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 . 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 . 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 .
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.
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 . 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 .
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 . In athletes with patellar tendinopathy, there was a reduction in pain and improvement in ultrasound hypoechogenicity following ultrasound guided dextrose prolotherapy . In younger patients with patellar tendon apophysitis, better known as Osgood-Schlatter disease, prolotherapy as also effective .
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 .
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 .