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Introduction

Prolotherapy (Sclerotherapy, Ligament Sclerosant Therapy) is an injection treatment to strengthen weakened ligaments and muscular attachment points, and is used most commonly to treat low back pain. It is a technique which has practiced by medical osteopaths and musculoskeletal physicians since the 1930's.

About Ligaments

• Ligaments are strong, non-contractile structures which join two bones together, giving the skeleton strength and structural integrity.
• They have a poor blood and nerve supply, which is derived from the surface of the bones (periosteum) they attach to. Pain receptors are found in this periosteal attachment area, sometimes known as the fibro-osseous junction or the enthesis.
• Ligaments can cause pain after they have been sprained by an injury. The sprained ligament usually has a partial tear at the fibro-osseous junction, rather than in the main body of the ligament. Partial tears are usually much more painful than full tears, which can sometimes be painless.
• Problems originating from the enthesis of a ligament or muscle attachment is often called an enthesopathy. An example of this is Osgood Schlatter's Disease affecting teenage boys, where there is a sprain affecting the patellar ligament attachment to the tibial tuberosity (See Joint Pain below).
• The point where muscles attach to the bony skeleton is also a type of fibro-osseous junction, and can be thought of as another type a ligament. These muscle-bone attachment points are not strictly classed as ligaments anatomically, but they can act in a similar way to sprained ligaments after an injury, with pain receptors activated in the periosteum.

About Prolotherapy

• Injecting sclerosant solution around the weakened fibro-osseous junction of ligaments and muscles causes a local sterile inflammatory response, with proliferation  of fibroblasts (hence the word prolotherapy), followed by the laying down of extra strong collagen for about 2 months after the injection. Sclerosing solutions are therefore called proliferants, and can be thought of as acting like a "super glue" repair to the fibro-osseous junction.
• Some practitioners perform a diagnostic local anaesthetic / steroid injection before proceeding to prolotherapy to check that the source of the pain is coming from the ligament under suspicion, and not somewhere else. A positive response to a diagnostic injection usually means that there will be a favourable response to Prolotherapy.
• Prolotherapy is usually performed on 2-3 occasions with 1-4 weeks between each treatment. A common proliferant solution in the UK is a 50/50 mixture of P-2-G and 2% lignocaine. P-2-G contains phenol 2%, with a strong concentration of glycerol 25% and dextrose 25%. A weaker solution for those who react adversely to P2G is 12.5 - 15% dextrose in dilute lignocaine.
• The technique involves local anaesthetic to the skin, and sometimes the use of entonox (gas and air), or intravenous sedation in the anxious. In people who are of large build or obese, the treatment is performed using X-ray guidance.
• In those where the technique is successful, there is usually a period of greatly reduced pain from the ligament for many months. Pain relief should be accompanied by steadily increasing levels of activities. Some patients, especially those with back pain, require "top up" treatments every 12-18 months.
• Sclerotherapy can also be used to "collapse down" large varicose veins in the legs. After an injection into the vein, the legs are tightly bound for about 48 hours. This technique is usually performed by general surgeons in the out-patient clinic.
• See Aftercare and Warning for more information.

Low Back Pain

The spinal ligaments in the lower lumbar and pelvic region are known as the Lumbo-pelvic Ligaments, and can be the cause of chronic low back, and a variety of referred (non nerve) pain patterns in the legs.

Anatomy

• Ligaments and Injection Points
• Lumbo-pelvic Ligaments Front View
• Lumbo-pelvic Ligaments Back View
• Supraspinous / Interspinous Ligament (4, 5, LS) connects the tips of the vertebral spinous processes together, and also connects the lowest vertebra (L5) to the sacrum. These ligaments are important in limiting the degree of forward flexion in the spine. Can be sprained during lifting injuries.
• Iliolumbar Ligament (IL) connects the tip of the transverse processes of L4 and L5 to the iliac crest . Forms a supportive sling for the lower two vertebrae to help prevent them from slipping forwards. Can be sprained during lifting injuries, and causes chronic LBP in spondylolisthesis. Referred Pain Patterns
• Posterior Sacroiliac Joint Ligaments (SIJ) connect the ilium (pelvic) bone to the sacrum and can be divided into upper (A), middle (B), and lower (C) (further down than the dimples and more central). Can be sprained during lifting injuries, and also during/after pregnancy when they are softened by female hormones. Referred Pain Patterns
• Posterior Superior Iliac Spine (D) is one of the main attachment points for the erector spinae (back muscles), and can be sprained during a lifting injury.
• Sacrotuberous and Sacrospinous Ligaments (ST and SS) connect the lower part of the ilium (bum bone) to the lower part of the sacrum. Usually injured by hard falls onto your bottom e.g. 3 point landing slipping on ice. Can be a cause of coccydynia. Referred Pain Patterns

Mechanism

• The lumbo-pelvic ligaments can cause chronic back pain when they are placed under an increased load. The commonest culprit is the Iliolumbar Ligament which supports the L4 and L5 vertebra like a sling. The two main causes of increased iliolumbar ligament tension are:-
  • Disc degeneration with loss of disc height (very common = Lumbo-pelvic Ligament Syndrome).
  • Spondylolisthesis where the L5 vertebra slips forward on the sacrum (less common).
• The main back muscles (erector spinae) also have their anchor points in the lumbo-sacral region, and fasten to the inside curve of the iliac crest, posterior iliac spine, and across the middle of the sacral bone. These areas are commonly sprained during lifting injuries producing chronic back pain.

Treatment

• A diagnostic ligament injection is first performed with local anaesthetic / steroid. If the ligaments are the cause of the backache, then there is usually a dramatic reduction in pain afterwards for usually 2-3 weeks, the backache returning to its normal state afterwards.
• A decision is then made whether or not to proceed to Prolotherapy . See Introduction above for more information.

Whiplash Injury

• Whiplash (Flexion/Extension) injuries are frequently associated with the following:-
  • Injury to the fibro-osseous junction of the Posterior Neck Muscles where they fasten to the occiput (back of the head).
  • Injury to the Nuchal, Supraspinous, and Interspinous Ligaments where they attach to the vertebral spinous processes between the occiput and as far down as T3/4.
• Referred pain is common from these ligamentous injuries.
  • The occipital area refers pain to the back of the head, temple, and behind the eye.
  • The spinal ligament injuries refer pain in their appropriate Dermatome .
• Prolotherapy is a useful technique to repair these injuries. See Introduction above for more information.

Joint Pain

Prolotherapy can be used in and around almost any joint in the body where a sprain of a muscle or ligament fibro-osseous attachment is thought to be the cause of the pain. It can also be used to treat severely affected osteoarthritic joints. See below for some treatment examples. Those marked with ** usually require X-ray guidance:-

• Temporo-mandibular Joint (TMJ)
• Shoulder Region
  • Intra-articular Shoulder Injection ** for osteoarthritis affecting the gleno-humeral joint.
  • Acromio-clavicular Joint Injection ** for sprains and osteoarthritis.
  • Sterno-clavicular Joint Injection for sprains and osteoarthritis.
  • Coracoid Process Injection for sprains to the attachment of the pectoralis minor and coracobrachialis muscles.
• Elbow Region
  • Lateral Epicondyle Injection for chronic tennis elbow.
  • Medial Epicondyle Injection for chronic golfer's elbow (beware the Ulnar Nerve).
  • Radial Head and Annular Ligament Injection for sprains and osteoarthritis.
• Wrist and Hand
  • Wrist and Hand Ligament and Joint Injection for sprains and osteoarthritis.
• Hip Region
  • Hip Joint Injection ** for osteoarthritis.
  • Greater Trochanter Injection for chronic trochanteric bursitis.
  • Ischial Tuberosity Injection for chronic hamstring strains.
• Knee Region
  • Intra-articular Knee Injection for osteoarthritis.
  • Medial Collateral Ligament Injection for ligament sprains (other side is injected for the lateral collateral ligament).
  • Coronary Ligament Injection for cartilage sprains.
  • Patellar Ligament Injection for ligament sprains and Osgood Schlatter's Disease in teenagers (Enthesopathy of the Tibial Tuberosity). Green arrows represent other treatment injection points.
  • Superior Tibio-fibulo Joint Injection for osteoarthritis and sprains (beware the Common Peroneal Nerve).
• Ankle Region
  • Medial Ligament (Deltoid) Injection for ligament sprains.
  • Lateral Ligament Injection for ligament sprains.

Aftercare

• Following prolotherapy treatment the usual pattern is of worse pain for about 1-2 weeks. The solution works by inducing a sterile inflammatory response at the ligament fibro-osseous junction, with the activation of all the usual inflammatory mediators and pain mechanisms.
• There is usually an increased analgesic requirement during this period. See Analgesic Flow Chart for further advice.
• Between 2 - 4 weeks this initial pain resolves, and as the ligament strengthening process proceeds, the pain begins to steadily diminish to lower levels. It may not be possible to achieve 100% relief with this technique.
• In my experience, the first prolotherapy treatment is the worst, with subsequent treatments appearing not to cause so much initial pain reaction.

Warning

• As with any medical treatment, there is a small chance that the pain could be worse afterwards compared to beforehand. In most cases the pain resolves after 1-2 weeks, but in some people the pain seems to stay worse permanently, with the cause being unclear.
• A diagnostic ligament injection should help to decide whether prolotherapy is the right treatment for your type of pain. Those who react adversely to this test run should not proceed to prolotherapy using a sclerosant.
• Particular care is needed when prolotherapy is contemplated in the following areas:-
  • Tip of the transverse process of L4 and L5 - the ureter (tube connecting the kidney to the bladder) lies just in front of the tips of these structures, and damage to the ureter can occur if the proliferant (sclerosant) is injected too deeply. This can lead to ureteric obstruction and kidney failure. I would recommend the use of X-ray guidance when injecting in this particular area to help reduce this risk.
  • Supraspinous / Interspinous Ligaments - when injecting in this area, the needle can accidentally cause a dural tap and a post dural puncture headache (PDPH). It is important that a dural tap is recognised early so that sclerosant is not injected directly into the spinal fluid, spinal cord and spinal nerves. A PDPH usually resolves with simple analgesics and oral fluids after 1 - 2 weeks.
  • Spina Bifida Occulta - if you are known to have this harmless congenital abnormality, please inform your doctor prior to treatment as it increases the risk of a dural puncture when injecting in the area. Spina Bifida Occulta is the congenital absence of the back part of the vertebra (lamina and spinous process) at usually a single level. You may be able to feel a hole in the middle of your back with your fingers where these bones are missing.
  • Neck - it is important that the injecting needle does not enter the spinal canal or vertebral artery when injecting around the occiput or cervical spine.
  • Anatomically Sensitive Areas - adjacent to peripheral nerves and major arteries and veins.

Pictures taken with thanks from "Ligament and Tendon Relaxation Treated by Prolotherapy" by Hackett, Hemwall and Montgomery 1993. Institute in Basic Life Principles, Box One, Oak Brook, IL 60522-3001 USA