Regenerative Medicine in the Treatment of Sports Injuries: Prolotherapy and Extracorporeal Shock Wave Therapy

Dong Rak Kwon

doi:10.5763/kjsm.2016.34.1.1

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Kwon: Regenerative Medicine in the Treatment of Sports Injuries: Prolotherapy and Extracorporeal Shock Wave Therapy

Review Article

Korean J Sports Med 2016;34(1):1-9.

Published online: 19 January 2016

DOI: https://doi.org/10.5763/kjsm.2016.34.1.1

Regenerative Medicine in the Treatment of Sports Injuries: Prolotherapy and Extracorporeal Shock Wave Therapy

Dong Rak Kwon

Department of Rehabilitation Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea

Correspondence: Dong Rak Kwon Department of Rehabilitation Medicine, Catholic University of Daegu School of Medicine, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 42472, Korea Tel: +82-53-650-4878, Fax: +82-53-622-4687 E-mail: coolkwon@cu.ac.kr

Received 24 May 2016 Revised 16 May 2016 Accepted 24 May 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The treatment of sports injuries traditionally has included the use of the PRICE principle (protection, rest, ice/cold, compression, and elevation), analgesics/nonsteroidal anti-inflammatory drugs (NSAIDs), and, commonly, corticosteroids. Although NSAIDs, modalities, and corticosteroids may be helpful for short-term pain reduction and early recovery of function, they do not typically reverse the structural changes associated with degenerative conditions and may contribute to even worse long-term outcomes by potentially interfering with tissue healing. Regenerative interventions, including prolotherapy and extracorporeal shock wave therapy, recently have been used to treat refractory painful conditions such as chronic tendinopathies because of the potential of these interventions to facilitate tissue healing. The true utility of prolotherapy and regenerative medicine for sports injuries will become clearer as more high-quality research is published.

Keywords: Prolotherapy, Extracorporeal shockwave, Sports, Injuries, Wound healing

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Fig. 1.

Wound healing stages.

Fig. 2.

Rationale of prolotherapy.

Fig. 3.

Posterior photo of right lower leg showing injection points for management of Achilles tendinopathy. The ‘X’ markings represent the anteromedial, posterior midline and anterolateral margins of the tendon, with orange lines demarking the Achilles tendon¹⁷⁾.

Fig. 4.

Anteroposterior photograph of knee illustrating injection points marked ‘X’ starting over the most distal area of pain on the tibial tuberosity and moving proximally in 1-cm increments to the most proximal painful point with pressure. The orange lines represent the attachment of the patellar tendon from the patella to the tuberosity or its fragments¹⁷⁾.

Fig. 5.

A case of successful treatment with prolotherapy in patient with lateral common extensor tendon tear (A). Ultrasound findings before prolotherapy: complete rupture of right common extensor tendon (red arrows), cortical erosive change with periosteitis involving right lateral epicondyle. (B) Normal findings of left epicondyle. (C, D) Color Doppler shows increased vascularity in Rt. common extensor. (E, F) Three months after prolotherapy with 25% dextrose injection, when compared with previous study, previously suspected tendon defect of common extensor tendon is filled with soft tissue echo (red arrow). No increased vascularity is detected. Erosive bony cortex is not changed. Rt.: right, Lt.: left.

Fig. 6.

Plantar photograph of left foot illustrating the injection site for management of plantar faciopathy. The ‘X’ marking represents the medial heel site used for the ultrasound-guided platelet-rich-plasma and prolotherapy injections, with the orange lines demarking the medial band of the plantar fascia¹⁷⁾.

Fig. 7.

Conversion of energy flux density from radial to focus type.

Fig. 8.

Calcific lateral epicondylitis. (A) Pre-treatment. (B) Longitudinal view. (C) Transverse view post-treatment. (D) Longitudinal view. Transverse view, 2,000 shocks, 3 times weekly, 0.1 mJ/mm², 3 Hz, focus type, calcification (white arrows).

Table 1.

Prolotherapy for common musculoskeletal conditions

Diagnosis	Evidence summary	SOR∗
Achilles tendinopathy	When added to eccentric exercise, DPT results in faster and sustained	A
(non-insertional)	improvement in pain and function¹³⁾
Knee osteoarthritis	DPT improves pain scores and flexion ROM^14,15)	A
Low back pain (mechanical)	No evidence of use in subacute and chronic low back pain^16,18)	A
Epicondylosis (lateral)	A single study found DPT more effective than saline injections for reducing	B
	pain; pain control sustained at 1 year¹⁹⁾
Osgood-Schlatter disease	A single study found improved overall pain and pain with specific	B
	sports activity²⁰⁾
Plantar fasciosis	Small studies show DPT can improve pain at rest and during activity^21,22)	B
Chondromalacia patella	Evidence lacking for use of DPT of chondromalacia patella or other	C
(PFPS)	causes of PFPS²³⁾

SOR: strength of recommendation, DPT: dextrose prolotherapy, ROM: range of motion, PFPS: patellofemoral pain syndrome. ∗A: good-quality patient-oriented evidence, B: inconsistent or limited-quality patient-oriented evidence, C: consensus, usual practice, opinion, disease-oriented evidence, case series.

Table 2.

Differences between focus type and radial type

Type	Focus	Radial
Pressure	100−1000 bar	1−10 bar
Pulse duration	0.2 μs	0.2−0.5 ms
Pressure field	Focused	Radial, divergent
Penetration depth	Deep	Small, superficial
Effect	Cell	Tissue

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