What is Prolotherapy and how does it treat chronic joint pain?

Prolotherapy is a simple, non-surgical injection technique that stimulates the body’s immune system to repair painful joints.

Prolotherapy is considered an alternative treatment for:

  • commonly prescribed anti-inflammatory medications
  • pain medications
  • cortisone or steroid injection
  • surgery and joint replacement

The basic concept of Prolotherapy is simple. A proliferant (something that awakens and ignites the immune system’s healing process) is injected into damaged joint and spinal ligaments or tendons, which leads to local inflammation.

The localized inflammation triggers a wound healing cascade, resulting in the deposition of new collagen, the material that ligaments and tendons are made of. New collagen shrinks as it matures. The shrinking collagen tightens the ligament that was injected and makes it stronger. Prolotherapy has the potential of being 100 percent effective at eliminating and chronic pain due to ligament and tendon weakness, but depends upon the technique of the individual Prolotherapist. The most important aspect is injecting enough of the solution into the injured and weakened area. If this is done, the likelihood of success is excellent.

Prolotherapy involves the treatment of two specific kinds of tissue: tendons and ligaments. A tendon attaches a muscle to the bone and involves movement of the joint. A ligament connects two bones and is involved in the stability of the joint. A strain is defined as a stretched or injured tendon; a sprain, a stretched or injured ligament. Once these structures are injured, the immune system is stimulated to repair the injured area. Because ligaments and tendons generally have a poor blood supply, incomplete healing is common after injury.This incomplete healing results in these normally taut, strong bands of fibrous or connective tissue becoming relaxed and weak. The relaxed and inefficient ligament or tendon then becomes the source of chronic pain and weakness.

The greatest stresses to the ligaments and tendons are where they attach to the bone, the fibro-osseous junction. The most sensitive structures that produce pain are the periosteum (covering of the bone) and the ligaments. It is important to note that in the scale of pain sensitivity (which part of the body hurts more when injured), the periosteum ranks first, followed by ligaments, tendons, fascia (the connective tissue that surrounds muscle), and finally muscle. Cartilage contains no sensory nerve endings. If you are told that your cartilage is the cause of your pain, you have been misinformed; the cartilage cannot hurt because they contain no pain sensing nerves. If there is cartilage damage, the ligaments are typically the structures that hurt. Ligaments are weakest where they attach to bone. The periosteum is the most sensitive area to pain and the ligaments second. It is now easy to understand why this area hurts so much. This is where the Prolotherapy injections occur, and thus eliminate the chronic pain of many conditions including arthritis, mechanical low back pain, degenerative disc disease, cartilage injury, and sports injuries.

Prolotherapy works by exactly the same process that the human body naturally uses to stimulate the body’s healing system, a process called inflammation. The technique involves the injection of a proliferant (a mild irritant solution) that causes an inflammatory response which “turns on” the healing process. The growth of new ligament and tendon tissue is then stimulated. The ligaments and tendons produced after Prolotherapy appear much the same as normal tissues, except that they are thicker, stronger, and contain fibers of varying thickness, testifying to the new and ongoing creation of tissue. The ligament and tendon tissue which forms as a result of Prolotherapy is thicker and stronger than normal tissue, up to 40% stronger in some cases!

Prolotherapy for you?

Prolotherapy is superior at curing chronic pain and, most importantly, getting people back to a happy and active lifestyle. Since this website may be your introduction to Prolotherapy, let us first present you with a case that may be very familiar to you. In fact, this person may be YOU! Your physical pain is standing between the activities you once enjoyed: golf, swimming, running. Eventually, it is standing between you and your ability to work or play with your children or grandchildren. Once you decide it is bad enough to seek a professional medical opinion, the patient’s scenario goes something like this:

  • Visits numerous allopathic and university specialists without success.
  • Tries chiropractic treatments.
  • Tries physical therapy.
  • Tries massage therapy.
  • Begins prescription anti-inflammatory medications.
  • Moves to stronger prescription anti-inflammatory medications.
  • Decides to get a cortisone shot.
  • Receives a nerve block.
  • And finally, receives SURGERY!

The end result of this scenario is that the patient continues to suffer with the painful condition for an even longer duration of time. Even worse, the patient has spent a lot of time and money with no resolution of the pain. What a terrible fate!

Why does this happen to millions of people? The answer: None of the treatments in this scenario actually fix the root cause of the patient’s problem. What gives Prolotherapy patients a higher chance at permanently curing the pain is the fact that Prolotherapy is aimed to fix the root cause of the problem, ligament and tendon weakness resulting in underlying joint instability. Throughout this book you will learn in greater detail why and how this happens and how Regenerative Medicine works to cure pain, not just cover it up.

The basic mechanism of repairing joint instability and pain with Prolotherapy is simple.

  • Prolotherapy dextrose solutions are injected into the painful areas, which produces local inflammation in the injected area(s).
  • The localized inflammation triggers a wound-healing cascade, resulting in the deposition of new collagen. New collagen shrinks as it matures. The shrinking collagen tightens the ligaments that were injected and makes them stronger and more secure, thus stabilizing the unstable joint(s).

Hackett-Hemwall dextrose Prolotherapy stimulates repair of a painful area. The primary proliferant, dextrose, sets off the healing cascade in the injected area, attracting immune cells to the degenerated structure for the purpose of repair and healing.

Prolotherapy has the potential of being 100% effective at eliminating sports injuries and chronic pain, depending upon the technique of the individual Prolotherapist and the extent of the comprehensive healing program. One of the most important aspects of healing is injecting enough of the right type of solution into the entire injured and weakened area(s). If this is done, the likelihood of success is excellent.

In the experience of many Prolotherapy doctors, most neck, back, knee, and other musculoskeletal pains are due to weakness, specifically weakness in the ligaments and tendons, which in turn, leads to joint instability.

Prolotherapy is superior at curing chronic pain and, most importantly, getting people back to a happy and active lifestyle. Since this may be your introduction to Prolotherapy, let us first present you with a case that may be very familiar to you.

In some painful conditions, cellular proliferants are needed for the desired healing effect. These cases can be treated with Cellular Prolotherapy, which utilizes a person’s own (called “autologous”) growth factors and stem cells as the primary proliferant, delivering them directly to the injured area. As with all types of Prolotherapy, the goal is to assist the body in repair of the injured structures with tissues that are functionally,  structurally, and mechanically equivalent to the pre- injured or pre-damaged tissue, along with elimination of pain and the return to full activities and sports.

A joint is only as strong as its weakest ligament

Simply put, pain is due to weakness. In our experience, most neck, back, knee, and other musculoskeletal pains are due to weakness, specifically weakness in the ligaments and tendons, which in turn, leads to joint instability.

  • George S. Hackett, MD, grandfather of Prolotherapy, stated, “A joint is only as strong as its weakest ligament.” He further stated, “Ligament relaxation is a condition in which the strength of the ligament fibers has become impaired so that a stretching of the fibrous strands occurs when the ligament is submitted to normal or less than normal tension.”(1)

This statement was made many years ago by Dr. Hackett, who believed chronic pain was simply due to ligament weakness in and around the joint. Dr. Hackett coined the phrase “ligament and tendon relaxation,” which is synonymous with ligament and tendon weakness, and subsequently developed the treatment known as Prolotherapy.

  • Webster’s Third New International Dictionary defines Prolotherapy as “the rehabilitation of an incompetent structure, such as a ligament or tendon, by the induced proliferation of new cells.”(2)

For more citations on Research into the use of Prolotherapy.

Prolotherapy stimulates structures to repair and strengthen, thus it can eliminate most structural musculoskeletal pain located anywhere in the body. When the body sustains significant force or trauma, an injury will occur either where the force is greatest or at the structures’ weakest point(s). In the musculoskeletal system, the weak link in the system is typically located in the joints and the structures that hold them in place. The force is typically felt in the ligaments, especially if there is a rotatory component to the stress. Ligaments are injured at the point(s) where they attach to the bone(s) which is known in Prolotherapy circles as the fibro-osseous junction or in traditional medicine circles the enthesis (singular; plural is entheses). When we discuss proper Prolotherapy technique, we say that the needle touches the bone at the point where the ligament attaches to the bone; thus Prolotherapy injections are strengthening the entheses; with the exception of intra-articular joint injections which are given inside the joints.


The enthesis is the point at which the connective tissue structures, such as a joint capsule, fascia, ligament, tendon, or muscle attach to the bone. Pathology (cause of disease) in the enthesis is called an enthesopathy. The term enthesopathy typically refers to a degenerated enthesis; though when modern medicine uses this term, they typically mean enthesitis. The problem occurs when allopathic physicians think every pain is due to inflammation and subsequently prescribe NSAIDs and corticosteroid shots


A true systemic inflammatory condition causes a true enthesitis, which occurs in conditions such as chondrocalcinosis, diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, Reiter’s syndrome, rheumatoid arthritis, psoriatic arthritis, and other spondyloarthropathies.

There may be a limited role for anti-inflammatory medications in these conditions, but we can assure you that none of these conditions are caused by an “ibuprofen deficiency!” A comprehensive assessment by a qualified practitioner is needed to cure these types of conditions. We review things in the patient’s life that might be producing stress on the body, including the foods consumed, job, family relationships, and emotional state.

A person with a systemic inflammatory condition is more likely to be taking anti-inflammatory or immune-suppressive medications. These medications make the patient less likely to heal a ligament or tendon injury when it occurs. Everyone sustains some kind of injury every once in a while, such as a sprained ankle. In these cases we still utilize Prolotherapy for people suffering with various spondyloarthropies such as ankylosing spondylitis and autoimmune diseases such as systemic lupus erythematosus or rheumatoid arthritis, however, we recommend that the underlying systemic inflammatory condition be treated.

  • It is becoming clear through medical research that the area where a ligament and tendon attaches, the enthesis, should really be called “the enthesis organ.”(3).
  • This is a specialized area of the musculoskeletal system that contains fibrocartilage and other adjacent or congruous structures such as articular cartilage fat pads, bursae, or synovium.(4,5)

This “organ” may be damaged like any organ of the body. In our experience, the entheses are typically damaged by medications. NSAIDs and corticosteroids are the most common culprits, but the medical literature contains many studies and case reports on various antibiotics damaging these structures, especially the quinolone antibiotics.(6,7,8)

Most tendinopathies are actually enthesopathies; thus the injury occurs to the tendon where it attaches on the bone.  Steroid injections and other medications specifically have been shown to weaken this area.(7,8) Fortunately there is a treatment that is specifically designed to strengthen the entheses: Prolotherapy!

The major cause of degenerative arthritis, chronic pain, and injury is joint instability. Most structural chronic painful conditions involve ligament laxity.Most tendinopathies are caused by joint instability and ligament laxity. To cure these conditions, it is typically best to treat all or most of the ligaments of an unstable joint if that joint and/or its surrounding structures are painful to palpation. Many injections are needed to produce enough of a healing reaction to restore proper joint function to an unstable painful joint. It is a lot like spot welding.

Because the solutions are safe and well-tolerated, many joints and structures can be treated at the same visit. The neck, thoracic, and low back facet joints can also be thoroughly and safely treated without the need of fluoroscopy, which keeps costs down.

With a comprehensive approach, we utilize many different types of Prolotherapy solutions, individualizing each treatment according to the patients’ unique needs. The solutions are changed depending on the individual patient and the amount of inflammatory reaction required to produce sufficient healing and new collagen growth. We use natural ingredients that can be added to the dextrose-based solutions, such as minerals, fatty acids, and hormones; and of course, cellular proliferants such as blood, PRP (platelet rich plasma), bone marrow, and stem cells.

Comprehensive Prolotherapy is typically well-tolerated and does not require use of narcotic medications or NSAIDs, and certainly not steroid injections. Most patients receive treatments and are able to return to work the same or next day. Immediately following Prolotherapy treatments, we ask our patients to refrain from vigorous exercise for at least 4 days. After that, the patients are allowed to let their bodies be their guides.

Results speak for themselves! We have documented our patient results in many published papers which we will review in more detail throughout this book. Suffice it to say, we can unequivocally state that Prolotherapy is effective at producing pain relief in greater than 90% of the patients.

Prolotherapy for joint instability

Would you like more information about Prolotherapy?

1 Hackett G, et al. Ligament and Tendon Relaxation Treated by Prolotherapy. Third Edition. Springfield, IL: Charles C. Thomas, 1958, pp. 5.
2 Babcock P, et al. Webster’s Third New International Dictionary. Springfield, MA: G. & C. Merriam Co., 1971. pp. 1815.
3 Benjamin M, Moriggl B, Brenner E, Emery P, McGonagle D, Redman S. The “enthesis organ” concept: why enthesopathies may not present as focal insertional disorders. Arthritis & Rheumatology. 2004 Oct 1;50(10):3306-13.
4 Slobodin G, Rozenbaum M, Boulman N, Rosner I. Varied presentations of enthesopathy. In Seminars in arthritis and rheumatism 2007 Oct 31 (Vol. 37, No. 2, pp. 119-126). WB Saunders.
5 Shaibani A, Workman R, Rothschild BM. The significance of enthesopathy as a skeletal phenomenon. Clinical and experimental rheumatology. 1993;11(4):399-403.
6 Corrao G, Zambon A, Bertù L, Mauri A, Paleari V, Rossi C, Venegoni M. Evidence of tendinitis provoked by fluoroquinolone treatment. Drug safety. 2006 Oct 1;29(10):889-96.
7 Blanco I, Krähenbühl S, Schlienger RG. Corticosteroid-associated tendinopathies. Drug safety. 2005 Jul 1;28(7):633-43.
8 Haraldsson BT, Langberg H, Aagaard P, Zuurmond AM, van El B, DeGroot J, Kjær M, Magnusson SP. Corticosteroids reduce the tensile strength of isolated collagen fascicles. The American journal of sports medicine. 2006 Dec;34(12):1992-7.