I have to thank my deceased and beloved friend, Richard Bachrach, and his lovely wife, Leslie. Richard, for making a believer out of me; and Leslie, for giving me the impetus to carry the ball after Richard passed away. Richard was an avid practitioner of prolotherapy, an injection technique which has been used worldwide since 1935. The technique, simply, requires a carefully-placed injection, which in the foot can be done with a very thin-bore needle, thus relatively painlessly. The substances injected are a tiny bit of dextrose, or sterile sugar-water, and lidocaine, a local anaesthetic, although other anaesthetics can be used if there is allergy to this substance.
The technique establishes integrity to small ligament tears, by injecting the substances (which are pre-mixed together in the syringe, thus requiring only one injection per ligament) at the interface of bone and ligament, which is the source of the fibroblasts, or scar cells, which mend ligaments. Thus it is important to be able to localize this interface, and also establish if there is a tear, and the extent of the tear. Complete ligament tears do not usually respond favorably to prolotherapy, and may require surgery or constant braces or reduced activity. Partial-thickness tears often heal unsatisfactorily via therapy or temporary brace usage. It is for these cases that I’ve received many hundreds of referrals from orthopedists and physical therapists who as I do treat top professional dancers and athletes. Of course, I also offer prolotherapy to non-dancers/athletes. It also works, and usually more quickly, for them.
Essential to my confidence in using this technique and achieving a good outcome are two things. First, the maintenance of cleanliness and sterility at the injection site. Besides the de rigueur policy I’ve had in my office of a nightly cleaning service, plus an additional separate Friday evening office detailer, and wiping all patient contact surfaces with disinfectant after each patient for the past 35 years, I triple scrub the bottle top containing the solution with alcohol, triple scrub the injection site with alcohol, and then proceed to scrub the injection site further with a Hibiclens® (pre-operative skin cleanser) swab for thirty seconds prior to the injection. If I am using the ultrasound probe to watch needle placement during the injection, I will use a sterile probe cover and sterile ultrasound gel.
Secondly, confidence in and reliance upon my ultrasound diagnostic skills. I have now performed an ultrasound scan on over three thousand patients since 2007. I have leased nine ultrasound machines, each successor a technological upgrade. With this machine, a skilled operator can detect pathology down to one-tenth millimeter in size. When dealing with structures in the foot such as the tiny ligaments and tendon retainers (retinacula) often injured, the sensitivity of the ultrasound machine far exceeds that of an MRI. Additionally, the ultrasound machine can detect injuries which are not evident on the MRI, as one must remain absolutely still during MRI. With ultrasound, bones, joints and tendons can be moved into theoretically-challenging positions, which only then might evince an image which demonstrates the pathology.
My ultrasound scanner enables me to perform an instant, objective evaluation of how a patient’s injury is responding to treatment. Reliability is enhanced as the scan is being done by the same examiner and employing a standardized technique. I always try to use bony landmarks to zero in on the same area of pathology from treatment to treatment. Ultrasound can also determine if a mass is vascularized, like most tumors, or simply a cyst or scar tissue, lacking inordinate blood supply.
If the injection site is tiny enough that I do not need the ultrasound probe for guidance, I will skin-marker a ring whose center is at the ligament-bone interface I wish to target, then insert until I feel the interface with the needle, then inject.
As prolotherapy, like prp, is trying to induce a “construction project” in the foot (moderately-robust scar formation at the site of the damage), a component of which is inflammation, it is important that my patient take no anti-inflammatories (aspirin, advil, bufferin, ibuprofen, aleve, motrin, Indocin, voltaren, etc.,) for 7-10 days prior to the prolo shot, and at least as many days (I’d prefer 30) after the shot. One baby aspirin might quell the results of the shot. Additionally, it is advisable to rest from vigorous activity for at least 7-10 days after the shot, and use taping or other supports for weight bearing injuries during initial healing.
Parenthetically, prp (platelet-rich plasma) injections are of a patient’s blood, centrifuged to separate the platelets and plasma, thus platelet-rich plasma, or “prp”. Prp is useful for tendon injuries which often occur so far away from the bone that prolotherapy would be less effective. Prp is injected into the tendon, which requires ultrasound guidance, thus three individuals often take part in this technique: an ultrasound technician who holds the probe, the interventional radiologist performing the injection, and a phlebotomist, who draws the blood. I have not performed prp injection for some years now, as I am delighted there now finally exist competent facitlities where the technique can be done efficiently and effectively. Prp works well for tendons, fortifying them, so that simple techniques like calf stretches will resolve, rather than exacerbate, tendon tears.
Dancers and professional athletes often require more than one shot, given at three to four-week intervals, up to 5-6 shots. Non-athletes usually require fewer shots, sometimes only one.
What would be some examples of prolotherapy shots which I’ve done over the years?
These are cases which I remember off the top of my head. There are several hundred more whose details I cannot recall spontaneously.