Mustafa—Prolotherapy for MCL Sprain 68 ALTERNATIVE THERAPIES, JULY/AUG 2015 VOL. 21, 4

Treatment of a Medial Collateral Ligament Sprain Using Prolotherapy: A Case Study

Ahmet Mustafa, ADA, MD; Ferdi Yavuz, MD

CASE STUDY

ABSTRACTProlotherapy is effective in treating refractory tendinopathies, but inadequate clinical evidence exists to recommend its use as a treatment for acute or chronic, medial collateral ligament (MCL) injuries. The current case study documents an illustrative case of a rugby player who had a grade 2 sprain of the MCL and shows the clinical and radiological outcomes following injections of 15% dextrose combined with 0.2% lidocaine. In his case,

the prolotherapy, together with an exercise therapy, lasted 3 wk. At the end of the 3 wk, the patient was pain free, with a full range of motion (ROM), and he was able to perform all rugby-specific movements. The mean duration for recovery with conservative treatment of isolated, complete tears of the MCL is normally 4-8 wk. (Altern Ther Health Med. 2015;21(4):68-71.)

Ahmet Mustafa, ADA, MD, is a sports medicine specialist at TAF Sport Medicine School in Ankara, Turkey. Ferdi Yavuz, MD, is a physiatrist at the Clinic of Physical Medicine and Rehabilitation, Military Hospital of Etimesgut, in Ankara.

Corresponding author: Ferdi Yavuz, MDE-mail address: ferdiyavuz@yahoo.com

The collateral ligaments play a major role in medial-lateral stability of the knee joint. These structures are vulnerable to injury from direct trauma, producing varus and valgus stress.1 The medial

collateral ligament (MCL), which is also known as the tibial collateral ligament, is the most commonly injured knee ligament in contact sports such as soccer, rugby, or hockey.  When a valgus force occurs to the knee joint, it stretches or tears the ligament on the inner side of the knee.2 Depending on the degree of trauma, injuries to the medial meniscus and the anterior cruciate ligament (ACL) may also be involved for patients with an MCL injury.

Isolated MCL tears or sprains can usually be treated conservatively. However, the MCL injury combined with an ACL tear, a large bony avulsion, or a tibial plateau fracture

may require surgical treatment. Because the rehabilitation program and treatment methods will be different when those conditions exist, it is important to rule out an injury to any of the associated structures in the MCL injury.3

Due to the fact that isolated MCL injuries, including all degrees of sprains and grade 1 and grade 2 tears, are likely to heal spontaneously, the treatment is usually conservative. However, a grade 3 tear or the presence of valgus instability in 0 degrees of knee flexion may require surgery. Conservative management consists of ice therapy, anti-inflammatory medication, use of a hinged knee brace, physical therapy, and exercise programs. The authors of the current article suggest that regeneration injection therapy, which is also called prolotherapy and involves platelet-rich plasma (PRP), hypertonic dextrose, and platelet-derived growth factor β, may be appropriate for inclusion in recognized, conservative standards for therapy for the condition.3,4 Hyperosmolar dextrose show its treatment effect indirectly by stimulating the production of some growth factors, whereas PRP and platelet derived growth factor β show their treatment effects by delivering growth factors directly to lesions.

Prolotherapy is now recognized as one of the most popular complementary medical therapies used to initiate a natural wound-healing cascade in soft-tissue injuries by the stimulation of growth factors. Hypertonic (15%-25%) dextrose is one of the most commonly used solutions in prolotherapy. Studies have shown that a hypertonic dextrose

Mustafa—Prolotherapy for MCL Sprain ALTERNATIVE THERAPIES, JULY/AUG 2015 VOL. 21, 4 69

solution can lead to an increase in ligament size and strength and can stimulate the repair of articular cartilage defects.5-7

Some clinical studies8-10 and case series6,11 have suggested that prolotherapy is effective in treating refractory tendinopathies, particularly for lateral epicondylitis, achilles tendinopathy, hip adductor tendinopathy, and plantar fasciopathy. However, inadequate clinical evidence exists to recommend the use of prolotherapy as a treatment for acute or chronic MCL injuries. On the basis of promising results from animal studies,12-14 the authors decided to treat an MCL lesion with prolotherapy. This case report documents an illustrative case that shows clinical and radiological outcomes following injections of dextrose with lidocaine in a rugby player who had a grade 2 sprain of the MCL. Written informed consent was obtained from the patient for publication of this report.

CASE PRESENTATIONA 21-year-old male rugby player sustained stress trauma

to the knee valgus. Four days after his sports-related injury, the player was referred to the authors’ outpatient clinic for sports medicine. He had severe pain over the medial side of his right knee and a swollen knee joint. His pain dramatically increased with any weight bearing. On physical examination, notable tenderness was observed over the MCL. Using a valgus stress test, the authors found a painful opening of the medial knee joint at 10- to 15-degree flexion, but no laxity existed at the full knee extension. Swelling around the knee joint was also found. Anteroposterior and lateral radiographs did not reveal any abnormalities. Magnetic resonance imaging (MRI) showed a grade 2 sprain of the MCL, subchondral bone marrow edema, and contusion at the corner of the lateral tibial plateau (Figure 1).

The patient was informed about his diagnosis and gave consent for treatment with prolotherapy and home-based exercise. The patient received 3 prolotherapy treatments for 3 weeks at 1-week intervals. During each prolotherapy session, the femoral and tibial bony attachments of the MCL and tender points over the lateral tibial plateau were injected using the peppering technique. After inserting the needle, the tender area was peppered with 20 to 30 injections using a 5-mL syringe with a 23-gauge, 5-cm needle. A total of 4 to 5 mL of solution consisting of 15% dextrose and 0.2% lidocaine were used per injection session.

After the first injection, isometric and active range-of-motion (ROM) exercises—3 sets of 8 repetitions, up to 3 times daily—were given as an initial exercise program. The rugby player reached 120 degrees for ROM on the fifth day postinjection and started progressive resistance training. The patient was able to walk without knee pain at the 10th day postinjection. He was then instructed to begin light use of an exercise bicycle.

By day 21 postinjection, the patient was pain free, with a full, active ROM. The strength of his quadriceps and hamstrings was within 85% of the unaffected leg, as assessed by isokinetic testing. The patient was able to perform all rugby-specific movements, such as sprinting, accelerations, and decelerations, without any restrictions. After completion of a full week of group training without symptoms, the player was able to play in a rugby match 12 weeks after initiation of prolotherapy, without residual symptoms or functional deficit. His posttreatment MRI at the sixth month showed a well-healed, relatively homogeneous MCL (Figure 2). Subchondral bone marrow edema at the corner of the lateral tibial plateau had also diminished, as shown on an MRI.

Figure 1. Grade 2 sprain of the MCL, subchondral bone marrow edema, and contusion at the corner of the lateral tibial plateau were seen on a T2-weighted MRI.

Abbreviations: MCL, medial collateral ligament; MRI, magnetic resonance imaging.

Figure 2. Posttreatment MRI at 6 mo shows a well-healed, relatively homogeneous MCL and no evidence of subchondral bone marrow edema or contusion at the corner of the lateral tibial plateau.

Abbreviations: MRI, magnetic resonance imaging; MCL, medial collateral ligament.

Mustafa—Prolotherapy for MCL Sprain 70 ALTERNATIVE THERAPIES, JULY/AUG 2015 VOL. 21, 4

DISCUSSIONThe current case study shows the successful repair of an

MRI-confirmed, grade 2 sprain of the MCL in a male rugby player, using dextrose-with-lidocaine prolotherapy and an exercise therapy. After the treatment, the patient regained full knee function and returned to his recreational sports without any restrictions. A posttreatment MRI at the sixth month revealed the healing of the MCL sprain.

Sports-related injuries, including those to ligament and tendon structures, are usually seen in sports medicine. The recovery time for ligament and tendon injuries varies according to severity of the injury and the treatment method. It is very important for the participants in sports to return to their preinjury level of function, ideally in the shortest time possible. Because an early return to the sports activity is the most important expectation for participants in sports, the treatment methods that provide a shorter time and a more effective recovery, without compromising tissue-level healing, have recently been preferred in sports medicine.15

Previous studies’ results showed that the mean duration of conservative treatment for isolated complete tears of the MCL was 4 to 8 weeks.16,17 In the current case, prolotherapy combined with an exercise therapy lasted 3 weeks. At the end of the 3 weeks, the patient was pain free with full ROM, and he was able to perform all rugby-specific movements.

Prolotherapy, which has been recently referred to as regenerative injection therapy, is presumed to stimulate the body’s self-healing mechanisms, leading to the reestablishment of structural integrity and improved function.18 Because prolotherapy is a treatment modality that may provide a solution to a patient’s pain symptoms and a positive contribution to tendon healing, it may be beneficial for the acute treatment of tendon or ligament pathologies related to sports injury.

The use of various injection therapies by medical practitioners for the treatment of tendinopathies is widespread. The solutions most commonly injected into peritendinous areas are often a combination of corticosteroids and anesthetics. However, some recommendations suggest limiting the use of the intratendinous injection of corticosteroids due to their negative mechanical effects, such as reduced tensile strength and a loss of viscoelasticity in tendons.19-21 Thus, prolotherapy remains a promising option for the treatment of tendinopathies due to its regenerative effects.

Prolotherapy is relatively safe, with few adverse reactions, which can include mild pain or bleeding at the injection site. The development of a postinjection pain flare is usually self-limited and often resolves within 1 to 2 days.22

Despite some promising animal studies,12-14 clinical evidence is lacking for the use of prolotherapy as a treatment of MCL lesions. Those studies have reported significant biological effects for improvement in  MCL healing using a platelet-derived, growth factor β for prolotherapy injections. Although no clinical trials have investigated the effectiveness of prolotherapy in the treatment of MCL lesions, 1 recent case study has reported positive effects for prolotherapy

using PRP on an injured MCL.23 In that case, an individual with a complete tear of the MCL experienced pain reduction, had improvement in isometric strength, and was able to return to unrestricted sports activity at 3 weeks posttreatment.

In the current case, similar results were found using dextrose-with-lidocaine prolotherapy. Although both injected solutions are thought to be irritants, hyperosmolar dextrose delivers its treatment effect indirectly by stimulating the production of some growth factors involved in tendon or ligament repair, whereas PRP produces its effect by delivering growth factors directly to lesions. In either case, a localized inflammatory response at the site of injection begins with activation of granulocytes and macrophages. Thus, the wound-healing cascade can be initiated. However, the relative effectiveness of one prolotherapy solution as compared with another has not been previously investigated in any clinical trial. Therefore, the issue of whether the content of one injected solution is superior to another solution in treatment efficacy is unclear. Because growth-factor prolotherapy is a more expensive option than prolotherapy using dextrose with lidocaine, in the current case, the authors had selected hyperosmolar dextrose.

CONCLUSIONSThe current case report shows that prolotherapy using

dextrose with lidocaine seems to be effective as an alternative option for the treatment of MCL lesions related to sports injury. Further, clinical research assessing prolotherapy as a treatment for ligament tears is needed to make specific recommendations including ideal protocols and optimal indications.

AUTHOR DISCLOSURE STATEMENTThe authors had no conflicts of interest related to the current case study.

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