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Prolotherapy For Knee Pain

Prolotherapy For Knee Pain

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Published by ligagenix
A reasonable and conservative approach to knee tendonitis/tendonosis, sprain-strains, instability, diagnosis of meniscal tear, patellofemoral pain syndrome including chrondro- malacia patellae, degenerative joint disease, and osteoarthritis pain
A reasonable and conservative approach to knee tendonitis/tendonosis, sprain-strains, instability, diagnosis of meniscal tear, patellofemoral pain syndrome including chrondro- malacia patellae, degenerative joint disease, and osteoarthritis pain

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Published by: ligagenix on Oct 13, 2010
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70
Practical PAIN MANAGEMENT, July/August 2007
P
rolotherapy is a method of injectiontreatment designed to stimulatehealing.
1
Many musculoskeletal in- juries and pain syndromes lend them-selves to prolotherapy treatment includ-ing low back and neck pain, chronicsprains and/or strains, whiplash injuries,tennis and golfer’s elbow, knee, ankle,shoulder or other joint pain, chronic ten-donitis/ tendonosis, and musculoskeletalpain related to osteoarthritis. Prolothera-py works by raising growth factor levels oreffectiveness to promote tissue repair orgrowth.
2
It can be used years after the ini-tial pain or problem began, as long as thepatient is healthy.This month’s article focuses on the useof prolotherapy for knee pain and in- juries, including ligament and meniscalinjuries, tendonitis and tendonosis,patellofemoral syndrome, and os-teoarthritis pain including degenerative joint disease.
Prolotherapy Mechanism ofAction Review
Prolotherapy works by causing a tempo-rary,low grade inflammation at the site of ligament or tendon weakness (fibro-os-seous junction), “tricking” the body intoinitialing a new healing cascade. Inflam-mation activates fibroblasts to the area, which synthesize precursors to mature col-lagen, reinforcing connective tissue.
2
Thisinflammatory stimulus raises the level of growth factors to resume or initiate a newconnective tissue repair sequence to com-plete one which had prematurely abortedor never started.
2
Prolotherapy is alsoknown as “regenerative injection therapy(RIT),” “non-surgical tendon, ligament,and joint reconstruction” or “growth fac-tor stimulation injection therapy.”
Ligament Injuries Lead toDegenerative Arthritis
Osteoarthritis almost always begins as lig-ament weakness.
3
Unresolved ligamentsprains (overstretching) results in liga-ment relaxation and weakness. Relax-ation of the ligament results in joint in-stability and a change in joint biomechan-ics which eventually results in osteoarthri-tis of that joint as bones glide over eachother unevenly. The observation thatbones remodel and grow in response totheir mechanical environment is best ex-plained in Wolff’s Law which states:
Prolotherapy
By Donna Alderman, DO
Prolotherapy For Knee Pain
Areasonable and conservative approach to knee tendonitis/tendonosis, sprain-strains,instability, diagnosis of meniscal tear, patellofemoral pain syndrome including chrondro-malacia patellae, degenerative joint disease, and osteoarthritis pain
F
IGURE
1.
 How soft tissue injury leads to degenerative arthritis. From Hauser, “Prolotherapy: An Alternative to Knee Surgery,” Beulah Land Press, Oak Park, IL, 2004. Used with permission.
 
“Bones respond to stress by making newbone.”
4
Tendon injuries, if unresolved,over a long period of time also have aninfluence on joint biomechanics and cancontribute to the development of os-teoarthritis.This has been well demonstrated in themedical literature. One study of femalesoccer players who had sustained knee lig-ament injuries showed a very high per-centage with knee osteoarthritis 12 yearslater.
5
 Another study, published in SportsMedicine, observed the increased inci-dence of osteoarthritis with individuals who engaged in certain sports. These in-cluded wrestlers, boxers, baseball pitch-ers, football players, ballet dancers, soc-cer players, weightlifters, cricket players,and gymnasts.
6
Postgraduate Medicine re-ports in its investigation of the causes of human arthritis:“There is no question that trauma andmechanical stress on the joint lead to thedevelopment of osteoarthritis.”
7
Even in veterinary medicine, it is well-established that ligament sprains favor thedevelopment of osteoarthritis in animals.
8
If ligament and tendon injuries arestimulated to heal, biomechanics can berestored and the downward progression of degenerative changes can be prevented orstopped. Prolotherapy can, therefore, beseen as a method to prevent or stop thearthritic process because it strengthensthe joint and thus ends the need for theknee or other treated joint, to grow boneor form bone spurs
9
(see Figure1).
Prolotherapy for Patients withDegenerative Arthritis
Prolotherapy has been used successfullyeven after the diagnosis of osteoarthritisand degenerative joint disease. This maybe because of its ability to strengthen theexisting intact, but weakened, ligamen-tous and tendinous structures. There isalso some clinical evidence that prolother-apy may help to regenerate cartilage.Reeves and Hassanein in Kansas City in- vestigated prolotherapy in degenerativeosteoarthritis with and without ACL laxi-ty. In their double blind, placebo-con-trolled study,enrolled patients had eithergrade 2, or more, joint narrowing orgrade 2, or more, osteophytic change. Inaddition to subjective indexes such as vi-sual analogue scale for pain, swelling, andfrequency of leg buckling, objective go-niometric flexion measurements as well asradiographic measures of joint narrowingand osteophytosis were taken before andafter prolotherapy. Arthrometric meas-urements of ACL laxity were also done.The study concluded that prolotherapytreatment resulted in clinically and statis-tically significant improvements in kneeosteoarthritis. Preliminary blinded radi-ographic readings (1-year) demonstratedimprovement in several measures of os-teoarthritic severity. ACL laxity, whenpresent, also improved.
10
Cartilage Regeneration
Clinical evidence exists that prolotherapycan help to stimulate cartilage regenera-tion, although no specific controlled stud-ies have yet been done to confirm this.Laboratory studies have demonstratedthat cartilage cells respond to injury (in-flammation) by changing into chondrob-lasts, cells capable of cell proliferation,growth, and healing.
11
Therefore, it wouldbe logical that in vivo use might stimulateasimilar phenomenon. One case reportby Dr. Ross Hauser in Oak Park, Illinois,showed clinical evidence of such a change.X-rays were taken of a patient with severeknee osteoarthritis one year apart, beforeand after prolotherapy treatments (seeFigure 2). The patient was a 62 year oldfemale who, when first seen, was unableto ambulate without a cane. After 12 pro-lotherapy sessions this patient was painfree with full mobility.Clearly,moreclin-ical trials need to be done, and this wouldbe a good future area of investigation.
MRIs Can Be Misleading
 When deciding what patients are candi-dates for prolotherapy,do not be misleadby the MRI or use the MRI for diagnosisalone. MRI’s may show abnormalities notrelated to the patient’s current pain com-plaint and so should always be correlatedto the individual patient. Many studieshave documented the fact that abnormalMRI findings exist in large groups of pain-free individuals.
12-18
The finding of asymp-tomatic changes in knee joints during sur-gery is also not uncommon.
19,20
One studylooked at the value of MRI’s in the treat-ment of knee injuries and concluded“Overall, magnetic resonance imaging di-agnoses added little guidance to patientmanagement and at times provided spu-rious [false] information.” So do not usean MRI alone to determine a treatmentcourse. The MRI should be used in com-bination with a history of the complaint,precipitating factors or trauma, and aphysical exam.
Meniscal Injury
The menisus is a C-shaped region of fibro-cartilage between the femur and the tibia which provides shock absorption. There isamedial and a lateral meniscus, with themedial being the more commonly injured(see Figure 3). Meniscal tears are a com-mon diagnosis, in part because MRI’sclearly show these tears. However,as notedabove, MRIs can be misleading, and thisis especially true with the meniscus. A kneeMRI study addressed this issue. The au-thors looked for meniscal abnormalities inasymptomatic, pain-free individuals agedin their 20s to 80s and found Grade 1, 2and 3 changes present in essentially alldecades, with an increase in prevalence with increasing age. 62% of individuals as
Prolotherapy
71
Practical PAIN MANAGEMENT, July/August 2007
F
IGURE
2.
 Xray beforeand after Prolotherapy. From Hauser, Prolotherapy: An Alternative to Knee Surgery, Beulah Land Press, Oak Park, IL, 2004. Used with permission.
 
Prolotherapy
74
Practical PAIN MANAGEMENT, July/August 2007
Case Reports
Case #1
51 year-old cameraman complaining of left knee pain for 6months which began after a two foot fall from an unstableriser at work. Two weeks after this injury, the patient was run-ning, as was his routine, and began to notice discomfort inhis left knee. Discontinuing running helped but, while at hisdaughter’s soccer game, he ran after a ball and a week laterbeganto have the same pain recur in his knee and has per-sisted. He feels the pain in the medial aspect of his knee when going up and down stairs, worse going up, and also when walking. NSAIDs have not helped. He has been toldhe has a torn meniscus and arthritis causing his pain.
Medical History:
Nomajor surgeries or medical issues.
Review of Systems:
No complaints other than seasonal al-lergies.
Medications:
Claritin
Physical Exam:
Left knee slightly swollen as compared toleft, but without erythema or deformity. Flexion to 110 de-grees, with restricted extension secondary to apparent Bak-ers cyst. Mild crepitus present. +1/2 drawer sign with later-al to medial motion present. Negative McMurray’s. Tender-ness present at the medial collateral ligament and pesanserius tendons.
MRI:
1. Mild tricompartmental osteoarthritis with carti-lage loss most severein the lateral facet and trochlea; 2. Com-plex grade III signal in the posterior horn of the medialmeniscus and body compatible with tearing; 3. Mild anteri-or cruciate ligament sprain as well as a grade I medial col-lateral ligament sprain. Meniscocapsular separation cannotbe excluded as the edema is most intense adjacent to themeniscus; 4. Small joint effusion and small lobulatedpopliteal cyst.
Prolotherapy Treatment:
 After 5 prolotherapy treatmentsone month apart, the patient reported 90% improvement. At the patient’s followup visit and treatment 3 months later,he reported continued improvement, now 95%, and reportsno pain with return to regular exercise. At one year followup, the patient reports continued stability and activity.
Case #2
63 year-old male, public relations executive, with 20 year his-tory of left knee pain on and off, status post 2 knee athro-scopic surgeries which gave him only short-term relief. Overthe past few years, he states the pain has worsened and re-cently exacerbated with a lifting injury. He has taken NSAIDssuch as Bextra which temporarily help, and followed theRICE protocol (rest, ice, compression, elevation), but thepain has continued. He has stiffness and difficulty gettingup from seated to standing position, and trouble going downstairs. He has been told he has cartilage degeneration andneeds a knee replacement.
Medical History and Review of Symptoms:
Tonsils outas a child and measles at age 30. No health issues except el-evated blood pressure, on medication.
Medications:
 Aspirin, Cozaar, Effexor, Bextra prn.
Examination:
 Valgus deformity,left greater than right.Flexion is restricted at 90 degrees of flexion with restrictedextension of 10 degrees from flat. There is mild swelling butno erythema. Tenderness to palpation at the medial collat-eral ligament and pes anserious tendon. +1/2 drawer signand negative McMurray.
Prolotherapy Treatment:
 After 10 prolotherapy treat-ments one month apart, the patient felt he was 85% im-proved and was no longer considering a knee replacement.He reported far less pain under load and resting, better flex-ibility, walking down stairs easily, and no stiffness when get-ting up from sitting or after driving. At 2-1/2 year follow-up, he had continued stability with range of motion onlymildly restricted in extension and with full range of motionin flexion.
Case #3
14 year-old male with anterior knee pain for one year afterbeing active in several sports for many years, including bas-ketball, football, soccer and baseball. No prior known trau-ma. He states he was diagnosed with Osgood-Schlatter dis-ease and was told therewas nothing he could do about it.The patient wakes up in the morning with the pain and itlasts throughout the day and has prevented him from par-ticipating in his usual sports. Subsequently, he dropped outof all his athletic activities and is not currently active in anysport yet still experiences daily pain.
Medical History and Review of Systems:
Negative
Medications:
None
Examination:
Enlargement of the tibial tuberosity withtenderness to palpation at the patellar tendon insertion onthe tuberosity bilaterally. Rest of exam within normal limits.
Prolotherapy Treatment:
 After one treatment to the rightknee and three treatments to the left knee at 3 to 4 week in-tervals, patient states he is 95-100% better in both knees, andback to full sports activity. He reports he can now “do any-thing.” Followup at 1 and 2 years showed stable improve-ment with continued full return to all sports.
Case #4
32 year-old female, former Olympic Taekwondo competitor, with history of right knee pain for three years, status post ACL reconstruction (patella technique) with partial medialmenisectomy. The patient’s pain returned 1 year later andshe underwent arthroscopic debriding which confirmeddamage to her articular cartilage. This provided only tem-porary relief. She has done rehab exercise on her own butdespite this, over the last year, medial knee pain has returnedand is now persistent and fairly constant. The pain is aggra- vated by walking and activity.
Medical History and Review of Systems:
Healthy,nohealth issues or complaints.
Medications:
None
Exam:
Right knee: patellar tracking deficit and crepitus.+2 drawer sign. Range of motion within normal limits. Neg-ative McMurray. Tender to palpation at MCL, patellar ten-don and pes anserious tendon insertion.
Prolotherapy Treatment:
The patient was given six treat-ments on her right knee, approximately every 4 weeks. Shefelt immediate reduction in her pain starting with the first

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