Prolotherapy for Osteoarthritic Knees
Report by Dr Peter Baratosy.
Prolotherapy is defined as “an alternative therapy for treating musculoskeletal pain that involves injecting an irritant substance (as glucose) into a ligament or tendon to promote the growth of new tissue.” (Merriam-Webster Medical Dictionary).
This definition can be extended to the treatment of osteoarthritic joints by injection the prolotherapy glucose solution directly into the joint. Used mainly for knee joints as the knee joint is very easily accessible!
Osteoarthritic Knee pain is very common and is a cause of much morbidity. It has a compounding effect as people with painful knees cannot exercise which can lead to obesity and other health issues. Also note that obesity can put extra pressure on the knees and cause more wear and tear. People with painful knees can be prevented from getting out and about and can become socially isolated.
The usual treatments include: -
Conventional – non steroidal anti-inflammatory agents, analgesics – e.g. paracetamol.
Un-conventional – anti-inflammatory herbs – e.g. Curcumin, Boswelia, Ginger, also glucosamine, and chondroitin
2/ Physical therapies
Conventional – physiotherapy
Un-conventional – chiropractic, osteopathy. Also we can include Acupuncture into this group.
3/ Injection therapies
Conventional – steroid injections
Un-conventional – prolotherapy, Platelet Rich Plasma (PRP)
stem cell injections
Knee surgery is one of the choices, however, I believe that it is logical and makes sense to try simpler, less invasive treatments first. Many are reluctant to go down the surgical pathway - once done there is no going back – except for more surgery!
I have personally talked with many who are reluctant to have the knee replacement because they know of people – family, friends and acquaintances, with a knee replacement – and they are not satisfied with the results, in fact are worse off. I should add here that there are also many who are very satisfied with the results of the surgery.
I have also seen many with one knee replaced with continuing problems and are reluctant to have the other knee operated on!
Also we mustn’t forget that knee replacement surgery is a big operation and many with osteoarthritic knees are old and medically unfit for the anaesthetic. Many surgeons are reluctant to operate on this group.
There is great interest in trying other forms of treatment first.
Many have started down the conventional way and then many may wish to go down the alternative pathway. The use of Prolotherapy can fit in here.
Overall the procedure is very simple. As the knee joint is easily accessible for injection, the treatment consists of a 10 ml injection of glucose and local anaesthetic into the knee joint, as well as to tender points around the knee.
There is one structure – the Pes Anserinus that is generally quite tender in anyone with knee osteoarthritis. An injection of 1-2 mls of solution to this area can be quite beneficial.
(Pes anserinus (literally “goose’s foot”) is the anatomic name given to the conjoined tendons at the medial aspect of the knee that insert onto the anteromedial aspect of the tibia. Its name comes from the webbed-foot appearance of the tendons insertion onto the tibia. (https://radiopaedia.org/articles/pes-anserinus)
The course of treatment consists of a series of injections into the knee at approximately 2 weekly intervals. Since people are very different – the benefits may begin to be realised in as little as 1 treatment or could take as much as 5 treatments! Generally if there is no improvement by 5 treatments – then I would consider that the treatment to have failed… though some have contacted me months later and told me that they eventually had felt benefit – a delayed reaction!
With improvement, treatments can continue at 2 weekly intervals till a state is reached where the person is happy with the result. “Top up” treatments may be done as needed. I personally have had patients come back regularly every 2 months for “top up” treatments and at the other end of the spectrum, others have returned years later for another treatment.
Response of course, is variable. Unfortunately the treatment does not have a 100% success rate….but then no treatment does!
There are 2 major types of complications. 1/ infection and 2/ needle damage to underlying structures. Both these complications can be avoided by using a sterile technique and a good knowledge of anatomy!
What is the evidence?
A paper (Dextrose Prolotherapy for Knee Osteoarthritis: A Randomized Controlled Trial) was published in 2013 looking at this. The paper concludes:- “Prolotherapy resulted in clinically meaningful sustained improvement of pain, function, and stiffness scores for knee osteoarthritis compared with blinded saline injections and at-home exercises.” (Ann Fam Med. 2013; 11(3): 229-237)
A Systematic review and meta-analysis was published in 2016 (Sci Rep. 2016 May 5;6:25247. Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: A systematic review and meta-analysis.) The conclusion – “Overall, prolotherapy conferred a positive and significant beneficial effect in the treatment of knee OA.” The researchers however continued in their summary with the usual proviso - “Adequately powered, longer-term trials with uniform end points are needed to better elucidate the efficacy of prolotherapy.”
So far – so good….. but what about long term results?
This was looked at in another paper published in 2015 (Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis: Long term outcomes.) The conclusion:- “Prolotherapy resulted in safe, significant, progressive improvement of knee pain, function and stiffness scores among most participants through a mean follow-up of 2.5 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care.” (Complement Ther Med. 2015 Jun;23(3):388-95).
These x rays were taken from the Journal of Prolotherapy. 2009;1(1):22-28.and shows long term benefits of prolotherapy.
It should be pointed out that Prolotherapy is not generally accepted by main-stream medicine. They consider Prolotherapy un-proven – despite the many studies done.
Prolotherapy is a simple and safe – albeit non mainstream treatment for osteoarthritis of the knee. There are peer reviewed studies published in Medical journals that show that the treatment is effective and safe.
Note – I use the name glucose in this article and the word dextrose is used in some of the references. What is the difference? There are 2 isomers of glucose : L-glucose and D-glucose. Dextrose is D-glucose and may be referred to as dextrose or glucose because dextrose is actually a form of glucose.
Osteoarthritis (OA) is the most common joint disorder in the United States. Symptomatic knee OA occurs in 10% men and 13% in women aged 60 years or older. The number of people affected with symptomatic OA is likely to increase due to the aging of the population and the obesity epidemic. OA has a multi-factorial etiology and can be considered the product of an interplay between systemic and local factors. Old age, female gender, overweight and obesity, knee injury, repetitive use of joints, bone density, muscle weakness, and joint laxity all play roles in the development of joint osteoarthritis, particularly in the weight-bearing joints. Modifying these factors may reduce the risk of osteoarthritis and prevent subsequent pain and disability.