Ross A. Hauser, MD & Joseph J. Cukla, LPN
From the Journal of Prolotherapy. 2009;1:22-28.
Abstract
Degenerative joint disease is the most common form of arthritis. The condition is marked by progressive destruction of the articular cartilage which is easily documented by standard X-ray studies. The regeneration of this articular cartilage in clinical practice has been difficult. Five knees with articular cartilage degeneration were treated with Prolotherapy in this report. Each of the five knees showed improvement of their standard clinical X-rays after the Prolotherapy, signifying articular cartilage repair with Prolotherapy. It is suggested that before and after X-ray studies can be used to document the response of degenerated joints to Prolotherapy.
Introduction
Osteoarthritis (OA) is one of the major problems affecting our aging population. It has been estimated that two to three percent of the adult American population suffers from regular pain from Osteoarthritis OA, and approximately one-third of adults in the US between the ages of 25-74 have radiological evidence of OA in at least one of the major joints.1 Autopsy specimens have demonstrated a 90% prevalence of articular cartilage degenerative changes in weight bearing joints in individuals older than 40 years old.2 The knee is the most symptomatic joint affecting 6.1% of all adults over the age of 30 but rising to 16% of adults over the age of 45.3-5 Because there is no currently accepted method to stop or reverse joint degeneration, the incidence of symptomatic OA increases by about 1% each year.6
Osteoarthritis is the most common form of knee arthritis and can involve any or all three compartments in the knee: the medial compartment (medial tibial plateau and medial femoral condyle); the lateral compartment (lateral tibial plateau and lateral femoral condyle); or the patellofemoral compartment (patella and femoral trochlear notch).
The increasing number of joint complaints and radiological OA is matched by the rising number of major joint replacements. In one state alone the total number of total knee replacements increased by 81.5% from 1990 to 2000, with a subsequent rise in costs for these procedures of over 200%.7 It is estimated that in the US, the total number of joint replacement surgeries of the hip and knee will increase from 684,000 cases in 2003 to over a million by 2013.8
The current conservative treatments for OA including medications, exercise, physical therapy, corticosteroid injections, weight control, Synvisc and Hyalgan injections, and operative treatments including arthroscopy often leave people with residual pain.9-12 Because of this, many people with OA are seeking alternative treatments including Prolotherapy.13-14
Prolotherapy, also known as regenerative injection therapy, involves the injection of substances into degenerated or injured areas to stimulate healing.15-17 While it has been traditionally used for ligament and tendon injuries, it has a long history of use in OA.18-20 Two placebo-controlled double-blind studies by K. Dean Reeves and associates have demonstrated beneficial effects of Prolotherapy on OA including some X-ray changes.21-22
This report documents the results in five degenerated knees treated with Prolotherapy. Before and after X-rays were available to document articular cartilage regeneration with Prolotherapy.
Methods
Three patients representing five degenerated knees underwent Prolotherapy at the private practice of the primary author at Caring Medical and Rehabilitation Services in Oak Park, Illinois. Each patient underwent standard Hackett-Hemwall Prolotherapy to the knee.23 Each patient had the following areas injected: intraarticular, pes anserine, medial collateral and lateral collateral ligament attachments, and medial side of the patella. The basic solution used was 15% dextrose and 10% Sarapin. Each joint received 2IU of Human Growth Hormone by injection. A total of 5 to 10cc of Prolotherapy solution was injected into the joint at each visit. Four hundred milligrams of glucosamine sulfate was added to one of the 10cc syringes. A total of 30 to 40cc of Prolotherapy solution was used per knee at each visit. This represented 20 to 30 injections per knee per visit.
Case Descriptions
Case One: CW is a 72 year-old woman who presented in July 2004, complaining of a five-year history of severe right knee pain. She rated her knee pain on the visual analogue scale (VAS) at a level of 6 on a scale of 0 to 10. She experienced daily pain throughout the whole knee and noted that the severity of the pain was also increasing. Her other symptoms were increased pain upon sitting for long periods of time, difficulty with stairs, and increased pain with walking. She was not exercising. She had no previous history of trauma or knee surgery. Three previous hyaluronic acid treatments provided diminishing relief. She used the oral pain relievers, tramadol hydrochloride and acetaminophen, as needed. X-rays done in 2002 showed osteoarthritis, marked loss of joint space medially, subchondral sclerosis and osteophyte formation. CW was told by an orthopedist that she needed a total knee replacement. She read about Prolotherapy in an alternative medicine newsletter and wanted to try it instead of surgery.
Physical examination showed normal knee alignment. Lachman, anterior drawer, valgus and varus stress tests were all negative. She exhibited joint line tenderness both medially and laterally, but worse medially, as well as quite a bit of crepitus in the knee throughout the range of motion. There was no swelling present in the knee. Her range of motion was 3 to 95 degrees.
Prolotherapy treatments began in July 2004. CW received nine treatments on her right knee through May 2005. She reported an incremental decrease in pain and increased mobility as she was interviewed every four to six weeks during the course of treatment. Her range of motion had improved to full extension and flexion to 110 degrees. Her crepitus was nearly nonexistent. She reported at this time, “I am 97% better. I have no pain (VAS score 0), just mild stiffness that subsides with walking.” She was treated one more time and told to return to the clinic if the pain returned. She no longer needed medications or a total knee replacement.
CW returned to the clinic in May 2006 because she twisted her knee and some of her pain returned. Her physical exam at that time was unchanged from when she was seen in May 2005, except she showed more medial joint line tenderness and tenderness at the pes anserine area. She received four more treatments over the next four months, making incremental improvements in her pain. At this time, the patient was doing great, yet desired to see “how my cartilage was doing.” The X-rays showed a large increase of medial joint space. (See Figure 1.) By this time, the patient had received 14 Prolotherapy treatments to her knee.
Seventeen months after her last Prolotherapy doctor treatment, the patient continues to have full function of the knee with almost no pain (0 to 1 on VAS). She has returned to full activities without pain and is on no pain medications.
Figure 1. Standard weight bearing knee X-rays of C.W. before and after Prolotherapy. The widening of the medial joint space width indicates that cartilage regeneration has taken place.
Go to the Journal of Prolotherapy to read Case Two: Three year history of bilateral knee pain.