Prolotherapy for Ischial Tuberosity Pain

Ross Hauser, MDRoss Hauser, MD

When a patient complains of pain on the bottom of the buttock, especially when sitting and running, this could be indicative of ischial tuberosity pain. When a doctor examines this area, sometimes, they will find it to be tender to palpation, and give you a diagnosis of ischial bursitis. The treatment of Rest, Ice, Compression, and Elevation will be suggested and sometimes an anti-inflammatory drug is prescribed. Cortisone injections may follow. A true bursitis is rare.

Prolotherapy for Ischial Tuberosity Pain

Before a patient receives a buttock Steroid injection a consultation with a Prolotherapy doctor should be considered. Prolotherapy doctors know that the hamstring muscles and sacrotuberus ligaments attach to the ischial tuberosity, and all that Prolotherapy to the area can resolve the buttock pain.

Acute, moderate, or severe hamstring strains are common injuries among runners. Hamstring injuries occur frequently despite the prevalence of stretching programs. Is it possible that these stretching programs are predisposing athletes to these injuries? Repetitive hamstring strains can occur because of some weakness at the origin of the hamstring muscle onto the ischial tuberosity. If the athlete has pain at the attachment site and in the belly of the muscle, Prolotherapy is given. This will strengthen the hamstring attachment onto the ischial tuberosity and resolve the pain.

The sacrotuberus ligaments go from the sacrum to the ischial tuberosity and, generally, both attachment sites are tender. This is an often-overlooked cause of buttock pain. Prolotherapy to both attachments can resolve the buttock pain and often the lower back pain that is associated with it.

Degenerated Hip

Ross Hauser, MDRoss Hauser, MD

Prolotherapy: Only 10% the cost of a traditional steroid shot under X-ray guidance and gives more immediate and long-term relief! 

First let me start by saying, most people who know me and have read some of the articles I have written know that I am not a big fan of giving injections under X-ray.

Here are a few of my objections to performing injections under X-ray:

1. No study anywhere in the world that I know of reports that injections under X-ray actually give better results compared to injections given without X-ray guidance.

2. Insurance companies pay billions of dollars for these injections under X-ray, yet no documentation exists showing improvement in patient care.

3. Steroids are the typical solutions physicians use for these injections under X-ray (called fluoroscopic guidance), yet steroids have been shown to cause cartilage deterioration.

4. Prolotherapy injections under X-ray guidance cost 10 times the amount as normal Prolotherapy injections.

5. Only one injection is typically given when performed under fluoroscopic guidance, so what is the likelihood that the injection is going to give long-term pain relief? I would say the answer to that is “very low.”

If you don’t agree with the above, let’s look at one example from a patient who was just here at the office last week:

Mark came into the clinic with a two year history of bilateral hip pain, right hip worse than the left. The pain started two years ago during a run. Mark typically ran 28-30 miles per week, but had not run for about two years, since the hip pain started. As a 51-year-old, he was getting pretty discouraged because he had tried physiotherapy, chiropractic care, electrical stimulation, laser treatments, and all the recommendations given to him pointed him toward bilateral hip replacement. The last treatment he tried was a fluoroscopically guided steroid injection into his severely degenerated hip. The net result was almost no pain relief and an expense of $2700.

I hope to provide you with documentation of what I am saying so you will know beyond a shadow of a doubt that what I am saying is true. These are real patients with real stories. I know most of you believe me, but for the skeptics, you will see more real arthroscopy reports, X-ray reports, and invoices from other providers.

Back to Mark. He received a steroid injection under X-ray guidance at some would say is one of the best medical centers for sports medicine care. In other words, Mark received the best of traditional medical care and I am saying it was ridiculous, ludicrous, and consciously unethical to perform an almost $3000 steroid shot on a person with bone on bone osteoarthritis.

This steroid shot was absolutely not indicated and should not have been performed. Another interesting part of his medical chart was the Pain Diary that he completed post-steroid injection.

He reported a 7/10 pain level prior to the injection.

 In the hours post-procedure, this is what happened:

1 hour = 0/10;
2 hours= 2/10;
3 hours=4/10;
4 hours=4/10;
5 hours=7/10;
6 hours=8/10.
You can interpret that for yourself!

Please see his X-ray report below:
Examination: Xray Hip (RIGHT)
Perf: 3/19/2009 10:35:00 AM

Indication: Right hip pain
Impression: Moderate changes of osteoarthritis, with joint space narrowing, subchondral sclerosis, subchondral cysts and marginal osteophytes are noted in the right and left hip, right greater than left. Otherwise, no abnormalities are identified. There is evidence of fracture dislocation.

From the above report, Mark basically has extensive osteoarthritis, with the right hip worse than the left hip. On my physical examination with his hip flexed 90 degrees, he only had 17 degrees of external rotation on his left hip and even less on his right (less than 10 degrees). In other words, this is extremely bad osteoarthritis. The only treatment that can keep someone from a hip replacement is Prolotherapy. But I first want you to hear some more about the treatment that Mark had received prior to coming in to see me.

Mark brought some of his medical records with accompanying billing for me to review at his initial consultation. You can clearly see the following charges: initial consultation and the initial steroid shot: $2689.00 of which he had to pay $2019.60 out of pocket.

In my opinion, this was a total waste of money, not to mention a treatment that would worsen his condition. I believe that the science of steroids on cartilage is that steroids degenerate it, while Prolotherapy regenerates it. 

At Caring Medical, Mark received a Prolotherapy treatment to his right hip and the procedure went well. We received this email from Mark in response to our post-Prolotherapy follow-up call:

Hello Dr. Hauser,
Just a few lines regarding the 1st treatment. You and your staff are a pleasure to interact with. The injections were not without pain, however, after a few hours the injection pains subsided and to my pleasant surprise, my hip pain also was reduced. The mobility of the hip was noticeably improved and I am looking forward to my next treatment. Thank you. M.K.

You might be thinking, “How could the mobility in his hip be better one day after Prolotherapy?” The answer: it provided pain relief! With less pain, you obviously are able to more freely move your joints! What will be Mark’s ultimate outcome? While I cannot predict the future, there is a good chance he will get out of pain. Whether he will run again is yet to be determined, but I am sure he will be an avid cyclist!

The bottom line here is that Prolotherapy has a chance to get him better – I would give it a 90% chance. Steroids have a 0% chance to get him better. In the end, Prolotherapy costs a fraction of what a steroid shot costs. In my mind, there is no competition. Prolotherapy for degenerative arthritis is the most effective and least costly treatment option available!

Women, Back Pain, and Hormones

Ross Hauser, MDRoss Hauser, MD

During pregnancy, a woman’s body secretes a hormone called relaxin which causes ligaments to loosen in preperation for birth. Ligament laxity is normal during pregnancy. Relaxin’s effects include the production and remodeling of collagen, increasing the elasticity and relaxation of muscles, tendons, and ligaments. The point is that relaxin has a direct negative effect on the strength of collagen. Relaxin is secreted by all females, the highest levels being during the middle of the luteal phase (ovulation) of the menstrual cycle (days 20-23).

Because of the double whammy of estrogen and relaxin, women have increased ligamentous laxity and flexibility compared to men. This excessive laxity is the reason that there is an increased incidence of patellar subluxations and ligament sprains seen in female athletes. (Glick, J. The female knee in athletics. Physician and Sports Medicine. 1973; 1:35-37.;Powers, J. Characteristic features of injuries in the knees of women. Clin. Orthop. Rel. Res. 979; 143:120-124.) This laxity is especially present during pregnancy when the risk of ankle sprains and ligamentous injuries is highest. (Lutter, J.M., Lee, V. Exercise in pregnancy. In Pearl AJ, (ed.), The Female Athlete in Human Kinetics. Champaign, IL: 1993; p. 81-86.) If this was not bad enough, articular cartilage (see also Articular Cartilage Growth) has estrogen receptors located on it. Like ligamentous tissue, estrogen has a direct negative effect on cartilage growth and repair. (Rosner, I. Estradiol receptors in articular cartilage. Biochem. Biophys. Res. Commun. 1982; 106:1378-1382.)

The net effect of all of this is that the joints of females, even females who have no pain whatsoever, are not normal. They cannot possibly be normal because of all the negative effects of estrogen as the prime instigator and relaxin as a lessor instigator. The turnover time (or half-life) of ligaments and cartilage is about one to two years. This means that about half of the cartilage or ligaments is regenerated about every 300 to 700 days. This is a very, very slow rate. Fibroblastic cells, which make collagen, and chondrocytes that make cartilage tissue, are stable cells in the fact that they do not proliferate easily. They need to be stimulated to proliferate. Injury to tissue stimulates them to some degree, but exercise does not noticeably change this rate. The primary way to stimulate the fibroblasts and chondrocytes (see research paper) is by direct proliferative therapy (Prolotherapy). Prolotherapy injections are given right where the fibroblasts and chondrocytes are located-at the fibro-osseous junction. This is where ligaments attach to bone or directly on the outside of the cartilage. This causes a massive stimulation of fibroblastic and chondrocyte growth, with the net effect being ligament and cartilage growth. It is this treatment that offers the only hope to women to not only get rid of their chronic pain, but also cure their sports injuries.

Jan Brynhildsen and colleagues from the Department of Obstetrics and Gynecology, Faculty of Health Sciences, University Hospital, Linkoping, Sweden, sent questionnaires to 1,324 women who were in menopause. This questionnaire included questions about current hormone replacement treatment, previous and current back pain, medical care for back problems, parity, exercise and smoking habits, and occupation. The questionnaire was returned by 85 percent of the women. There was a significant positive association between current use of hormone replacement treatment and low back pain. Previous back problems during pregnancy was a strong risk factor for current back pain, whereas neither current smoking nor regular physical exercise was a risk factor (nor was exercise protective). Their conclusion was that women receiving hormone replacement treatment had a significantly higher prevalence of current back pain than non-users, which could not be explained by differences in occupation, smoking habits, or current physical activity. (Brynhildsen, J. Is hormone replacement therapy a risk factor for low back pain among postmenopausal women? Spine. 1998; 23:809-813.) They speculated that hormonal effects on joints and ligaments may be involved.

Others have also speculated that oral contraceptive pills are a risk factor for low back and pelvic pain among women. The theory proposes that estrogen steroid hormones affect joints and ligaments, leading to pubic symphysis weakening and low back pain. In our opinion, this is not theory, but fact. Estrogen negatively affects collagen growth with only one result emerging, and that result is not good. Many general practitioners, gynecologists, orthopedic, midwives, and physiotherapists (at least in Sweden) believe there is an association between the use of these estrogen pills and the development of back problems. Approximately one-fourth of the active professionals in Sweden recommend that some women with back problems abandon their use of oral contraceptives. (Brynhildsen, J. Oral contraceptives and low back pain: Attitudes among physicians, midwives and physiotherapists. Acta. Obste. Gynecol. Scan. 1995; 74:714-717.) Many believe the oral contraceptives increase the risk of back problems, just like what occurs during pregnancy. As many as 50 percent of all women experience back problems during pregnancy. Because back problems develop so early during pregnancy, they cannot be explained as related only to the increased mechanical stress from the weight gained in the front of the body; therefore, hormonal factors have been proposed as the cause. Sex hormones are thought to affect ligaments and increase flexibility in the pelvis. This increased flexibility, or laxity, then leads to the low back pain.

Prolotherapy: A Literature Review and Retrospective Study

Robert G. Schwartz, M.D. and Noreen Sagedy, M.D. Prolotherapy: A Literature Review and Retrospective Study. The Journal of Neurological and Orthopadic Medicine and Surgery, Vol. 12. No. 3. 1991

Abstract

Proliferative therapy (Prolotherapy) is the process whereby dextrose, P25G or sodium morrhuate is injected into ligaments in order to produce a proliferating response of that ligament. The purpose of these injections is to strengthen ligamentous structures and relieve pain. A review of the literature is provided and a retrospective study presented which demonstrates a 66% redction of sacroiliac low back pain in two-thirds of the patients who received this form of treatment.

Key Words: Prolotherapy, Sclerotherapy, Low Back Pain, Sacroiliac pain.

Ligaments consist of many strands of fibrous tissue which may run parallel or crisscross at various angles to each other. They provide stabilization of joints in all positions. Pain occurs when normal tension on a ligament stretches the fibers. This results in stimulation of the sensory fibers which do not stretch along with the ligament1. In sprain or tearing, the fibers become separated from bone, and tthere is an accumulation of lymphy or blood at the site of injury. Healing occurs through initiation of the wound response cascade mediated by chemotactic agents and inflammatory cells. Fibrin is produced and develops into a permanent strong fibrous tissue attached to bone.

There is also a production of bone at the enthesis.1 The healing process can be interfered with. Subsequent activity can cause separation, or the repair capacity in the individual can be deficient. This results in ligament relaxation which is a weakness of the attachment. If this remains, predisposition to repeat injury, chronic pain, and altered range of motion can persist.1, 2

The healing process can be stimulated by the infiltration of a proliferative solution within the ligament. Thus, the development of firm permanent fibrous tissue with reduction of pain can take place.1-8

Literature Review

The rich supply of nerve endings in articular ligaments was first described by Lerich in 1930 and later by Gardner in 1953. Hackett described most joint pain as ligament pain. He was the first to scientifically demonstrate a method of strengthening ligaments by the injection of a proliferative solution. Inflammation was produced and a permanent increase in ligament size by 35-40% resulted.

Hackett claimed a cure rate of 82% in 1600 patients with low back pain.1 At this time, proliferative therapy was know as sclerotherapy. This was because the irritants used in Prolotherapy were thught to work by creation of scar tissue rather than by the development of proliferative response. Tome of the irritants used in prolotherapy had been used to sclerose varicose veins as well.5

A 1982 study by Li et al. quantified biochemically in a double-blind study the influence of injecting a proliferative solution (100ml of 5% sodium morrhuate) into rabbit medical collateral ligaments in situ. Results revealed a highly signigicant increase of the ligament’s mass, thickness, enthesis strength, and its weight/length ratio in comparison with the saline injected controls.9

A 1985 study, also using 5% sodium morrhuate, was conducted by Maynard et al. They did a series of five 100ml injections into intact rabbit patellar tendons and Achilles tendon. This study showed that not only is there an increase in the number of cells but also a wider variety of cell types, including fibroblast, neutrophils, lymphocytes, plasma cells, and unidentifiable cells in the injected tissues. An increase in water content and amino sugar content were also noted. Interestingly, a decrease in the mean collagen fibril diameter and hydroxyproline content were documented despite an overall increase in fibrin mass.10

In 1987, a double-blind study was done by Ongley et al. comparing 40 patients who received spinal manipulation and ligament strengthening proliferative therapy with 41 patients who received minor manipulations and 0.9% saline injections. One injection per week was done for 6 weeks. The solution used was 2.5%phenal/25% dextrose/25% glycerin/47.5% pyrogen free water (P25G).

At 6 months following the end of the Prolotherapy treatments, 35 patients in the experimental group reported greater than 50% improvement compared with only 16 in the control group. Furthermore, 15 patients in the experimental group were disability-free compared with 4 patients of the control group reporting no disability.3

In a different study by R.G. Klein in 1989 histologic documentation of ligament proliferation in human subjects in response to proliferative injections was demonstrated. Biopsy specimens of posterior sacroiliac ligaments were performed pre- and posttreatment in three patients with low back pain. Each patient received a series of six weekly injections using the P25G solution into the sacroiliac ligaments. The proliferative injections resulted in collagen of objectively increased diameter and was associated with decreased pain along with an objective increase in range of motion.4

Biochemical Basis

The healing of a wound has been divided into three phases: 1.inflammatory (early and late), 2. granulation tissue formation, and 3. matrix formation and remodeling.11 Inflammation is the reaction of living tissues to all forms of injury. It involves vascular, neurologic, humoral, and cellular responses at the site of injury. Increased vascular permeability is the first mechanism. It allows the escape of plasma proteins and white cells. This is known as exudation. Neutrophils appear in perivascular spaces and they are followed by monocytes/macrophages.11

The most important chemotactic factors for both neutrophils and macrophages include C5a, a compnent of the complement system, leukotriene B4, a product of arachidonic acid metabolism, and bacterial products. Macrophages are also attracted by the basic peptides in the lysosomal granules of neutrophils and this explains why they appear as the second line of defense. These cells then destroy or neutralize the injurious agent by phagocytosis allowing for the repair of the damaged site to then occur.12

Repair is the process by which lost or destroyed cells are replaced by new, living cells. The tissue defect is initially filled up with highly vascularized connective tissue called granulation tissue. It consists of newly formed small blood cells embedded in loose ground substance containing fibroblasts and inflammatory cells. Fibroblasts migrate into the wound bed under the influence of chemotactic factor.11, 12

As granulation tissue matures, inflammatory cells decrease in number, fibroblasts lay down collagen, and the capillaries become less prominent. An avascular, relatively acellular tissue with inactive spindle-shaped fbroblasts tucked in between collagen fibers emerges. The collagen fibers then aggregate into mature fibrils. The acquisition of tensile strength follows a sigmoid curve.12 The orderly movement and proliferation of cells within a healing wound is influenced by both cell signals and extracellular matrix (e.g., fibronectin and growth-stimulating factors). Thus, a wound-healing cascade is present. The growth associated with repair is regulated and ceases when healing is completed.12

Proliferants are substances which cause a localized tissue reaction leading to an inflammatory response. The wound – healing cascade is thus triggered resulting in fibroplasia and collagen deposition. The healing cascade begins with granulocyte infiltration followed by monocyte/macrophage invasion. Growth factors are released and thus activated fibroblasts are recruited to the site to secrete new matrix. This new matrix includes collagen fibrils.2, 6, 7, 13

Any factor which leads to fibroplasia can be a proliferative. There are three categories of proliferants that have been used: irritants, osmotic shock agents, and chemotactic agents Irritants (e.g., phenol, quaicol, tannic acid, and quinine) create a local tissue reaction which causes granulocyte infiltration. Osmotic shock agents (e.g., glucose, glycerin, ZnSO4) creat a local tissue reaction to stimulate a granulocyte infiltration by dehydration. Dhemotactic agents (e.g., sodium morrhuate) cause direct activation of local inflammatory cells.13

In some instances the injected factor is altered in vivo. Phenol oxidizes to reactive quinine and sodium morrhuate as an arachidonic acid compound is a precursor to many cytokines, including leukotrienes, thromboxanes, and prostaglandins.13 Growth factors are a fourth category currently being researched at Biogenteic Laboratories (e.g., EFG, PDGF, IFG-I, FGF, TGF-beta). They directly recruit and activate local fibroblasts.13

Materials And Methods

The effects of prolotherapy on 43 patients with chronic sacroiliac strain were retrospectively reviewed. There were no sciatic tension signs, motor weakness, sensory deficits, or patients with bone abnormalities entered into the study. The patients had all failed to respond to other forms of treatment including surgery. Ages ranged from 20 to 70 years.

Treatment consisted of three injections into the insertion of the posterior sacroiliac ligament, beginning at its most caudal one-third and moving superiorly by one-third of its length with each injection (figure 1.) The injections were done 2 weeks apart. The proliferant used was a mixture of 1 cc of 5% sodium morrhuate and 1 cc of 1% Xylocaine. A needle of proper length was used that assured the proliferant was placed on bone. The solution was distributed throughout the fibro-osseous junction.

Each patient was informed that there would be a 2- to 3- day period of discomfort in the area of the injection due to the initiation of the wound-healing cascade. Instructions were given to avoid aspirin, ibuprofen, or other prostaglandin inhibitors, and to use only acetaminophen to relieve pain. Activity was encouraged. The patients were instructed in sacroiliac mobilization exercises and fitted with a sacroiliac belt.

Each patient was seen on 2-week follow-up after the third injection. Subjective percentages of relief were recorded. If satisfactory pain relief had been obtained, they were discharged from treatment and instructed to return on an as-needed basis.

Results

At the conclusion of the three injection series, on 2-week follow-up, 20/43 patients reported 95% improvement, 31/43 75% or better improvement, and 35/43 reported 66% or better improvement. Thus, 2/3 of the patients received 66% relief. No improvement was reported by 3/43. While no formal mechanism for prolonged follow-up was in place 10/40 or 25% reported some level of recurrence (Table 1).

No. of Patients
(43 total)
0%
Relief
33%
Relief
50%
Relief
66%
Relief
75%
Relief
99%
Relief
Reported Relief 3 1 4 4 11 20
Recurrence
(10 total)
1 1 2 2 4

Table 1. Relief obtained in 43 patients after a series of prolotherapy injections (three injections, once every other week).

Discussion

The sacroiliac joint can be considered to be unstable when the ligaments are relaxed. Because of this joint’s weight-bearing spinal mechancis the ligaments supporting it frequently become damaged. This can lead to intense pain, which may become chronic. It can result in abnormal compensatory movement as well. The altered spinal kinesiology can lead to further injury of other structures such as lumbar vertbrae, sacrum, and intervertebral disks.

Prolotherapy is designed to strengthen the sacroiliac ligaments so as to develop normal tension in them. Numbing of the ligament with Xylocaine and obtaining immediate relief provides for temporary comfort from the injection. The ensuing painful reaction that occurs from the proliferative injection represents the activity of the initiated wound-healing response. Prostaglandin inhibiting medications should be avoided.

It important to choose the proliferative solution wisely and to make sure the needle is on bone when injecting. Three cases of paralysis and two deaths have been documented after inadvertant injection of psyllium seed oit and zinc sulfate into the subarachnoid space.14-16

Other investigators have used a phenol/dextrose/glycerin solution (P25G) and obtained significant results without complications. While the percentage of phenol in P25G is very dilute and probable safe, many clinicians prefer to use either dextrose or sodium morrhuate, as both of these agents have also been used intravenously for other medical conditions.8, 17

Prolotherapy has been utilized at other ligamentous structures in addition to the sacoiliac area. Intraspinous, ileolumbar, fibulocalcaneal, medial and lateral collateral (about the knee), radiohumeral, coracoclavicular, and sternoclavicular ligaments are frequent ligamentous injection sites. Intraarticular ligamentous injections have also been performed.2, 7, 8

Although this study is a retrospective one, the data support the studies of Lui, Maynard, Ongley, and Klein. While we have not done biopsy studies to prove a proliferative effect occurred, we did obtain significant pain relief without any undue side effects.2, 3, 9, 10

Figure 1. Needle Location used for injection of the sacroiiac ligaments.
Trigger point of ligaments: (IL) Iliolumbar: (LS) Lumbosacral-supra and interspinus: (A,B,C,D,) Posterior sacroiliac; (SS) Sacroapinus; (ST) Sacrotuberus;(SC) Sacrococcygeal;(H) Hip-Articular; (SN) Sciatic nerve (With permission from G.S. Hackett, Ligament and Tendon Relaxation. Charles C. Thomas Co., 1958)

Conclusion

We conclude from this study and the aforementioned literature that it is possible to induce proliferation of collagen in human ligaments using prolotherapy. The tissue that proliferates is a dense collagen and is associated with a reduction in pain. Mechanical back pain can be relieved by this method and other compensatory injuries prevented.

References

  1. Hackett GS. Ligament and tendon relaxation treated by prolotherapy, 3rd ed. Springfield, Ill: Charles C. Thomas, 1958
  2. Cyriax J. Textbook of orthopaedic medicine. Philadelphia: Bailliere Tindall, 1982.
  3. Onlgey MJ, Klein RG, Dorman TA, Eek BC, Hubert LJ. A New Approach to the Treatment of Chronic Low Back Pain. Lancet. 1989; 11:143-146.
  4. Klein RG, Dorman TA Johnson CE. Proliferant injections for low back pain: histological changes of injected ligaments and objective measurements of lumbar spine mobility before and after reatment. J Neurol Orthop Med Surg. 1989; 10:123-126.
  5. Injection therapy helps low back pain, study reveals. Back Pain Monitor. 1988; 6:12:161-172.
  6. Gearhardt JJ. Interdisciplnary rehabilitation in trauma. Baltimore, Md: Williams and Wilkins, 1987.
  7. Mirman MJ. Sclerotherapy. Springfield, PA, 1986.
  8. Leedy RF. Basic techniques of sclerotherapy. Osteop Med. 1987;9.
  9. Liu YK, Tipton CM, Matthes RD, An in situ study of the influence of a sclerosing solution in rabbit medial collateral ligaments and its junction strength. Connect Tissue Res. 1983; 11:95-102.
  10. Maynard JA, Pedrini VA, Pedrini-Mille A, Romanus B, Ohlerking F. Morphological and biochemical effects of sodium morrhuate on tendons. J Orthop Res. 1985;3:236-248.
  11. Wyngarden JB. Cecil textbook of medicine. Philadelphia;W.B. Saunders, 1988.
  12. Robbins SL, Kumar V. Basic pathology, 4th ed. Philadelphia: W.B. Saunders, 1987.
  13. Banks A. Biochemical effects of prolotherapy. First Annual High Country Prolotherapy Workshop, Denver, Co., 1989.
  14. Hunt WE, Baird WC. Complications following injections of sclerosing agent to precipate fibro-osseouis proliferation. J Neurosurg. 1961; 18:461-65.
  15. Keplinger JE, Bucy PC. Paraplegia from treatment with sclerosing agents-report a case. JAMA. 1960: 73:1333-36.
  16. Schneider RC, Williams JI, Liss L. Fatality after injection of sclerosing agent to precipitate fibro-osseous proliferation. JAMA. 1960; 170:1768-1772.
  17. Lawson AW. Acute esophageal variceal sclerotherapy. JAMA. 1986; 255:497-500.

About the author:  Dr. Schwartz is a Prolotherapy doctor in Greenville, South Carolina:  Contact him

Low Back Pain and Sacroiliac (SI) Pain

Ross Hauser, MDRoss Hauser, MD

Prolotherapy treatments consist of injections that stimulates the repair of connective tissues such as tendons and ligaments by causing a mild inflammatory response which initiates an immune response. This mimics what the body does naturally to heal soft tissue injuries.

Prolotherapy is effective in SI pain because we have found it fairly rare for sacroiliac pain to be caused by a pinched nerve or by a slipped or herniated disc. Much more common is a ligament injury which caused ligament laxity or ‘looseness.”

Research published in the medial journal Spine, (A. Schwarzer, 1995) states “ligament laxity in the sacroiliac joint is the number one reason for ‘sciatica’, or pain radiating down the side of the leg, and is one of the most common reasons for chronic low back pain.”

Our clinical experience has been that if we treat back pain with Prolotherapy, administering injections into the  lumbar and SI ligament attachments that exhibit tenderness, the pain and referred pain diminishes, even when MRI’s showed disc abnormalities. The injections are not given near the discs yet the back pain is completely healed.

Ligaments and the SI Joint

Ligaments connect bones to each other, like the vertebrae to each other and the sacrum to the pelvis. The sacrum is the part of the spine below the fifth and last lumbar vertebrae and above the coccyx. The uppermost portion of our pelvis is called the ilium. The area that connects these structures is called the sacroiliac joint (SI): sacro from the sacrum, iliac from the ilium. There is an expansive mesh of ligaments that make up this sacroiliac joint which is frequently injured. A problem here can affect the groin, pubis, hips and lower lumbar areas as well.

A Success Story: From one of the Caring Medical staff – Joe the male nurse

One of my own injuries that was successfully treated with Prolotherapy perfectly illustrates the point made in the above paragraph. I have been one of Dr. Hauser’s nurses for nearly six years and have had several areas treated. My worst injury began as a left hamstring injury incurred from increasing my pace on a training run. The original point of injury was where the hamstring attaches to the ischial tuberosity (IT), the bottom most part of the pelvis, the bone you sit down on.

As with most people, I tried rest, heat, stretching, not stretching, nothing seemed to help. Even me, a person with access to a great Prolotherapy doctor, put off the injection treatment to see if I could heal it on my own.

Can you blame me? Nurses don’t like shots either. The problem was my IT hurt on my left so while driving I leaned on my right. After a month of doing this, can you guess what happened? That’s right; the pain was now traveling up into my left SI joint, and was beginning to affect my sleep. The abnormal motion of sitting just on my right buttock caused an imbalance in my SI joint. Because I was educated in the mechanics of the pelvic ligaments, I knew that if left unchecked, my IT and SI problem could eventually cause a problem in my lumbar ligaments. So two months after my original injury, it was time to get up on the Prolotherapy table and take my medicine!

 

After the soreness from the treatment wore off in a few days, I estimated my pain as 40% less. I needed three more treatments spaced about four weeks apart to completely resolve my problem.

We’ve seen many diagnoses for back pain and oftentimes patients ask how Prolotherapy can help with their specific back condition. Whether it’s a pinched nerve, sciatica pain or spinal stenosis, Prolotherapy helps by addressing the root cause of the issue – ligament laxity. Most back pain conditions result from a degenerative cascade that occurs along the spine.

Degenerative Cascade and Prolotherapy

Degenerative Cascade.

Ligament Instability

The degenerative cascade explains the origin of degenerative disc disease, bone overgrowth and spinal stenosis. In other words, disc issues arise with increasing instability of the spinal structure. As can be seen from the illustration, instability of the spine is a part of the degenerative cascade. If the instability isn’t treated, the end result will be the overgrowth of bone and the potential for various pinched nerves (spinal stenosis).

Ligament Laxity

Instability in the lower back, neck or thoracic spine occurs because various ligaments become torn, weakened or stretched. As the ligaments weaken they lose the ability to hold their specific vertebrae in place. As the vertebrae move excessively much force is placed on the intervertebral disc and facet joints. As excess movement occurs and force increases the discs and facet joints start to deteriorate at an accelerated rate. The body tries to stabilize the spine by muscle spasms. When this doesn’t work the body overgrows bone that leads to pinched nerves via spinal stenosis, facet syndrome, or multilevel spondylosis (osteoarthritis).

Prolotherapy Halts the Degenerative Cascade

While surgery is an option once a person reaches the pinched nerve stage, Prolotherapy often is all that is needed. Prolotherapy is an injection technique that created a mild inflammatory response mimicking the body’s natural response to soft tissue injury. The inflammation draws in healing factors that regenerate cartilage leading to stabilization of the spine through strengthened ligaments. When a person has the burning pain down the leg or arm in a certain position (like walking or with the neck extended), Prolotherapy can diminish the pain by affecting the ligament laxity and thus the stability of the vertebral segments one to the other. Once the stabilized vertebral segments move in unison, the instability stops and along with it the degenerative cascade and the chronic pain.

In the ideal situation, the person would receive Prolotherapy early in the degenerative cascade. If spinal pain is not relieved within a few weeks of therapy, exercise, rest or osteopathic/chiropractic work then Prolotherapy should be considered. The earlier a client comes in for Prolotherapy, generally the fewer treatments are needed. Typically Prolotherapy is given every three to five weeks and generally three to six visits are needed. . For more information on Prolotherapy for your specific back condition, give us a call at 708-848-7789 or email us at drhauser@caringmedical.com.