In the horsecart days of, say, 2002, a runner might get that achey breaky tightness in the hammie and be diagnosed with tendonitis, the -itis suffix inferring inflammation. If rest, exercises and Advil didn't help, he might have been a candidate for a cortisone shot or even surgical intervention. Surgery fixed something, usually the pocketbook, and required significant down time. Cortisone injections fixed the pain, temporarily, and were happily reimbursed by insurers. Unfortunately, cortisone, an anti-inflammatory, is the right answer for the wrong diagnosis.
"Corticosteroids treat the pain, not the problem," said Rob Johnson, professor of family medicine at the University of Minnesota and team physician for University of Minnesota athletics. The problem is that doctors used to (and some still do) think overuse and tiny tears in the tendon caused inflammation, and that by reducing inflammation, they could eliminate pain and restore function. Johnson cites studies by Wayne Leadbetter and Karim Khan, doctors who found that previously (mis)diagnosed tendonitis tissue in fact had no inflammatory cells. Instead, they found the tendon tissue degenerated (thus more correctly termed tendinosis) by repeated stress to the point that it was too overwhelmed to get some healthy remodeling going. Remodeling, which is doctor-speak for healing, starts with inflammation.
Like instigating a controlled burn to jump-start healthy plant growth, prolotherapy for tendinosis employs irritant solutions that stimulate an inflammatory response and subsequent healing cascade. While still relatively new, prolotherapy is very safe, minimally invasive, and requires one or at most two procedures with minimal down time.
Johnson has performed more than 340 prolotherapy procedures since 2008, with 66-75 percent of his patients reporting that the technique contributed to their return to normal activity.
In the same way that a fever makes you feel like crap but is actually an essential step in the healing process, inflammation causes transient pain but is the body's healthy response to trauma, bringing healing and growth agents to the scene of the crime. Prolotherapy, which Johnson advocates when training modification and strengthening exercises have proved ineffective, is actually carefully directed acute trauma, a step up from the everyday low-grade stress the runner has already accomplished on her own. It's injury done right.
Prolotherapy is the broad term for irritating a tendon or other tissue to stimulate repair. The injury or irritation is accomplished both by mechanical means (the needle poking into the tendon) and by the substance the syringe is injecting -- dextrose, saline solution, anesthetic, autologous blood, platelet-rich plasma or some combination.
Platelet-rich plasma enjoys some boutique appeal because the patient's blood is spun in a centrifuge, concentrating the platelets and presumably their healing power. But the equipment is expensive, a whopping 18cc or more of blood is needed and it takes longer to administer without a better result than using whole blood based, on head-to-head research. Johnson said a PRP injection costs between $300 and $2,000. Autologous blood injection is whole blood, with all of the same healing qualities as PRP, taken from the patient's arm and injected into the injured tendon. Johnson prefers ABI because it requires nothing more than a tourniquet, a "butterfly" to draw blood and a syringe, takes 10-15 minutes and uses just 3cc of blood. ABI at Johnson's clinics costs between $125 and $148, which many insurers will not reimburse.
"There's a lot of money in PRP," Johnson said. "ABI is under the radar because it's far less lucrative. I always tell patients three things: It hurts when I do it, insurance probably won't cover it, and it may not work."
He can't be accused of sugarcoating. Here's how it's done: Johnson finds the point of maximal tenderness, usually at the tendon-bone junction, and injects some numbing lidocaine there. He draws 3cc of blood from the patient's arm, changes needles and, with one point of insertion, redirects the syringe 15 or 16 times in a quarter-sized area of the tendon, depositing blood at each point. The resulting inflammatory response lasts 48 to 72 hours during which there's no running and no use of Aleve, Advil, Motrin, etc. that would blunt the intended inflammation.
So that's the tough part. After that, Johnson counsels runners to return to the modified training, crosstraining and strengthening they were doing before prolotherapy. He said most runners can work out at six weeks and the tendon should be fully remodeled by three months. While one injection is usually sufficient, he offers a second between four and eight weeks from the first.
Prolotherapy has a tough-guy minimal quality runners find strangely compelling. "I was kind of skeptical, and the injection did hurt, though not any worse than cortisone shots I've had in the past," said 2:35 marathoner Michelle Frey. "But the prolotherapy definitely worked." Frey went to Johnson with high hamstring pain that wasn't responding to reduced mileage. After the initial inflammatory response and no running for a few days, she eased into 30 to 40 careful miles/week and crosstrained, did hamstring curls on the balance ball and received active release therapy. At six weeks, she had a second prolotherapy procedure in the same location and, three weeks later, was running 80 miles/week. "That was a couple years ago, and I've been training since then with no relapse," she said.