Effectiveness and safety of prolotherapy injections for management of lower limb tendinopathy and fasciopathy: a systematic review

Rapid Decrease in Dextrose Concentration After Intra-Articular Knee Injection: Implications for Mechanism of Action of Dextrose Prolotherapy

BACKGROUND

D-glucose (dextrose) is used as a 5000-25,000 mg% solution in the injection-based pain therapy known as dextrose prolotherapy (DPT). The number of peer-reviewed clinical trials supporting its use is growing. However, the mechanism of action is unknown, limiting further research. A commonly expressed theory is that hyperosmotic dextrose injection induces inflammation, initiating a healing-specific inflammatory cascade. In vitro study models have used continuous exposure to high concentration dextrose. But the rate of dextrose clearance after intra-articular injection, and, therefore, the duration of exposure of tissues to any particular dextrose concentration, remains unknown. We therefore determined the rate of dextrose concentration diminution in one human participant's knees after intra-articular dextrose knee injection.

METHOD

In this pre-post N-of-1 study, the first author (KDR), a well 70-year-old male without knee-related pathology, injected his own knees with 30 mL of 12,500 mg% dextrose on three occasions; performed serial aspirations of 1.2 mL of intra-articular fluid from 7 to 360 min post-injection; and assessed synovial dextrose concentration. Dextrose clearance kinetics were determined using Minitab and GraphPad Prism software.

RESULTS

Dextrose concentration dropped rapidly in all three trials, approximating an exponential or steep S curve. A third order chemical reaction pattern was found, suggesting factors other than dilution or glucose transporter activity, such as rapid diffusion of dextrose across the synovial membrane, may have contributed to the rapid drop in dextrose concentration.

CONCLUSION

This pre-post N-of-1 study shows that, after intraarticular injection of 30 mL of 12,500 mg% dextrose injection into a well knee, the concentration of dextrose diminished rapidly, suggesting that intra-articular cells, tissue, and anatomic structures are exposed to an initially high dextrose concentration for a very short time. This likely affects the mechanism of action of DPT and should inform in vitro study methods.

Regenerative Medicine in Orthopedic Surgery: Expanding Our Toolbox

Regenerative medicine leverages the body's inherent regenerative capabilities to repair damaged tissues and address organ dysfunction. In orthopedics, this approach includes a variety of treatments collectively known as orthoregeneration, encompassing modalities such as prolotherapy, extracorporeal shockwave therapy, pulsed electromagnetic field therapy, therapeutic ultrasound, and photobiomodulation therapy, and orthobiologics like platelet-rich plasma and cell-based therapies. These minimally invasive techniques are becoming prominent due to their potential for fewer complications in orthopedic surgery. As regenerative medicine continues to advance, surgeons must stay informed about these developments. This paper highlights the current state of regenerative medicine in orthopedics and advocates for further clinical research to validate and expand these treatments to enhance patient outcomes.

Twenty-Three-Year-Old Patient With Chronic Pain and Fainting Spells-A Clinical Vignette

ABSTRACT

Care for and clinical presentation of patients with connective tissue disorders, specifically hypermobile Ehlers-Danlos syndrome, is poorly understood. Diagnosis can often take years, and comprehensive care can be difficult to coordinate for these patients. This vignette aims to show the clinical characteristics of a young female with Hypermobile Ehlers-Danlos, as well as the evaluation of her diagnostic presentation and subsequent treatment. The demographic data of this population are yet to be established, and as it can vary widely between individuals, it is important to recognize symptoms that distinguish this disorder from others with similar presentations. Education of physicians on this syndrome will allow earlier recognition of symptoms and lead to better outcomes of these patients overall.

Enhanced Pain Relief and Function Improvement in Children with Osgood-Schlatter Disease: Leukocyte-Rich Platelet-Rich Plasma (LR-PRP) as a Complementary Treatment to Standard Conservative Therapy

BACKGROUND Osgood-Schlatter disease (OSD) causes pain and loss of function of the knee in growing children. This study aimed to evaluate pain and function of the knee joint in 152 growing children with chronic OSD before and after treatment with LR-PRP when used with standard conservative treatment. MATERIAL AND METHODS Treatment efficacy was evaluated using the VAS, Tegner, Lyshom, and KOOS scales. Patient satisfaction, post-surgery athletic performance, and X-ray assessment were also used to determine the success of the procedure. RESULTS We found that 75% of the subjects were satisfied with the results of the treatment, and 72% of the subjects returned to full physical activity. The analysis showed a significant decrease in the median VAS score after treatment compared to the pre-treatment score (P<0.05), and an increase in the median scores of the Tegner, Lysholm, and KOOS scales compared to the pre-treatment score (P<0.05; P<0.05; P<0.05, respectively). The results showed that the shorter the duration of the disease, the better the treatment results were received. Return to activity and patient satisfaction were highest in the study group previously rehabilitated. CONCLUSIONS LR-PRP injection of the tibial tuberosity in patients with chronic OSD with open growth cartilage is an effective and uncomplicated method. We did not observe any adverse effects, which suggests the relatively high safety of the procedure. The use of PRP in the earlier phase of the disease and additional rehabilitation before treatment significantly increases the effectiveness of treatment.

Effectiveness of Hypertonic Dextrose Injection (Prolotherapy) in Plantar Fasciopathy: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To systematically review the effectiveness of hypertonic dextrose prolotherapy (DPT) in plantar fasciopathy (PF) compared with other non-surgical treatments.

DATA SOURCES

PubMed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, Allied and Complementary Medicine Database, Global Health, Ovid Nursing Database, Dimensions, and WHO ICTRP were searched from inception to April 30th, 2022.

STUDY SELECTION

Two independent reviewers selected randomized controlled trials (RCTs) that evaluated the effectiveness of DPT in PF compared with non-surgical treatments. Outcomes included pain intensity, foot and ankle function, and plantar fascia thickness.

DATA EXTRACTION

Two independent reviewers conducted data extraction. Risk of bias (RoB) assessment was conducted using the Cochrane Risk of Bias 2 (RoB 2) tool, and certainty of evidence was assessed with Grading of Recommendation Assessment, Development, and Evaluation (GRADE).

DATA SYNTHESIS

Eight RCTs (n=469) met the inclusion criteria. Pooled results favored the use of DPT versus normal saline (NS) injections in reducing pain (weighted mean difference [WMD] -41.72; 95% confidence interval [CI] -62.36 to -21.08; P<.01; low certainty evidence) and improving function [WMD -39.04; 95% CI -55.24 to -22.85; P<.01; low certainty evidence] in the medium term. Pooled results also showed corticosteroid (CS) injections was superior to DPT in reducing pain in the short term [standardized mean difference 0.77; 95% CI 0.40 to 1.14; P<.01; moderate certainty evidence]. Overall RoB varied from "some concerns" to "high". The overall certainty of evidence presented ranges from very low to moderate based on the assessment with the GRADE approach.

CONCLUSION

Low certainty evidence demonstrated that DPT was superior to NS injections in reducing pain and improving function in the medium term, but moderate certainty evidence showed that it was inferior to CS in reducing pain in the short term. Further high-quality RCTs with standard protocol, longer-term follow-up, and adequate sample size are needed to confirm its role in clinical practice.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Emerging Treatment Options for Chronic Tendinopathy of the Foot: A Clinical Vignette

ABSTRACT

The patient is a 65-year-old female recreational skier and avid walker who presented with a several-month history of right ankle and foot pain. The patient's pain began without inciting event and was described as a constant aching pain aggravated by downhill walking and alleviated with rest. She was diagnosed with right distal tibialis anterior tendinopathy with partial thickness tear noted on magnetic resonance imaging and musculoskeletal ultrasound. Given symptoms recalcitrant to conservative measures, the patient opted to pursue an ultrasound-guided prolotherapy injection and a course of physical therapy; unfortunately, she did not have any improvement in symptoms. The patient subsequently underwent ultrasound-guided percutaneous ultrasonic tenotomy and debridement of the distal tibialis anterior tendon, followed by a postprocedure rehabilitation protocol of physical therapy with transition to home exercise program with complete resolution of her pain. Prolotherapy, and percutaneous ultrasonic tenotomy and debridement are two treatment modalities that show promise in the treatment of painful, chronic tendinopathy.

Ultrasound-Guided Injection of Dextrose Versus Corticosteroid in Chronic Plantar Fasciitis Management: A Randomized, Double-Blind Clinical Trial

DESIGN

Chronic plantar fasciitis (PF) is a common cause of chronic heel pain, with different conventional treatment options. In this randomized clinical trial, the effect of ultrasound-guided injection of dextrose versus corticosteroid in chronic PF was evaluated and compared.

METHODS

A total of 44 patients suffering from chronic PF who visited the physical medicine and rehabilitation clinic were enrolled in the study. Two table-randomized groups were formed. They received an ultrasonography-guided, single injection of either 40 mg methylprednisolone or 20% dextrose. Numeric Rating Scale (NRS), Foot and Ankle Ability Measure questionnaire with 2 subscales, Activities of Daily Living (FAAM-A) and Sports (FAAM-S), along with ultrasonographic parameters were evaluated before and at 2 and 12 weeks after the injection. Results. A total of 40 participants completed the study. Both interventions significantly improved pain and function at 2 and 12 weeks postinjection. After 2 weeks, compared with the dextrose prolotherapy, the corticosteroid group had significantly lower daytime and morning NRS scores (2.55 vs 4.1, P = .012, and 2.75 vs 4.65, P = .004), higher FAAM-S (66.84 vs 54.19; P = .047), and lower plantar fascia thickness at insertion and 1 cm distal to the insertion zone (3.89 vs 4.29 mm, P = .004, and 3.13 vs 3.48 mm, P = .002), whereas FAAM-A was similar in both groups (P = .219). After 12 weeks, all study variables were statistically similar between corticosteroid and dextrose prolotherapy groups. No injection-related side effects were recorded in either group.

CONCLUSION

Both methods are effective. Compared with dextrose prolotherapy, our results show that corticosteroid injection may have superior therapeutic effects early after injection, accompanied by a similar outcome at 12 weeks postinjection.

LEVELS OF EVIDENCE

Level II.

A protocol for a randomized clinical trial assessing the efficacy of hypertonic dextrose injection (prolotherapy) in chronic ankle instability

BACKGROUND

Lateral ankle sprain (LAS) is a common injury. Conservative care is not uniformly effective. Chronic ankle instability (CAI) results in up to 70% of patients with LAS in the physically active population. LAS, together with subsequent osteochondral lesions and pain in many patients, leads to the development of post-traumatic osteoarthritis, resulting in a substantial direct and indirect personal and societal health burden. Dextrose prolotherapy (DPT) is an injection-based therapy for many chronic musculoskeletal conditions but has not been tested for CAI. This protocol describes a randomized controlled trial to test the efficacy of DPT versus normal saline (NS) injections for chronic ankle instability (CAI).

METHODS AND ANALYSIS

A single-center, parallel-group, randomized controlled trial will be conducted at a university-based primary care clinic in Hong Kong. A total of 114 patients with CAI will be randomly allocated (1:1) to DPT and NS groups. The primary outcome will be the Cumberland Ankle Instability Tool scores at 1 year. The secondary outcomes will be the number of re-sprains in 1 year, the Star Excursion Balance Test, the 5-level of EuroQol 5-dimension questionnaire, and the Foot and Ankle Ability Measure. All outcomes will be evaluated at baseline and at 16, 26, and 52 weeks using a linear mixed model.

DISCUSSION

We hypothesized the DPT is a safe, easily accessible, and effective treatment for patients with CAI. This RCT study will inform whether DPT could be a primary non-surgical treatment for CAI.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000040213 . Registered on 25 November 2020.

The effectiveness of dextrose prolotherapy in plantar fasciitis: A systemic review and meta-analysis

BACKGROUND

Dextrose prolotherapy (DPT) is considered to be a type of regenerative therapy and is widely used in various musculoskeletal disorders. Plantar fasciitis is a common cause of heel pain that affects the quality of life of many people. We aimed to evaluate the effectiveness and safety of DPT for plantar fasciitis.

METHODS

PubMed, Embase, and the Cochrane Library were searched from their respective inception dates to June 2021. Only randomized controlled trials comparing DPT and other interventions for plantar fasciitis were included in this review. Standardized mean differences (SMDs) with 95% confidence intervals were calculated for comparison. The outcome measurements included visual analog score, numeric rating scale, Foot Function index, Revised Foot Function index, American Orthopedic Foot and Ankle Score, and plantar fascia thickness. Post-treatment duration was classified as short-term (1-2 months), medium-term (3 months), or long-term (6 months).

RESULTS

Six studies with 388 adult patients diagnosed with plantar fasciitis were included for the meta-analysis. In terms of pain scores improvement, DPT was superior to placebo or exercise in the short-term (SMD: -1.163, 95%CI: -2.17 to -0.156) and the medium-term (SMD: -1.394, 95%CI: -2.702 to -0.085). DPT was inferior to corticosteroid injection in the short-term (SMD: 0.781, 95%CI: 0.41 to 1.152). For functional improvement, DPT was superior to placebo or exercise in the short-term (SMD: -1.51, 95%CI: -2.96 to -0.059), but inferior to corticosteroid injection (SMD: 0.526, 95%CI: 0.161 to 0.89) and extracorporeal shock wave therapy in the short-term (SMD: 0.484, 95%CI: 0.145 to 0.822). Randomized controlled trials showed a better pain improvement in the long-term for patients treated with DPT compared to corticosteroid (P = .002) and exercise control (P < .05). No significant differences were found between patients treated with DPT and patients treated with platelet-rich plasma.

CONCLUSION

Dextrose prolotherapy was a safe and effective treatment option for plantar fasciitis that may have long-term benefits for patients. The effects were comparable to extracorporeal shock wave therapy or platelet-rich plasma injection. Further studies with standardized protocols and long-term follow-up are needed to address potential biases.

A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis

The number of systematic review and meta-analyses on plantar fasciitis is expanding. The purpose of this review was to provide a comprehensive summary of reviews on the topic pertaining to plantar fasciitis, identify any conflicting and inconsistent results, and propose future research direction. A qualitative review of all systematic reviews and meta-analyses related to plantar fasciitis up to February 2021 was performed using PubMed, Embase, Web of Science, and the Cochrane Database. A total of 1052 articles were initially identified and 96 met the inclusion criteria. Included articles were summarized and divided into the following topics: epidemiology, diagnosis, and treatment. While the majority of reviews had high level of heterogeneity and included a small number of studies, there was general consensus on certain topics, such as BMI as a risk factor for plantar fasciitis and extracorporeal shockwave therapy as an effective mode of therapy. A qualitative summary of systematic reviews and meta-analyses published on plantar fasciitis provides a single source of updated information for clinicians. Evidence on topics such as the epidemiology, exercise therapy, or cost-effectiveness of treatment options for plantar fasciitis are lacking and warrant future research.

A systematic review on conservative treatment options for OSGOOD-Schlatter disease

OBJECTIVES

Osgood-Schlatter disease (OSD) is a sport- and growth-associated knee pathology with locally painful alterations around the tibial tuberosity apophysis. Up to 10% of adolescents are affected by OSD. Treatment is predominantly conservative. The aims of this systematic review are to comprehensively identify conservative treatment options for OSD, compare their effectiveness in selected outcomes, and describe potential research gaps.

METHODS

A systematic literature search was conducted using CENTRAL, CINAHL, EMBASE, MEDLINE, and PEDro databases. In addition, ongoing and unpublished clinical studies, dissertations, and other grey literature on OSD were searched. We also systematically retrieved review articles for extraction of treatment recommendations.

RESULTS

Of 767 identified studies, thirteen were included, comprising only two randomised controlled trials (RCTs). The included studies were published from 1948 to 2019 and included 747 patients with 937 affected knees. Study quality was poor to moderate. In addition to the studies, 15 review articles were included, among which the most prevalent treatment recommendations were compiled.

CONCLUSION

Certain therapeutic approaches, such as stretching, have apparent efficacy, but no RCT comparing specific exercises with sham or usual-care treatment exists. Carefully controlled studies on well-described treatment approaches are needed to establish which conservative treatment options are most effective for patients with OSD.

No superiority of dextrose injections over placebo injections for Osgood-Schlatter disease: a prospective randomized double-blind study

PURPOSE

Osgood-Schlatter disease (OSD) is a traction apophysitis of the tibial tuberosity. Patellar tendinopathy and deep infrapatellar bursitis have recently been shown to contribute to pain in patients with OSD. We compared the effects of dextrose injection and saline injection.

METHODS

We performed a clinical trial from April 2012 to January 2016 and included 49 knees from 37 boys and 1 girl (mean age, 12.3 ± 1.1 years) for whom conventional conservative therapy for > 1 month was ineffective. They were randomly assigned to receive double-blind injections of 1% lidocaine (1 mL) with 20% dextrose (1 mL; dextrose group) or 1% lidocaine (1 mL) with saline (1 mL; saline group). Injections were administered monthly for 3 months by a single investigator. The Victorian Institute of Sport Assessment (VISA) score was used to evaluate anterior knee pain.

RESULTS

Overall, 43 knees were included; 6 knees were lost to follow-up. The mean pre-injection VISA scores in the dextrose and saline groups were 58.7 ± 18.3 and 63.4 ± 16.4, respectively. No significant differences were found between the two groups at any time point. The mean VISA score before injections significantly increased at the 1-month follow-up in both groups (P < .01). The injection had no adverse effects.

CONCLUSIONS

We were not able to show the efficacy of dextrose injections compared to that of saline.

LEVEL OF EVIDENCE

Randomized controlled trial. Level I.

A rare case of Haemophilus parainfluenzae septic knee following prolotherapy injections

Prolotherapy injections are becoming increasingly popular as a non-surgical treatment option for many chronic musculoskeletal conditions. Proposed benefits include reduced pain, reduced joint laxity and increased tendon strength. While a number of studies report that prolotherapy reduces pain and increases function for many conditions, the academic evidence remains extremely weak. Here, we discuss a case of a complex intra-articular knee infection in a young, previously healthy, female following prolotherapy injections for management of a partial-thickness anterior cruciate ligament (ACL) tear. To the best of our knowledge, this is the first report of its kind describing a potential complication of intra-articular prolotherapy injections.

Dextrose injections for failed back surgery syndrome: a consecutive case series

PURPOSE

Patients with chronic low back pain, who do not respond to conservative treatment methods, generally undergo surgical revision operations, and sometimes an undesirable condition called failed back surgery syndrome (FBSS) may be inevitable. Hereby, dextrose is one of the regenerative methods that has gained popularity in the treatment of many musculoskeletal problems, and we aimed to present and evaluate the outcomes of 5% dextrose for the treatment of FBSS.

METHODS

It has been designed as a consecutive case series. A total of 79 patients with FBSS, who had minimum 6 months of symptoms and did not respond to 3 months of conservative methods between May 2014 and March 2016, participated in the study. Prolotherapy injections were applied in posterior and lateral approaches. Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were used for the pre- and post-treatment evaluations. Patient satisfaction was assessed with using a 5-point Likert scale by phone contacting.

RESULTS

There was statistically significant difference between repeated VAS and ODI measurements.

CONCLUSIONS

These results may be the first step giving a lead to an undiscovered field. This treatment method should be kept in mind for FBSS patients before giving a decision of revision surgery. These slides can be retrieved under Electronic Supplementary Material.

Role of a combination dietary supplement containing mucopolysaccharides, vitamin C, and collagen on tendon healing in rats

Objective

The aim of this study was to investigate the effect of mucopolysaccharide, vitamin C, and collagen supplementation on the healing of Achilles tendon in rats.

Methods

Sixteen rats were separated into 2 groups. Both Achilles tendons of all rats were transected 5 mm above the insertion and repaired using a Kessler suture. After the surgical repair, the study group received the daily recommended amount of the supplement by gastric gavage, while the control group received a placebo. At the end of the third week, the animals were sacrificed. The biomechanical properties of the groups were compared with ultimate tensile strength and stiffness tests. The biological properties of the 2 groups were assessed with a histomorphometric comparison to determine the amount of collagen type I (COL1), proliferating cell nuclear antigen (PCNA), and transforming growth factor β1 (TGF-β1) expression in 3 different tissue subgroups (collagen matrix, tenocytes, and endotenon fibroblasts).

Results

Analysis of histomorphometric results revealed that the rats receiving dietary supplements demonstrated a significant increase in PCNA (mean value of 86 in the control group and 168.85 in the trial group; p < 0.05) and TGF-β1 (mean value of 87.57 in the control group and 161.85 in the trial group; p < 0.05) in the endotenon fibroblasts of the repair site. However, there was no difference between the groups in PCNA or TGF-β1 when the collagen matrix and the tenocytes of the repair site were examined. Furthermore, no significant difference could be found between groups in COL1 in any of the 3 tissue subgroups (collagen matrix, tenocytes, and endotenon fibroblasts). The statistical analysis also indicated that the rats receiving supplements did not demonstrate a significant increase in the ultimate tendon tensile strength or stiffness.

Conclusion

The results of this study revealed no advantage to the oral administration of the trial supplement in collagen synthesis or biomechanical properties in rats after 3 weeks using the presented study design. However, the increased expression of PCNA and TGFβ1 seen in the endotenon fibroblasts of the repair site might play a role in the continuum of tendon healing.

Journal of Foot and Ankle Research: the first ten years

Journal of Foot and Ankle Research (JFAR) was launched in July 2008 as the official research publication of the Society of Chiropodists and Podiatrists (UK) and the Australasian Podiatry Council, replacing both the British Journal of Podiatry and the Australasian Journal of Podiatric Medicine. This editorial celebrates the 10 year anniversary of the journal.

Prolotherapy Induces an Inflammatory Response in Human Tenocytes In Vitro

BACKGROUND

Proliferative therapy, or prolotherapy, is a controversial treatment method for many connective tissue injuries and disorders. It involves the injection of a proliferant, or irritant solution, into the site of injury, which causes small-scale cell death. This therapeutic trauma is theorized to initiate the body's wound-healing cascade, perhaps leading to tissue repair. The immediate effects of many of these proliferants are poorly characterized, as are the cellular responses to them; here, we sought to evaluate the immediate effects of two common proliferants (dextrose and P2G, a combination of phenol, glucose, and glycerin) on the cellular response of human tenocytes, and begin to explicate the mechanisms with which each proliferant functions.

QUESTIONS/PURPOSES

We asked: What are the effects of treating cultured tenocytes with proliferative treatment agents on their (1) cellular metabolic activity, (2) RNA expression, (3) protein secretion, and (4) cell migration?

METHODS

Using human hamstring and Achilles tendon cells, we attempted to answer our research questions. We used a colorimetric metabolic assay to assess the effect of dextrose and P2G proliferant treatment on cell mitochondrial activity compared with nontreated tenocytes. Next, using quantitative PCR, ELISA, and a reporter cell line, we assessed the expression of several key markers involved in tendon development and inflammation. In addition, we used a scratch wound-healing assay to evaluate the effect of proliferant treatment on tenocyte migration.

RESULTS

Results showed that exposure to both solutions led to decreased metabolic activity of tenocytes, with P2G having the more pronounced effect (75% ± 7% versus 95% ± 7% of untreated control cell metabolic levels) (ANOVA; p < 0.01; mean difference, 0.202; 95% CI, 0.052-0.35). Next, gene expression analysis confirmed that treatment led to the upregulation of key proinflammatory markers including interleukin-8 and cyclooxygenase-2 and downregulation of the matrix marker collagen type I. Furthermore, using a reporter cell line for transforming growth factor-β (TGF-β), a prominent antiinflammatory marker, we showed that treatments led to decreased TGF-β bioactivity. Analysis of soluble proteins using ELISA revealed elevated levels of soluble prostaglandin E2 (PGE2), a prominent inducer of inflammation. Finally, both solutions led to decreased cellular migration in the tenocytes.

CONCLUSIONS

Taken together, these results suggest that prolotherapy, more so with P2G, may work by decreasing cellular function and eliciting an inflammatory response in tenocytes. Additional studies are needed to confirm the cellular signaling mechanisms involved and the resulting immediate response in vivo.

CLINICAL RELEVANCE

If these preliminary in vitro findings can be confirmed in an in vivo model, they may provide clues for a possible cellular mechanism of a common alternative treatment method currently used for certain soft tissue injuries.

Outcomes of prolotherapy for intra-tendinous Achilles tears: a case series

BACKGROUND

The intra-tendinous tear is a new pathology that is defined as a discontinuity of fibres situated entirely within the tendon. Prolotherapy involves injecting an irritant, such as hyperosmolar dextrose, to stimulate a tissue healing response and ultimately reduce pain.

METHODS

43 consecutive patients diagnosed with an intra-tendinous tear were included (27 males: 16 females, mean (SD) age 41 (11.3). Patients were injected with 0.4ml-1.5ml (mean 0.8ml) of 50% dextrose and 0.5% marcaine mixed in a 1:1 ratio. A 4-6 week period of walking boot immobilisation was followed by progressive rehabilitation (6-8 weeks). Outcomes were assessed with a VISA-A questionnaire at baseline, 3 months and a mean 12.6 (7.0) months post-treatment. Ultrasound scans were conducted before treatment and 5.2 (2.3) weeks later to assess sonographic changes.

RESULTS

30 patients (70%) responded with VISA-A scores increasing by 31 (30.5) points after 3 months (f=0.62, p<0.05) and by 40 (29.3) points after 12.60 (7.0) months (f=0.87, p<0.05). After 5.2 (2.3) weeks, echogenicity was significantly reduced (p<0.05) and 27% of tears were no longer detectable. No significant differences were observed in remaining tears with respect to tear size, tendon thickness or neovascularisation.

CONCLUSION

Treatment resulted in clinically significant improvements and controlled trials are warranted.

LEVEL OF EVIDENCE

IV.

Effectiveness of prolotherapy in the treatment of chronic rotator cuff lesions

BACKGROUND

Rotator cuff lesions are one of the major causes of shoulder pain and dysfunction. Numerous non-surgical treatment modalities have been described for chronic rotator cuff lesions, but the debate continues over the optimal procedure. The aim of this report is to present the results of prolotherapy in the treatment of chronic refractory rotator cuff lesions.

HYPOTHESIS

Dextrose prolotherapy will reduce pain and improve shoulder function and patient satisfaction.

MATERIAL AND METHODS

We recruited 120 patients with chronic rotator cuff lesions and symptoms that persisted for longer than 6 months. Patients were divided into two groups: one treated with exercise (control group; n=60) and the other treated with prolotherapy injection (prolotherapy group; n=60). In the latter, ultrasound-guided prolotherapy injections were applied under aseptic conditions. In the former, patients received a physiotherapy protocol three sessions weekly for 12 weeks. Both groups were instructed to carry out a home exercise program. Clinical assessment of shoulder function was performed using a visual analog scale (VAS) for pain, Shoulder Pain and Disability Index (SPADI), Western Ontario Rotatory Cuff (WORC) Index, patient satisfaction, and shoulder range of motion. Patients were examined at baseline, weeks 3, 6, and 12, and last follow-up (minimum of one year).

RESULTS

A total of 101 patients (44 controls and 57 in the prolotherapy group) completed all study protocols and were included in the study. Using a within-group comparison, both groups achieved significant improvements over baseline, as measured by the VAS, SPADI, WORC index, and shoulder range of motion (P<0.001). Using a between-group comparison, a significant difference was found in the VAS scores at baseline, weeks 3, 6, and 12, and last follow-up. In addition, significant differences were found in the SPADIs and WORC indices at weeks 6 and 12 and the last follow-up. Significant differences were found in shoulder abduction and flexion at week 12 and last follow-up, and in internal rotation at last follow-up. However, no significant was found in external rotation at any follow-up period. In the prolotherapy group, 53 patients (92.9%) reported excellent or good outcomes; in the control group, 25 patients (56.8%) reported excellent or good outcomes.

CONCLUSION

Prolotherapy is an easily applicable and satisfying auxiliary method in the treatment of chronic rotatory cuff lesions.

STUDY TYPE

Randomized prospective comparative trial.

LEVEL OF EVIDENCE

Level of evidence 1.

A high-glucose diet affects Achilles tendon healing in rats

Chronic and acute tendinopathies are difficult to treat and tendon healing is generally a very slow and incomplete process and our general understanding of tendon biology and regeneration lags behind that of muscle or bone. Although still largely unexplored, several studies suggest a positive effect of nutritional interventions on tendon health and repair. With this study, we aim to reveal effects of a high-glucose diet on tendon neoformation in a non-diabetic rat model of Achilles tenotomy. After surgery animals received either a high-glucose diet or a control diet for 2 and 4 weeks, respectively. Compared to the control group, tendon repair tissue thickness and stiffness were increased in the high-glucose group after 2 weeks and gait pattern was altered after 1 and 2 weeks. Cell proliferation was up to 3-fold higher and the expression of the chondrogenic marker genes Sox9, Col2a1, Acan and Comp was significantly increased 2 and 4 weeks post-surgery. Further, a moderate increase in cartilage-like areas within the repair tissue was evident after 4 weeks of a high-glucose diet regimen. In summary, we propose that a high-glucose diet significantly affects tendon healing after injury in non-diabetic rats, potentially driving chondrogenic degeneration.

Technical Innovation Case Report: Ultrasound-Guided Prolotherapy Injection for Insertional Achilles Calcific Tendinosis

We describe the use of ultrasound guidance for hyperosmolar dextrose (prolotherapy) injection of the distal calcaneal tendon specifically just anterior to identified enthesophytes in patients with insertional Achilles calcific tendinosis refractory to conservative treatment. This specific technique has not to our knowledge been described or used in literature previously.

A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain

OBJECTIVE

The aim of this study was to systematically review dextrose (d-glucose) prolotherapy efficacy in the treatment of chronic musculoskeletal pain.

DATA SOURCES

Electronic databases PubMed, Healthline, OmniMedicalSearch, Medscape, and EMBASE were searched from 1990 to January 2016.

STUDY SELECTION

Prospectively designed studies that used dextrose as the sole active prolotherapy constituent were selected.

DATA EXTRACTION

Two independent reviewers rated studies for quality of evidence using the Physiotherapy Evidence Database assessment scale for randomized controlled trials (RCTs) and the Downs and Black evaluation tool for non-RCTs, for level of evidence using a modified Sackett scale, and for clinically relevant pain score difference using minimal clinically important change criteria. Study population, methods, and results data were extracted and tabulated.

DATA SYNTHESIS

Fourteen RCTs, 1 case–control study, and 18 case series studies met the inclusion criteria and were evaluated. Pain conditions were clustered into tendinopathies, osteoarthritis (OA), spinal/pelvic, and myofascial pain. The RCTs were high-quality Level 1 evidence (Physiotherapy Evidence Database ≥8) and found dextrose injection superior to controls in Osgood–Schlatter disease, lateral epicondylitis of the elbow, traumatic rotator cuff injury, knee OA, finger OA, and myofascial pain; in biomechanical but not subjective measures in temporal mandibular joint; and comparable in a short-term RCT but superior in a long-term RCT in low back pain. Many observational studies were of high quality and reported consistent positive evidence in multiple studies of tendinopathies, knee OA, sacroiliac pain, and iliac crest pain that received RCT confirmation in separate studies. Eighteen studies combined patient self-rating (subjective) with psychometric, imaging, and/or biomechanical (objective) outcome measurement and found both positive subjective and objective outcomes in 16 studies and positive objective but not subjective outcomes in two studies. All 15 studies solely using subjective or psychometric measures reported positive findings.

CONCLUSION

Use of dextrose prolotherapy is supported for treatment of tendinopathies, knee and finger joint OA, and spinal/pelvic pain due to ligament dysfunction. Efficacy in acute pain, as first-line therapy, and in myofascial pain cannot be determined from the literature.

Erratum to: Effectiveness and safety of prolotherapy injections for management of lower limb tendinopathy and fasciopathy: a systematic review

[This corrects the article DOI: 10.1186/s13047-015-0114-5.].