by Dr. John Neustadt

When I had my medical practice, a large part of it was doing prolotherapy injections on patients with chronic joint pain. And even though I’m no longer in medical practice, people often ask me for help. I find myself frequently recommending people look into prolotherapy as a possible solution.

But my recommendations on how to heal musculoskeletal pain aren’t mere theory or clinical experience. I’ve had the unfortunate history of needing to figure out how to fix myself. When our son Nate was about three or four years old and we were living in Montana, we went sledding.

He was in front and I was holding onto him and sled in the back. The hill was filled with other families, so it seemed perfectly safe. We were having a blast. But in the third run of the day, the sled hit a bump and we caught some air.

It was icy and I knew two things for sure. I could lay the sled over and bail out with him. We both were wearing helmets, but I feared that he might still get hurt. Or I could stay with the sled and him and take the full impact on my rear end when we hit the ice. 

I chose the latter because I’d rather me get hurt than him. I cracked my sacrum and couldn’t sit for several days. It was agonizing, but given the same situation I would not change my decision.

What followed was years of chronic back pain. I tried exercise and chiropratic, until I finally decided to do what I knew would be the ultimate fix. I made a series of appointments with a colleague to get prolotherapy injections.

This fixed my back and I am no longer in chronic discomfort. In fact, after my accident I never thought I’d run again. But I’m back to jogging and am feeling fantastic.

In 2018 I injured my shoulder. I tore my rotator cuff in several places and also had a labral tear. The pain was so severe that I couldn’t put on or take off a shirt without it hurting. I started prolotherapy injections and took Joint Relief product between treatments to promote joint health and I’m now able to exercise my shoulder, get dressed without pain and do all the activities I used to do.

Not surprising, over the years lots of folks have asked me questions about Prolotherapy. So I put together this FAQ. 

Q: What is Prolotherapy?

A: Prolotherapy is a medical procedure for musculoskeletal pain. The prefix “prolo” comes from the word, “proliferate,” since this treatment stimulates the body’s natural ability to create new connective tissue. Frequently, the underlying cause of musculoskeletal pain is weak ligaments (connective tissue that connects bones to each other) or weakness at the sites where tendons attach to bones (e.g., rotator cuff injuries). Simply put, Prolotherapy causes ligaments and tendons to heal themselves. Prolotherapy is also called “regenerative injection technique” because it stimulates cells to regenerate damaged tissues.

An alternate name for this technique is “regenerative injection technique (RIT).” If you’re looking for doctors who do this, if you see the words Prolotherapy or Regenerative Injection Technique, they’re referring to the same thing.

Q: Which conditions can be helped by Prolotherapy?

A: Prolotherapy is an excellent treatment for musculoskeletal pain. The underlying cause of this pain is often a weakened ligament. Prolotherapy can restore joint integrity and relieve pain from arthritis, whiplash, sciatica, disk problems, low back pain, rotator cuff (shoulder) pain, tennis elbow, old sports injuries that are now acting up, knee pain (osteoarthritis, ACL or PCL injuries), and TMJ (temporomandibular joint) dysfunction.

Q: How does Prolotherapy work?

A: Prolotherapy works by stimulating the production of new connective tissue. It does this by creating a local, controlled inflammation, which signals specific cells in the area (fibroblasts) to strengthen ligaments and tendons. It also increases blood flow and growth factors in the area to help with healing. 

Q: What are ligaments?

A: Ligaments are tightly woven strands of connective tissue that holds bone together to form joints. There are a lot of nerves where ligaments attach to bones, and in capsules that surround many joints. When a ligament gets stretched or weakened these nerves can be activated even by normal, routine tasks like picking up a cup of coffee (wrist, elbow, and/or shoulder pain), bending at the waist (low back pain), or walking up or down stairs (ankle, knee or hip pain).

Q: What substances are injected in Prolotherapy?

A: There are different substances that can be put in the syringes. Sugar water (dextrose) diluted with a local anesthetic is the oldest solution used and has been used for more than 70 years. Studies have repeatedly shown it to be safe and effective. It’s also the least expensive form of regenerative injections.

The other two commonly used solutions are platelet rich plasma (PRP) and autologous stem cells. In PRP, your blood is drawn, spun down to concentrate the platelets and growth factors and injected back into you at the site of injury. With stem cell therapy, your own stem cells are harvested from one of your bones using a needle. They’re then processed and injected back into you at the site of damage.

Q: How long has Prolotherapy been practiced?

A: The concept of strengthening ligaments goes back to the time of Hippocrates. Reports shoulder joint instability and its many repair methods date back to Hippocrates’ treatise, “On Joints.” Hippocrates described the practice of using cautery to cause the capsule to scar and thus tighten around the joint. While his technique is no longer used, the underlying concept is similar to Prolotherapy—strengthen the ligaments.

In the 1930s many case reports emerged in France and the United States of musculoskeletal disorders, such as TMJ, knee pain, and sacroiliac joint (SI joint, which holds your pelvis to your lower back), being successfully treated with Prolotherapy. In 1956, George Hackett, MD, a surgeon, published the first edition of the textbook Ligament and Tendon Relaxation Treated by Prolotherapy. Dr. Hackett reported a 12-year success rate of 82% in the treatment of 1,800 patients with back pain using Prolotherapy.

Then, in 1983, microscopic examination of rabbit tendons after Prolotherapy treatment confirmed the that Prolotherapy stimulates connective tissue repair. This study was published in the journal, Connective Tissue Research. Another landmark study was published in 1987 in the prestigious journal Lancet by Dr. Thomas Dorman, who was my mentor with whom I logged more than 300 hours of clinical work. This study demonstrated the effectiveness of using Prolotherapy to treat back pain.

More clinical trials have concluded that prolotherapy can be an effective treatment for osteoarthritis, tendinopathy (damage to tendons), plantar fasciitis, rotator cuff injuries, tennis elbow (lateral epicondylitis), sacroiliac joint (low back) pain, whiplash injuries from motor vehicle accidents and more. And I was a coauthor of a position paper on prolotherapy for the Journal of Prolotherapy. See References for links to these studies.

Q: Is Prolotherapy safe?

A: Yes, Prolotherapy is very safe. Dr. Gustav Hemwall, who practiced Prolotherapy for forty years, treated over 10,000 patients with more than 4 million injections, without ever experiencing any serious adverse effects. Prolotherapy has been practiced safely for over 70 years. Since 1955, one fatality and four cases of substantial neurologic impairment have been reported in the medical literature (all were attributed to the use of a strongly inflammatory proliferant that Dr. Neustadt does not use). Prolotherapy is much safer than the long-term use of non-steroidal anti-inflammatory medicines (eg, Tylenol, Ibuprofen, Alleve), undergoing a surgical procedure, or of enduring the effects of chronic pain on the body.

Q: Is Prolotherapy painful?

A: A shot is a shot, but I always tell my chronic pain patients that the pain of the injections is nothing compared to what they live with every day. For most patients this is true, and very few patients require painkillers to undergo the treatment. Frequently I would numb the area first with a local anesthetic to make patients more comfortable during the injections.

Q: Are there side effects from the injections?

A: The only common side effects of the injections are soreness and bruising at the injection site and temporary stiffness. These tend to last less than a few days. Some injection discomfort is expected but it can be lessened with some topical technique or anesthetic creams. Most people tolerate the procedure very well.

Q: Are imagine studies (eg, a MRI) necessary before getting Prolotherapy?

A: Not usually. There are very few cases when obtaining an image prior to the injections would be helpful. A good history of your condition taken by Dr. Neustadt and an excellent orthopedic physical examination are the most useful indicators for determining whether someone is a candidate for Prolotherapy.

Q: How many treatments are required?

A: The answer to this depends on the area being treated, the severity of the injury and which solution is being injected. Generally, dextrose requires more treatments, usually four treatments and PRP and stem cells require fewer injections. However, because of the added costs for doing PRP and Stem Cell injections, even with fewer injections, these techniques could end up costing you more money. Generally, treatments are spaced out over 4 weeks, but some docs may repeat injections sooner.

Q: How will I feel after Prolotherapy?

A: Frequently the treated areas may feel stronger immediately after Prolotherapy. Patients can generally expect to return to work that same day after the treatment with only a minimal of residual soreness from the injections.  It is common to experience some stiffness, soreness, swelling, or even increased pain after Prolotherapy. These effects are usually mild and last less than three days. It is normal to experience muscle soreness for a few weeks after the treatment.

Then there is a “window period” of about two weeks as inflammation subsides but healing of the ligament is not complete. During this period there may be a return of some of the original pain. Starting around four weeks after a treatment, ligament strengthening is occurring. Re-evaluation and treatment is usually scheduled six weeks apart because it takes about six weeks for most ligaments to heal in most people. These effects are part of the body’s healing process and are considered therapeutic.

Q: Are there any activity restrictions following the injection?

A: Most of the time careful resumption of activities, as tolerated by the patient, facilitates healing and is encouraged. This can include normal exercise routines, walking, sports, and other activities. Physical therapy, massage, chiropractic and other treatment does not usually need to be stopped. Additionally, Dr. Neustadt prescribes specific exercises that can be done at home, in a pool, or on a stationary bike, to patients after treatment, depending on the areas treated.

Q: Are the effects of Prolotherapy permanent?

A: The benefits of Prolotherapy are generally regarded as permanent. By restoring structural integrity to the ligament and, therefore, the joint, the relief from pain and dysfunction can be permanent. Pain sometimes recurs episodically, but is usually less severe, and more easily treated with a single injection. Patients whose pain is cured should remember, however, that they are not immune to injury. There are no bionic joints.

Q: What is the success rate of Prolotherapy treatments?

A: As with all forms of treatment, no one can guarantee 100% success; however, a large number of scientific studies have validated the method. Dr. Hackett, originator of the technique, found a 35 to 40% increase in diameter and weight of tendons injected with proliferative solutions compared to control tendons. He also did a study with 656 patients over 19 years. Twelve years after completion of their Prolotherapy treatment, 82% of the patients considered themselves cured.

In 1974, Dr. Gustav Hemwall published the results of his data collection on 2,007 Prolotherapy patients. Of these, 1,871 patients completed treatment, and 1,399 (75.5%) reported complete recovery.

In 1995, Dr. Harold Wilikinson, professor and former chairman of the Division of Neurosurgery at the University of Massachusetts Medical Center, presented the results of 349 Prolotherapy treatments for chronic low back pain. Most of the patients were “failed surgery” patients whom no one could help. One treatment totally relieved 29% of the patients, and a total of 76% had significant pain relief with only one treatment. He also studied other areas of the body and found that 43% of people had complete pain relief and 89% had partial pain relief with only one treatment. He stated, “a sizable portion of people with unresolved chronic pain had more than a year’s pain relief with only one Prolotherapy injection”.

Q: How much does Prolotherapy cost?

A: Compared to many treatments that are much less permanent and carry greater risk, it is very cost-effective. Prolotherapy treatment costs depend on the area being treated, what’s being injected (dextrose, PRP or stem cells) and the number of treatments. The total cost of a course of treatment may easily be less than the cost of an MRI scan and a series of X-Rays. Insurance companies, in general, are slow to realize the tremendous gain in cost-effectiveness that Prolotherapy offers them. Many practitioners of Prolotherapy thus must charge their patients on a cash/fee-for-service basis.

Q: How can I learn more about Prolotherapy?

A: There are many excellent resources out there. A couple on the internet are Prolotherapy.com (www.Prolotherapy.com), Caring Medical (www.CaringMedical.com).

Some books that might be helpful are, Prolo your pain away by Ross Hauser, MD and Prolotherapy: Living Pain Free, both by Marc Darrow, MD. These and many other books on the subject can be found on the Amazon.com website.

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