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LINICAL NOTE

igh-Resolution Ultrasound and Magnetic Resonance Imagingo Document Tissue Repair After Prolotherapy: A Report of 3ases

radley D. Fullerton, MD

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ABSTRACT. Fullerton BD. High-resolution ultrasound andagnetic resonance imaging to document tissue repair after pro-

otherapy: a report of 3 cases. Arch Phys Med Rehabil 2008;89:77-85.

High-resolution ultrasound imaging of musculoskeletal tis-ue is increasing in popularity because of patient tolerability,ow cost, ability to visualize tissue in real-time motion, anduperior resolution of highly organized tissue such as a tendon.rolotherapy, defined as the injection of growth factors orrowth factor production stimulants to grow normal cells orissue, has been a controversial procedure for decades; it isurrently gaining in popularity among physiatrists and otherusculoskeletal physicians. This report describes imaging of

endons, ligaments, and medial meniscus disease (from traumar degeneration). Although these tissues have been poorlyesponsive to nonsurgical treatment, it is proposed that tissuerowth and repair after prolotherapy in these structures can beocumented with ultrasound and confirmed with magnetic res-nance imaging. Directions for future research application areiscussed.Key Words: Case report; Magnetic resonance imaging;edial menisci; Rehabilitation; Sprains and strains; Tendi-

opathy; Ultrasound.© 2008 by the American Congress of Rehabilitation Medi-

ine and the American Academy of Physical Medicine andehabilitation

HE TERM PROLOTHERAPY was coined by Hacket1 inthe 1940s and 1950s to imply proliferation of normal tissue

t ligamentous and tendinous entheses; the procedure has beenescribed by other terms, such as sclerotherapy, regenerativenjection therapy, and stimulated ligament repair. More re-ently, Reeves defined prolotherapy as injection of growthactors or growth factor production stimulants to grow normalells or tissue.2 The proliferant solution and technique variesccording to physician training and preference. Commonlyeported proliferants include 10% to 15% dextrose, P2G (phe-ol, glycerin, glucose), and sodium morrhuate. Opponents ofrolotherapy have proposed that improvements are related tohe placebo effect3 and point out that randomized, controlledrials in low back pain (LBP) have had mixed results.4 How-

From the Patient-Physician Partnership, Austin, TX.Presented in part to the American Academy of Physical Medicine and Rehabilita-

ion, October 26, 2005, Philadelphia, PA, and the American Association of Orthope-ic Medicine, April 27, 2006, Washington, DC.No commercial party having a direct financial interest in the results of the research

upporting this article has or will confer a benefit upon the authors or upon anyrganization with which the authors are associated.Reprint requests to Bradley D. Fullerton, MD, 2714 Bee Cave Rd, Ste 106, Austin,

X 78746, e-mail: [email protected].

d0003-9993/08/8902-11682$34.00/0doi:10.1016/j.apmr.2007.09.017

ver, proponents of prolotherapy argue that needling and in-ection of saline into a ligament or tendon is an active, not alacebo, treatment5 and that these injections have producedignificant and sustained improvements in chronic LBP.6 Pro-onents also point out that randomized controlled trials of kneesteoarthritis, in which needle trauma is minimal, have shownignificant benefit of dextrose over anesthetic injection7 andhat machine measurements have shown tightening of liga-ents objectively.8 One recent physiatric study9 reported full

eturn to sport in 22 of 24 elite athletes with chronic groin painnd the inability to participate in their sport. Several crucialuestions must be answered before prolotherapy can be ac-epted as a common medical practice. Does prolotherapy ac-ually stimulate tissue growth? If so, is that tissue less orga-ized (ie, scar) or more organized (ie, normal fibrous tissue)?lthough definitions of prolotherapy imply growth of normal

issue, not scar, some are still using the term sclerosing toescribe injection of proliferants,10 which does not suggestormal fibrous tissue. High-resolution ultrasound now providesn accessible, inexpensive method for serial studies of theseissues to objectively evaluate tissue quality. The purpose ofhis report was to determine if ultrasonography can be a usefulool in evaluating tissue healing and organization in response torolotherapy.

CASE DESCRIPTIONSProlotherapy involves injections of small amounts

0.5�1.0mL) of the proliferative solution at multiple enthe-is points (for tendon, ligament, and fascia) and/or muscu-otendinous junctions. When joints are treated, an intra-rticular injection is commonly performed. In most cases, 2o 6 treatment sessions are required over 2 to 12 months toeach maximum effect.11 Standard protocol includes restric-ion from nonsteriodal anti-inflammatory drugs 1 to 2 daysefore treatment and 10 to 14 days after treatment. Allltrasound imaging was performed by me, and I have morehan 4 years of experience in musculoskeletal ultrasoundmaging using real-time ultrasound equipmenta with 10- to2-MHz, 8- to 16-MHz, and 5- to 10-MHz broadband linearransducers. At each follow-up ultrasound study, patient andoint position were reproduced. The previous ultrasoundmage was visible next to the ultrasound machine to allowhe reproduction of the exact machine settings (power andain) and near exact probe position and angulation (usingone landmarks). Magnetic resonance images were obtainedefore and after completion of all treatments with readingsy a board-certified radiologist who specializes in musculo-keletal radiology.

A brief review of ultrasound terminology will assist innterpreting the images in this article. Tissue appearance onltrasound is determined by the density and organization ofhe tissue. Black tissue on ultrasound is described as ane-hoic; the tissue reflects no sound wave back to the trans-ucer. Dense tissue such as bone appears bright white and is
escribed as highly echoic. Tissue deep to normal cortical bone
Arch Phys Med Rehabil Vol 89, February 2008

[email protected].

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378 ULTRASOUND IMAGING AND PROLOTHERAPY, Fullerton

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annot be visualized because the bone reflects all the soundaves. Sound passes through water without reflection; thus,uid collections and normal cartilage (which has high waterontent) appear black on ultrasound. Normal tendons and lig-ments are described as echoic structures with a tightly packed,niform fibrillar pattern on longitudinal images. The normaleniscus has mixed echogenicity because of its fibrocartilag-

nous histology. An abnormal tendon, ligament, or cartilage isore variable or heterogonous in appearance (eg, in tendinopa-

hy, the linear fiber pattern breaks down becoming more diffi-ult to identify). This fiber breakdown along with edema resultn a tendon that is thicker than normal. Diseased tissue does noteflect sound wave normally and may be described as hypo-choic (reflecting less sound than normal, eg, an edematousendon) or hyperechoic (reflecting more sound wave than nor-al, eg, a calcific tendon). This case series consists of patientsho showed ultrasound abnormalities in tendon, ligament, andeniscus while also having a recent magnetic resonance im-

ging (MRI) of the same area to allow comparison after treat-ent was completed.

ase 1: Patellar Tendinopathy With a Partial TearA 34-year-old man with no significant medical history

resented with intermittent, progressively worsening medialnd anterior knee pain over the past 3 years. He relates theain to 2 previous mild injuries. Three years before presen-ation, he felt a “pop” in the anterior knee while jumping inpool; 1 year earlier he suffered a valgus sprain to the kneehile playing basketball. Neither injury was associated with

mmediate-onset pain or swelling, but both contributed to

rch Phys Med Rehabil Vol 89, February 2008

is progressive pain with athletic endeavors. The pain wors-ned with sitting and playing tennis and volleyball; it inter-ered with sleep and has prevented him from jogging overhe past year. The physical examination was significant forenderness over the medial joint line and medial collateraligament (MCL) without crepitus, whereas tenderness overhe quadriceps tendon insertion and patellar tendon originas associated with crepitus and mild edema. The McMur-

ay sign, patellar ballottement, and ligament laxity testingere negative. An MRI ordered by a previous physician

evealed “thickening of the medial collateral ligament con-istent with an old injury, but not abnormal signal at thisime” and “tendinosis and partial tearing of the patellarendon at its insertion on the patella with associated reactivedema within the bone marrow of the patella” (figs 1A, B).

Ultrasound examination confirmed the MRI findings (figsA, B) and also revealed mild degenerative changes in theuadriceps tendon. Initial treatment sessions in November004, December 2004, and February 2005 involved injection oftandard dextrose prolotherapy solution (15% dextrose/0.3%idocaine) via 25-G, 2-in needles at enthesis points that wereender to palpation; these included MCL origin and insertion,uadriceps tendon insertion, and patellar tendon origin andnsertion. At a follow-up in March 2005, the patient reportedignificant improvement in pain and stated “there haven’t beenny really bad pain days” despite increasing athletic activity.he patellar tendon was much less tender to palpation. Ultra-ound at that time showed improved fibrillar pattern and echo-enicity in the MCL, quadriceps tendon, and patellar tendon,figs 2C, D). Because of continued pain with athletic activity

Fig 1. Proton density, fat satura-tion MRI of the knee (pre- andpostprolotherapy). Top row, Oc-tober 2004; bottom row, October2005. (A and C) Sagittal views ofleft knee. The thin arrow (origi-nally added by the interpretingradiologist) indicates a high sig-nal in the deep, midportion ofthe patellar tendon consistentwith partial tear. Note the reac-tive edema in the inferior poleof the patella (A) in 2004. Post-prolotherapy, the edema is re-solved and a subperiosteal cystis noted (C). Images on the right(B, D) are axial views of the leftknee through the patellar ten-don; the large arrow in B pointsto the region of the thickened,abnormal tendon with high-signal intensity just distal to thepatellar enthesis, indicating apartial patellar tendon tear. Thepostprolotherapy (D) shows
new tendon growth and partialrepair of the tear.

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379ULTRASOUND IMAGING AND PROLOTHERAPY, Fullerton

nd pain interfering with sleep, he elected to have a fourthreatment in May 2005, which included standard P2G solution1.25% phenol, 12.5% dextrose, 12.5% glycerin, 0.5% lido-aine) in the same locations.

At a follow-up in August 2005, the patient reported signif-cant improvement in knee pain with athletic activity and sleep.e had minimal tenderness to firm pressure over the proximalatellar tendon. Ultrasound on that date again showed anmproved fibrillar pattern and echogenic signal (figs 2E, F).

RI in October 2005 was compared with images from thenitial MRI. These showed marked improvement in tissue sig-al, reduction of the partial tendon tear, and resolution of theatellar edema (figs 1C, D).During a telephone follow-up in January 2006, the patient

eported complete resolution of nighttime pain and painhile exercising. He had returned to full participation in

ig 2. Patellar tendon ultra-ound (pre- and postpro-

otherapy). Top row, November004; middle row, March 2005;ottom row, August 2005. A

ongitudinal view (A) shows ahickened (>10mm; normative,4mm), hypoechoic tendon withpoor fibrillar pattern diagnosticf tendinopathy. A transverse

mage (B) confirms a thickened,ypoechoic tendon and revealsnechoic (black) deficit in theeep, midportion consistentith a tear (*). The images

hown in C–F are at the sameocation after prolotherapy withextrose and P2G, respectively.s treatment progresses, the

endon improves in tissue echo-enicity, uniformity of signal,nd fibrillar pattern. The ane-hoic tear has partially filled inith new tissue (ie, it is no

onger anechoic), and the mainortion of the tendon is near nor-al thickness. Abbreviation: P,

nferior pole of patella. Legend:ertical yellow lines in the rightmages indicates position ofrobe just lateral to midline forhe longitudinal images on left,nd the dashed yellow lines out-ine the tendon in transverseiews on the right.

ennis, lower-extremity weight training, jogging, and yoga. t

ase 2: An Anterior Talofibular Ligament SprainA 17-year-old female softball pitcher with no significantedical history presented with pain, swelling, crepitus, and

ensation of instability in the left ankle 4.5 months after annkle sprain from a motor vehicle collision (MVC). Radio-raphs in a hospital emergency department on the day of thenjury revealed a small joint effusion but no fracture. She hadeceived 6 weeks of physical therapy focused on strengtheninghe left ankle with only mild improvement in symptoms. Sincehe MVC in May 2004, she has required an ankle orthotic toitch and run. At presentation to me in October 2004, thehysical examination was remarkable for anterolateral ankledema, tenderness, and palpable crepitus associated with aositive anterior drawer sign, an equivocal inversion stress test,nd an equivocal distal tibiofibular compression test. Her or-
hopedic surgeon ordered an MRI in October 2004, which

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evealed “chronic appearing tear of the anterior talofibular liga-ent” (ATFL) with associated fibrosis (fig 3A), probable tear of

he calcaneal fibular ligament, partial tear involving the deep fibersf the deltoid ligament, bone contusion of the medial talar dome

ig 4. Sequential transverseleft column) and longitudinalright column) ultrasounds ofhe left ATFL. Top images (A, B)October 2004) of prepro-otherapy showing free edges

ith anechoic cleft on longitu-inal images indicating full-hickness tear (plane of probeor transverse view). The trans-erse view shows markedlyhickened, hypoechoic, poorlyefined ATFL. After 1 prolother-py treatment (C, D) (December004), the longitudinal andransverse images have im-roved echogenicity and tissuelane definition. The anechoicleft in the top image is identi-able only as a region of hypo-choic signal. After 2 prolother-py treatments (E, F) (March005), the longitudinal viewow shows identifiable fibrillarattern bridging the previousnechoic gap. Both views showmproved echogenicity and tis-ue plane definition. After 3rolotherapy treatments (G, H)July 2005), the longitudinaliew shows improved fibrillarattern and echogenicity. Ab-reviations: F, fibula; T, talus.
egend: dashed yellow linesutline the ligament.

nd body, and small tibiotalar joint effusion.” Ultrasound exami-ation in October 2004 (figs 4A, B) confirmed a near full-thick-ess tear of ATFL on static and stress imaging as well as a mildistal, anterior tibiofibular ligament sprain.

Fig 3. T2-fat saturated axialMRI of the left ankle. Left panel,October 2004; right panel, Au-gust 2005. (A) MRI 4.5 monthsafter an injury from an MVC.The arrow indicates ATFL withhigh-signal intensity indicatinga near complete tear. (B) MRIafter 3 treatments with dex-trose prolotherapy. The liga-ment remains abnormally thick-ened, but the high signal hasresolved. NOTE. These imageswere obtained on different MRImachines by different technol-ogists resulting in significantimage-quality variability; theimages have not been altered.Abbreviations: F, fibula at liga-ment enthesis; T, talus at liga-ment enthesis.

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Her orthopedic surgeon released her for full participation inport with ankle orthotic; however, she continued to complainf ankle weakness, pain, and instability. With her mother’sonsent, she agreed to try 1 treatment in November 2004 withtandard dextrose prolotherapy solution. Injections of ligamen-ous entheses were performed via 27-G, 1.25-in needles asollows: anterior talofibular, anterior tibiofibular, calcaneofibu-ar, anterior joint capsular ligament on talus, middle deltoid,nd lateral talocalcaneal. At a follow-up in December 2004, theatient reported some reduction in swelling but no significanthange in pain or instability. A physical examination confirmededuction in edema and on anterior drawer testing; the patientemarked “it does not move nearly as far as it used to.”ltrasound on that date showed remarkable improvement in theTFL (figs 4C, D).She requested a second treatment, which was performed in

anuary 2005, to the same locations except the middle deltoidigament enthesis, which was no longer tender to palpation. Atfollow-up in March 2005, she reported significant reductions

n pain, swelling, and sensation of instability. A physical ex-mination was remarkable for the absence of edema, reducedenderness to palpation over the anterolateral ankle, and anquivocal anterior drawer sign. Ultrasound on that date againhowed significant improvement (figs 4E, F).

She elected to delay further treatment because of the start ofer final softball season as a senior in high school. She com-leted the season by using an ankle orthotic only during com-etition and intense practice but not during conditioning orunning. She returned in May stating, “it feels so much betterhan it used to.” A third treatment with the same solution andnjection locations was performed in May 2005. At a follow-upn July 2005, she estimated she was “at 90%” of full function

ig 5. Sagittal proton density,at saturation MRI of the leftnee. (A) (December 2003) Areprolotherapy image show-

ng a high signal in the poste-ior horn of the medial menis-us indicating a horizontalleavage tear. (B) (December004) A postprolotherapy im-ge showing only mild degen-
rative signal and no evidencef the previous tear.
ithout using the ankle orthotic. Examination showed onlyild tenderness to palpation over anterolateral ankle; the an-

erior drawer sign remained equivocal. Ultrasound on that dategain showed improved echogenicity, tissue plane definition,nd fibrillar pattern in the ATFL (figs 4G, H).

Before full release to participate in college softball, MRI wasbtained in August 2005. This MRI was compared with imagesrom the initial MRI. The report indicated “enlargement andbrosis of the anterior talofibular ligament is noted consistentith healing of a prior ligament tear” (fig 3B), “A prior partial

ear of the deltoid ligament has healed without evidence ofbnormality,” and “the adjacent reactive marrow edema in thealus has resolved.” During a telephone follow-up in January006, she reported playing “full-speed” without pain, weak-ess, instability, and without need for the orthotic.

ase 3: A Degenerative, Complex Tear of theedial MeniscusA 59-year-old white woman with a history of coronary artery

isease status post stent, remote uterine cancer treated by hyster-ctomy, and chronic LBP caused by lumbar degenerative diskisease, with sacroiliac joint dysfunction and osteoarthrosis of theight knee after arthroscopic débridement for degenerative menis-al tear presented in November 2003 with complaints of left kneeain, swelling, and sensation of instability. She felt that the leftnee was “going to give out like the right one did last year.” Sheenied trauma to the knee. A physical examination of the left kneeas remarkable for antalgic gait, tenderness to palpation (over theedial joint line, MCL, tibial tuberosity, and pes anserine inser-

ions), and positive McMurray sign. MRI in December 2003evealed “complex tear of the medial meniscus includes horizontalleavage tear of the posterior horn and body, as well as radial tear


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hich transverses the posterior horn-body junction; medial jointpace degenerative chondromalacia with minimal reactive marrowdema adjacent to the meniscal pathology; prominent inflamma-ion surrounding the medial collateral ligament, may be degener-tive in the absence of recent trauma; mucoid degeneration signals suspected within ACL” (figs 5A, 6A). Based on the examinationnd MRI, her orthopedic surgeon scheduled arthroscopic débride-ent in early 2004. Ultrasound imaging in December 2003 con-rmed the degenerative changes in the MCL and complex, de-enerative tears of the medial meniscus posterior horn and bodyfigs 7A, 8A).

After discussion, the patient agreed to 1 prolotherapy treatmentefore undergoing arthroscopic débridement in March; this firstreatment was performed in January 2004. This treatment includedtandard dextrose prolotherapy with injections via 25-G, 2-ineedles at tender entheses, including MCL (proximal and distal),oronary ligaments attaching the medial meniscus to the tibiaanteromedially, medially, and posteromedially), and pes anserineendons. The day after the first treatment she slipped on a wet flooresulting in a nondisplaced fracture of the contralateral (right)atella. The right knee was immobilized during weight bearing forweeks; during this time, she decided to delay the arthroscopy

ndefinitely. Subsequent treatments with dextrose prolotherapyccurred in April, May, and June. Follow-up ultrasounds wereerformed in March, May, and July (figs 7B–D, 8B–D). At the last

ig 6. Coronal, T2-fat saturation MRI of the left knee (A) (December003, preprolotherapy). This image shows the linear high signalithin the medial meniscal body, reaching the peripheral (large

rrowhead) and possibly the articular surface, which is indicative of

otear. The lower image (B) (December 2004, postprolotherapy)

hows healing of the peripheral tear (thin arrow).


ffice follow-up, she reported complete resolution of her left kneeymptoms, and her knee examination was normal. During a tele-hone follow-up in December 2004, she denied any recurrence ofer previous left knee symptoms and agreed to a follow-up MRIfigs 5B, 6B), which was read as “mild intrasubstance signalithin the posterior horn of the medial meniscus but without

riteria for tear. Otherwise unremarkable MRI of the left knee.”uring a telephone follow-up in January 2006, she again denied

ny recurrence of her previous left knee pain, instability, or swell-ng. She did volunteer that the right, postarthroscopy knee contin-ed to have intermittent pain and feelings of weakness.

DISCUSSIONThese cases show the potential utility of high-resolution ultra-

ound to document pathology in soft tissues and tissue responseso treatment. Ultrasound images of animal tendons have beenorrelated with histology studies.12 In the evaluation of tendons,an Holsbeek has observed that “ultrasound has a significant

dvantage over MRI . . . tissues with few mobile protons emitittle or no signal and, therefore, the internal architecture of theendon is not well demonstrated [on MRI].”13(p77) The first patientn this report shows this advantage of ultrasound in evaluation ofendon organization. Both MRI and ultrasound show the tissueartially filling in the tear; however, only the ultrasound revealshe progressive improvement in fiber organization (on longitudinalmages) over time. This advantage is vital in the evaluation ofhronic tendinopathy because tendon degeneration (ie, progres-ive fiber disorganization over time) usually precedes tendon tear.he second case report shows similar issues in the evaluation of

igament. Normally, the complex, interlacing fiber patterns ofigaments result in a less regular fiber pattern on ultrasound. Theltrasound images show an identifiable fiber pattern within thenterior talofibular ligament, whereas the postprolotherapy MRInly shows a uniform mass of tissue. The third case report showshe limited application of ultrasound in evaluation of meniscus.lthough clearly visible on MRI, the posterior horn tear was notell shown on ultrasound. The ultrasound, however, did clearly

how healing of the medial body tear and progressive organizationf the posterior horn. Healing of a complex, degenerative medialeniscal tear has not been reported in the literature previously.Many past efforts to validate prolotherapy have focused on

onspecific LBP and have produced mixed results. Dagenais etl10 recently surveyed spine prolotherapists and estimated theumber of patients treated with prolotherapy “in the hundredsf thousands.” This survey indicated that prolotherapy in thepine has a low incidence of reported adverse events andncouraged further prospective studies. Future research mayocus on tissues readily visible with ultrasound, such as thoseescribed in this report. Although these cases are intriguing,eproducible imaging of musculoskeletal tissue with ultrasounds technically difficult. Ultrasound images of highly organizedissue such as a tendon can look vastly different with onlylight changes in probe angulation; a phenomenon known asanisotropy.” This contributes to the operator dependence thaturrently limits clinical application of ultrasound in the mus-uloskeletal system. As training in ultrasound progresses, thisoncern should lessen. Anisotropy also casts doubt on serialmaging such as this case series; bias could be easily introducedn each subsequent image with a simple tilt of the probe. Thus,RI, which is common and has proven reliability, is important

o confirm tissue repair seen on ultrasound. Studies usingltrasound imaging of tendon response to various treatmentsave, thus far, used qualitative interpretations to determineissue changes.14 Valid, quantitative ultrasound techniques areeeded. An ultrasound scale for grading tissue quality and
rganization in tendinopathy could be developed, similar to an

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shworth Scale used for spasticity grading. Once validated, acale would be useful in blinded evaluation of tendon qualityre- and postintervention, such as prolotherapy. Quantitativenalysis of ultrasound images by using computerized texturenalysis is being used in the evaluation of muscle15; similarechniques could be used on tendons. Also, ultrasound can beerformed frequently and at low cost, providing multiple dataoints and potentially increasing statistical validity in a partic-lar study.Physiatry improves patient’s lives by focusing on practical,

unctionally based treatments. However, rehabilitative interven-ions by their nature have been difficult to quantify and study.dvances in quantitative ultrasound and their application in reha-ilitation research may lend more objectivity to physiatric inter-

ig 7. (A) This image (December003, preprolotherapy) showshat the normal, well-defined tri-ngular shape of the medialeniscal body (yellow, dashed

ines outline the meniscus) isartially defined and attachedo the overlying MCL bridginghe femur (F) and tibia (T). Theblique tear seen on MRI is re-roduced well (*). The proximalCL is markedly hypoechoicith a complete loss of normal,

brillar pattern, indicating mu-oid degeneration. (B) After 1rolotherapy treatment (March004), the oblique tear is stillisible. (C) After 2 treatmentsMay 2004), the tear is no longerisible. The MCL has improvedchogenicity and fibrillar pat-ern. (D) After 4 treatments inuly 2004, the meniscus hasniform signal with no evi-ence of a tear.

entions in general. r

CONCLUSIONSUltrasound imaging can show tissue growth and repair.

hese case reports appear to confirm that prolotherapy doestimulate tissue growth in tendon (patellar), ligament (ante-ior talofibular), and meniscus (medial meniscus) and thathis is an organized growth with a return toward a normalppearance on ultrasound. Further clinical studies with ul-rasound confirmation are recommended. The developmentf quantitative methods to analyze ultrasound images will bealuable in blinded efficacy studies of prolotherapy andther rehabilitative interventions.

Acknowledgment: I thank Vince Wiseman, MD, for assistance in
eviewing the MRI studies.


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Fig 8. (A) In this image (Decem-ber 2003, preprolotherapy), thenormal, well-defined triangularshape of the posterior horn ispoorly defined because of mu-coid degeneration (yellow,dashed lines outline the menis-cus). The horizontal tear seenon MRI is not visible on ultra-sound. (B) After 1 prolotherapytreatment (March 2004), thenormal triangular shape is evi-dent and the meniscal signal ismore homogenous. (C) After 2treatments (May 2004), echoge-nicity, homogeneity, and tissuedefinition continue to improve.(D) After 4 treatments (July2004), the meniscus has normalechogenicity, uniform signal,and clear definition. Abbrevia-
tions: F, posterior femoral con-dyle; T, posterior tibia.

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References1. Hacket GS. Ligament and tendon relaxation treated by prolother-

apy. Springfield: CC Thomas; 1956.2. Reeves KD. Prolotherapy: regenerative injection therapy. In: Waldman

SD, editor. Pain management. Philadelphia: WB Saunders; 2007. p1106-27.

3. Loeser JD. Point of view. Spine 2004;29:16.4. Kim SR, Stitik TP, Foye PM, Greenwald BD, Campagnolo DI.

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5. Reeves KD, Klein RG, DeLong WB. Re: Yelland MJ, Glasziou PP,Bogduk N, et al. Prolotherapy injections, saline injections, and exercisesfor chronic low-back pain: a randomized study. Spine. 2003;29:9-16.[letter]. Spine 2004;29:1839-40; author reply 1842-3.

6. Yelland MJ, Glasziou PP, Bogduk N, Schluter PJ, McKernon M.Prolotherapy injections, saline injections, and exercises forchronic low-back pain: a randomized trial. Spine 2004;29:9-16.

7. Reeves KD, Hassanein K. Randomized prospective double-blindplacebo-controlled study of dextrose prolotherapy for knee osteo-arthritis with or without ACL laxity. Altern Ther Health Med2000;6:68-74, 77-80.

8. Reeves KD, Hassanein K. Dextrose injection prolotherapy forACL laxity. Altern Ther Health Med 2003;9:58-62.

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1. Reeves KD. Prolotherapy: basic science, clinical studies and tech-nique. In: Lennard TA, editor. Pain procedures in clinical practice.2nd ed. Philadelphia: Hanley & Belfus; 2000. p 172-90.

2. Martinoli C, Derchi LE, Pastorino C, Bertolotto M, Silvestri E.Analysis of echotexture of tendons with US. Radiology 1993;186:839-43.

3. Van Holsbeek M. Musculoskeletal ultrasound. 2nd ed. St Louis:Mosby; 2001.

4. Ohberg L, Lorentzon R, Alfredson H. Eccentric training in pa-tients with chronic Achilles tendinosis: normalised tendon struc-ture and decrease thickness at follow-up. Br J Sports Med 2004;38:8-11.

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Supplier. Diasus; Dynamic Imaging Ltd, 9 Cochrane Sq, Brucefield Industrial

Pk, Livingston, Scotland, EH54 9DR.


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