In this article we will present three non-surgical treatment options for chronic ankle pain. Prolotherapy, Platelet Rich Rich Plasma Therapy, and Stem Cell. In this retrospective observational study of chronic unresolved ankle pain, Hackett-Hemwall dextrose prolotherapy helped promote a. The ankle is the joint where the human foot and leg meet, consisting of a complex network of bones, ligaments, tendons and muscles. The ankle is strong.

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The aim of this review was to identify and evaluate existing research to determine the clinical effectiveness and safety of prolotherapy injections for treatment of lower limb tendinopathy and fasciopathy. Methodological quality of studies was determined using a modified evaluation tool developed by the Cochrane Musculoskeletal Injuries Group.

Data analysis was carried out to determine the mean change of outcome measure scores from baseline to final follow-up for trials with no comparative group, and for randomised controlled trials, standardised mean differences between intervention groups were calculated. Pooled SMD data were calculated where possible to determine the statistical heterogeneity and overall effect for short- intermediate- and long-term data.

Adverse events were also reported. Two hundred and three studies were identified, eight of which met the inclusion criteria. These were then grouped according to tendinopathy or fasciopathy being treated with prolotherapy injections: Achilles tendinopathy, plantar fasciopathy and Osgood-Schlatter disease.

The methodological quality of the eight included studies was generally poor, particularly in regards to allocation concealment, intention to treat analysis and blinding procedures. Results of the analysis provide limited support for the hypothesis that prolotherapy is effective in both reducing pain and improving function for lower limb tendinopathy and fasciopathy, with no study reporting a mean negative or non-significant outcome following prolotherapy injection. The analysis also suggests prolotherapy injections provide equal or superior short- intermediate- and long-term results to alternative treatment modalities, including eccentric loading exercises forAchilles tendinopathy, platelet-rich plasma for plantar fasciopathy and usual care or lignocaine injections for Osgood-Schlatter disease.

No adverse events following prolotherapy injections were reported in any study in this review. The conclusions of this review were derived from the best available scientific evidence. It is intended that the results of this study will assist clinical decision-making by practitioners.

The results of this review found limited evidence that prolotherapy injections are a safe and effective treatment for Achilles tendinopathy, plantar fasciopathy and Osgood-Schlatter disease, however more robust research using large, methodologically-sound randomised controlled trials is required to substantiate these findings.

The online version of this article doi: Lower-limb pain has been identified as a risk factor for locomotor disability, impaired balance, increased risk of falling and reduced health-related quality of life [ 1 ].

Causes of lower limb pain are varied, including but not limited to, osteoarthritis, previous trauma, inflammatory and overuse injuries [ 12 ]. Current non-surgical treatments for lower-limb musculoskeletal pain include activity modification, physical therapy, therapeutic ultrasound, extracorporeal shock wave therapy, dry needling, strapping, foot orthoses, mobilisations, corticosteroid injection, platelet-rich plasma injection and prolotherapy injection [ 12 ].

It is an increasingly popular regenerative injection technique for treatment of a wide range of musculoskeletal pathologies [ 3 ]. Most prolotherapy research focuses on its use in sprained and degenerated ligaments, however it is also reported to be an effective treatment for concomitant pain and joint dysfunctions caused by laxity of damaged periarticular dense connective tissues, and can be applied to other damaged dense connective tissues structures such as tendons and entheses [ 4 — 12 ].

The most commonly used prolotherapy substance reported in current literature is dextrose, a simple aldostic monosaccharide synonymous with glucose that is readily available in Australia and the United Kingdom in various concentrations [ 12 ]. The mechanism of action, safety and efficacy of dextrose prolotherapy is well represented in current literature.

It is hypothesised that injection of dextrose causes local cell necrosis as a direct result of osmotic shock [ 5 ]. As stresses are placed on the new tissue, the collagen fibres align in the direction of the stress [ 11 — 13 ].

The effect of dextrose on the biomechanical aknle of human tendons and the histological analysis are as yet unknown [ 5 ].

According to deChelli et al. Several case-series reports of participants prolothsrapy anterior cruciate ligament laxity, coccygodynia, abdominal tendinosis and chronic back, hip adductor, ankle, foot and first metatarsophalangeal pain have also reported in favour of prolotherapy, however the poor methodological quality of these studies significantly reduces the weight of these findings [ 22 — 29 ].


Prolotherapy has been reported with increasing frequency in recent literature for treatment of chronic, painful lower-limb tendon and fascia overuse conditions [ 30 — 37 ]. Most prominently in the lower-limb, these include Achilles tendinopathy and plantar fasciopathy [ 30 — 36 prolotherap. Recent evidence also suggests that prolotherapy prolothfrapy may be an effective treatment for painful traction apophysitis pathologies through treatment of associated tendinopathy; such as patellar tendinopathy associated with Osgood-Schlatter disease [ 37 ].

In this situation, it is speculated that prolotherapy may reverse the neovascularisation accompanying tendinopathy and fasciopathy and prolotherappy the release of multiple growth factors that aid in tissue repair [ 37 ]. In examining the safety of prolotherapy, Dorman conducted a retrospective analysis ofparticipants who all underwent prooltherapy injections for various pathologies [ 38 ].

Dorman reported that very few adverse effects were found following prolotherapy injections and of these, the majority of serious complications were overwhelmingly in areas of the body outside the lower limb [ 38 ]. These included 29 reports of pneumothoraces, 24 proltoherapy of allergic reactions none classified as serious and 12 other reports of hospitalisation [ 38 ].

Prolotherapy has been suggested to be a safe and effective treatment for a range of axial and upper limb pathologies. The aim of this study was to review the clinical effectiveness and safety of prolotherapy injections for treatment of lower limb tendinopathy and fasciopathy. The types of studies considered for this pdolotherapy included both randomised and non-randomised trials, cohort studies, case-series, cross-sectional studies and controlled trials.

Exclusion criteria included retrospective studies without a comparative control group, case reports, systematic reviews, review articles and general articles. While the authors would have preferred to include only randomised or quasi-randomised controlled trials in this review this would have significantly reduced the number of studies included in the analysis. Studies involving non-human participants i. All age groups and both sexes were included.

Prolotehrapy undertaken where no specific treatment was reported were excluded. Outcomes sought included both objective and subjective outcomes. One reviewer LS conducted all screening of identified studies according to the pre-determined inclusion criteria.

The Cochrane library was searched initially to ensure no systematic reviews had previously been conducted on this topic. Titles and abstracts were screened initially and those found to be irrelevant were excluded prior to screening full-text manuscripts.

Citations within obtained articles were hand-searched and scrutinised to identify additional studies. The relevant databases on the above list were searched for completed published, unpublished and ongoing unpublished studies. Conference proceedings were examined using the Index to Scientific and Technical Conference Proceedings [ 42 prolotherpay.

Attempts to access the grey literature were made using the Health Management Prlotherapy Consortium database, and System for Information on Grey Literature.

Dextrose Prolotherapy Injections for Chronic Ankle Pain

Attempts to access prolothrrapy written in languages other than English were made using orolotherapy Virtual Health Library and foreign language articles with abstracts were assessed. All relevant review articles and systematic reviews were also analysed to ensure no other relevant studies were missed.

An assessment of methodological quality was undertaken by one assessor LS using an evaluation tool developed by the Cochrane Musculoskeletal Injuries Group, which was modified for use in this systematic review.

The following aspects of internal and external validity were considered:. SPSS software version ankkle The standardised mean difference SMD; difference in mean effects between groups divided by the pooled standard deviation was calculated for studies with a control group or multiple interventions. If the difference in mean effects between groups was not available, the SMD was calculated from the post-intervention mean scores and corresponding standard deviation. The authors of one study, Yelland et al.

Ankle and Foot Treatment with Prolotherapy

SMD values of 0. Pooled SMD data were also calculated where possible to determine the statistical heterogeneity and overall effect for short- intermediate- and long-term data. A total of studies were identified through electronic search.

Following the review of titles and abstracts, 26 studies were extracted for full review and finally, 8 studies were considered appropriate for inclusion Additional file 1. The reasons for the exclusion of studies are available in Additional file 2. A flow diagram, as described by Moher et al.


The included studies were assigned to one of three categories, based on the following comparisons: Five studies were included in the Achilles tendinopathy section, two studies in the plantar fasciopathy section and one study in the Osgood-Schlatter Disease section of the review.

All studies that met the inclusion criteria reported dextrose as the primary prolotherapy agent. The methodological quality of the studies in this review was generally poor. Allocation concealment the procedure for protecting the randomisation process so that the treatment to be allocated is not known before the participants enter into the study was poorly conducted in the majority of studies analysed in this review.

The trials by Topol et al. All studies scored poorly for participant blinding, which is particularly difficult in injection intervention trials, with Topol et al.

Only Anklee et al. In general, the selection of outcome measures was clinically appropriate and the duration of prolotherapyy was adequate. The blinding of assessors was attempted in only prolotgerapy trials, although it is recognised that it may be difficult to blind an assessor when there may be evidence of the procedure being undertaken from post-injection signs. Many studies also failed to conduct, or provide data for, intention to treat analysis. Although all studies had reasonable scores regarding the definition and usefulness of outcome measurements item Ithey were generally very poor in quality regarding intention to treat analysis item B and blinding procedures items C, Dalthough this may not have been possible in several of the studies.

Lyftogt [ 30 ] conducted a prospective case-series of 16 wnkle with non-insertional Achilles tendinopathy, to evaluate the clinical effectiveness of prolotherapy for relieving painful symptoms. Ninety-nine participants 58 men and 48 women with painful midportion 86 and insertional 22 Achilles tendinopathy pain received the same prolotherapy regimen, outcome measures and treatment schedule as described by Maxwell et al.

Dextrose Prolotherapy Injections for Chronic Ankle Pain

The participants were randomly allocated using a computer-generated randomisation schedule to receive prolotherapy injections alone 15 participantseccentric loading exercisesalone 14 participants or a combination therapy of prolotherapy and eccentric loading exercises 14 participants. Posterior photograph of right lower leg showing injection points most commonly used by Yelland et al.

Participants with odd participant sequence numbers were allocated to the prolotherapy group 11 participantswhile participants with even sequence numbers were placed in the autologous platelet-rich plasmagroup 10 participants. The injection procedure was peolotherapy under aseptic conditions using a gauge needle. Both interventions consisted of two injections at 2-weekly intervals.

Outcome measures including the Foot Function Index FFI and VAS pain were recorded at baseline and the final treatment consultation, with a follow-up telephone interview conducted a mean pgolotherapy Plantar photograph prolptherapy left foot illustrating the injection site used by Kim et al.

In the only study included in this analysis that assessed prolotherapy injections for Prolotherxpy Disease, Topol et al.

Participants mean age Locations and technique for the lignocaine and pgolotherapy injections can be seen in Fig. This study assessed sport alteration and sport-related symptoms in adolescent athletes with Osgood-Schlatter Disease. The orange lines represent the attachment of the patellar tendon from the patella to the tuberosity or its fragments. Meta-analysis was only possible for three of the included studies.

SMDs were calculated for Yelland et al. Data from the remaining five studies could not be pooled due lack of a comparator group, and qualitative and quantitative analysis of all individual studies are discussed in the following pathology-specific sections.

Standardised mean differences SMD for improved pain after prolotherapy vs comparator intervention for plantar fasciopathy, Porlotherapy Schlatter disease and Achilles tendinopathy. Five studies of moderate to good methodological quality involving participants reported on management of painful Ptolotherapy tendinopathy with prolotherapy injections. All five studies reported a significant reduction in pain following prolotherapy treatment.

Lyftogt [ 30 ] reported a mean reduction in VAS pain score of In another study, Lyftogt [ 31 ] reported a mean reduction in VAS scores for three different prolotherapy regimens with results as follows:

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