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We no longer offer PRP and Stem Cell procedures until further scientific evidence of its efficacy. We do PROLO Therapy for specific orthopedic conditions.

Rotator Cuff Tendinopathies: A case for regenerative injection therapies?

 Rotator Cuff Tendinopathies: A case for regenerative injection therapies?

A painful shoulder is one of the most common complaints seen by orthopaedists.  Athletes who participate in repetitive overhand throwing sports such as baseball, basketball, and volleyball are at increased risk for shoulder injuries.  The same holds true for those who work in an occupation requiring overhead activity.  Pain and dysfunction to the shoulder(s) can also arise from normal aging.  The term rotator cuff syndrome is often used when referring to tearing within the rotator cuff tendons.

 

Anatomically, the rotator cuff is made up of four tendons: supraspinatus, infraspinatus, subscapularis and the teres minor.  These tendons originate along the scapula and attach at various points along the head of the humerus.  Within the shoulder there are several bursa which normally facilitate smooth gliding of the tendons and muscles.

Many painful conditions related to overuse that encompass the rotator cuff tendons and surrounding soft tissues, are commonly referred to as rotator cuff tendinopathy.  Rotator cuff tendinopathy is a very complex, multifactorial process involving both intrinsic (within a tendon) and extrinsic (outside of a tendon) factors.  Clinically, patients often complain of pain with specific motions such as reaching overhead, with lifting, and often at night when sleeping on the affected shoulder. Loss of normal range of motion may also be present with forward elevation of the shoulder and with abduction (moving arm away from the body).  Weakness and further loss of motion often result from disease progression. These symptomatic complaints may be caused by underlying degenerative changes within the tendons resulting in mechanical overload. Additionally, compression on the tendon(s) caused by bony structures may also accompany the forementioned intrinsic factors.

 

The combination of a good detailed patient history of complaints, a sound physical examination, and an MRI of shoulder can help the physician provide the proper clinical diagnosis and direct treatment.  Traditionally, treatment for tendinopathies has included NSAIDs, physical therapy, and corticosteroid injections.  Many can be successfully managed utilizing these non-surgical treatments.  As previously mentioned, rotator cuff tendinopathy is a complex condition and in some cases traditional treatments fail to help improve symptoms.   While there are varying surgical options depending on the specific underlying issue(s), the risks of the procedure and outcomes must be weighed.

In the last decade, the use of regenerative injection therapies for rotator cuff tendinopathies, has been developed and continues to evolve. Prolotherapy, Platelet-Rich Plasma (PRP), and even stem cell therapies have been applied.  Presently there is limited data to support regenerative injection therapies as a part of a standard medical treatment plan for rotator cuff tendinopathies.  However, its use has been reported with increasing frequency by the media among professional athletes.

A few randomized controlled trials and prospective studies utilizing Prolotherapy and/or PRP have been published in the last few years. Outcome measures have focused on pain scales, patient satisfaction, and disability indexes (Western Ontario Rotator Cuff Index, Shoulder Pain and Disability Index).  The results for the most part have been positive.  Further studies to show efficacy are needed.

 

References:

Bertran H, Reeves KD, Bennett CJ, Bicknell S, Cheng AL. Dextrose Prolotherapy versus Control Injections in Painful Rotator Cuff Tendinopathy. Arch Phys Med Rehabil. 2015 Aug 21.

Scarpone M, Rabago D, Snell E, Demeo P, Ruppert K, Pritchard P, Arbogast G, Wilson JJ, Balzano JF. Effectiveness of Platelet-rich Plasma Injection for Rotator Cuff Tendinopathy: A Prospective Open-label Study. Glob Adv Health. Med. 2013 Mar;2(2):26-31.

 

 

 

Regenerative Injection Therapies for Hip Bursitis

Regenerative Injection Therapies for Hip Bursitis

Trochanteric bursitis, or hip bursitis, as it is commonly referred to as, is a common orthopedic condition that normally is self-limiting. The condition refers to inflammation of a fluid filled sac (bursa) that sits along the outside of the hip. This area, known as the greater trochanter, is formed from the upper end of the femur bone. This is attachment point for muscles and tendons and is an area where friction may develop. The body’s response to friction is to produce bursa tissue.

What causes bursitis and what are the common symptoms?

Trochanteric bursitis typically develops gradually. Injury to the lateral (outside) part of the hip, an overuse injury such as standing for prolonged periods of time, poor posture, lower spinal related disorders, calcium deposits in the surrounding tendons, a sudden change in a workout or training routine, a leg length discrepancy, and other medical conditions such as rheumatoid disease, gout, or thyroid disease can cause hip bursitis. Bursitis also may develop following a hip replacement.

Pain usually develops along the outside of the hip and may begin to radiate downward. There may be tenderness along the bony ridge that forms the greater trochanter. There may be pain with standing from a seated position or with stair climbing. As the disease progresses, increased stiffness within the hip may lead to a limp. Sufferers of hip bursitis often complain of increased pain at night while lying on the affected side.

Treatment for trochanteric bursitis may include activity modification, rest, non-steroidal anti-inflammatory (NSAID) medication, and physical therapy and corticosteroid injections. As systematic review published by Lustenberger et al (2011) found that as many as 33% of patients treated required a second corticosteroid injection to alleviate symptoms of hip bursitis while some had 5 injections!

Surgical management of trochanteric bursitis may be recommended for those who have tried and failed all of the conservative treatment options and still remain symptomatic.
A 2014 study published by the American Academy of Orthopaedic Surgeons (AAOS), compared a single corticosteroid injection to a single platelet rich plasma (PRP) injection for chronic hip bursitis. Twenty patients were included in each group. Outcomes were measured based on validated outcome questionnaires that looked at pain levels, function, and stiffness. Patients treated with PRP had greater improvements in post-treatment scores and had lasting effect (at 1 year after injection) whereas those treated with a cortisone injection had scores that returned back to pretreatment levels within 3 months. The results of the small study appear promising, but further well controlled studies are needed to fully delineate the effectiveness of PRP injections for hip bursitis.
At present, the medical literature is very limited on studies looking at PRP injections and Prolotherapy for hip bursitis. There are a few case reports about patients being successfully treated with either PRP or Prolotherapy. Both PRP and Prolotherapy appear safe and may offer suffers long lasting relief.

Hip bursitis is one of the most common causes of pain in the adult population. It is normally a condition that can be treated non-surgically for most. Unfortunately, some will not improve with treatment resulting in a chronic condition that is much harder to cure. Regenerative injection therapies such as PRP and Prolotherapy should be considered if clinical improvements are not seen early in the treatment process.

References:
Lustenberger DP, Ng, YV, Best TM, Ellis TJ. Efficacy of Treatment of Trochanteric Bursitis: A Systematic Review. Clin J Sports Med. 2011 Sept: 21(5): 447-453.
Monto RR. Paper #778. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 11-15, 2014; New Orleans

PRP / Prolo for Whiplash

· Prolotherapy · No Comments

 Prolotherapy for Post-Traumatic Neck Pain Caused by a Whiplash Type Injury

 

 

 

Over 2.3 million people were injured on U.S. roadways in 2013.  When looking at injuries sustained from nonfatal crashes, whiplash is among one of most commonly reported injuries.  Whiplash can also occur from other traumatic events including falls, sports injuries, physical violence and work related accidents.

 

The term “Whiplash” is actually a generic term referring to a rapid forward then backward motion of the head and head.  The true definition of whiplash debateable.  In medical terms, this is a hyperflexion – hyperextension or acceleration-deceleration type injury.  With the forces that cause this type of injury, the cervical spine is believed to go beyond its normal range of motion and has the potential to injure the surrounding soft tissue structures (ligaments) and discs. As a protective mechanism, the neurological system attempts to stabilize the area by contracting the surrounding muscles. There are several known factors (and some unknown) which may determine the extent of injury. This includes prior level of health, physical condition, posture or position of neck at the time of impact, and awareness of pending impact.

 

Commonly reported symptoms of a whiplash type injury include immediate or a delayed onset of neck pain with or without referred pain to the upper back and shoulders, tingling and numbness to the upper extremities, headaches, dizziness, and blurred vision.  Often patients will complain of referred pain to the arm(s) which may include tingling and numbness, yet clinically there may be no loss of strength, sensation, or function.

 

Treatment for whiplash injuries has also been all across the board.  Some focus on rest and immobilization of the neck while the general consensus for treatment for those with a whiplash type injury (without neurologic deficit) has been promoting an active lifestyle. Specific treatments may include non-steroidal anti-inflammatory medication and physical therapy.

 

Taken from a 2008 systematic review and meta-analysis of the literature, Kamper et al looked at 37 published articles focused on acute whiplash injuries.  The findings from this showed that a significant proportion of those injured recovered in the first three months following an accident.  The authors concluded that pain and disability tends to reduce most rapidly during the initial 3 months but after that time period, little improvement occurs. 

 

There are many inconsistencies in looking at what factors are important for determining the prognosis.  Some of the postulated factors found in the literature associated with a poor recovery include high pain levels, disability levels, depression, and neck range of motion, mechanical hyperalgesia, and the presence of post-traumatic stress symptoms.

 

So what treatment options exist for those who do not improve initially and develop chronic pain? Some are told to live with the pain while surgery may be recommended for others.   Prolotherapy may be a reasonable option for this subset of patients.  While the literature is very limited in regards to studies involving prolotherapy for post-traumatic neck pain or whiplash, reports from as early as the 1960’s published in the literature, showed treatment success in the range of 90% for this specific application. An observational study published by Hauser et al (2007) showed significant improvements in pain levels, cervical range of motion, and disability levels for the study population.  Hooper et al (2007) reported on 18 patients treated with dextrose Prolotherapy. The findings from this study were similar to Hauser et al.  Significant improvements were seen in pain scores and disability measures. Limited conclusions can be drawn based on the methodology and outcomes of these types of studies, however, the results do show the potential for prolotherapy as a viable treatment for those with chronic neck pain from a whiplash type injury.

 

 

 

 

 

References:

 

U.S. Department of Transportation. NHTSA. Traffic Safety Facts. December 2014.

 

Kamper SJ., Rebbeck TJ., Maher CG., McAuley JH., Sterling M. Course and prognostic factors of whiplash: a systematic review and meta-analysis. Pain. 2008 Sept 15; 138(3): 617-629.

 

Hackett G. Prolotherapy in whiplash and low back pain. Postgraduate Medicine. 1960. pp 214-219.

 

Hauser RA, Hauser MA. Dextrose Prolotherapy for Unresolved Neck Pain. Practical Pain Management. 2007.

 

Hooper RA, Frizzell JB., Faris P. Case Series on Whiplash Related Neck Pain Treated with Zygspophysial Joint Regeneration Injection Therapy. Pain Physician. 2007 Mar; 10(2): 313-8.

 

 

 

 

 

Update on Achilles Tendiopathy

An update to the use of PRP in the treatment of Achilles Tendinopathy

In an update to our recent post regarding the use of PRP for Achilles Tendinopathy, a retrospective analysis of 26 patients was published this past month in Foot and Ankle Specialist (Oloff et al 2015). One of the authors has used PRP to treat Achilles Tendinopathy for both those patients who have needed surgery and for those treated non-operatively for the condition.  Outcomes were based on the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire and evaluation of pre and post treatment MRI images. There was a statistically significant degree of improvement seen on pre and post MRI images. Both groups (surgical and non-surgical) improved to a similar degree. 

One criticism is that this is a level IV study (evidence based medicine) and is based on a case series.  It adds to the current body of literature which has shown that PRP may be helpful for Achilles Tendinopathy.  Certainly, data from larger well controlled clinical trials is needed to determine effectiveness of PRP therapy and to define more specific treatment protocols.

References:

Oloff L., Elmi E., Nelson J., Crain J. Retrospective Analysis of the Effectiveness of Platelet-Rich Plasma in the Treatment of Achilles Tendinopathy: Pre-Treatment and Posttreatment Correlation of Magnetic Resonance Imaging and Clinical Assessment. Foot Ankle Spec. 2015 Aug 7.

 

PRP in Professional Athletes

· Platelet Rich Plasma (PRP) · No Comments

If PRP injections are used to treat professional athletes, could I benefit from them?

Are Platelet Rich Plasma injections effective for various soft tissue injuries and joint complaints or is it marketing hype with nothing to back it?  As has been discussed on our website and at various places across the web, the use of PRP to treat musculoskeletal conditions has accelerated during the current decade.  More and more studies are being designed, conducted, and published looking at the efficacy of PRP injections.  Admittedly, there are many unknowns at this point. Data from high quality, randomized clinical trials using PRP is beginning to grow. Add to that many anecdotal or case reports, and the common theme is that PRP may be effective in the treatment of conditions such as tennis elbow, Achilles tendinitis, hamstring injuries, and other tendon disorders.  

PRP has been used amongst professional athletes for many years with increasing frequency.  Many of these players are paid millions of dollars to perform, often on a daily basis. Their ability to recover expeditiously from an injury is vital to their future and often to that of their team. 

Using major league baseball as a good example,  more than two-thirds of the season has now past and just within the last 6 weeks, a handful of starting players (some well-known), have been injured and treated with PRP.   Here are the latest based on news reports:

Boston Red Sox pitcher, Clay Buckholz, was given a PRP injection several weeks ago for a strained flexor muscle in his right elbow.  Based on published reports from earlier this week, his is supposed to be seeing orthopaedic surgeon, Dr. James Andrews, for evaluation and to be released back to throwing.  This same type of injection was given to pitcher Chris Sale of the Chicago White Sox. We was placed on the disabled list for nearly 5 weeks, but he been one of the best pitchers in baseball since his return.

Jesse Hahn, of the Oakland A’s, was shut down from pitching in mid-July for a forearm strain. He received at least one PRP injection.  It is reported that he is still feeling stiffness with strengthening exercises. His time to return is unknown at present.

Pirates star pitcher, A.J. Burnett was placed on the disabled list last week for a flexor strain in his right elbow. It was expected that he would be out for four weeks. He was given a PRP injection to the elbow and based on reports is making faster than expected recovery. He has already began catching.

Dustin Pedroia, second baseman for the Boston Red Sox was also recently treated with PRP. He suffered a re-aggravation of a hamstring injury in late July.  He is currently looking to return to the lineup in mid-August based on report.

Atlanta Braves first baseman, Freddie Freeman was put on the disabled list in late June with a right wrist contusion.  He received a PRP injection to “help with the healing process.”  The team leader in home runs returned to the lineup after 5 weeks, but unfortunately recently ended up on the 15 day disabled list with a right oblique strain.

This is just a highlight of how PRP is being used amongst professional baseball players with some of the  observed results.  Even for those of us who do not go to bat or are required to pitch on a daily basis, but do suffer from soft tissue injuries,  PRP injection therapies are something that you will continue to hear more about and appear to be promising for certain musculoskeletal problems.

 

 

 

Achilles Tendinopathy

Regenerative Injection Therapies for Achilles Tendinopathy

Achilles tendonitis is one of the most common overuse injuries seen by orthopaedists.  While there are several different known causes of Achilles tendonitis, overuse and degeneration are two of the most common reasons.  In the truest sense, Achilles tendinopathy more accurately describes the condition.  Tendinitis means inflammation within a tendon whereas, tendinosis refers to micro tears commonly as the result of overuse. Collectively tendinopathy incorporates both of these findings.

Those who suffer from Achilles tendinopathy typically complain of pain either along the midportion of the tendon or at the insertion site at the heel.  Stiffness in the morning and increasing pain with activity is common. Thickening of the tendon can result from injury or from degenerative changes seen with age.  For some, swelling and redness may also be present.

Historically, the normal treatment course for Achilles tendinopathy has focused on activity modification including rest, ice, non-steroidal ant inflammatory medication (NSAID), and stretching exercises. In rare cases, corticosteroid injections have been given for Achilles tendonitis, but there is concern for risk of tendon rupture associated with this.

Unfortunately for some, Achilles tendinopathy can become a chronic condition in which adhesions can may form between the tendon and tendon sheath.  This is a much harder condition to treat. There are several different surgical approaches to address this problem however, recovery can be prolonged and return to certain activities may be limited on a long term basis.

Beyond the standard treatments mentioned above, regenerative injection therapies including Prolotherapy and PRP also may also have a place in the management of Achilles tendinopathy.   On the Prolotherapy side, a randomized clinical trial that was conducted in Australia (Yelland et al 2011) showed that Prolotherapy when combined with specific exercises was very effective early at reducing stiffness and allowing for increased activity.   Several studies have evaluated the use of PRP for Achilles tendinopathy.  A European study that is due to publish this month in Foot and Ankle Surgery, reported on 83 Achilles tendons that were followed for an average of 50 months after a single PRP injection. Statistically significant score improvements were seen on the Victoria Institute of Sports Assessment – Achilles (VISA-A) questionnaire. 91.6% of the patients were satisfied with the treatment at final follow-up. No tendon ruptures were seen.

A similar study by Filardo et al (2014) showed a positive outcomes for 27 cases of chronic Achilles tendinopathy treated with leucocyte positive PRP with an average of 54 months of follow-up.

The published data on the use of regenerative injections for Achilles tendinopathy is very limited at the present time. This is an area that is presently being investigated. The results do appear to be promising so far.

 

Is Platelet Rich Plasma (PRP) effective for knee osteoarthritis?

Traditional treatment for knee osteoarthritis has been focused on knee strengthening, the use of non-steroidal anti-inflammatory medication (NSAIDs), and corticosteroid injections. Additional non-surgical options including viscosupplementation is also a treatment option for some with mild to moderate joint degeneration and have failed other first line treatment options.

Several studies have been published this year in regards to looking at the efficacy of PRP injections for patients who suffer from knee osteoarthritis.

A meta-analysis published by Campbell et al (May 2015), looked at the use of PRP versus corticosteroid injections, viscosupplementation injections, NSAIDs, and placebo. The findings from the literature searches did show that PRP injections led to significant improvements in pain and function at 6 months and maintained effect until 12 months post-injection. Those with milder findings of osteoarthritis radiographically appeared to have greater benefit from PRP injections.

A more recent double-blinded randomized clinical trial by Forogh et al (July 2015), evaluated one injection of PRP versus an intra-articular corticosteroid injection for symptomatic osteoarthritis of the knee. Patients with grade II/III osteoarthritis were randomly divided into two groups. Outcome measures included the Knee injury and osteoarthritis outcome score (KOOS), 20 meter walk test, knee range of motion, flexion contracture, and Visual Analog Scale (VAS) for pain assessment. Patients treated with one PRP injection had greater relief of pain compared to the corticosteroid group. A greater percentage of those treated with PRP were symptom free following injection, had improved activities of daily living and quality of life scores at follow-up.

In another randomized control trial conducted by Filardo et al (July 2015), researchers looked at the potential benefit of PRP injections compared to hyaluronic acid (viscosupplementation) injections for patients with at least a 4 month history of chronic knee pain and accompanying degenerative changes.

For this study, patients had 3 weekly intra-articular injections of either PRP or hyaluronic acid. Outcome measures included the International Knee Documentation Committee (IKDC) subjective score, KOOS score, EuroQol visual analog scale and Tegner score. The findings of the study revealed that both treatments were effective at improving knee functional status and decreasing pain. No significant differences were identified between PRP and hyaluronic acid.

While these studies do show the potential for PRP to be beneficial for those with knee osteoarthritis, it remains unclear as to how many injections are ideal. Furthermore, the preparation methods of the PRP, and the activating agent must also be considered.

Platelet Rich Plasma (PRP) Therapy in Orthopedics

Platelet Rich Plasma (PRP) has been used since the 1970’s. The last decade has seen tremendous focus on PRP applications in musculoskeletal medicine. The potential for PRP to promote tissue healing following injury or disease is attractive to many physicians, researchers, and patients alike. Unlike medications or cortisone injections which suppress or mask the underlying problem, PRP shows the potential to heal. The risk of disease transmission is limited since PRP is derived directly from a patient’s own blood. On the flip side, there is significant variability in PRP concentrations from one patient to another. This combined with different methods of preparing PRP, timing, and the selection of activating agents all present challenges in studying and standardizing treatment protocols.

Published studies of PRP use in adults and in animal models have shown promise for a number of orthopedic related conditions. This is especially the case for tendon and soft tissue injuries. The specific mechanism of how PRP works remains elusive, but several well controlled studies have shown positive outcomes with no significant adverse events.

In simplest form, when an injury occurs, the body’s own platelets release co-factors that stimulate recruitment of mesenchymal stem cells (MSCs) to the site of injury. Additionally, inflammation is reduced during this cascade of events and healing is promoted. Some of the known components of PRP included platelet-derived growth factors, insulin-like growth factor, transforming growth factor-beta, fibroblast growth factor-2. Each of these have differing functions in the healing and reparative process.

To date, many professional athletes have been treated with PRP injections. Success rates that appear in the published literature and across the web vary considerably. Some are reported at greater than 90%. Caution must be exercised in interpreting these results as outcome measures vary. Again it is very difficult to compare studies or even one individual versus another due to the issues described above.

We are just beginning to understand how PRP can be used and how effective it can be in the treatment of certain orthopedic conditions.

Platelet Rich Plasma (PRP) injections for tennis elbow: What is the evidence?

Lateral epicondylitis (“tennis elbow”) is one of the most common conditions seen by orthopedists. It is estimated that 1-4% of the population suffers from tennis elbow. The peak incidence usually occurs between ages 30 and 50. Lateral epicondylitis is classified as an overuse injury to one of the main forearm extensor muscles. The muscle becomes weakened from overuse and microscopic tears develop in the tendon that attaches to the bone (lateral epicondyle). The end result is chronic pain and inflammation.

Treatment has traditionally included bracing, corticosteroid injections, use of non-steroidal anti-inflammatory medications, exercise, and surgery. Acupuncture, cold laser therapy, and extra corporeal shock wave therapy have also been utilized by some with mixed success.

Treatment of tennis elbow with PRP injections has gained popularity over the last ten years. Many studies are being conducted across the U.S… Within the current published medical literature, there are numerous studies comparing the use of PRP to other treatment modalities in the treatment of tennis elbow. Studies range from high quality, controlled clinical trials to single case reports. Of the studies published in the last five years, evidence for the use of PRP has been mixed, but has favored a positive outcome overall.

In the most recent of studies (Behera et al 2015), PRP was compared to bupivacaine for chronic tennis elbow. Bupivacaine is also known as Marcaine and is a local anesthetic. Twenty-Five patients were studied for up to 1 year following one injection of either PRP or bupivacaine. Those who received bupivacaine had better improvements in pain and functional scores than those treated with PRP. However, at 6 months and 1 year after injection, PRP was far superior to bupivacaine.

In a randomized control trial comparing PRP to an active control group by Mishra et al (2014), 230 patients were studied. A successful outcome was defined as a 25% or greater improvement on the visual analog pain scale. The results of the study showed that there were no differences between groups at 12 months, but at 24 months PRP was superior (83.9% vs. 68.3% in control group).

A doubled blinded, randomized control trial by Gosens et al (2011) comparing PRP versus corticosteroid injections in patients with chronic lateral epicondylitis has similar findings to Mishra et al. In this study, 150 patients were randomly divided into the two groups. Patients treated with PRP were significantly improved versus those who had received a corticosteroid injection after two years of follow-up. No complications were noted.

There are additional published studies looking at PRP use in treating lateral epicondylitis. Evaluating these studies can be challenging as the comparison group (“controls”) and outcome measures often vary considerably. Unfortunately, some studies also have methodological flaws which may invalidate the results.

PRP for tennis elbow does appear to be safe and has so far shown the potential to be effective for a subset of patients.

Prolotherapy for Sacroiliac (SI Joint) Pain

Sacroiliac joint (SI Joint) dysfunction or sacroiliac syndrome as it is sometimes referred to as, can be a potential cause of low back pain. It is a condition that is not well understood as there is no gold standard for diagnosing and treating this problem. The SI Joint is considered a diarthrodial joint and connects the sacrum to the pelvis. Limited motion does occur and the SI joints are supported by surrounding muscles and strong ligaments. While not completely clear, it is believed that SI joint pain can be caused by either too much joint movement or too little movement. Pain can also come from surrounding structures including the discs and facet joints.

Diagnosis of SI joint dysfunction is often made based on tests conducted during a physical examination. Many practitioners also utilize a SI joint injection under fluoroscopic guidance (“live x-ray”) or CT guidance to confirm the diagnosis. If the patient receives relief of pain, even if temporary, then treatment can be focused on the SI joint. Non-surgical treatment options often include corticosteroid injections, manipulative physical therapy, and the use of non-steroidal anti-inflammatory medications. More advanced options include radiofrequency neurotomy and SI joint fusion. Results of a systematic review of the literature (Rupert el al 2009) found evidence for radiofrequency neurotomy use is very limited based on only a few quality studies. The number of SI joint fusions has increased significantly in the last few years including the use of minimally invasive approaches. The indications for a fusion is limited and there are concerns that by removing motion within the joint, more forces will be transmitted across the hips and lower spine leading to further problems.

So what other options exist for those who suffer from pain emanating from the SI joints? Prolotherapy has been suggested and has been used successfully in a number of documented cases. The medical literature is very limited in regards to using prolotherapy for this condition, but the results of some smaller studies have shown that Prolotherapy may be an option to consider. Cusi et al (2010) followed 25 patients with SI joint dysfunction following a hypertonic dextrose solution injection under CT guidance. A positive clinical result was present for 76% at 12 months after injection and 32% at 24 months. In a randomized controlled study, Kim et al (2010) compared Prolotherapy injections to corticosteroid injections. At 15 months post-injection 58.7% of those treated with a Prolotherapy injection had pain relief equal to or greater than 50% versus 10.2% for the corticosteroid group.

Going back to the underlying reason for SI joint pain, the common thinking is pain and dysfunction result from changes in ligamentous laxity. Prolotherapy is aimed at injecting an irritant into the joint and/or weakened ligamentous structures to promote a response by the body to heal the affected area. While limited data to support Prolotherapy for SI joint dysfunction exists, no significant adverse events have been reported in the literature and mostly observational studies have shown the treatment to be effective at alleviating pain for the subset of patients treated.