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Prolotherapy ( for information only )

(this therapy is not offered at the clinic . At this clinic we use Biomesotherapy as our preferred injection therapy)

Prolotherapy also called proliferation therapy is an injection-based treatment used in chronic musculoskeletal conditions.[1] It has been characterised as an alternative medicine practice.[2

A 2015 review found limited evidence that prolotherapy is safe and effective for Achilles tendinopathy, plantar fasciosis, and Osgood Schlatter disease.[3] The quality of the studies was also poor.[3] Another 2015 review assigned a strength of recommendation level A for Achilles tendinopathy, knee osteoarthritis and level B for lateral epicondylosis, Osgood Schlatter disease, and plantar fasciosis.[4] Level A recommendations are based on consistent and good-quality patient-oriented evidence while level B are based on inconsistent or limited-quality patient-oriented evidence.[4] Two 2016 review articles expanded level B strength of recommendations to include low back/sacroiliac pain and rotator cuff tendinopathy. As of 2016 evidence to support the use of prolotherapy in acute pain, myofascial pain or as first-line therapy, could not be determined.[5]

Low back pain

A 2007 Cochrane review of prolotherapy in adults with chronic low-back pain found unclear evidence of effect.[6] A 2009 review concluded the same for subacute low back pain.[7] A 2015 review found consistent evidence that it does not help in low back pain.[4] There was tentative evidence of benefit when used with other low back pain treatments.[6][8] Evidence of benefit remains tentative (level B) for dextrose prolotherapy in low back or sacroiliac pain.[9] [5]


A 2009 systematic review of the efficacy in the treatment of lateral epicondylitis concluded that these therapies may benefit people with lateral epicondylitis, but the evidence was limited.[10] A 2010 review concluded moderate evidence exists to support the use of prolotherapy injections in the management of pain in lateral epicondylitis, and that prolotherapy was no more effective than eccentric exercise in the treatment of Achilles tendinopathy.[11] A 2016 review found a trend towards benefit in 2016 for lateral epicondylitis.[12] A 2017 review found tentative evidence in Achilles tendinopathy.[13]

In 2012, a systematic review studying various injection therapies found that prolotherapy and hyaluronic acid injection therapies were more effective than placebo when treating lateral epicondylitis. Of the studies evaluated, one of ten glucocorticoid trials, one of five trials for autologous blood injection or platelet-rich plasma, one trial of polidocanol, and one trial of prolotherapy met the criteria for low risk of bias. The authors noted that few of the reviewed trials met the criteria for low risk of bias.[14]

Knee osteoarthritis[edit]

Tentative evidence of prolotherapy benefit was reported in a 2011 review.[6][8] One 2017 review found evidence of benefit from low-quality studies.[15] A 2017 review described the evidence as moderate for knee osteoarthritis.[16] A 2016 review found benefit but there was a moderate degree of variability between trials and risk of bias.[17]

Side effects[edit]

Patients receiving prolotherapy injections have reported generally mild side effects, including mild pain and irritation at the injection site[20] (often within 72 hours of the injection), numbness at the injection site, or mild bleeding. Pain from prolotherapy injections is temporary and is often treated with acetaminophen[20] or, in rare cases, opioid medications. NSAIDs are not usually recommended due to their counter action to prolotherapy-induced inflammation, but are occasionally used in patients with pain refractory to other methods of pain control.[18] Theoretical adverse events of prolotherapy injection include lightheadedness, allergic reactions to the agent used, bruising, infection, or nerve damage. Allergic reactions to sodium morrhuate are rare.[18] Rare cases of back pain, neck pain, spinal cord irritation, pneumothorax, and disc injury have been reported at a rate comparable to that of other spinal injection procedures.[8][18]


Prolotherapy involves the injection of an irritant solution into a joint space,[21] weakened ligament, or tendon insertion to relieve pain. [8] Most commonly, hyperosmolar dextrose (a sugar) is the solution used;[22] glycerine,[20] lidocaine (a commonly used local anesthetic),[23] phenol,[20] and sodium morrhuate (a derivative of cod liver oil extract) are other commonly used agents.[8][10] The injection is administered at joints or at tendons where they connect to bone.

Prolotherapy treatment sessions are generally given every two to six weeks for several months in a series ranging from 3 to 6 or more treatments.[18][20] Many patients receive treatment at less frequent intervals until treatments are rarely required, if at all.[24]


  1. ^ Jump up to: a b Rabago, D; Nourani, B (2017). “Prolotherapy for Osteoarthritis and Tendinopathy: a Descriptive Review”. Current Rheumatology Reports. 19 (6): 34. doi:10.1007/s11926-017-0659-3. 
  2. Jump up ^ Rabago, D; Slattengren, A; Zgierska, A (March 2010). “Prolotherapy in primary care practice”. Primary care. 37 (1): 65–80. doi:10.1016/j.pop.2009.09.013. PMC 2831229Freely accessible. PMID 20188998. 
  3. ^ Jump up to: a b Sanderson, LM; Bryant, A (2015). “Effectiveness and safety of prolotherapy injections for management of lower limb tendinopathy and fasciopathy: a systematic review”. Journal of Foot and Ankle Research. 8: 57. doi:10.1186/s13047-015-0114-5. 
  4. ^ Jump up to: a b c Covey, CJ; Sineath, MH Jr; Penta, JF; Leggit, JC (2015). “Prolotherapy: Can it help your patient?”. Journal of Family Practice. 64 (12): 763–768. PMID 26844994. 
  5. ^ Jump up to: a b Hauser, RA; Lackner, JB; Steilen-Matias, D; Harris, DK (2016). “A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain”. Clinical Medicine Insights. Arthritis and Musculoskeletal Disorders. 9 (4): 783–823. doi:10.4137/CMAMD.S39160. 
  6. ^ Jump up to: a b c Dagenais, Simon; Yelland, Michael J; Del Mar, Chris; Schoene, Mark L; Nelemans, P (2007). “Prolotherapy injections for chronic low-back pain”. Cochrane Database of Systematic Reviews. 34 (1): 49–59. doi:10.1002/14651858.CD004059.pub3. PMID 17443537. 
  7. Jump up ^ Staal, J Bart; De Bie, Rob A.; De Vet, Henrica C. W.; Hildebrandt, Jan; Nelemans, Patty (2009). “Injection Therapy for Subacute and Chronic Low Back Pain”. Spine. 34 (1): 49–59. doi:10.1097/brs.0b013e3181909558. PMID 19127161. 
  8. ^ Jump up to: a b c d e f g Distel, Laura M.; Best, Thomas M. (2011). “Prolotherapy: A Clinical Review of Its Role in Treating Chronic Musculoskeletal Pain”. PM&R. 3 (6): S78–81. doi:10.1016/j.pmrj.2011.04.003. PMID 21703585. 
  9. ^ Jump up to: a b Reeves, KD; Sit, RWS; Rabago, D (2016). “Dextrose Prolotherapy: A narrative review of basic science and clinical research, and best treatment recommendations”. Physical Medicine & Rehabilitation Clinics of North America. 27 (4): 783–823. doi:10.1016/j.pmr.2016.06.001. PMID 27788902. 
  10. ^ Jump up to: a b c Rabago, D; Best, TM; Zgierska, AE; Zelsig, E; Ryan, M; Crane, D (2009). “A systematic review of four injections therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood, and platelet-rich plasma”. British Journal of Sports Medicine. 43 (7): 471–481. doi:10.1136/bjsm.2008.052761. PMC 2755040Freely accessible. PMID 19028733. 
  11. Jump up ^ Coombes, Brooke K; Bisset, Leanne; Vicenzino, Bill (2010). “Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: A systematic review of randomised controlled trials”. The Lancet. 376 (9754): 1751–67. doi:10.1016/S0140-6736(10)61160-9. PMID 20970844. 
  12. Jump up ^ Morath, O; Kubosch, EJ; Lin, XB; Burger, C; Paul, C; Wang, ZL; Kong, FL; Welle, K; Jiang, ZC; Kabir, K (2016). “Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis”. British Journal of Sports Medicine. 50 (15): 900–908. doi:10.1136/bjsports-2014-094387. 
  13. Jump up ^ Dong, W; Goost, H; Taeymans, J; Zwingmann, J; Konstantinidis, L; Südkamp, NP; Hirschmüller, A (2017). “The effect of sclerotherapy and prolotherapy on chronic painful Achilles tendinopathy-a systematic review including meta-analysis”. Scandinavian Journal of Medicine and Science in Sports. Apr 27: 4–15. doi:10.1111/sms.12898. 
  14. Jump up ^ Krogh, T. P.; Bartels, E. M.; Ellingsen, T.; Stengaard-Pedersen, K.; Buchbinder, R.; Fredberg, U.; Bliddal, H.; Christensen, R. (2012). “Comparative Effectiveness of Injection Therapies in Lateral Epicondylitis: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials”. The American Journal of Sports Medicine. 41 (6): 1435–46. doi:10.1177/0363546512458237. PMID 22972856. 
  15. Jump up ^ Krstičević, M; Jerić, M; Došenović, S; Jeličić Kadić, A; Puljak, L (2017). “Proliferative injection therapy for osteoarthritis: a systematic review”. International Orthopedics. 41 (4): 671–679. doi:10.1007/s00264-017-3422-5. 
  16. Jump up ^ Hassan, F; Trebinjac, S; Murrell, WD; Maffulli, N (2017). “The effectiveness of prolotherapy in treating knee osteoarthritis in adults: a systematic review”. British Medical Bulletin. 122 (1): 91–108. doi:10.1093/bmb/ldx006. 
  17. Jump up ^ Sit, RW; Chung, VCh; Reeves, KD; Rabago, N; Chan, KK; Chan, DC; Wu, X; Ho, RS; Wong, SY (2016). “Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: A systematic review and meta-analysis”. Scientific Reports. 6 (May 5): 25247. doi:10.1038/srep25247. 
  18. ^ Jump up to: a b c d e f Rabago, D; Slattengren, A; Zgierska, A (2010). “Prolotherapy in Primary Care Practice”. Primary Care: Clinics in Office Practice. 37 (1): 65–80. doi:10.1016/j.pop.2009.09.013. PMC 2831229Freely accessible. PMID 20188998. 
  19. ^ Jump up to: a b c d “Prolotherapy”. University of Pittsburgh Medical Center. 2012. Retrieved 16 December 2012. 
  20. ^ Jump up to: a b c d e f Judson, Christopher H.; Wolf, Jennifer Moriatis (2013). “Lateral Epicondylitis”. Orthopedic Clinics of North America. 44 (4): 615–23. doi:10.1016/j.ocl.2013.06.013. PMID 24095076. 
  21. ^ Jump up to: a b Bauer, Brent A. (2012). “Prolotherapy: Solution to low back pain?”. Mayo Clinic. Retrieved 16 December 2012. 
  22. Jump up ^ Davidson, J.; Jayaraman, S. (2011). “Guided interventions in musculoskeletal ultrasound: What’s the evidence?”. Clinical Radiology. 66 (2): 140–52. doi:10.1016/j.crad.2010.09.006. PMID 21216330. 
  23. Jump up ^ Johannes, Laura (October 19, 2010). “A Pinch of Sugar for Pain”. Wall Street Journal. Retrieved 16 December 2012. 
  24. Jump up ^ Banks, AR (1991). “A Rationale for Prolotherapy” (PDF). Journal of Orthopaedic Medicine. 13 (3). 
  25. Jump up ^ Hackett, GS (1956). Ligament and tendon relaxation treated by prolotherapy. Springfield, IL: Charles C. Thomas. 
  26. ^ Jump up to: a b Seidenberg, P (2008). The Sports Medicine Resource Manual. Philadelphia: Elsevier. pp. 611–9. ISBN 978-1-4160-3197-0. 
  27. Jump up ^ Waldman, S (2010). Pain Management. Philadelphia: Saunders (Elsevier). pp. 1027–44. ISBN 978-1-4377-0721-2. 
  28. Jump up ^ Brody, Jane E. (7 August 2007). “Injections to Kick-Start Tissue Repair”. New York Times. Retrieved 24 July 2008. Prolotherapy involves a series of injections designed to produce inflammation in the injured tissue 
  29. Jump up ^ “Clinical Policy Bulletin: Prolotherapy”. Aetna, Inc. 2013. Retrieved 12 October 2013. 
  30. Jump up ^ “Prolotherapy for Musculoskeletal Indications” (PDF). Medical Policy. UnitedHealthCare. 2013. Retrieved 12 October 2013. 
  31. Jump up ^ “Corporate Medical Policy” (PDF). Prolotherapy. BlueCross BlueShield of North Carolina. 2013. Retrieved 12 October 2013. 
  32. Jump up ^ “Decision Memo for Prolotherapy for Chronic Low Back Pain)”. Centers for Medicare and Medicaid Services. Retrieved 12 October 2013. 

Further reading[edit]

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