High-Resolution Ultrasound and Magnetic Resonance Imaging to Document Tissue Repair After Prolotherapy: A Report of 3 Cases

doi:10.1016/j.apmr.2007.09.017

Archives of Physical Medicine and Rehabilitation

Volume 89, Issue 2, February 2008, Pages 377-385

Presented in part to the American Academy of Physical Medicine and Rehabilitation, October 26, 2005, Philadelphia, PA, and the American Association of Orthopedic Medicine, April 27, 2006, Washington, DC.

https://doi.org/10.1016/j.apmr.2007.09.017 Get rights and content

Abstract

Fullerton BD. High-resolution ultrasound and magnetic resonance imaging to document tissue repair after prolotherapy: a report of 3 cases.

High-resolution ultrasound imaging of musculoskeletal tissue is increasing in popularity because of patient tolerability, low cost, ability to visualize tissue in real-time motion, and superior resolution of highly organized tissue such as a tendon. Prolotherapy, defined as the injection of growth factors or growth factor production stimulants to grow normal cells or tissue, has been a controversial procedure for decades; it is currently gaining in popularity among physiatrists and other musculoskeletal physicians. This report describes imaging of tendons, ligaments, and medial meniscus disease (from trauma or degeneration). Although these tissues have been poorly responsive to nonsurgical treatment, it is proposed that tissue growth and repair after prolotherapy in these structures can be documented with ultrasound and confirmed with magnetic resonance imaging. Directions for future research application are discussed.

Section snippets

Case Descriptions

Prolotherapy involves injections of small amounts (0.5−1.0mL) of the proliferative solution at multiple enthesis points (for tendon, ligament, and fascia) and/or musculotendinous junctions. When joints are treated, an intra-articular injection is commonly performed. In most cases, 2 to 6 treatment sessions are required over 2 to 12 months to reach maximum effect.¹¹ Standard protocol includes restriction from nonsteriodal anti-inflammatory drugs 1 to 2 days before treatment and 10 to 14 days

Discussion

These cases show the potential utility of high-resolution ultrasound to document pathology in soft tissues and tissue responses to treatment. Ultrasound images of animal tendons have been correlated with histology studies.¹² In the evaluation of tendons, Van Holsbeek has observed that “ultrasound has a significant advantage over MRI … tissues with few mobile protons emit little or no signal and, therefore, the internal architecture of the tendon is not well demonstrated [on MRI].”¹³^(p77) The

Conclusions

Ultrasound imaging can show tissue growth and repair. These case reports appear to confirm that prolotherapy does stimulate tissue growth in tendon (patellar), ligament (anterior talofibular), and meniscus (medial meniscus) and that this is an organized growth with a return toward a normal appearance on ultrasound. Further clinical studies with ultrasound confirmation are recommended. The development of quantitative methods to analyze ultrasound images will be valuable in blinded efficacy

Acknowledgment

I thank Vince Wiseman, MD, for assistance in reviewing the MRI studies.

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Cited by (20)

Everything old is new again: New developments in prolotherapy
2015, Techniques in Regional Anesthesia and Pain Management
Citation Excerpt :
Prolotherapy is indicated for almost any ligament laxity or enthesopathy. Just a few examples include treatment of the enthesopathy that causes rotator cuff tendinopathy,11,12 lateral epicondylitis,13 whiplash,6,14 temporomandibular joint (TMJ) dysfunction,15,16 knee osteoarthritis and ligament instability,17,18 meniscal tears,19 Osgood-Schlatter disease,20 plantar fasciitis,21 Achilles tendonitis,22 sacroiliac and pelvic girdle dysfunction,23,24 axial low back pain after spinal surgery,25 and chronic low back pain.26 The Table shows some of the indications that have been described for prolotherapy.
Prolotherapy, or fibroproliferative therapy, is a regenerative injection therapy, first popularized in the 1940s and 1950s. Unfortunately, the combination of “better” surgical techniques and a series of high-profile medical catastrophes by poorly trained providers relegated the technique into the “fringe” arena. However, recent recognition of the failure of surgical interventions, combined with better technology and a burgeoning interest in the continuum of regenerative injection options, has renewed the interest and research into this “old” technique.
Ultrasonography in regenerative injection (prolotherapy) using dextrose, platelet-rich plasma, and other injectants
2010, Physical Medicine and Rehabilitation Clinics of North America
Citation Excerpt :
Typical prolotherapy technique with dextrose includes injection of multiple extraarticular structures (in addition to the intraarticular injection) that are easily accessible with MSKUS, such as the peripheral medial meniscus and adjacent medial collateral ligament. A case report has been published showing repair of a complex degenerative medial meniscus tear in a 59-year-old woman.32 The ultrasound findings were confirmed before and after treatment on MRI.
Effect of Regenerative Injection Therapy on Function and Pain in Patients with Knee Osteoarthritis: A Randomized Crossover Study
2012, Pain Medicine (United States)
Citation Excerpt :
In some laboratory conditions, RIT resulted in increases in ligament mass, ligament thickness, cross-sectional strength, and osteotendinous junction strength [15–17]. In clinical case studies, magnetic resonance imaging and ultrasound attest to tissue repair postinjection [18,19]. The underpinning mechanisms potentially responsible for these effects include the elimination of nerve fibers associated with neovascularization [20–22], inflammation and tissue repair, increase in cross-sectional area of ligaments and tendons [15,16,23], and the disruption and subsequent healing of the collagen fibril [20,21,24].
We assessed the effectiveness of regenerative injection therapy (RIT) to relieve pain and restore function in patients with knee osteoarthritis.
Crossover study where participants were randomly assigned to receive exercise therapy for 32 weeks in combination with RIT on weeks 0, 4, 8, and 12 or RIT on weeks 20, 24, 28, and 32.
Thirty-six patients with chronic knee osteoarthritis.
RIT, which is made up of injections of 1 cc of 15% dextrose 0.6% lidocaine in the collateral ligaments and a 5 cc injection of 20% dextrose 0.5% lidocaine inside the knee joint.
The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index of severity of osteoarthrosis symptoms (WOMAC) score (range: 0–96).
Following 16 weeks of follow-up, the participants assigned to RIT presented a significant reduction of their osteoarthritis symptoms (mean ± standard deviation: −21.8 ± 12.5, P < 0.001). WOMAC scores in this group did not change further during the last 16 weeks of follow-up, when the participants received exercise therapy only (−1.2 ± 10.7, P = 0.65). WOMAC scores in the first 16 weeks did not change significantly among the participants receiving exercise therapy only during this period (−6.1 ± 13.9, P = 0.11). There was a significant decrease in this groups' WOMAC scores during the last 16 weeks when the participants received RIT (−9.3 ± 11.4, P = 0.006). After 36 weeks, WOMAC scores improved in both groups by 47.3% and 36.2%. The improvement attributable to RIT alone corresponds to a 11.9-point (or 29.5%) decrease in WOMAC scores.
The use of RIT is associated with a marked reduction in symptoms, which was sustained for over 24 weeks.
Ultrasound-guided pain management for chronic musculoskeletal pain
2022, Journal of Medical Ultrasound
A Comparative Study of Short-Term Efficacy of Intra-articular Hypertonic Saline and Hypertonic Dextrose Prolotherapy in Knee Osteoarthritis: A Randomized Controlled Trial (RCT)
2022, Journal of Rehabilitation Sciences and Research
Ultrasound-Guided Prolotherapy for Acromial Enthesopathy and Acromioclavicular Joint Arthropathy: A Single-Arm Prospective Study
2019, Journal of Ultrasound in Medicine

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Clinical noteHigh-Resolution Ultrasound and Magnetic Resonance Imaging to Document Tissue Repair After Prolotherapy: A Report of 3 Cases

Abstract

Section snippets

Case Descriptions

Discussion

Conclusions

Acknowledgment

Arch Phys Med Rehabil

Ligament and tendon relaxation treated by prolotherapy

Point of view

Spine

Critical review of prolotherapy for osteoarthritis, low back pain, and other musculoskeletal conditions: a physiatric perspective

Am J Phys Med Rehabil

Prolotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized study

Spine

Spine

Clinical note
High-Resolution Ultrasound and Magnetic Resonance Imaging to Document Tissue Repair After Prolotherapy: A Report of 3 Cases