“Eight weeks after treatment I began carefully increasing mileage using a planned training regimen. This year, I’m back to full performance, running two half marathons, a 10K and I enjoyed Notre Dame’s first Storm the Stadium.” — Dr. Randall Kline
By Dr. Randall Kline, DPM, FACFAS, FAPWCAAllied Bone and Joint
I’d like to introduce you to a medical treatment that approaches healing from a unique perspective. Most of us have heard of getting a cortisone shot in a joint or area of inflammation. In fact I’ve discussed such treatment in previous articles on plantar fasciitis and neuromas. Such an injection is targeting an area of inflammation with the goal of shrinking the thickened/irritated tissue and restoring function. There are, however, other treatments available that repair injured tissues and restore function without the danger of weakening the surrounding structure. These are referred to as regenerative medicine procedures.
A Look at Regenerative Medicine Procedures
Regenerative medicine includes a spectrum of treatments. (The most common and the one with more than 80 years of clinical use is dextrose prolotherapy.)
- The simplest form of regenerative medicine is fenestration. Fenestration is the repetitive needling to a tendon causing local bleeding. The blood contains growth factors so regeneration or repair can occur at the site being treated. Injections of whole blood have been utilized as a regenerative technique as well.
- The next level of treatment is dextrose prolotherapy. A solution of 12.5 percent dextrose with lidocaine is injected into the site of the joint, tendon or ligament injury. This causes local tissue irritation and ultimately attracts the migration of fibroblasts to the site of the injection. The fibroblasts lay down collagen repairing the site of injury. It does not create scar tissue but new healthy tissue.
- The next level of prolotherapy is the utilization of platelet-rich plasma. With this technique the patient’s blood is drawn and spun down and the layer of plasma with a high concentration of platelets is drawn off and injected into the area of damaged cartilage, tendon or ligament. The final level of regenerative medicine or prolotherapy is the injection of stem cells. These may be derived from placental cord blood from a donor, a patient’s bone marrow or from the patient’ abdominal fat or adipose tissue.
“I avoid the use of steroid injections in this population because although the patient will feel better after cortisone, repeated cortisone injections will cause a weakening and disorganized repair of the injured tissue while prolotherapy stimulates the growth of normal healthy tissue.” — Dr. Mark Cantieri
Below is my own personal experience with dextrose prolotherapy, which has brought me back to an age-appropriate level of running. While I wouldn’t consider it a replacement for all other methods of treatment, it certainly holds well as a nonsurgical method of treating injury, with an excellent predictability for a favorable outcome.
“Something happened along the way, however, that my generation is not dealing with very well. I got older and my body no longer responded favorably to the same intensity that I enjoyed in my earlier years.”
I began serious distance running in the mid 1990’s. Once a baseline of mileage was established, hills and speed work naturally followed. It felt good and harder work was rewarded with greater performance. Something happened along the way, however, that my generation is not dealing with very well. I got older and my body no longer responded favorably to the same intensity that I enjoyed in my earlier years. One morning while seeking to increase speed on a treadmill, I was forced to stop due to a stabbing pain in my left knee. The pain initially hurt all the time, then tapered to a sharp pain with impact activity and endured for nearly two years. My X-rays were negative for significant joint injury, but did demonstrate a middle-aged knee (as expected).
During this time, I employed many conservative efforts that had limited success including rest, ice, compression, NSAIDS, and modification of activity. I truly enjoy weight training, but began resigning myself to thinking that my running days were over, and I’d just have to suffice with the elliptical trainer for cardiovascular exercise. Over time, the symptoms began to taper into a localized area in the anterior medial knee, just inferior to the patella. There’s no doubt that a knee arthroscopy could find areas to clean out in this high-mileage joint, but would likely miss the more superficial area of pain.
I began to correlate my symptoms with training I’d received during residency from my friend, mentor and instructor, Dr. Mark Cantieri. Below is Dr. Cantieri’s evaluation of my situation that may relate to something you’re experiencing—or may experience in the future for this common, yet not well-known injury.
A Word From Dr. Cantieri
When I evaluated Dr. Kline I noted a very well localized area of pain along the medial aspect of the tibial plateau. This is where the medial meniscus is attached to the tibia by the coronary ligament. Palpation of this structure caused exquisite pain. I injected this area with solution of 12.5% dextrose and 0.5% lidocaine.
Prolotherapy is a technique that has been around for many years. The first article on prolotherapy was written in 1937 for the treatment of chronic sacroiliac joint pain.
Many of the athletes, including runners, that I see deal with pain problems involving their hips, low back, knees, feet and ankles. Prolotherapy can successfully treat many of these chronic pain issues and prevent these athletes from requiring surgery. I avoid the use of steroid injections in this population because although the patient will feel better after cortisone, repeated cortisone injections will cause a weakening and disorganized repair of the injured tissue while prolotherapy stimulates the growth of normal healthy tissue.
A common misconception is that it creates scar tissue, it does not as documented by biopsies of areas treated with prolotherapy. There is good documentation of the efficacy of prolotherapy in the treatment of many different tendon and ligament injuries. A good resource for reviewing these articles is: https://www.drreeves.com/research.html. After receiving prolotherapy appropriate rehabilitation is necessary to achieve the absolute best results.
Back in the Game
Since I’ve undergone prolotherapy, the pain associated with the coronary ligament has resolved with prior function restored. Eight weeks after treatment I began carefully increasing mileage using a planned training regimen and this year I’m back to full performance, running two half marathons, a 10K and I enjoyed Notre Dame’s first annual “Storm the Stadium,” (so far).
These bodies of ours won’t last forever, but I’m in hopes that if there is a nagging area within your musculoskeletal system that is preventing your participation in the activity you love, prolotherapy may be part of the solution to regaining mobility and function.
As always, run safely my friends!