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From the Journal of
Prolotherapy
Journal of Prolotherapy. 2010;2(3):416-437.
KEYWORDS: human growth hormone, meniscal degeneration, meniscal tear, meniscus,
platelet rich plasma, Prolotherapy.
The Case for Utilizing Prolotherapy as First-Line Treatment
for Meniscal Pathology:
A Retrospective Study Shows Prolotherapy is Effective in the Treatment of
MRI-Documented Meniscal Tears and Degeneration
Ross A. Hauser, MD, Hilary J. Phillips, and Havil S. Maddela
ABSTRACT
Meniscus injuries are a common cause of
knee pain, accounting for one sixth of
knee surgeries. Tears are the most common form of
meniscal injuries, and have
poor healing ability primarily because less than 25% of the menisci receive a
direct blood supply. While surgical treatments have ranged from total to partial
meniscectomy, meniscal repair and even meniscus transplantation, all have a high
long-term failure rate with the recurrence of symptoms including pain,
instability, locking, and re-injury. The most serious of the longterm
consequences is an acceleration of joint degeneration. This poor healing
potential of
meniscus tears and degeneration has led to the investigation of
methods to stimulate biological meniscal repair.
Research has shown that damaged menisci lack the growth
factors to heal. In vitro studies have found that growth factors, including
platelet derived growth factor (PDGF), transforming growth factor (TGF), and
others, augment menisci cell proliferation and collagen growth manifold.
See
The Regeneration of
Articular Cartilage with Prolotherapy
Animal
studies with these same
growth factors have confirmed that meniscal tears and
degeneration can be stimulated to repair with various growth factors or
solutions that stimulate growth factor production. The injection technique
whereby the proliferation of cells is stimulated via growth factor production is
called Prolotherapy.
Prolotherapy solution can include dextrose,
human growth
hormone (HGH),
platelet rich plasma, and others, all of which stimulate connective
tissue cells to proliferate. A retrospective study was done involving 24
patients, representing 28 knees, whose primary knee complaints were due to meniscal pathology documented by
MRI. The average number of Prolotherapy visits
was six and the patients were followed on average 18 months after their last
Prolotherapy visit.
Prolotherapy caused a statistically
significant decline in the patients’ knee pain and stiffness. Starting and
ending knee pain declined from 7.2 to 1.6, while stiffness went from 6.0 to 1.8. Prolotherapy caused large improvements in other clinically relevant areas such
as range of motion, crepitation, exercise, and walking ability. Patients stated
that the response to Prolotherapy met their expectations in 27 out of the 28
knees (96%)
Only one out of the 28 patients ended up getting surgery after Prolotherapy. Based on the results of this study, Prolotherapy appears to be an
effective treatment for meniscal pathology. While this is only a pilot study,
the results are so overwhelmingly positive that it warrants using Prolotherapy
as first-line therapy for meniscal pathology including meniscal tears and
degeneration.
Epidemiology of Meniscal Injuries
Knee injuries are a common concern resulting in over 1 million surgeries
performed to the knee in the United States every year.1-3 According
to the National Athletic Trainers’ Association, knee injuries account for 10% to
19% of high school sports injuries and 60.3% of all high school athletic-related
surgeries.4 Similar studies of collegiate sports have shown that knee
injuries make up 7% to 54% of athletic injuries, varying by the nature of the
sport.5-9 The leading injuries to the knee, in both adults and
children alike, are primarily
patellofemoral derangements or
ligament strains
and tears.10-12
Secondary to these injuries are meniscal tears, which
have generated particular interest in both the young and elderly population as
studies over the past several decades have revealed a rise in both degenerative
and traumatic meniscal injuries. Meniscal tears occur as early as childhood,
where they serve as the leading cause of pediatric
arthroscopy, and increase
with age and activity.13,14 An estimated one sixth of knee surgeries
are performed for lesions of the meniscus, and it is likely that many more
remain untreated every year.15,16 In one study of cadaver knees,
untreated meniscal lesions were found in 34% of the autopsied subjects.17
A significant percentage of meniscal injuries result from athletic injury. On a
professional level, meniscal tears accounted for 0.7% of all injuries sustained
in the National Basketball Association, totaling 3,819 days missed by NBA
athletes over a 10 year span.18
In college sports, studies conducted
over a 16 year span by the National Collegiate Athletic Association Injury
Surveillance System found internal knee derangement was second only to ankle
sprains in both men’s and women’s college basketball and men’s and women’s
soccer.5-8 An independent study of college football had equally
devastating statistics, reporting injuries to the meniscus in roughly one in
five elite college football athletes.9 With participation in college
sports on the rise, the number of meniscal injuries and subsequent surgeries are
consequently rising at an alarming rate.19 Although athletes appear
to have the highest instance of injury, meniscus injuries can happen anywhere,
regardless of a person’s level of activity. A research study conducted in Greece
showed that meniscal tears developed equally from traumatic and non-traumatic
causes with 72% of all meniscal tears occurring during normal activities of
daily living.20
Anatomy and Function
 The menisci (plural of meniscus) are a pair of C-shaped fibrocartilages which
lie between the femur and tibia in each knee, extending peripherally along each
medial and lateral aspect of the knee. (See Figure 1.) The anatomy of both
menisci is essentially the same, with the only exception being that the medial
meniscus is slightly more circular than its hemispherical lateral counterpart.
Each meniscus has a flat underside to match the smooth top of the tibial
surface, and a concave superior shape to provide congruency with the convex
femoral condyle. Anterior and posterior horns from each meniscus then attach to
the tibia to hold them in place. The meniscus is comprised of approximately 70%
water and 30% organic matter. This organic matter is primarily a fibrous
collagen matrix consisting of type I collagen, fibrochondrocytes,
Proteoglycans,
and a small amount of dry noncollagenous matter.21,27 There has been
a great deal of speculation and research dedicated to what exact function the
meniscus serves, but today there is general consensus that the menisci provide
stability in the joint, nutrition and lubrication to
articular cartilage, and
shock absorption during movement.21-25 The menisci provide stability
to the knee joint by both restricting motion and providing a contour surface for
tibiofemoral bone tracking. The function of stability is shared with several
ligaments which work together to prevent overextension of any motion. The
transverse ligament connects the two menisci in the front of each knee and
prevents them from being pushed outside of the joint at any point. Hypermobility
is avoided through the connection of the
medial collateral ligament (MCL)
to the
medial tibial condyle, femoral condyle, and medial meniscus, and the connection
of the
lateral collateral ligaments (LCL) to the lateral femoral epicondyle and
the head of the fibula; these ligaments provide tension and limit motion during
full flexion and extension, respectively. The anterior and posterior
meniscofemoral ligaments form an attachment between the lateral meniscus and the
femur and remain taut during complete flexion. Lastly, the
anterior cruciate ligament
(ACL)
and posterior cruciate ligament (PCL) are responsible for
preventing too much backward or forward motion of the tibia.23,24 The
menisci also provide shock absorption and stability by equally distributing
weight across the joint.
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