02/23/2015    Robert Kornfeld, DPM

Prolotherapy for Plantar Fasciitis (Richard Benjamin, DPM)

I have been using prolotherapy for over 15 years
with great success. But it behooves every
practitioner to understand that you can NEVER
evaluate any therapy on its own as the only
statistical barometer of efficacy. Realize that
the indication for prolotherapy is to stimulate
connective tissue healing in CHRONIC conditions.

This is the MOST important information because it
tells you that you already have a patient whose
immune system is struggling to heal. So before you
make a diagnosis and fill your syringe as the
"answer" to the problem, the reasons why this
patient's immune system was not up to the task of
healing MUST be identified. Once these mechanisms
have been identified and addressed, then you can
begin using a therapy such as prolotherapy. Its
design is to stimulate the repair process, but
will not work in patients who continue to have
unaddressed immune burdens.

This is where statistical analysis fails to reveal
its true value. If all we do is take these chronic
pain patients and begin injecting proliferants, it
is nothing more than hit or miss. This skews the
statistics toward failure. As a profession
specializing in foot and ankle pathology, we need
to remember that we are not treating a foot or
ankle problem, we are treating patients with foot
or ankle problems. Each presents with their own
unique genetics, epigenetics and physiology. The
future of any and all successfully implemented
protocols MUST include a complete assessment of
WHY this patient is presenting with this
condition.

So, when treatments such as prolotherapy are
administered on a patient-specific basis with an
understanding of that patient's unique immune
challenges, the statistics will reveal a powerful
and potent therapy that in my opinion is largely
misunderstood and misused.

Robert Kornfeld, DPM, Port Washington, NY

Other messages in this thread:

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02/21/2015    David T. Weiss, DPM

Prolotherapy for Plantar Fasciitis (Richard Benjamin, DPM)

I feel compelled to comment on the inquiry
regarding prolotherapy. This treatment has been
helpful for me in treating many muskuloskeletal
problems that we see as podiatrists. Simply put,
prolotherapy counts on the body’s own ability to
heal itself. I spent a lot of time with a
physiatrist (MD) who helped me learn these
techniques. My father was a chiropractor, and I
have always kept an open mind to “alternative
health techniques.”

There are many types of injections that can be
used to trigger a healing response in tissue.
Common substances include sodium morrhuate, 50%
dextrose, and more popular, PRP (platelet rich
plasma). I have been performing Topaz
radiofrequency ablation for over 15 years, and
have experienced similar good results.

Radiofrequency ablation is a form or prolotherapy.
These “non-surgical” techniques for recalcitrant
muskoloskeletal pain certainly are an intelligent
way to help our patients. They don’t work for
everyone, but when they do, it makes complete
sense - especially when one is quick to jump to
irreversibly change the anatomy in one of our
patients.

We are seeing cases of plantar fascioses, Achilles
tendinosis, TPT and peroneal tendon
enthesiopathies, and mild plantar plate
pathologies responding to prolotherapy. The
treatment is not intended for an acute
inflammation, but for the more stubborn chronic
condition (fasciosis).

The key to success is understanding when to use
the injection, and the type of patient that will
respond. We get the best results on younger, more
active healthy patients, who are non-smokers.
Remember, we are relying on the patient’s own
collagen to repair itself, and with the help of
chemical mediators of inflammation, stop pain.

We get worse outcomes in those patients who are
smokers, diabetics, and obese.

There are many prolotherapy resources on the
Internet, and the research on this technique is
getting more plentiful and popular. Double-blind
studies have been done, and they are encouraging.

David T. Weiss, DPM, Richmond, VA

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02/21/2015    David Secord, DPM

Prolotherapy for Plantar Fasciitis (Richard Benjamin, DPM)

Prolotherapy is being employed here and with some
interesting agents (although not unknown agents).
A number of agents used in the past for
prolotherapy include extracts from several plants,
the least unfamiliar being psyllium seed extract
or Sylnasol, a product no longer available, and an
extract from fish oil, still available in the
pharmacopeia - sodium morrhuate.

The chief proliferant agents as judged by the
frequency of usage are, however: 1. Glucose, 2.
Glycerin and 3. Phenol. They are usually used in
the following combination:
phenol 1.25%
glucose 12.5%
glycerin 12.5%
made up with 0.5% of lidocaine for local analgesia
in water. (This preparation is also called P25G or
P2G).

Klein [1] and Banks [2] have classified the
injectable proliferating solutions that initiate
the wound healing cascade into: 1) Irritants,
which cause a direct chemical tissue injury, which
attract granulocytes. Phenol, quinine and tannic
acid are agents in this category, 2) Osmotic shock
agents, which cause bursting of cell membranes
leading to local tissue damage. Hyperosmolar
dextrose (12.5 to 15% maximum) and glycerin are
examples of the most commonly used agents in this
category, 3) Chemotactic agents, which activate
the inflammatory cascade. Sodium morrhuate is a
prototype of this group. These compounds are the
direct biosynthetic precursors of the mediators of
inflammation, i.e., prostaglandins, leukotrienes,
and thromboxanes, 4) Particulates, such as pumice
flour, which are small particles on the order of 1
micron, which lead to longer-lasting irritation
and the attraction of macrophages to the site.

The modern use of sclerotherapy hails to the
herniologists of the era which antedated
antiseptic surgery. In 1837 Valpeau of Paris
described the use of scar formation in hernias for
their repair. The genealogy of herniology, and
later the management of hydroceles and a variety
of vein sclerosis techniques, was reviewed
extensively earlier this century by Yeomans [3]
and the tradition of vein sclerosis persists into
contemporary medical times.

Earl Gedney, an osteopath from Philadelphia
familiar with the sclerosing techniques of
herniologists and venologists, was the first to
introduce injection techniques for ligaments in
1937. [4] Gedney injected a hypermobile SIJ first
with salutary results. The term sclerotherapy
continued to be used for about two decades until
the mid-1950s when the great organizer of
prolotherapy, George Hackett, MD, acquired the
skills of injection techniques from the
osteopathic profession, evaluated its benefit in
an initial series of studies, and published a
number of articles about his experiences.

The idea of sclerotherapy or prolotherapy is
tightening of a capsule or ligamentous structure
via initiation of an inflammatory cascade and the
formation of scar tissue and tightening of the
structure. How this would apply in the treatment
of plantar fascial pain or fasciosis is beyond me.

1 Klein 1995 The theory and practice of
prolotherapy, 12th Annual AAOM Meeting
PalmSprings, California.
2 Banks A 1991 A rationale for prolotherapy.
Journal of Orthopaedic medicine 13:3 199 54-59.
3 Wollf J 1870 Die innere Architektur der Knochen.
Arch Anat Phys 50.
4 Gedney EH 1937 Hypermobile joint. Osteopathic
Profession 4:30-31.

David Secord, DPM, Corpus Christi, TX