What Is Prolotherapy?

Prolotherapy is short for “proliferation therapy,” Proliferation, of course, means “rapid production.” What Prolotherapy is said to rapidly produce is collagen and cartilage. Collagen is a naturally occurring protein in the body that is a necessary element for the formation of new connective tissue that holds the skeletal infrastructure together. These include, tendons, ligaments, muscle fascia and joint capsular tissue.

Prolotherapy is given as an injection of a mild irritant, often dextrose (a simple sugar), into a specific area of the body that is arthritic, worn down, or injured.  When the irritant is injected into the knee or other area, it causes the body’s immune system to stimulate the inflammatory process. While it may seem counterintuitive to create more inflammation, it is in fact inflammation that is part of the body’s natural healing response.

This burst of increased inflammation attracts fibroblasts (immature cells present in connective tissue) and chondrocytes (cells that produce cartilage) and brings them to the area of degeneration or injury.

These cells rebuild the collagen (more specifically, what is called the “collagen matrix” of the tissue) and enable it to strengthen and restore the body part in many cases to pre-injury status.

There is a long history of medical studies on the effectiveness of Prolotherapy for chronic musculoskeletal pain.

A February 2023 paper (1) wrote: “Prolotherapy is beneficial in a variety of different musculoskeletal conditions, including, but not limited to, lateral epicondylosis, rotator cuff tendinopathy, plantar fasciitis, Achilles tendinopathy, osteoarthritis, low back pain, sacroiliac joint pain, and TMJ laxity.”

A September 2022 paper (2) wrote: “(Knee Pain) and disability were significantly improved with prolotherapy and platelet rich plasma injections (PRP) compared with exercise therapy. Although PRP is more effective than prolotherapy in the first month after treatment, prolotherapy may be preferred due to its low cost, long-term efficacy, and low complication rates. . . ”

A September 2022 paper reported (3) that ultrasound-guided dextrose prolotherapy and corticosteroid injections had similar positive outcomes in alleviating pain in carpal tunnel syndrome. The benefit of using Prolotherapy is that dextrose would have less side-effects than the triamcinolone (steroid).

My story as a Prolotherapy patient

I love competition and was once one of the top gymnasts in the state of Illinois. Every sport I participated in, including golf and tennis, was performed with the precision of a gymnast. I am still not fulfilled unless I drive a golf ball 300 yards or ace my opponent with a rocket-speed tennis serve. I also lifted a lot of weights, occasionally until my arms turned black and blue.

By the time I was in my 20′s I had racked up my share of injuries. A fall during gymnastics landed me on my tail bone; a high-speed water skiing fall, among many other injuries, left me with back, neck and joint pain that persisted for years.

It wasn’t until I severely wrenched my right shoulder while lifting weights that I came to understand how medicine had failed pain sufferers and how Prolotherapy was a “miracle.”

After a year of failure with two cortisone injections and physical therapy to rehabilitate my shoulder, a “simple” arthroscopic surgery was performed. I was promised that I would be back to playing sports within three weeks.

After the surgery, in a story that is sadly too familiar, my shoulder became much worse. It blew up like a balloon filled with fluid. Enough so that when I walked, it sloshed.

It took a year after the surgery to return my shoulder to even the baseline pain I had experienced before the surgery. On top of this, chronic neck and back pain, and my right wrist, which had suffered years of abuse from the constant wear and tear of gymnastics, tennis and golf, was bothering me and I had a wicked case of tennis elbow. Pain was my constant companion. Like many of my patients, I learned to live with pain. After all, I “knew” there would never be a cure.

Being in chronic pain, I did worry that I would be crippled as the pain extended to different areas of my body. Many of the injuries I suffered in my teens and twenties, which I thought were healed, revisited me, one by one.

Then a light turned on. During my fourth year of residency in Physical Medicine and Rehabilitation (PM&R) at UCLA, I heard about Prolotherapy. Could it really help 80-90% of patients. What didn’t make sense was why none of us had heard about Prolotherapy.

I realized how traditional medicine failed those in pain.

Despite my aches and pains, I refused to stop playing sports. During one golf outing a misguided swing caused me enormous pain in my wrist. As I was swinging, I missed the ball and hit the ground with my club at about 100 miles per hour. My right wrist was forcefully hyper-extended causing me excruciating pain. The lingering pain was so intense I could barely write. Treatment did not help and the pain would not go away. I had to give up all sports except running. Needless to say, I was miserable.

I was invited me to a medical convention for the American Association of Orthopedic Medicine. During a workshop on Prolotherapy I happened to complain to one of the lecturers that my wrist was probably worse than the one he was describing. He quickly told me that he could fix my wrist with Prolotherapy.

When he explained to me that he would inject my wrist with dextrose and lidocaine, and that this would heal my injury. I had to hide my skepticism.

“Inject me with sugar water? He had to be kidding!”

After about 24 hours, my wrist felt about 50 percent better. How could this happen after months of pain with no improvement? I then went on to inject the wrist myself over the course of the next several weeks. It was after that when the miraculous occurred. My wrist healed. I could hardly believe it myself, but it was true!

I had also cured my tennis elbow and long standing shoulder pain with my own injections. On several occasions doctors have injected every vertebrae from my neck to my sacrum. I, thankfully, was back to playing hours of tennis! My sports life was regained.

After my own healing, I started to perform Prolotherapy on any of my patients I could convince to try it.

Now my Prolotherapy Practice has morphed to Platelet Rich Plasma and Stem Cells, proliferants much stronger and more efficacious than dextrose.


The idea of introducing an irritant to an injured joint certainly isn’t new. In ancient Greece, Hippocrates used heated metal probes to treat dislocated and painful shoulders of javelin throwers. He believed this technique created tough scar tissue that tightened the shoulder capsule and kept the joint in place.

George S. Hackett, MD, continued to build on Hippocrates’ theories in 1939. While working with car accident survivors, he realized that patients experienced pain when ligaments and tendons were injured. He believed that repairing connective tissue could resolve most of the pain. Dr. Hackett introduced an irritating compound to activate the body’s natural mechanisms and prompt production of new collagen tissues—a proliferation process that became known as Prolotherapy.

Also known as proliferation therapy, Prolotherapy is a pain management technique that can treat degenerative or chronic injury to ligaments, tendons, muscle fascia and joint capsular tissue. It also can be effective for areas that are painful, but not tender to the touch, such as the inside of a joint.

Through injections, Prolotherapy allows rapid production of collagen and cartilage. Collagen, a naturally occurring protein in the body, is a crucial element to the formation of new connective tissue. And healthy connective tissue creates a solid foundation to hold the skeletal infrastructure together.

Healing Mechanisms

Prolotherapy helps produce collagen by injecting mild chemical or natural irritants, such as dextrose—sugar. The injections stimulate the immune system’s healing mechanism to create collagen naturally. This strengthens and restores joints, which provides permanent pain relief.

Consider a condition such as chronic pain, in which injured, loose or stretched out ligaments often cause ligament laxity. Laxity produces pain and discomfort, especially during movements. This occurs because the connection of ligaments and tendons to bone may be inflamed, and a joint may be moving beyond its normal range of motion.

The body, therefore, must create collagen to heal injured tendons and ligaments. But it doesn’t provide ligaments and tendons with a proper blood supply, which means lower collagen production and a poor chance for complete healing.

The same holds true in cases of degenerative disease and aging. In particular, collagen may dry out and lose its stretching ability. This process is more severe in some people, and researchers don’t know why. Theories behind this include poor genetic makeup, blood type with specific dietary requirements, viral or bacterial load, pathological conditions, body acidity or food allergies.

In healthy ligaments or tendons, collagen fibers are flexible and elastic. But injuries can stretch fibers beyond their designed lengths, and repetitive motion frays or tears them. When tissues are stretched beyond their normal limits, inflammation occurs. A patient experiences inflammation, the immune system’s response to injury, when the body tries to heal damage. However, a weakened immune system or severe injury also can restrict the ability of ligaments and tendons to heal correctly. Since connective tissue around joints and cartilage has such poor blood circulation, injuries to connective tissue are often irreparable. In a future article we will go into great detail concerning Prolotherapy Injections and PRP treatment.

The key to prolotherapy is stimulating collagen development and growing new ligament and tendon tissue. By growing stronger ligaments and tendons, you can repair the injury, and reverse the degenerative cycle of arthritis and wear-and-tear disorders.

Injection Ingredients

Injection ingredients for Prolotherapy consist of compounds that alleviate chronic pain. To trigger the healing process, clinicians use mild chemical irritants, such as phenol, guaiacol or tannic acid.

After injection, these substances attach to cell walls to stimulate the body’s reactive healing process. Some clinicians prefer to use chemotactic agents, such as sodium morrhuate, a fatty acid derived from cod liver oil.

Osmotic shock agents—the most frequently used compounds in Prolotherapy—are simple compounds, such as dextrose and glycerine. They work by causing cells to lose water, which leads to cellular dehydration and then inflammation, triggering the healing response. Because these ingredients are water-soluble, they’re excreted from the body after producing the desired effect.

Practitioners can add cofactors, such as the anti-oxidant mineral manganese. Or they can use a combination of glucosamine sulfate and condroitin sulfate, which may aid arthritic joint repair. Based on the combinations of compounds, these cofactors may increase efficacy.

Research by Liu observed that efficacy. In a study of prolotherapy’s effectiveness, Liu injected a 5 percent sodium morrhuate solution into the medial collateral ligaments of rabbits. After five injections, the ligament mass increased 44 percent, thickness increased 27 percent, and strength of the ligament bone junction increased 28 percent.2

Liu’s research confirmed the results of an earlier study; Dr. Hackett and colleagues examined the proliferant Sylnasol when it was injected into rabbit tendons.3 After 48 hours, an early inflammatory reaction surrounding the nerves and blood vessels with lymphocytic (immune system cells that remove damaged tissue) infiltration occurred in the area between two tendons and the tendons and sheath.

Two weeks after injections, fibrous tissue existed. Lymphocytic infiltration had diminished, although small levels were present, which indicated that new white fibrous tissue was still being stimulated. One month after injection, fibrous tissue was present, and lymphocytic and fibroblastic (immune system rebuilding cells) activity had diminished. In other words, the rebuilding cells had finished their job and moved on.

  • Although Prolotherapy compounds work differently and motivate the body to heal through various natural responses, the end result is the same: It cures pain by building new tissue and stabilizing joints.

Before administering prolotherapy, you should examine a patient by carefully and gently pressing on an area suspected of causing pain. You’ll know where to apply the prolotherapy injection when your touch elicits an intense pain reaction—a trigger or tender point.

Most of the prolotherapy solutions have a “double-edged” effect and should produce anesthetic and proliferant qualities. For example, the anesthetic agent alleviates the “pain trigger” and lets you know a solution was placed in the proper area. Simultaneously, the proliferant agent begins strengthening ligaments and tendons at the trigger point or tender point site with the Prolotherapy Injections.

Injections at trigger points cause irritation that stimulates the body’s natural process for repairing damaged tissue. It does so by causing an influx of fibroblasts and chrondroblasts, the healing cells that create collagen and cartilage. Joints are gradually pulled back into proper alignment as newly produced collagen reinforces muscles, tendons and ligaments. Then, as collagen shrinks, it tightens the joint capsule and prevents excessive, unnatural movement.

The number of treatments and injections required per treatment are based on the type of injury. For example, two Prolotherapy treatments for patellofemoral syndrome of the knee (runner’s knee) will usually eliminate the pain. But for a more complex problem, such as bone-on-bone arthritis, it may take six to eight treatments over two months. Back and neck pain may call for a series of four to eight Prolotherapy Injections treatments overall.

Anti-inflammatory medications are contraindicated during Prolotherapy. And higher doses of NSAIDS, such as aspirin, ibuprofen, Celebrex or Vioxx, may inhibit the necessary inflammation and reduce the positive effects of Prolotherapy. Studies on chronic NSAID users actually show greater joint destruction, compared to patients who don’t take these medications.

Remember that every patient heals differently, and recovery depends on overall health status and how frequently a patient uses an affected area. Regardless of health status, prolotherapy may be the answer to effectively reduce or eliminate chronic pain.

1 Hsu C, Vu K, Borg-Stein J. Prolotherapy: A Narrative Review of Mechanisms, Techniques, and Protocols, and Evidence for Common Musculoskeletal Conditions. Physical Medicine and Rehabilitation Clinics. 2023 Feb 1;34(1):165-80.
2 Ceylan CM, Sahbaz T, Karacay BC. Demonstrating the effectiveness of Platelet Rich Plasma and Prolotherapy treatments in knee osteoarthritis. Irish journal of medical science.
3 Babaei-Ghazani A, Moradnia S, Azar M, Forogh B, Ahadi T, Chaibakhsh S, Khodabandeh M, Eftekharsadat B. Ultrasound-guided 5% dextrose prolotherapy versus corticosteroid injection in carpal tunnel syndrome: a randomized, controlled clinical trial. Pain Management. 2022 Jun;12(6):687-97.

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