Managing Refractory Tendinopathy (Part 3): Dextrose Prolotherapy

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Managing Refractory Tendinopathy (Part 3): Dextrose Prolotherapy


Previously, we have discussed the use of topical nitroglycerin and needle tenotomy for refractory tendinopathies. In this post, we will review the literature behind dextrose prolotherapy. 

Prolotherapy is an injection therapy used to treat musculoskeletal pain, including tendinopathies. Loosely defined, it involves the injection of hypertonic dextrose solution combined with a local anesthetic into painful areas of the tendon or ligament with the goal of stimulating inflammation. Although dextrose is most commonly used, other potential irritants include polidocanol, manganese, zinc, human growth hormone, pumice, ozone, glycerin, or phenol [9]. Prolotherapy may increase collagen deposition, thickening of healing ligaments and reverse neovascularization seen in pathologic tendons. A major goal of  of prolotherapy in chronic musculoskeletal conditions is the stimulation of regenerative processes in the joint that will facilitate the restoration of joint stability by augmenting the tensile strength of joint stabilizing structures, such as ligaments, tendons, joint capsules, menisci, and labral tissue [10]. The exact mechanism through which this occurs remains unclear. 

The use of ultrasound is generally suggested for prolotherapy. Some areas, such as the tibial tubercle may not require ultrasound. However most pathologic tendons benefit from increased procedural accuracy with ultrasound use and some obviously require it. Prolotherapy also appears to demonstrate sonographic changes associated with tissue healing [5].

The dosage and frequency of dextrose prolotherapy injections remains unclear in the literature. Some studies use 12.5% dextrose while others use 25% or 50%. The volume of injectant is generally low, ranging from 5 - 10 mL when including local anesthetic. Most studies involve multiple injections chronologically, anywhere from 3 - 5 total, for example at 0, 4 and 8 weeks.

Prolotherapy is also generally safe with few adverse effects reported in the literature. The pro-inflammatory response may result in a transient increase in pain or swelling for some patients. Dextrose is also cheap and readily available. 

Dextrose prolotherapy has some limited evidence to support it’s use in a variety of tendinopathies. In patients with painful rotator cuff tendinopathies, dextrose prolotherapy was superior to placebo for long term pain improvement and patient satisfaction [1]. In the elbow, a double blind, randomized controlled trial demonstrated that dextrose prolotherapy was well tolerated and effective at reducing pain and improving strength testing in patients with lateral epicondylosis [6].

For soccer and rugby players with chronic groin pain from osteitis pubis and/or adductor tendinopathy, dextrose prolotherapy demonstrated a significant reduction in chronic pain [3]. In athletes with patellar tendinopathy, there was a reduction in pain and improvement in ultrasound hypoechogenicity following ultrasound guided dextrose prolotherapy [7]. In younger patients with patellar tendon apophysitis, better known as Osgood-Schlatter disease, prolotherapy as also effective [12].  

In patients with Achilles tendinopathies, dextrose prolotherapy demonstrated a significant reduction in pain at rest and during tendon loading activities [4, 5]. When combined with eccentric exercises, gave more rapid improvement in symptoms than eccentric exercises alone, however long term VISA-A scores were similar [2].

In addition to chronic tendinopathies, It is worth noting that dextrose prolotherapy has some research supporting its use for plantar fasciitis, low back pain, temporomandibular joint pain and osteoarthritis of the knee and finger [6].

In summary, dextrose prolotherapy represents a relatively cheap, safe and reasonable alternative treatment strategy for managing stubborn tendinopathies. There is limited evidence for rotator cuff, lateral epicondyle, adductor canal, patellar tendon and Achilles tendon. Despite the generally positive findings, the studies are small and overall underwhelming. More research is needed along a broader spectrum of tendinopathies to better clarify the role of prolotherapy in the treatment landscape. Prolotherapy also likely has a role in treating other musculoskeletal conditions. 

References

[1] Bertrand, Helene, et al. "Dextrose prolotherapy versus control injections in painful rotator cuff tendinopathy." Archives of physical medicine and rehabilitation 97.1 (2016): 17-25.

[2] Yelland, Michael J., et al. "Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial." British journal of sports medicine 45.5 (2011): 421-428.

[3] Topol GA, Reeves KD, Hassanein KM. Efficacy of dextrose prolotherapy in elite  male kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil. 2005 Apr;86(4):697-702. 

[4] Maxwell, Norman J., et al. "Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the Achilles tendon: a pilot study." American Journal of Roentgenology 189.4 (2007): W215-W220.

[5] Ryan, Michael, Anthony Wong, and Jack Taunton. "Favorable outcomes after sonographically guided intratendinous injection of hyperosmolar dextrose for chronic insertional and midportion achilles tendinosis." American Journal of Roentgenology 194.4 (2010): 1047-1053.

[6] Scarpone, Michael, et al. "The efficacy of prolotherapy for lateral epicondylosis: a pilot study." Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine 18.3 (2008): 248.

[7] Ryan, Michael, et al. "Ultrasound-guided injections of hyperosmolar dextrose for overuse patellar tendinopathy: a pilot study." British journal of sports medicine 45.12 (2011): 972-977.

[8] Ryan MB, Wong AD, Gillies JH, Wong J, Taunton JE. Sonographically guided intratendinous injections of hyperosmolar dextrose/lidocaine: a pilot study for the treatment of chronic plantar fasciitis. Br J Sports Med. 2009 Apr;43(4):303-6. doi: 10.1136/bjsm.2008.050021.

[9] Hackett, G.S. , Hemwall, G.A. , Montgomery, G.A. Ligament and Tendon Relaxation Treated by Prolotherapy. 5th ed.Oak Park, IL: Gustav A. Hemwall; 1993. 

[10] DeChellis, D.M. , Cortazzo, M.H. Regenerative medicine in the field of pain medicine: prolotherapy, platelet-rich plasma therapy, and stem cell therapy-theory and evidence. Tech Reg Anesth Pain Manag. 2011; 15(2): 74–80. 

[11] Hauser, Ross A., et al. "A systematic review of dextrose prolotherapy for chronic musculoskeletal pain." Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders 9 (2016): CMAMD-S39160.

[12] Sanderson, L.M. , Bryant, A. Effectiveness and safety of prolotherapy injections for management of lower limb tendinopathy and fasciopathy: a systematic review. J Foot Ankle Res. 2015; 8: 57.