When thinking through the root cause of chronic pain and sports injury, Prolotherapy should make sense as the first line treatment in many of these injuries. Unfortunately standard treatments for chronic pain injuries ignore the root cause, going after the symptoms and potentially causing more injury and pain. Labral tears are one of these injuries. An article published in Current Reviews in Musculoskeletal Medicine conducted a comprehensive review of hip labral tears that pointed out some crucial facts about these tears1. In short, the hip surgeries that remove or debride the hip labrum are taking away from the vital function of the labrum.
Hip labral repair
Most structures of the body have significant function and purpose. Removing a natural structure of the body is almost never a good thing. Take the hip labrum. Its function is shock absorption, joint lubrication, pressure distribution and hip stability. It resists the movement of the femoral head in the acetabulum. It also acts as seal to maintain the synovial fluid, thereby lowering the stresses and strains in the hip joint.
Hip labral tear
When looking at the function of the hip labrum it is clear that a tear is more than significant. Damage to the labrum, typically caused by trauma, hypermobility or degeneration, is linked to osteoarthritis (OA). It is known that the anterior and superior aspects of the labrum contain free nerve endings and sensory nerve organs; meaning damage produces pain, pressure and deep sensation.
Treatments for hip labral tears
With the advance of medical technology, hip labral tears are diagnosed more often than in the past. While conservative treatments such as rest, nonsteroidal anti-inflammatory medications, and physical therapy are done, surgery is almost always performed. Removal of the labrum used to be the surgical treatment of choice, but with the knowledge of how important the labrum is, surgical treatment now involves arthroscopy to remove the unstable flap that causes the hip pain or discomfort. In some cases, repairs are made with cadaver grafts. These also can prove unsuccessful and lead to complications and pain after surgery.
Problems with surgery for hip labral tear
The study mentioned above points out the problem with completely removing the labrum but also points to problems with tears:
“Without the labrum, the articular cartilage must withstand significantly increased pressure, and a compromise of this system could lead to early joint deterioration. A study testing a labrum-free model of the hip showed that, without the labrum, contact stress may increase by as much as 92%. A tear in the labrum would also likely destabilize the hip joint. This explains why there is an association between acetabular labral tears and early onset OA.”1
Prolotherapy for hip labral tears
Unfortunately removing any part of the labrum will lead to further degeneration and most likely OA. Since the labrum is vital to hip joint function, both doctors and patients should desire to preserve the hip labrum. While standard treatments prove unsuccessful, Comprehensive Prolotherapy is an excellent alternative to surgery for hip labral tears. Specifically, Platelet Rich Plasma Prolotherapy (PRP) can be greatly beneficial in delivering growth factors to the damaged labrum.
Prolotherapy works very well for labrum (hip and shoulder) and menisci degeneration and tears and even more so when Platelet Rich Plasma Therapy (PRP) is added. So what is PRP and how does it work?
What is PRP?
Platelets play a central role in blood clotting and wound healing. Tissue repair begins with clot formation and platelet degranulation, which release the growth factors necessary for wound repair. Platelet-derived growth factors are biologically active substances that enhance tissue repair mechanisms.
After platelets are activated at a wound site, proteins are released that directly and indirectly influence virtually all aspects of the wound healing cascade. Studies have shown a direct correlation between the platelet concentration and the level of secretory proteins, as well as the amount of proliferation involved in the wound healing.
In basic terms, PRP involves the application of concentrated platelets, which release a supra-maximal quantity of growth factors which stimulate recovery in non-healing injuries. PRP causes a mass influx of growth factors, such as platelet-derived growth factor, transforming growth factor and others, which exert their effects of fibroblasts causing proliferation and thereby accelerating the regeneration of injured tissues. Specifically PRP enhances the fibroblastic events involved in tissue healing including chemotaxis, proliferation of cells, proteosynthesis, reparation, extracellular matrix deposition, and the remodeling of tissues. Bottom line here is that tissues can heal faster with PRP!
Platelet rich plasma for labral tear and meniscal injury
The preparation of therapeutic doses of growth factors consists of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.) In other words, PRP is done just like any other Prolotherapy treatment, except the solution used for injection is plasma enriched with growth factors from your own blood. Typically patients are seen every 4-6 weeks like other Prolotherapy patient. Typically two to six visits are necessary per area.
Where is PRP used?
In the scientific literature are reports of soft tissue injuries treated with PRP including tendinopathy, tendonitis, acute and chronic muscle strain, muscle fibrosis, ligamentous sprains and joint capsular laxity. PRP has also been utilized to treat intra-articular injuries. Examples include arthritis, arthrofibrosis, articular cartilage defects, meniscal injury, and chronic synovitis or joint inflammation.
PRP has been used successfully to enhance surgical outcomes in maxillofacial, cosmetic, spine, orthopedic, and podiatric surgery. In regard to its use today, you will see that the majority of doctors using it apply it onto their current knowledge-base of Prolotherapy. In other words, the doctors doing PRP are using it as a proliferant, much like they use other solutions in Prolotherapy. In simple terms, PRP is a type of Prolotherapy!
Is there research on Platelet Rich Plasma Therapy? The answer to this question depends on what condition you are talking about and who you ask. In regard to lateral epicondylosis, according to one author, “There is strong pilot-level evidence supporting the use of Prolotherapy, polidocanol, autologous white blood and platelet rich plasma injections in the treatment of lateral epicondylosis.” If you ask Dr. Hauser, “Absolutely Prolotherapy with or without PRP works great for lateral epicondylosis (Tennis Elbow/lateral elbow pain)! This is just one example. In my experience, PRP works great for tendinosis, menisci or labrum degeneration or tears, and ligament injuries not healing with other Prolotherapy solutions.
Why PRP makes sense? Ligament injury like tendon pathology often involves tissues with poor blood supplies. Tendon pathology has many manifestations, for instance from spontaneous rupture to chronic tendinitis or tendinosis (degenerated tendon); the etiology and pathology of each are very different and poorly understood. Tendon is a comparatively poorly vascularized tissue that relies heavily upon synovial fluid diffusion to provide nutrition. During tendon injury, as with damage to any tissue, there is a requirement for cell infiltration from the blood system to provide the necessary reparative factors for tissue healing. Obviously if a tissue has a poor blood supply (like tendons and ligaments) then the reparative factors necessary for healing are likely not going to get to the injured area or not mount a sufficient response to fully repair the tissue. Thus, you see the need for Prolotherapy – with or without PRP! One of the growth factors in PRP is vascular growth factor which helps with new blood vessel formation. It could be this growth factor and others that causes the remarkable healing with PRP.
What about using PRP in osteoarthrtic joints? If you look at the various studies on PRP, a theoretical basis for using PRP to effect joint pathology exists at this time. Study authors conclude, “Intra-articular administration of PRGF (platelet rich growth factor) might be beneficial restoring hyaluronic acid concentrations and switching angiogenesis to a more balanced status, but does not halt the effects of IL-1 beta on synovial cells.”
What does this mean? Bottom line in this study – PRGF significantly enhanced hyaluronic acid secretion compared with platelet-poor preparations. When you see hyaluronic acid, you have to think joint fluid. If you think more joint fluid, think of the joint being lubricated. What would happen to a joint that was not lubricated if it were to become more lubricated? You got it, less stiffness, more motion, and ,of course, less pain! This is what we have found with Prolotherapy and with Prolotherapy and PRP.
What is really great about PRP? Ultrasound studies before and after PRP are showing that the tissue is healing! This is something we knew all along with Prolotherapy, but we just had a hard time proving it! Now that ultrasounds are showing degenerated tendons being regenerated with Prolotherapy PRP, the critics are being answered. Yes, it is true that Prolotherapy stimulates the body to repair painful areas. This can be done by injecting simple solutions such as dextrose in the area, to more complicated solutions using the use of Glucosamine sulfate, manganese, natural hormones, to a person’s own growth factors through the use of PRP.
So what are you to do? If you have pain or know of someone in pain that you care about, then let them know that there is a potential cure for chronic pain and that cure is Prolotherapy!
1. Groh MM, Herrara J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009 June; 2(2): 105–117.
Pietrzak WS, Eppley BL. Platelet rich plasma: biology and new technology. Journal of Craniofacial Surgery. 2005; 16:1043-1054
Crane D, Everts P. Platelet Rich Plasma Matrix Grafts. Practical Pain Management. 2008; Jan/Feb: 12-26.
Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Current Reviews in Musculoskeletal Medicine. 2008; 3:165-174.
Rabago D, Best TM, Zgierska A, et al. A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet rich plasma. British Journal of Sports Medicine. 2009; 43:
Sanchez A, Nurden AT, Zalduendo MM, et al. Platelet-released growth factors enhance the secretion of hyaluronic acid and induce hepatocyte growth factor production by synovial fibroblasts from arthritic patients. Rheumatology. 2007;46:1769-1772.