person has a problem with coagulation because that makes them more likely to have problems with bruising and soreness.” Feedback

I am the physician who treated the hockey player described in your article. First, thank you for your interest in Prolotherapy. Prolotherapy is a very effective method of treating patients with musculoskeletal injuries degenerative diseases and the consequences of these ailments. I would like to comments on following issues. Prolotherapy is a controlled injury- the physician inserts the needle and delivers the solution into the capsulo-tendo-ligamental-osseous area (CTLO). This action causes: 1.Mechanical injury-damage of this area and small bleeding. This blood and its cellular components-platelets, macrophages etc release growth factors to the injured area. 2.Extravasated blood and plasma create oncotic pressure gradient between cells and extracellular space. This leads to further injury of local cells – connective tissue and release of growth factors. 3.Hypertonic (Dextrose) or hypotonic (0.25% of Lidocaine) solutions induce injury by osmotic pressure gradient and chemical irritation resulting in release of growth factors 4.P2G is another Glucose/Phenol/Glycerin/ solution causing an injury in CTLO area and release of growth factors 5.There are also other chemicals which are useful in inducing injury and the release of growth factors. Thus, several different mechanisms involved in the initial injury, lead to one, uniform reaction–release of growth factors. Following these reactions, the growth factors stimulate the cascade of cellular, biochemical, hormonal and neuromodulating events, leading to repair of the damaged tissue.

In addition to injections, the physician must clearly understand anatomy, biomechanics and postural compensatory mechanisms. Neurological, psychoemotional, nutritional and hormonal imbalances involved in each particular case must be addressed and treated with manipulative technique, physical therapy, exercises, nutritional and hormonal counseling and orthotics if necessary. Prolotherapy is NOT a PLACEBO!!! It is a real and scientific method–much more scientific than prescribing of Tylenol, Motrin, Ibuprofen, bed rest, cold /heat application which proven to be ineffective, and sometimes dangerous. Success in treating the hockey player is not anecdotal. My colleagues and I have treated hundreds of patients using prolotherapy with very good results. Certainly, the physicians practicing Prolotherapy must nave good knowledge of anatomy, orthopedics, and good injection technique to be successful. We share our knowledge and expertise with Physicians in USA as well as abroad in Italy, Mexico, Honduras. There are few organization which provide scientific conferences, seminars and workshops. –Jon Trister MD


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