1. Restorative Injection Therapy
(Reconstructive Therapy)
(Prolotherapy)
Andrea Trescot, MD
With special thanks to my mentor,
Dr. Felix Linetsky

2. The History of Prolotherapy
Started with Hernia Repairs
Installation of irritating substances into a pathologic, fluid filled
cavity has been known since Aurelius Cornelius Celsus (25 B.C.– 50
A.D.) described the injection of saltpeter (potassium nitrate), to cure
hydroceles and hernias.
Hernia

3. Observations on referred pain
Kellgren JH. Cl Sci 1937;3:175-190
• 75 medical students
– You could do anything you wanted with
medical students in those days
• Injected with 1cc 6% hypertonic saline
into the midline spinous ligament
– Asked them to map out where they felt
the pain

4. Kellgren et al Cl. Sci.1937-1938.

6. George S. Hackett, M.D.
(1/14/1888 –
8/17/1969)
Joint stabilization
through induced
ligament sclerosis.
Ohio State Medical
Journal
1953, 49, 877–884.

7. First edition just 97 pages
Fibro-osseous
Proliferation
Fibroproliferative
Therapy
Prolotherapy

9. Third edition

10. Inherited Characteristics

13. Hackett’s paradigm:
• A joint is only as strong as its weakest
ligament, majority of chronic pain is
caused by connective tissue deficiency
complicated by injury or repetitive strain.
• Predominant clinical manifestation of
this pathology is local tenderness, and
diagnostic test is relief of pain after
anesthesia.
• Prolotherapy or injection of irritants to
stimulate repair of fibrous connective
tissue, is the treatment of choice.

14. Hackett in 1955 presented at the
AMA Annual Meeting
• 656 patients
• Aged 15 to 88 years old
• Average duration of symptoms 4.5
years
• Followed patients for 12 years after the
injections
– 82% of patients considered themselves
“cured”

15. Treatment Dilemma

16. Enthesopathy
• A disease pathology at the 'entheses',
i.e. attachment sites of muscles,
tendons, joint capsules, ligaments and
fascia to the bone.

17. Enthesopathy
• The body’s response is inflammation
and subsequent calcification
• Locations: knees, hips, shoulders,
ankles, spine, etc
• The diagnosis is made by palpation,
Xrays, ultrasound, and diagnostic
injection

18. Enthesopathy

19. InflammationTrauma

20. InflammationNSAIDs

21. Knee Replacements
Ibuprofen OTC 1984
Ibuprofen introduced in US 1974

22. Degenerative Disc Disease is
Progressive

23. DDD is a progressive condition

29. Palpation

35. Cervical Injuries

44. Spinous

67. So, What is the
Evidence?

69. Proliferant injections for low back pain:
Histologic changes of injected ligaments and
objective measurements of lumbar spine
mobility before and after treatment.
Klein, Dorman & Johnson 1989. J of Neuro. & Ortho. Med.& Surg.10(2),
123–126.
• Posterior SIJ ligaments biopsied in 3
patients before treatment, and 3 month
after last treatment.
• Light microscopy – fibroblastic hyperplasia

70. PLAIN MICROSCOPY: a) BEFORE INJECTIONS, b) AFTER INJECTIONS
a b
Histologic changes of injected ligaments after
treatment. Klein et al, J. Neuro. & Ortho. Med. Surg. 1989;10/ 123-25.

71. ELECTRON MICROSCOPY: a) BEFORE INJECTIONS, b) AFTER INJECTIONS
a b
Ibid Klein et al,

72. Efficacy of dextrose prolotherapy in elite male kicking-sport
athletes with chronic groin pain
Topol, et al
Arch Phys Med Rehabil. 2005 Apr;86(4):697-702.
• 24 professional rugby and soccer players disabled
because of chronic groin pain, unresponsive to
standard therapy.
• Average 2.8 injections of 12.5% dextrose and
lidocaine to pubic insertions of thigh adductor and
suprapubic abdominal muscles.
VAS improved from 6.3 to 1.0 ( P <.001)
• 20 of 24 had no pain and 22 of 24 returned to full
sport activities.

73. A new approach to the treatment of chronic low back pain.
Ongley, Klein, Dorman, Eek et al. 1987, July 18. Lancet, 143–146.
81 pts with chronic LBP (av. duration 10 yr)
randomized in 2 groups, series of 5 double blinded injections
0.2-0.4ml at each side, total volume 20ml + exercise
Needles:19g 3.5”
•Both groups improved,
“therefore it must be
placebo effect”.
•But the treated group
improved more than the
control

74. WAS IT A
PLACEBO???

75. Large Needle Contact with
Bone
• Disrupts cell membranes
– Release of phospholipids and inflammatory
cascade
• Creates microbleeding
– Platelet response
• Local anesthetic or saline is not a
placebo, but a less effective active
agent if injected onto periosteum

76. New Treatments

77. Platelet Rich Plasma
PRP
Stem Cells

79. • PRP group = 15, bupivacaine = 5; single injection
• 8 weeks after tx, PRP patients improved 60%
– control patients improved 16%
(P =.001)
• 6 months, PRP patients improved 81% in VAS
(P=.0001).
• Final follow-up (mean, 25.6 months; range, 12-38
months), PRP patients reported 93% reduction in pain
compared with before the treatment
(P <.0001).
• “Platelet-rich plasma should be considered before
surgical intervention”.
Treatment of chronic elbow tendinosis with
buffered platelet-rich plasma.
Mishra A, Pavelko T. Am J Sports Med. 2006Dept. Orthopedic Surgery, Stanford

80. Regeneration of meniscus cartilage in a knee
treated with percutaneously implanted autologous
mesenchymal stem cells.
Centano CJ, Busse D, Kisiday, et al.
Med Hypothesis 2008;71:900-908
• Because of their multi-potent capabilities,
mesenchymal stem cells (MSC) have been used
successfully in animal models to regenerate articular
cartilage and in human models to regenerate bone.
• “This review highlights the developments in cellular
and regenerative medicine, as well as a case of
successful harvest, expansion, and transplant of
autologous mesenchymal stem cells into an adult
human knee that resulted in an increase in meniscal
cartilage volume.”

81. What Does it Cost?
• Prolotherapy
– $100 - $400/session
– UW $150/session (5 sessions = $750)
• UW charges an additional $250 facility
fee/session
• Platelet rich plasma
– $500 - $1000/session
• Stem cells
– $8,000

82. What is the Alternative?
• Spinal fusion
– $70,000 for hospitalization
• Plus meds, PT, work loss
• Total knee replacement
– $35,000 for hospitalization
• Plus meds, PT, work loss
• Inpatient Rehabilitation for MVA
– $11,265 per patient per year
• US Dept of Transportation 2006

84. Every Thing Old is New Again
Thank you
drtrescot@gmail.com
amt57@aol.com