Prolotherapy Frequently Asked Questions

Almost any painful joint area can be treated if that area is deemed to have an appropriate problem after an evaluation. This includes pain in the knee, shoulder, neck, back, elbow, wrist, fingers/toes, hip, ankle, and foot. In addition, painful or injured or sprained ligaments, tendons, muscles, knee meniscus, shoulder or hip labrum, and sciatica—as well as joint osteoarthritis (OA)—are generally all problems which can be considered for treatment. However, the specifics of each patient history and issue need to be evaluated on an individual basis to determine if a person is a good candidate to receive Prolotherapy treatment.

Prolotherapy is a regenerative treatment that stimulates repair. Think of a skin cut that has healed. Once the skin has healed, it has healed. After a treatment course is completed, the patient is “graduated,” and maintenance is not required. However, this does not make the person bionic! It is possible to re-injure the site, and that does sometimes occur; in those cases, a person would come back for a “tune-up.” In some cases, the problem treated has a structural abnormality to begin with, and we can only go so far with treatment. In those cases, a patient may want to come back periodically for treatment. However, in most cases, patients do not need to come back for maintenance; when they are done with a course of treatment, they are done.

The diagnosis of “bone on bone” is unfortunately given to many patients, but can mean different things. Often, this term refers to a small portion of a joint, with most of the joint in good shape, and this person may very well be an excellent candidate for Prolotherapy treatment. Other factors are which joint is affected by the “bone on bone” situation. The knee, for instance, is a very forgiving joint; it can have a large portion of “bone on bone” and still do very well with Prolotherapy treatment. On the other hand, the hip is a very unforgiving joint, so even a small amount of “bone on bone” may make this patient difficult to treat. The bottom line is not to feel discouraged if you are told “bone on bone,” and you have an interest in Prolotherapy treatment; it is usually worthwhile to get a consultation and evaluation.

Most insurance companies do not cover regenerative injection therapies such as Prolotherapy. Therefore payment is out of pocket and required at time of service. If you have a PPO insurance plan (PPO stands for “Preferred Provider Organization,” a type of insurance with more flexibility) and your plan pays for out-of-network physicians, you might be able to get some reimbursement for a portion of the consultation or office visit, depending on the terms of your policy. We will provide you with a coded superbill receipt after your visit which you can submit to your insurance company for any possible reimbursement, however this is between you and your insurance carrier. Note that other insurers, such as Medicare, have made it clear that they will not cover any aspect of Prolotherapy treatment. Also, even though standard medical insurance coverage itself does not generally cover these procedures, payment with health savings accounts is generally accepted.

It is interesting to note that there are some exceptions. Arkansas began granting medical coverage for orthopedic regenerative injection therapies for government employees and teachers under the Emerging Therapies Act of 2017.[1] There is also Unity Health in Madison, Wisconsin, which will grant coverage for some preauthorized injections. There are also some Kaiser Permanente facilities offering dextrose prolotherapy and/or PRP, depending on the medical staffing at those facilities.

The cost of Prolotherapy treatment varies between doctors within a given area and also between different states. If you would like a current fee schedule from our office either call or email us and we would be happy to provide this to you.

This will depend on what is being treated, the type of Prolotherapy used, and the type of job you have (physical or not). In most cases, it is a good idea to be able to have the option to rest the day after the procedure. However, as long as the job is not physical, a person can return to work almost immediately. If there is a physical aspect to the job that may re-injure the treated area, this can be discussed and an appropriate amount of time off can be arranged to be taken off after a procedure.

The initial consultation is scheduled for 2 hours. This allows time for the doctor to take a thorough history, do the diagnostic ultrasound, and then go over the findings/results and options. If you are deemed a good candidate, and wish to proceed, you can usually receive your first treatment on the same day as your consultation. Returning dextrose Prolotherapy treatments are scheduled for an hour. Returning PRP procedure appointments are scheduled for an hour and a half. Biocellular (stem cell-rich) procedure appointments are scheduled for two to three hours.

A fast-acting, local anesthetic is used during PRP or Biocellular Prolotherapy. For Dextrose Prolotherapy, there is also a local anesthetic which is mixed into the formula. In most cases, that is all that is needed for patients to tolerate procedures well, without sedation or other pain medication. However, if a patient is particularly anxious or pain intolerant, a light oral sedative or pain medication can be given prior to treatment. Be sure to discuss this with the doctor if you feel you will need to take something prior to the procedure.

In most cases, yes (unless you have taken medication prior to treatment). However, for your first treatment, we recommend having someone accompany you to drive you home afterward. This is because while most people feel fine after a treatment, other individuals may have some discomfort and prefer not to have to drive. After the first treatment, you will then see what is involved and how you feel, and decide if you need a driver going forward.

In the past, the answer to this was unclear. However, over the past ten years, evidence has emerged that supports that Prolotherapy can indeed stimulate cartilage growth and repair. A 2016 study of patients with moderately severe knee osteoarthritis (OA) demonstrated evidence of cartilage building effects after Dextrose Prolotherapy.[2] With the advanced formulas, there is also evidence of this. Platelet-rich plasma has been shown to protect against cartilage damage[3] and to play a part in its regeneration, as well as slow the progression of OA.[4] And in multiple investigations, in both basic research and clinical studies, have demonstrated the effectiveness of using adult stem cells for cartilage repair.[5]

The answer is not clear-cut; however, there has been concern in recent years that lidocaine might reduce the effectiveness of platelet-rich plasma[6] or be toxic to stem cells.[7] Because of this, many practitioners use more cell-friendly local anesthetics (such as polocaine or ropivacaine) when doing advanced Prolotherapy procedures.

The use of regenerative therapies has exploded in the last ten years. Although many orthopedic and sports clinics and doctors now offer these therapies, there is wide variation of methods practiced. Protocols vary, as does the type and method of preparation of platelet-rich plasma used, or what type of stem cell source is used. The bottom line is not all facilities offer the same treatment; therefore, do your homework to determine which facility and method you are most comfortable with.

Because all the various forms of Prolotherapy are intended to stimulate inflammation in order to promote healing, the recommendation is to not take NSAIDs while getting treatment. If you are taking a baby aspirin for your heart, this can continue during Prolotherapy treatment, as the low dose will not affect treatment results. If you are taking a higher dose, this should be discussed with your physician prior to treatment. Regarding other NSAID medication, some patients may need to take these for some other reason, such as headaches that, for that person, may only respond to that type of medication. The advanced formulas (platelet-rich plasma and biocellular) seem to be more forgiving of briefly taking NSAIDs, especially if timed so that they are not taken during the most critical periods of healing. However all of this should be discussed with your treating physician prior to treatment so a plan of action can be determined.

There is some controversy regarding whether anti-platelet medications interfere with the therapeutic ability of PRP. Many studies indicate no effect or minimal effect;[8] others indicate a negative effect.[9] Regardless, most physicians agree that it is not wise to discontinue these medications and that Prolotherapy, including PRP Prolotherapy, treatment may usually still be done as long as there is no excessive bleeding time. If the patient is taking coumadin, a blood thinner which requires monitoring, we ask for a copy of the last 6 to 12 months of your blood monitoring testing (called an “INR,” which stands for International Normalized Ratio”) to see that your levels are stable. If there are any questions about a patient’s history or ability to go through a Prolotherapy treatment, the patient may be asked to clear the procedure with his/her primary care physician, internist, or specialist prior to treatment.

Any one Prolotherapy treatment may involve multiple injections; exactly how many depends on the area(s) being treated and the type of Prolotherapy being done. Dextrose Prolotherapy typically requires more injections since the area is “peppered” with multiple injections in order to stimulate growth factors. Since the advanced Prolotherapy formulas (PRP and Biocellular) include growth factors, fewer injections are needed. Also, the advanced formulas are often administered with the assistance of ultrasound, which helps the physician make precise injections to even microscopic tears in a tendon or ligament, and so fewer injections are needed for that reason as well.

Most patients tolerate the procedure very well; however, a shot is a shot, and there is a certain amount of discomfort involved. To help with discomfort, a local anesthetic is used. Also, the needles used are very thin, which helps with pain. The procedure is also relatively quick. In spite of this, some individuals may feel anxiety about having this type of procedure, especially if they have a low pain tolerance; therefore, a topical anesthetic can be applied prior to the injections or oral anti-anxiety or pain medication can be taken (be sure to discuss with the doctor if you think this may be needed). In the large majority of cases, no medication is needed.

As discussed earlier, a local anesthetic is used; typically, you wouldn’t feel too much discomfort immediately after the procedure. For the first hour or so afterward, you may even feel a decrease in the pain you came in for. After the anesthetic wears off, the treated area will generally feel stiff and sore, and may progress to moderate discomfort. For this reason, a short course of pain medication is generally prescribed after a treatment. Some individuals may also experience mild bruising, although this is rare.

The severity of after-treatment discomfort varies depending on pain tolerance, which sites are injected, and which formula is used. I cannot stress enough that the amount of after-treatment pain varies among patients. All individuals respond to treatment pain differently, so there is no way to predict exactly what your experience will be. In general, patients are somewhat sore for a day or two—with some individuals not sore at all, and some very sore for several days or up to a week. (Although after-treatment pain can last even longer than a week, such cases are rare.)

As for the injection sites: some joint locations are less “forgiving” than others and so tend to be more uncomfortable after treatment. Shoulders and elbows, for instance, are almost always very sore for a few days; knees tend to be moderately sore; low backs tend to be the least sore.

As for which formula is used, the different treatments have different typical after-treatment patterns.

Dextrose: Generally this is the least aggravating (even with its additional “peppering”). It also tends to be uncomfortable for just a few days and then gradually improves.

Platelet-Rich Plasma and Biocellular (adipose (fat) or bone marrow) Formulas: Both the platelet-rich plasma and biocellular formulas tend to cause an “ebb-and-flow” phenomenon, where there is initial discomfort for a day or two and then the discomfort goes away but comes back at a lower level, usually every week or so over the course of several weeks (for platelet-rich plasma) or even several months (for biocellular). This is because the advanced formulas are living cells that communicate with other cells; typically, there are multiple waves of healing as new cells arrive to continue the healing process. So, for some, it can feel like taking four steps forward and two steps back, but the important part to remember is that progress is being made.

When doing a Biocellular procedure, there is an additional step: that of extracting either adipose (fat) or bone marrow. This does make this procedure more involved and, yes, more uncomfortable than just doing a PRP treatment; however, in general, the extraction procedures are well tolerated. Once extraction is done, the injection process, whether its platelet-rich plasma or biocellular, is almost identical and feels about the same for most people.

Immediately after a treatment there can be a reduction of pain because of the local anesthetic. However, because regenerative treatments stimulate tissue repair and healing, there will usually be after-treatment discomfort/pain/stiffness (“good inflammation”) after the anesthetic wears off (1 to 3 hours). The length of time this discomfort/pain lasts varies between individuals. However, there is also a phenomenon where the patient’s existing pain will go away completely for several hours, days, or longer, immediately after a treatment, especially in the low back. There are a few reasons for this. One is that the injected formula itself, along with the initial fluid and positive inflammation that are induced, provide stability to the joint. Another reason is that “trigger points” (muscle knots surrounding weak joints) might have been released by the injections. In some cases, the release of these trigger points is so profound that the individual can experience a long-term relief of pain. However, because instability of the joint (ligament laxity) is the cause of the problem, and muscle spasm is just the body’s response, the pain usually returns, until there has been enough time for actual connective tissue healing to occur.

The number of treatments and the time between them will vary from case to case. The idea is to stimulate the body’s natural “stimulus-response” repair mechanism and then give the body enough time to heal. An average number of treatments for Dextrose or PRP Prolotherapy is from four to six treatments, spaced out. Since connective tissue takes an average of four to six weeks to heal after an injury, the general protocol is to repeat treatments every four to six or eight weeks for both Traditional and PRP Prolotherapy, with intervals starting closer together in the beginning and then time between treatments increasing over the course of treatment. With Biocellular Prolotherapy (using adipose or bone marrow), fewer treatments are needed, in many cases just one, sometimes two, and the intervals between treatments is usually longer—6 to 12 months.

Other variables to the number of treatments and length of intervals include how rapidly a person tends to heal and how active he/she is. Note too that sometimes the doctor will start with one formula and then move on to another after the improvement from the first has leveled off. For information on why a specific formula may be used over another, see Treatment Algorithm.

It usually takes at least two treatments before improvement is noticed. Although factors such as the changing of medication and routines can play a part, the main reason it takes a while to notice improvement is because it takes time for connective tissue to grow and heal. It takes six weeks to make new collagen, so you will be into your second treatment, usually, when there has been enough time for change to start showing up. That said, there are patients who notice improvement sooner, even after the first treatment, or who may not notice much change until after the third or even fourth treatment. There are also other factors, such as prior NSAID use and an increase or change in activity or life demands, that may affect perception of improvement. Therefore, patience is recommended; it’s better to expect it to take a while and then be pleasantly surprised if you are better sooner than expected.

Sometimes, there will be improvement in objective measurements, such as orthopedic testing to measure range of motion and strength. Similarly, ultrasound images of the problem site from before and after treatment may also show improvement in tissue quality or repair; however, these visual changes do not always show up right away. The most important measure of progress is subjective improvement: how you feel—i.e., decreased pain and increased activity, as well as need for less pain medication and feeling of increased stability.

Complete rest of the treated area is recommended for 24 hours after a treatment. This is especially true for the advanced formulas, because we want the blood and cells to “stay put” and activate within the injected location. But after that initial resting period, your body needs normal motion so it knows where to lay down new tissue; therefore, it is good to start moving the treated area in its normal range of motion. That said, it’s important to not “load” that joint too soon. Movement is good, loading or stressing the joint is not. So no heavy lifting! The rule on exercise, in general, is that a person can begin doing whatever exercise has historically not caused any of the pain that is being treated. That is, you should avoid any exercise or routine that has aggravated the treated area in the past, but you can resume activities that did not historically cause pain. When starting back to these activities (the ones that previously did not cause pain), it is best to start at about half the exercise/activity/intensity, see how you do, and then slowly increase until back to normal, again avoiding lifting or loading on the treated joint as much as possible. This general rule applies to the first treatment or two. After this, since that joint has had time to get stronger, you will usually be able to introduce the original exercises that had been the most difficult or challenging, but when you do, again, start at a lower level than you were doing previously, increasing the intensity slowly.

The usual rule is no heat, no ice for the first 24 hours after a treatment. After the first 24 hours use moist heat if needed, for periods of 20 minutes at a time but do not sleep with it. If your usual habit is to use ice, you can use ice for brief periods (5 to 10 minutes) if the need is felt. In any case it is always best to discuss the specifics of your situation, activity, and usual use of ice/heat, with the doctor so that the two of you decide on the best after treatment plan for you.

In explaining why multiple Prolotherapy treatments are needed, Dr. Ross Hauser (a well known prolotherapist) uses the analogy of getting children to clean their rooms when told to. There’s a slight chance it will happen on the first request, but that’s not likely. Usually, the task requires a gradual stimulus-response process, which goes something like this:

First stimulus: “Clean your room.”
First response: Child just stares at you.

Second stimulus: “Clean your room!”
Second response: Some toys are picked up and put back in their bins.

Third stimulus: “Clean your room!”
Third response: The bed gets made.

Fourth stimulus: “CLEAN! YOUR! ROOM!”

Fourth response: Everything is put away, and all the surfaces are tidied.

In other words, the idea in Prolotherapy is to get the body to heal by stimulating repair with repetition and an increase in the level of coaxing, as well as formula strength if required. Like the tortoise and the hare, the expectation should be slow-and-steady progress.

Trigger points are painful knots in a muscle where a spasm is occurring. After a muscle has been working for a while to hold in a weak joint, it can develop constant and automatic tight areas that help it secure the weak joint without the body having to “think about it.” Trigger points can be released in a variety of ways; sometimes, pressure or massage helps, but the ultimate way to release a trigger point is to shoot it with a needle and local anesthetic. While Prolotherapy injections are not directed to those trigger points themselves, because the injections go through the muscle to get to the targeted joint, sometimes these trigger points release, bringing immediate relief. Trigger point injection therapy is sometimes done as a stand-alone pain treatment; it was the basis of the research by Dr. Janet Travell, John F. Kennedy’s personal physician, in the 1950s. But, in general, unless the underlying joint weakness is resolved, the trigger point will return with time. That is why a treatment, such as Prolotherapy, which stimulates repair of the underlying joint is important, rather than just trigger point release itself. When the joint heals, these trigger points generally just go away on their own. In some cases, however, trigger points persist after Prolotherapy treatments. If trigger points continue after the joint has repaired, the doctor can easily inject them directly to release them.

To make platelet-rich plasma, a portion of the patient’s blood is drawn into a syringe that contains a small amount of an anticlotting agent. The blood is then processed to concentrate the platelets. The most common method uses a special FDA-cleared centrifuge that separates the blood into layers based on weight—a process that takes approximately 15 to 20 minutes. The platelet-poor plasma layer is the lightest; the red blood cell layer is the heaviest, and in between is a yellowish layer called the “buffy coat,” which contains a concentration of platelets (see Prolotherapy Formulas - PRP Basics).

The first step in Biocellular Prolotherapy using adipose is the removal of fat from the patient. In conjunction with adipose, PRP is usually done so blood is drawn first. Then the adipose extraction is done. This involves a sterile procedure similar to liposuction but on a much smaller scale. (Note that since the amount of fat needed is very small, its removal does not noticeably affect the patient’s shape.) The fat is extracted with a thin, blunt (not sharp), tube-like syringe instrument called a “microcannula” (from the Latin micro, meaning “small,” and cannula, meaning “little reed”). A pinhole-sized opening is made in the skin. The doctor inserts the cannula and gently moves the microcannula back and forth to slowly distribute fluid (saline and a very dilute anesthetic) and break up the adipose. After that, a small amount of suction is created by pulling the syringe plunger back and then adipose is extracted. The adipose is then separated by putting it in a centrifuge which then spins it, removes excess fluids, and concentrates the adipose. (see adipose tissue (fat) being harvested by a cannula and syringe for Biocellular (Stem Cell-Rich) Prolotherapy). The Biocellular formula is then made, and treatment proceeds, typically using ultrasound to guide the injection precisely into the injured tendon or joint location.

The first step is extraction of the bone marrow itself. This is a sterile procedure done in a procedure room, typically using a collection kit made by one of several manufacturers. The usual site of extraction is along the upper back portion of the pelvic bone. Prior to the extraction, a local anesthetic is injected through the skin to the top of the bone at the extraction site; this enables a relatively comfortable extraction. If a patient is anxious about the procedure, pain or anti-anxiety medication is often offered in advance.(see bone marrow being harvested for Biocellular (Stem Cell-Rich) Prolothreapy)

The bone marrow is then put into a centrifuge which spins it, removes excess fluids, and concentrates it. By this process, the extracted bone marrow has become “bone marrow aspirate concentrate” (“BMAC”) and is ready to be injected into the injured ligament, tendon, or joint—usually using ultrasound guidance to assist in precisely determining the injection sites.

A contraindication is a reason why treatment should not be done. One of the biggest contraindications is if the problem is determined to be one for which Prolotherapy will likely have no, or minimal, results, Another contraindication is an active underlying infection or illness. For instance, if a patient is not feeling well with a cold or flu, treatment should be delayed until he/she is better. Or if someone is currently receiving treatment for an active chronic illness or cancer, Prolotherapy would not be done as we do not want to interfere with that treatment. However, if the cancer was in the past, and now considered cured, this would generally not be a problem.

A contradiction can be “absolute”, meaning no matter what, or “relative”, meaning treatment can still be done depending on the specifics of the issue. An example of an absolute contraindication would be known allergy to any of the ingredients in the Prolotherapy formula or unwillingness to experience possible after-treatment discomfort. Patients should understand the course of the Prolotherapy treatment and be participants in their treatment plan. Relative contraindications include current, long-term use of high doses of opioid medications, because these medications can lower the immune system and response to treatment, but might be allowable under some circumstances. Current use of systemic corticosteroids or NSAIDS (anti-inflammatory medication) are also relative contraindications, as these are counterproductive to the inflammatory process, but, again, patients may still be able to receive treatment under some circumstances.

Prolotherapy is a medical procedure. Although there are risks associated with all medical procedures, the risk with Prolotherapy is considered to be low. The most common (expected) risk is that you will feel worse before you feel better, and some joint areas may be profoundly sore for a few days after a treatment. In some cases, there may be little or minimal soreness, and that is normal too. Most of the risk has to do with the fact that these are injections and the risk associated with that, which would be bruising and soreness from the injection itself. Remaining risks are rare and include headache; infection; temporary irritation of a nearby nerve; pneumothorax (collapse of lung) if doing injections near there, and allergic reaction to the formula ingredients. As for the latter, in a few rare cases, people with corn allergies have reacted to dextrose. It’s also possible that someone has a previously unknown allergy to local anesthetic. It’s theoretically possible that someone could have a reaction to his/her own blood platelets or cells, but there have been no reports of such a response happening. And, finally, since no medical treatment can be guaranteed, there is the risk that Prolotherapy will not work. Although it has a high success rate, for some individuals, it does not work.

There are a small percentage of Prolotherapy patients who do not respond to a course of treatment. In general, there are four reasons Prolotherapy would not work: