Ligaments are semi elastic, cable-like structures made up of "collagen" threads, connecting bone to bone to form joints.  All joints are held together with ligaments, whether it be knee, shoulder, back , neck, or pubic bones. Ligaments bend, but do not really stretch very well. They have within them nerve endings capable of transmitting pain impulses.  These nerve endings are sensitive to stretching, tearing, pressure, etc. For example, when you sprain your ankle, one or more of those ligaments may be injured.  The injury consists of tearing of the ligaments, the extent varying from microscopic fraying of a few fibers to total disruption.


     The body heals these tears through a process called "inflammation". This process is characterized by redness, swelling, heat, tenderness, and stiffness of the involved joint. Inflammation takes place in three overlapping stages:

  1. Acute inflammation: (duration approximately four days) In this phase, beginning directly at the time of injury, the cells are broken open and their contents spilled at the site of the tear.  Leukocytes, white blood cells, whose job is to clean out the injured area, flood the region.  Many chemicals are released which act as messengers, telling other cells what to do. "Macrophages" are attracted to the site, beginning the second phase.
  2. Granulation phase: (duration 10 days to two weeks) these white blood cells continue the clean up, digesting the broken down cell parts and secreting enzymes and hormones which stimulate the growth of new blood vessels and generate the ground substance in which the cells "float". They attract additional types of blood cells called fibroblasts to the site of injury.  These migrate to the fibro-osseous junction, where the ligament attaches to the bone, and then through stimulation by the macrophages, make massive amounts of the ligamentous building blocks, single, long collagen fibers. This leads to the third phase of healing:
  3. "Wound contraction" (duration 3 to 6 weeks) These new collagen fibers are organized through a complex process into ligaments, the collagen fibers winding about each other and contracting, expressing fluid, and becoming shorter and tighter, pulling the ends of the ligament together and tightening the support of the joint. The fibroblasts remain at the injury site after all the other clean-up cells are reabsorbed, continuing to secrete collagen and strengthening the joint for several months.

     When the inflammation process is successful, the ligaments are returned to their normal length and strength and the joint to its normal function. Should, however, the injury be too severe, or the disruption perpetuated by abnormal activity, or too much swelling, the ligaments will heal in an elongated, disorganized fashion. The result will be a hyper mobile joint, poorly supported by its ligaments and now dependent on muscles to maintain stability. Unfortunately, the principal function of muscles is joint movement, and only incidentally joint stabilization.

     Muscles forced to act as support structures, are unable to fulfill their obligations as motion agents, since they wind up in a state of perpetual contraction or spasm. The pain receptors in the now “stretched” ligaments, are sensitized and this is further complicated by the sensitization of trigger points in the tightened muscles, setting up myofascial pain syndromes, often referring pain to more distant sites and locally resulting in more muscle spasm, restriction of motion and pain.

     What's the solution? If exercise hasn't done it, if trigger point injections provide only temporary relief or chiropractic adjustments "don&'t hold", then the perpetuating factor most likely is ligament laxity contributing to joint instability. Surgery may help in certain cases but this is obviously fraught with its own dangers and risks, both immediate and long term. In fact the best answer may be:


     We propose that a significant proportion of back and joint pain is caused by chronic ligamentous laxity. This is a result of the failure of the body's effort to fully heal the torn or frayed ligaments through inflammation. Ligament injection therapy simply stimulates a controlled, more focused inflammatory process. This involves the deposition of natural chemical and physical irritants at the bony juncture with ligaments to stimulate their repair. In my practice, I typically use a combination on dextrose (sugar), glycerine, procaine or lidocaine (a local anaesthetic, commonly employed in dentistry), and a small amount of phenol (a chemical irritant, anaesthetic and anti-infective agent). Occasionally this is supplemented by a small amount of an extract of cod liver oil, sodium morrhuate. This stimulates the local production of prostaglandins, the messengers of inflammation, which draw to the site the agents we discussed earlier. Although the process is artificially stimulated, it is entirely natural.We also offer Platelet Rich Plasma as a stimulant alternative. 


     Following injection, there is normally swelling, heat, redness, tenderness and pain. This tells us that the inflammatory process we have deliberately induced is under way. The pain will gradually, but irregularly decrease, and as it does, normal movement and activity can safely be progressively resumed to tolerance. Normal movement will further enhance the laying down of collagen into ligamentous fibers. These injections are repeated as necessary, depending on the healing progress, every 3 to 6 weeks, until such time as the subjective and objective indications for them no longer pertain. That is, pain and function have normalized to the point that the patient feels they have achieved a satisfactory level of stability, and the physician no longer detects the objective signs of instability and joint disfunction. In our experience, this end-point has been reached in as few as one treatment session, and as many as 18.


     Although you will be asked to sign a standard informed consent form, the true risks are relatively minor. The injection may be a bit more painful than anticipated but after all, the intent of the technique is to create an inflammatory reaction which is accompanied normally by pain, swelling, and redness. This reaction usually does not last for more than 2 to 5 days and most frequently is over after two days. Local infection is another possibility, but I have never seen that and the reports in the literature of same are very scanty. The phenol in the solution acts to sterilize the injection site. Very occasionally there may be some temporary bruising of a nerve, but I have never seen any permanent adverse consequences as a result. There have been no reports of any deaths directly related to prolotherapy in the last 25 years during which time the number of prolotherapy treatments administered around the world has increased exponentially, as has the number of people benefiting from this procedure.

     In summary, prolotherapy is a minimally invasive technique utilizing the injection of, for the most part, organic substances into the site of the junction between ligaments and bones, thereby stimulating growth and tensile strength. With care in selection of subjects, and administration by well-trained, knowledgeable physicians, the treatment, although painful, is highly successful, safe and effective in relieving pain due to abnormal joint movement secondary to ligamentous laxity. Numerous patients have avoided joint replacement with this technique.