Proliferative Injections

What are Proliferative Injections?

Ligaments hold bones and joints together. Tendons attach muscles to bone.
When ligaments are injured from trauma, improper exercise or poor posture, they become overstretched, lax, inflamed and even torn.

Bones may become offset which stretches the ligaments even more.

These ligaments have nerve endings and we feel pain.

An adequate exercise program and manipulation aim at bone balancing; however, if the ligament remains stretched, the correction is only temporary and misalignment can reoccur.

A proliferative injection with dextrose (an irritant) and lidocaine (an anesthetic) can strengthen ligaments. This creates temporary inflammation, increases blood supply and brings nutrients to the injured ligament. New connective tissue is formed from fibroblasts.

Several strengthening injections are required, a week or two apart. The total number of injections depends on the area of injury.

Examples of areas injected:

  • Shoulder, elbow, wrist and hand (tendinitis)
  • Cervical (sub-occipital)
  • Lumbar spine/sacrum (iliolumbar, sacroiliac strain)
  • Sacrotuberous, sacrospinous ligaments
  • Piriformis, knee, foot

Technique:

Manipulation pre-injection is helpful to restore proper joint balance.

A local anesthetic spray desensitizes the area.

Daily stretching exercises are taught.

Ice and anti inflammatories should be avoided during the injection series.

Tylenol (acetaminophen) and heat can be used instead.

How the solution works:

The solution induces a temporary inflammatory response that mimics an early injury – repair sequence. Polypeptide fibroblast growth factor stimulates a proliferative response and accelerates repair. An inflammatory exudate occurs at 24 – 48 hours. Proliferation of fibroblasts occurs at 3-7 days.

New dense collagen fibrous tissue forms at 8 weeks. Ligament or tendon mass increases through fibroblast hyperplasia and an increase in collagen fiber diameter. It is as if a good scar is formed. The strengthening process continues 4-6 months, even 12 months, after the injections are completed.

To encourage normal pliability of the fresh scar and for proper proliferation of the new collagen in a parallel direction, daily stretching exercises are important. Walking, which varies ligament stress, is necessary during injections. If ligaments heal in a shortened position, they are susceptible to reinjury.

In the spine, passive elastic tissues, namely lumbosacral fascia, facet joint capsule, posterior longitudinal ligament and the annulus fibrosus of the disc provide static posterior support. Nerve endings, lodged in these structures, produce back pain from abnormal mechanical stress. Sacroiliac ligaments are powerful. However, if injured and lax, they can no longer absorb the forces of bending and twisting imposed on the spine.

When fascial and ligament support tissues function normally, the intervertebral disc is less exposed to external forces. Facet contact contributes to stabilization during flexion motion via interspinous ligaments. If they are overstretched, or infiltrated with fat, stress on discs is increased. The goal of an injection in the spine is to normalize the biomechanics of a segment and increase the support of connective tissue.1234

1Klein, R.G., et al. A randomized, double blind trial of dextrose-glycerine-phenol injections for chronic low back pain. Journal of Spinal Disorders, 1993; 6: 23- 33.

2DeLong, W.B., Klein, R.G. Ligamentous injections for low back pain. Surgical Rounds for Orthopedics, 1989.

3Hackett GS. Ligament and tendon relaxation treated by prolotherapy. 3rd ed. Springfield, Charles C. Thomas. 1958.

4Kenneth D. Reeves, Hypertonic dextrose injection (prolotherapy) in the treatment of symptomatic knee osteoarthritis: a systematic review and meta-analysis. Sci Rep April 07: 7: 45879 2017.

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