Prolotherapy Basics - Change Comes from Within!

Prolotherapy is based on a very simple principle: the body has the capacity to heal itself.
prolotherapy blueprint data conceptual overlay on an athletic woman

Let’s say you get a paper cut. You first notice there is a rip in your skin and a little blood. Then the wound stops bleeding; it gets a little red and sore, but within a few days it has healed. This example illustrates a stimulus-response system: you injure yourself (stimulus), which sets in motion a cascade of actions that result in healing (response). A healthy body routinely and automatically responds in this way—like a computer with “healing programs” installed.

With musculoskeletal and joint injuries, a similar “stimulus-response” process occurs. However, the healing time is much longer than with a simple paper cut, lasting weeks to months rather than days. Another difference is that, even for a healthy person, the body tends not to heal 100 percent from ligament, tendon, and joint injuries. In fact, it has been estimated that the usual best result of a ligament or tendon (connective tissue) repair cycle may be as little as 50 to 60 percent of preinjury strength.[1] To understand how Prolotherapy can help heal such unresolved injuries, it is important to understand some basics about the musculoskeletal system.

Prolotherapy 101

Looking at the illustration locate the red muscle on the arm. The whitish portion of the muscle is the tendon; it attaches muscles to bones. Notice that bones are connected to other bones by ligaments, which, like tendons, are composed of strong collagen fibers and are whitish in color. Ligaments and tendons are known as “connective tissue” because they connect the body’s framework of bones, providing stability and allowing for motion.

Looking again at this picture, answer these basic questions:

Question: Why do you think muscles appear red in color, while ligaments and tendons appear whitish? (If you’re not sure, consider this: What might make muscles appear red?)

Answer: Blood!

Your body needs blood to heal. Blood brings oxygen, nutrition, healing factors and cells to injured areas. Unfortunately, there is only a very small blood supply in ligaments and tendons, hence their whitish color. This also explains why a ligament or tendon injury takes a longer time to heal, once injured, than other areas of the body.

Question: Imagine someone has badly twisted and sprained his/her ankle (a sprain is overstretching or tearing of a ligament). What does that ankle look like an hour after being sprained

Answer: Swollen! You may even recall this happening if you have ever sprained an ankle. This is the body’s immediate response to a ligament injury. A signal is sent to the brain: “Send blood!”, since the ligament doesn’t have much and needs it to heal. This injury has created a “stimulus,” which then starts the “response” of healing. The body immediately tries to get blood to the area as a first response to begin repair, thus the swelling. This is also known as a “good inflammation.”

Anatomical views of the shoulder illustrating how tendons and ligaments connect bones and muscles .
Ligaments and tendons are known as “connective tissues”.
Even under the best of circumstances, proper rest and good nutrition, ligaments and tendons heal slowly, and often incompletely. A typical ligament or tendon injury can take four to six weeks to heal, with most of the healing occurring in the first two weeks. You can probably recall someone being on crutches or hobbling around for several weeks after a bad ankle sprain. Unfortunately, after four to six weeks, the body’s stimulus to heal diminishes significantly. In other words, if healing does not occur within the first four to six weeks after an injury, not much additional healing is likely to occur later, because the stimulus to heal is now so weak or gone. Even if an injury heals reasonably during the four to six week healing period afterwards, there is a risk that it may not return to 100 percent of where it was.[2] If connective tissue does not heal completely—even if healing is only at 95 percent rather than 100 percent—the joint becomes a little weaker and therefore more predisposed to another injury. Initially, the individual may not notice this small difference. However, injury to the same joint, followed by that joint’s failure to heal completely, may occur over and over again, each time reducing the area’s overall strength and stability. It can go from 100 percent to 95 percent, to 90 percent to 80 percent, etc., with repeated injuries. Each time this occurs, the ligaments and/or tendons become a little more injured and stretched, also known as “laxity”.

A person may experience this laxity as weakness or instability in the joint—and eventually as pain. If this happens enough times, or is severe enough, weakness, instability, and/or pain can become chronic, meaning the pain or instability does not go away even after several weeks. Note that injuries may be “acute”, meaning occurring suddenly with rapid progression, then improve after going through a connective healing period of six weeks. These injuries can also become “chronic”, meaning if healing is incomplete, or there are repeated acute injuries which do not heal completely, the pain may not go away. Note that the medical definition of chronic is “persistent or long lasting”, usually more than three months.[3]

Even disc herniations have been linked to connective tissue weakness. As early as 1952, Dr. P. H. Newman, a British surgeon with years of experience performing disc operations, concluded that torn or weakened ligaments around the spine preceded disc herniations, sometimes years in advance.[4] Dr. Newman believed the most common cause of chronic low back pain was strain in the spine area where ligaments had been weakened.[5]

The Vicious Cycle of Connective Tissue Injury

Ligaments and tendons are connective tissue composed of fibers—including collagen, a very strong protein—the purpose of which is primarily to provide strength to the joint connections. Therefore, while there is some flexibility, that flexibility has limits. Think about pulling on a rope; you can stretch it a little, but if you twist and pull it in unusual directions, or pull too hard, it will start to fray and eventually tear. Connective tissue can be overstretched, and sometimes this occurs gradually, as in repetitive motion injury, or all at once. If the injury is very severe, and the tendon or ligament has ruptured or been pulled off the bone, surgery may be needed. However that is rare, and, in most cases, the ligament or tendon has simply become lax (overstretched), with tears or micro-tears that have accumulated and not healed, resulting in weakness and eventually chronic pain.[6]

Unfortunately, the onset of chronic pain and weakness may start to limit the activities of an otherwise active or athletic person. This can be sudden, or it can be slow and progressive, until one day the individual finds that he/she can no longer participate in accustomed activities or sports without pain and may even give them up.

Montage of woman running and aquiring increasing ankle pain over time leading to inactivity.
Chronic pain and weakness leads to limited activities.

How Prolotherapy Regenerative Medicine Works

As discussed previously, the term Prolotherapy is short for “proliferation therapy,” so named because it stimulates the proliferation (growth) and regeneration of injured ligaments, tendons, and joints. The body, like a very sophisticated computer, has the programming in place to heal; it just needs to be stimulated in that direction. Remember, after the typical four to six week healing cycle that connective tissue goes through when injured, the stimulus to heal is very small or gone. Prolotherapy is designed to be a stimulus that starts the healing response up again. In fact, you could say that Prolotherapy “tricks” the body into into thinking it's injured again, beginning a new, strong and directed healing cycle for injuries that have not healed on their own.

Here’s how it works. A trained medical practitioner injects a natural solution (either dextrose, platelet-rich plasma, or stem cell-rich sources taken from your own body) precisely at the site of an injury. Even though these substances are natural, their introduction into connective tissue or joints is irritating and triggers a strong healing response.

The body reacts as it would if it were organically injured, but in a much more controlled, directed, and powerful fashion. There is also irritation caused by the needle itself. That, in combination with the Prolotherapy formula, stimulates increased blood flow to the area, resulting in a “sterile” (because it is done in a clean, sterile manner) “good inflammation.” This response is designed to raise growth-factor levels and effectiveness to resume or initiate a connective tissue healing cycle that is incomplete, ineffective, or was never started.[7] Prolotherapy produces a controlled, concentrated “stimulus-response” healing cycle at areas that otherwise would not be stimulated to heal on their own, and it does this with low risk and few side effects. It has a high success rate in helping repair and strengthen injured and weak ligaments, tendons, and joints, reducing or eliminating pain.

Prolotherapy Formulas

Different Prolotherapy formulas can be used depending on the nature of the injury. Traditional Prolotherapy uses concentrated dextrose (sterile sugar solution) as the main ingredient. Dextrose is an extract of corn, which is identical in composition to blood glucose; therefore, it is well tolerated. However, when concentrated dextrose is injected into connective tissue or joints, this causes a local irritation, which then brings on the desired good inflammation and healing response. In addition to dextrose, a local anesthetic is generally mixed in the formula and sometimes Sarapin (an extract of the pitcher plant) or other natural ingredients such as a small amount of zinc, manganese, or B12. Sometimes saline (salt water) is used as the main ingredient if the individual is sensitive to corn.
In addition to the traditional Dextrose Prolotherapy formula, more advanced Prolotherapy formulas are now used, specifically platelet-rich plasma and adult stem cell sources such as bone marrow or fat (medical term: adipose) taken from one’s own body. However, whichever formula is used, the mechanism is the same: getting the body to “wake up” and heal the injured area. As long as an individual is healthy, the body can be stimulated to heal, and Prolotherapy can be effective even years after the original injury, pain, or weakness occurred.

Bibliography

[1] Andriacchi T, Sabiston P, DeHaven K, Dahners L, Woo S, Frank C, Oakes B, Brand R, Lewis J. Ligament: Injury and repair. In Injury and Repair of the Musculoskeletal Soft Tissues (pp. 103–128). Park Ridge, Illinois: American Academy of Orthopedic Surgeons, 1988.

[2] Benjamin M, Ralphs JR. Tendons and ligaments-an overview. Histology and Histopathology. 1997; 12(4): 1135–1144.

[3] Medical definition of “chronic.” Medicine Net.com [cited 2022 March 20]. medicinenet.com

[4] Hackett GS, Henderson DG. Joint stabilization: An experimental, histologic study with comments on the clinical application in ligament proliferation. American Journal of Surgery. 1955; 80: 968–973; Alpers B.J. The problem of sciatica. Medical Clinics of North America. 1953; 37: 503.

[5] Hackett GS, Hemwall GA, Montgomery GA. In Ligament and Tendon Relaxation Treated by Prolotherapy, 5th ed. (p. 9). Commenting on work of Newman PH. Oak Brook, Illinois: Institute in Basic Life Principles, 1991.

[6] Reeves KD. Prolotherapy: Basic science, clinical studies and technique. In Pain Procedures in Clinical Practice, 2nd Edition (pp. 172–190). Philadelphia, Pennsylvania: Hanley and Belfus, 2000.

[7] Reeves KD, Fullerton BD, Topol G. Evidence-based regenerative injection therapy (prolotherapy) in sports medicine. In The Sports Medicine Resource Manual (p. 611–619). Philadelphia, Pennsylvania: Saunders (Elsevier), 2008.