Dedication Simple Solutions Experience

I can’t believe that it works, and I can’t believe it when it doesn’t work

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?

  • the 65 year-old golfer who came to me on orthopedic referral from Florida who had theretofore intractable pain at her second toe joint, where it meets
  • the ball of the foot, called the “metatarsophalangeal joint”, or mtp joint. Her pain abated after one shot.
  • the 24 year-old professional dancer who had a painful, unstable second mtp joint since he was a dance student at the age of sixteen. He required five shots. He is now a principal dancer.
  • the 78 year-old elegantly dressed woman who only had pain at her unstable second mtp joint when she wore her moderate heels, who required four shots.
  • the 50 year-old teacher who couldn’t play tennis due to instability at her second mtp joint, and couldn’t use orthotics because they’d exacerbated her Morton’s neuroma (pinched and thickened nerve in forefoot). She came back two years later for a second prolotherapy shot, having been asymptomatic for the interval.
  • the 19 year-old ballerina who sprained the joint in her big toe just behind the toenail when she decided to dance en pointe using an unaccustomed toe spacer, which only “spaced” the bottom half of the first toe web, allowing the tip of the big toe to push towards the second toe en pointe, spraining the joint.
  • the 20 year-old ballerina who’d just signed a contract with a major company who had sprained her big toe joint when she rehearsed in dead (broken-down) pointe shoes with a tired adagio partner.
  • the 51 year-old golf pro who had a partial rupture of his plantar fascia which worsened after a cortisone shot (prolotherapy, btw, is unlikely to work well if one receives a cortisone injection anywhere in the body for one month prior to, or one month after the shot).
  • the fifty-five year old housewife who’d unsuccessfully been receiving physical therapy for a partial tear of her plantar fascia for five months.
  • the twenty year-old ballerina who had just signed a contract with a major company and was reinjuring chronic, incompletely healed sprains at the medial and lateral ankle. She required six shots.
  • the 21 year-old jazz-modern dancer who’d had two ankle operations for removal of excess bone fragments in her ankle, and had done two years’ physical therapy, who still couldn’t point her foot without pain in the back of her ankle, because the ligaments were too lax in the front and allowed excessive jamming in the back when she pointed. She required six shots.
  • another dancer, a ballerina, who had a similar problem, pain in the back of her ankle when she pointed, but she had no excess bone in the back of her ankle; she simply had had several ankle sprains since she was sixteen and her pains had persisted since then, recalcitrant to physical therapy. She required two shots.
  • a 52 year old politician who had severe pain walking, whose part-torn anterior tibial tendon lay over an arthritic spur in her foot, who had circulatory issues which prevented surgery, and the presence of the spur precluded friction massage via physiotherapy. She had a clotting factor disorder which precluded prp. She required four shots.
  • the thirty-three year old from Turkey with long-lasting pain, not severe, but persistent at the little ligament in the front of our ankles which sprains so easily with common ankle sprains. She wanted to think about the shot when I first proposed it. She came back one week later, requesting the shot. She’d phoned her grandmother, in Turkey, who‘d had a prolotherapy series successfully in Turkey in the 1980s. She required one shot.
  • The two male dancers, one Broadway, one Ballet, who’d sprained their Lisfrack’s joints (in the midfoot, by the shoelaces). Neither was responding favorably to physical therapy. Neither had an injury which would be treatable by surgery. My theatrical dancer patient required two shots. My ballet dancer patient required six shots.

These are cases which I remember off the top of my head. There are several hundred more whose details I cannot recall spontaneously.

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