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Is hypertonic dextrose injection effective in the treatment of plantar fasciitis: A clinical randomized study



Objectives: We aimed to assess the efficacy of hypertonic dextrose injection (prolotherapy; PT) in the treatment of patients with plantar fasciitis (PFs). Material and methods: In this single-blind, randomized, controlled study, 30 PFs patients were randomly assigned into 2 groups. Group 1 (PT group) received 3 injections of 3 ml 15% dextrose into plantar fascia at an interval of 3 weeks and PFs exercise treatment; meanwhile Group 2 (control group) received 3 injections of 3 ml saline and PFs exercise treatment. Clinical assessments included measurement of pain intensity (VAS score), foot function index (FFI), RolesMoudsley Scoring, and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores. Assessments were performed before the first and after the last injections. All patients completed the study without any complication. Results: Significant improvements were observed in post-treatment VAS, FFI, AOFAS (pain, function, total) and Roles-Moudsley scores in both groups, however VAS, FFI and Roles-Moudsley score improvements were greater in the PT group when compared with the control group (p<0.001). Conclusion: PT improved pain and functional outcomes, and seems to be effective in the treatment of PFs. Further studies including larger number of patients and longer follow-up periods are needed to validate these results. Keywords: Plantar fasciitis, dextrose, prolotherapy, saline
Elif Umay Altas* 0002 4877 5871
Ayhan Askin
Aliye Tosun *0003 2827 6255
1 M.D., Department of Physical Medicine and Reha-
bilitaon, Kap Celebi University Ataturk Educaon
and Research Hospital, Izmir, Turkey
Correspondence: Elif Umay Altas, MD.
Department of Physical Medicine and Rehabilitaon,
Kap Celebi University Ataturk Educaon and Rese-
arch Hospital, 35360, Izmir, Turkey
Objecves: We aimed to assess the ecacy of hyper-
tonic dextrose injecon (prolotherapy; PT) in the tre-
atment of paents with plantar fasciis (PFs).
Material and methods: In this single-blind, randomi-
zed, controlled study, 30 PFs paents were randomly
assigned into 2 groups. Group 1 (PT group) received
3 injecons of 3 ml 15% dextrose into plantar fascia
at an interval of 3 weeks and PFs exercise treatment;
meanwhile Group 2 (control group) received 3 in-
jecons of 3 ml saline and PFs exercise treatment.
Clinical assessments included measurement of pain
intensity (VAS score), foot funcon index (FFI), Roles-
Moudsley Scoring, and American Orthopedic Foot
and Ankle Society (AOFAS) ankle-hindfoot scores. As-
sessments were performed before the rst and aer
the last injecons. All paents completed the study
without any complicaon.
Results: Signicant improvements were observed in
post-treatment VAS, FFI, AOFAS (pain, funcon, total)
and Roles-Moudsley scores in both groups, however
VAS, FFI and Roles-Moudsley score improvements
were greater in the PT group when compared with
the control group (p<0.001).
Conclusion: PT improved pain and funconal outco-
mes, and seems to be eecve in the treatment of
PFs. Further studies including larger number of pa-
ents and longer follow-up periods are needed to va-
lidate these results.
Keywords: Plantar fasciis, dextrose, prolotherapy,
Amaç: Plantar fasiitli (PF) hastalarda hipertonik deks-
troz enjeksiyonunun (proloterapi; PT) etkinliğini de-
ğerlendirmeyi amaçladık.
Materyal Metod: Değerlendiricinin kör olduğu ran-
domize kontrollü olarak tasarlanan bu çalışmada
PFs tanılı 30 hasta 2 gruba ayrıldı. 1. Gruba (PT grup)
%15’lik dextroz PT ve egzersiz, 2.gruba(kontrol grup)
salin enjeksiyonu ve egzersiz verildi. Enjeksiyonlar
3’er haa arayla 3 kez yapıldı. Klinik değerlendirmede
ağrı yoğunluğu (VAS skoru), ayak fonksiyon indeksi
(FFI), Roles-Moudsley skorlaması, Amerikan orto-
pedik ayak ve ayak bileği topluluğu ayak bileği arka
ayak skoru (AOFAS) kullanıldı. Değerlendirmeler ilk
Is hypertonic dextrose injecon eecve in the tre-
atment of plantar fasciis: A clinical randomized
Plantar fasiit tedavisinde hipertonik dekstroz en-
jeksiyonu etkili midir: Klinik randomize çalışma
Geliş Tarihi: 01/08/2018
Kabul Tarihi: 27/09/2018
Ege Klin Tıp Derg 2018; 56 (3): 102-108
enjeksiyon öncesi ve son enjeksiyonlardan sonra ger-
çekleşrildi. Tüm hastalar herhangi bir komplikasyon
olmaksızın çalışmayı tamamladı.
Bulgular: Her iki grupta da tedavi sonrası VAS, FFI,
AOFAS (pain, funcon, total) ve Roles-Moudsley skor-
larında anlamlı düzelme oldu. Ancak kontrol grubuna
göre VAS, FFI ve Roles-Moudsley skorundaki iyileş-
meler PT grubunda daha fazlaydı (p <0.001).
Sonuç: PFs tedavisinde PT, ağrı ve fonksiyonel so-
nuçlar üzerine etkili bir yöntem olmakla birlikte, bu
sonuçları doğrulamak için daha fazla sayıda hasta ve
uzun takip süreleri de dahil olmak üzere daha ileri ça-
lışmalara ihyaç vardır.
Anahtar Kelimeler: Plantar fasiit, dextroz, prolotera-
pi, salin
1. Introducon
Plantar fasciis (PFs) is a degenerave syndrome in
which repeang microtraumas cause tracon perios-
s on central band’s inseron point of plantar fascia
and microtears [1]. As a result, a sharp pain develops
just below the heel or on medial collateral tubercle
which increases by pressure. Some addional comp-
laints also include snging and intense pain that radi-
ates below the heel towards lower leg. This condion
might aect the mobility and movement capability of
the paent signicantly [2].
Since PFs is a self-liming clinical condion, most of
the paents show improvement with a conservave
treatment [3]. The paents who do not show impro-
vement with conservave measures such as stretc-
hing, orthoses, physical therapy, nighme splints
and immobilizaon might be treated with alternave
methods such as extracorporeal shock wave therapy
(ESWT), steroid injecons, prolotherapy, platelet-rich
plasma (PRP) injecons and in most severe cases,
surgery [4].
Hypertonic dextrose injecon (prolotherapy) is a
method in which an irritant soluon is injected to the
damaged ligament or tendon structures in order to
increase the new cell proliferaon on those structu-
res, therefore strengthening them [5, 6]. The main
goal of prolotherapy (PT) is to strengthen bro-osse-
ous inseron points of ligaments, tendons and joint
capsules by creang a ght and thick brous ssue
[7]. PT is thought to create a curave cascade by ca-
using a therapeuc trauma, characterized by increa-
sing cellular stress on the weakened ligament or ten-
don area and causing mild inammaon on injecon
site. This cascade includes granulaon ssue forma-
on, matrix formaon and remodeling of the ssue
[8, 9]. Macrophages clean out dead cells and fore-
ign materials by phagocytosis meanwhile broblasts
help new cell producon and development in addi-
on to collagen synthesis by increasing DNA synthe-
sis and protein by growth factor exposure. New cells
and matrix stack up with organizaon in the aected
area. Remodeling occurs weeks later. Contemporary
theory says that PT mimics the natural healing pro-
cess of the body [10-12].
PT was rst standardized by Hacke in 1950’s, and
hypertonic dextrose in addion to morrhuate sodium
is the most commonly used soluon today [13, 14].
Although its indicaon is usually reported as chronic
back pain, some studies reported successful results
when used in the treatment of thoracic and cervical
pain syndromes, whiplash injuries, lateral and medial
epicondylis, rotator cu or bicipital tendinosis, PFs,
coccygodynia and osteoarthris [15]. When all evi-
dence-based studies on PT were reviewed, evidence
level was classied as A in lateral epicondylis [13],
and B in Achilles’ tendinopathy [16], PFs [17] and os-
teoarthris [18].
To our knowledge, only two studies evaluated the ef-
cacy of PT in paents with PFs in English literature.
Ryan et al reported a good clinical response to dext-
rose injecons in 20 paents with PFs [17]. Kim et
al compared the ecacy of PT versus PRP on 20 PFs
paents, and reported that both treatments seemed
to be eecve, however PRP led to a beer inial
improvement in funcon [19]. In this study, our
main objecve is to assess the ecacy of PT treat-
ment on pain and funconal status in paents with
2. Material and Methods
Our study design was designed as a prospecve,
single-blind, randomized, controlled study. All par-
cipants were informed about the study and their
informed consents were obtained. Ethical approval
was obtained from our hospital’s local ethics com-
Paents with a clinical diagnosis of PFs (pain during
rst few minutes in the morning with walking and
with pain by pressure on calcaneal tubercle when
the foot was on passive dorsiexion) and with uni-
lateral symptoms ongoing for at least 2 months and
had minimal pain levels of 4 on VAS were included in
the study.
Paents were excluded if they used nonsteroidal an-
-inammatory drugs (NSAIDs) in the last 2 weeks,
received physical therapy for PFs in last 3 months, re-
ceived previous injecons, had history of foot, ankle
or heel surgical intervenons or haddetected anato-
mical anomalies such as pes planus or pes cavus on
x-rays. They were also excluded if theyhad infecons
on injecon site, coagulaon disorders / ancoagu-
Is hypertonic dextrose injecon eecve in the treatment of plantar fasciis: A
clinical randomized study
Plantar fasiit tedavisinde hipertonik dekstroz enjeksiyonu etkili midir: Klinik ran-
domize çalışma
lant treatments, pregnancy or nursing, peripheral ne-
uropathies or lower extremity paresis or paraplegia.
Paents were randomly divided into 2 groups by
a stascal soware. Group 1 received PT and PFs
exercise treatment; while Group 2 received saline in-
jecons and PFs exercise treatment.
Exercise programmes: Exercise programmes presc-
ribed to the paents included plantar fascial stretc-
hing, towel carrying using toes, rolling solid objects
with the sole, dorsiexion against resistance, resis-
tant plantar exion, inversion and eversion. Exercises
were iniated 72 hours following the inial injecons
and were demonstrated to the paents on their rst
sessions. Paents were instructed to connue to the
home-based exercise programmes for 3 months (one
session per day with a duraon of 10 minutes).
Prolotherapy injecons: Group 1 (PT group) received
3 injecons of 3 ml 15% dextrose into the plantar
fascia-bone inseron point at an interval of 3 weeks
under sterile condions. The applicaon was done
under asepc condions using a 22-gauge needle
with a single skin entry on the fascia ligament-bone
inseron point with peppering technique which con-
tained 5 penetraons.
Saline injecons: Group 2 (control group) received
3 injecons of 3 ml saline at an interval of 3 weeks
under asepc condions with the same peppering
Following injecons, the injecon area was exposed
to surface heat for 10 minutes and paents were as-
ked to remain in a sing posion for 30 minutes and
instructed to apply heat to the injecon surface 3 -
mes for 10 minutes for 3 days. Paents were warned
that their pain might worsen during that period and
were told not to take any NSAIDs during the treat-
ment, but can take acetaminophen for pain if neces-
sary. They were also adviced to avoid heavy loading
acvies and to begin exercises 72 hours aer the
injecons. None of the paents were given foot ort-
Clinical assessments were done prior to treatment
and on the 3rd month of the treatment by an asses-
sor who was blind to the treatments. Clinical assess-
ments included the measurement of pain intensity
(VAS score), foot funcon index (FFI), Roles-Mouds-
ley scores, and American Orthopedic Foot and Ankle
Society (AOFAS) ankle-hindfoot scores.
FFI is a funconal index that reviews the eect foot
pain has on the daily life of the paent. It is made of
23 quesons with pain, disability and acvity limita-
on subscales. Pain and disability subscales have 9
and acvity limitaon subscale has 5 quesons. The
paent scores each queson from 0 (no pain) to 10
(worst pain ever) [22].
Roles-Moudsley Scoring measures the relaonship
between pain in the extremity with acvity. It is gra-
ded as 1 point for asymptomac paent, 2 points
for paents with transient symptoms that respond
well to treatment, 3 points for paents with mild-
to-moderate pain following acvity and 4 points for
paents with no improvement in the symptoms [21].
AOFAS is a scoring system developed for measuring
the pain, limitaon in acvity, walking distance and
disorders, foot mobility, stability and alignment of
the foot [22].
At the follow up of the paents 3 months aer the
rst injecons; clinical assessments were repeated
by the same invesgator.
2.4.Stascal Analysis
All stascal analyses were performed by using SPSS
22.0 (IBM Corporaon, Armonk, New York, United
States) and Medcalc 14 (Acacialaan 22, B-8400 Os-
tend, Belgium) soware. Normality assessment was
made with Shapiro-Wilk test. Comparison of two in-
dependent groups was performed with independent
samples t-test and Mann Whitney U (Exact) test.
Wilcoxon’s signed-rank test were performed to de-
termine dierences within groups. Comparison for
categorical variables was made with Pearson Chi-
Square test and Monte Carlo simulaon technique
was applied. Variables were analyzed at 95% con-
dence level, and a p-value of less than 0.05 was ac-
cepted as signicant.
3. Results
Thirthy PFs paents were included in the study. No
signicant dierence was seen in baseline demog-
raphical and clinical values between the groups. The
demographical and clinical properes of the paents
were shown on Table 1.
Table 1. Demographic and clinical characteris-
cs of the paents in both groups.
Altas ve ark. Altas et al.
A signicant dierence was seen between Group 1
and 2 on VAS scores prior to treatment, with higher
VAS scores in Group 1 (p = 0.007). Similarly, acvity
limitaon (subscale of FFI) was signicantly dierent,
with higher values on Group 1 (p = 0.039). When
pre- and post-treatment results were compared,
signicant improvements were seen in both groups
on VAS, AOFAS (pain, funcon, total), FFI (pain, di-
sability, acvity limitaon, total) and Roles-Maudsley
scores. In addion, there was a signicantly higher
improvement in Group 1 compared to Group 2 in
terms of VAS, AOFAS (pain, funcon, total), FFI (pain,
disability, acvity limitaon, total) and Roles-Mauds-
ley scores in post-treatment results. Intergroup and
intragroup pre- and post-treatment improvement re-
sults were summarized on Table 2.
Table 2. Baseline / posntervenon comparisons in
outcome measures within and between the groups.
In intergroup improvement dierences, Group 1 had
signicantly beer outcomes except AOFAS (Align-
ment) parameter compared to Group 2. The die-
rences in improvement measures were shown on
Table 3.
Table 3. Comparison of median dierences in outco-
me measuresfrom baseline.
4. Discussion
Our study results revealed that PT treatment is more
eecve in improving pain and funconal outcomes
when compared to saline injecons. No signicant
improvement was seen in AOFAS – Alignment sub-
score in both groups. When groups were compared
in terms of improvement in all other scores, paents
who received PT revealed signicant improvements
compared to saline injecons. To the best of our
knowledge, our study is the rst randomized, cont-
rolled study that compared PT ecacy with saline in
PFs treatment.
PFs is a common disease without a clear eology
which causes pain and tenderness of the foot soles
with a wide clinical spectrum that might even cause
disability in some paents [23]. The underlying pat-
hology is thought to be the degenerave ssue on
the area where plantar fascia originates on the me-
dial tuberosity of calcaneus [24]. Structural deformi-
es, excessive foot pronaon, forefoot varus defor-
mity and weakness of bialis posterior muscle are all
though to be parts of eology [25]. The most frequ-
ently used conservave measures include changing
daily acvies, using orthoses, stretching exercises
and treatment with NSAIDs [26]. In more severe ca-
ses, extracorporeal shockwave treatment (ESWT),
Is hypertonic dextrose injecon eecve in the treatment of plantar fasciis: A
clinical randomized study
Plantar fasiit tedavisinde hipertonik dekstroz enjeksiyonu etkili midir: Klinik ran-
domize çalışma
laser therapy, acupuncture, dry needling and ion-
tophoresis can also be used [27, 29]. As those treat-
ments are thought to be eecve in almost 90% of all
cases, some authors argue that PFs is a self-liming
condion and that there is not enough evidence for
treatment ecacy, about 10% of more severe cases
might need more aggressive treatment intervenons
such as surgery [17, 29].
In placebo-controlled studies, corcosteroid (CS) tre-
atment was found to be eecve on the pain, but the
treatment eect is relavely short-lasng; between
4-12 weeks [30]. In addion, treatment complica-
ons such as fat pad atrophy, skin atrophy, plantar fas-
cia ruptures and osteomyelis in calcaneus limit the
usage of this treatment method [20]. PRP increases
rejuvenaon process by starng the inammatory
process which was interrupted by conservave treat-
ment of PFs by growth factors contained within [32].
PT is used for treang most of the musculoskeletal
paintypes including tendinopathies. PT works by cre-
ang a hypertonic environment which causes cell
rupture and up-regulang thrombocyte-rich growth
factor expression. Cellular shiing and increased
growth factors develop a healing cascade on the in-
jury. Fibroblasts’ exposure to growth factors increase
DNA synthesis and proteins, therefore causing new
cell growth and reproducon and collagen deposits
[33]. In the previous studies done on PT, Robago et
al, Distel and Best, Vara et al and Hauser et al all re-
ported successful results in majority of the cases,
however they did not have randomizaon or control
groups [18, 34]. In this perspecve, our study stands
out by its single-blind, prospecve randomized cont-
rolled study design. Rabago et al’s study done on 32
lateral epicondylis cases reported PT to be eecve
in improving pain and funcon in those paents [35].
Another study done on 61 paents with chondro-
malacia patella reported that PT caused a long-term
pain modicaon and could be a rst line of choice
in conservave treatment opons [36]. Yet another
randomized study done on 73 paents with chronic
shoulder pain caused by rotator cu tendinopathy
compared saline injecons with PT and reported PT
to be eecve on pain management [37]. A study
done on knee osteoarthris showed that PT caused
signicantly beer outcomes compared to saline
injecon and exercise; but warned that the results
showed heterogeneity and said that further studies
with wider paent series were necessary [38]. Again,
another study done on knee osteoarthris showed
that PT showed beer improvement compared to
local anesthec and CS injecons in 6-month term
and that there was no dierence in hand and knee
osteoarthris results [39]. A review done on lower
extremity tendinopathy and fasciopathy reported PT
to be benecial in Achilles’ tendinopathy, PFs and
Osgood-Schlaer disease, however more randomi-
zed controlled wider studies were necessary on this
subject [40]. Ryan et al’s study in which they made
3 PT injecons guided by USG with 6-week periods
reported that there was a signicant decrease in pain
severity during resng and acvity aer 18 months
[19]. There is only one randomized controlled study
done on PFs in the literature. Kim et al’s study with
20 PFs paents compared the ecacy of PRP and PT
by 2 injecons 2 weeks apart. The paents were fol-
lowed for 6 months and both methods were found to
be eecve. During inial period, PRP showed beer
outcomes in funconal improvement [19]. In accor-
dance with the previous results in the literature, we
also found out that PT treatment to be more eec-
ve in our study with 30 PFs paents. Our study’s main
advantages are the inclusion of larger number of pa-
ents, presence of control group and its randomized
and single-blind design. Therefore, we think that our
study, being a rst in this eld for the reasons stated
above, will make an extra contribuon to the litera-
ture on PFs.
No severe side-eects were reported on PT treat-
ments used on musculoskeletal system [29]. Dext-
rose is generally recognized as a safe proliferang
agent for injecon as it is a natural component of
blood biochemistry. The side eects which might
develop with the treatment are similar to other in-
jecon techniques and is mainly caused by injecon
technique rather than the agents injected [18]. No
adverse eects were seen in any of our paents du-
ring the study.
The main limitaon of our study is the short follow-
up period. As this was designed as a pilot study, alt-
hough the period was kept short, PT’s ecacy on PFs
treatment was proven. However, we sll need furt-
her randomized single-blind studies with longer pa-
ent series and longer follow-up periods to support
our results.
Prolotheraphy improved pain and funconal outco-
mes, and seems to be eecve in the treatment of
paents with PFs. It may be considered as a new tre-
atment opon for PFs. Further studies including lar-
ger number of paents and longer follow-up periods
are needed to validate these results.
PFs: Plantar fasciis; VAS score: Clinical assessments
included measurement of pain intensity, FFI: foot
funcon index, AOFAS: American Orthopedic Foot
Altas ve ark. Altas et al.
and Ankle Society; ESWT: extracorporeal shock
wave therapy, PRP: steroid injecons, prolotherapy,
platelet-rich plasma; PT: prolotherapy; NSAIDs: nons-
teroidal an-inammatory drugs; CS: corcosteroid
No nancial support was received for this project.
Availability of data and materials
The datasets analyzed during the current study are
available from the corresponding author on reaso-
nable request.
Compeng interests
The authors declare they have no compeng inte-
Consent for publicaon
Not applicable.
Ethics approval and consent to parcipate
Ethics approval was granted for this study by the
instute’s Ethics Commiee of Izmir Kap Celebi Uni-
versity, School of Medicine (21 July 2016, No. 124).
Informed consent was provided by all parcipants.
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Altas ve ark. Altas et al.
Cilt / No: 56  Sayı/No: 3 Aralık/December 2018
Fatma ŞİMŞEK ve Ark.
Elif Umay ALTAS ve Ark.
Ayşe Gülsün AKSÜT ve Ark.
Yıldızhan ŞENGÜL ve Ark.
Dilek UYSAL ve Ark.
Hakan ÇÖKMEZ ve Ark.
Erkan DOĞAN ve Ark.
Yasemin BALCI ve Ark.
Gürkan YILDIZ ve Ark.
Ozan GÖKDOĞAN ve Ark.
Deneysel İrritabl Bağırsak Sendromunun İntesnal Yüzey Epitelinde
Bulunan Dopaminerjik Yolaklar Üzerindeki Etkisi
The Eects of Experimental Irritable Bowel Syndrome on Dopaminergic Pathways in Intesnal Surface Epithelium
Is hypertonic dextrose injecon eecve in the treatment of plantar fasciis:
A clinical randomized study
Plantar fasiit tedavisinde hipertonik dekstroz enjeksiyonu etkili midir: Klinik randomize çalışma
Elif Umay ALTAS, Ayhan ASKIN, Aliye TOSUN
Farklı Hasta Gruplarındaki Tedavi Sürecinde Yaşam Kalitesinin Değerlendirilmesi
Evaluaon of Quality of Life in The Treatment Process in Dierent Paent Groups
Ayşe Gülsün AKSÜT, Nazlı SOYSAL, Umut Gök BALCI, Kurtuluş ÖNGEL
Esansiyel Tremor Hastalarında Yüz Duygu Tanıma
Facial Emoon Recognion in the Paents With Essenal
Yıldızhan ŞENGÜL, Abdulkadir TUNÇ, Onur YILMAZ, Ahmet ÖZTÜRK
Atrok Vaginit Tedavisinde Uzun Dönem Düşük Doz 17-β Estradiol
Vaginal Tablet Uygulamalarının; Klinik Etkinliğiİ ve Endometrial Sonuçları
The Clinical Ecacy and Endometrial Outcome of Long-term Low-dose
17-β Estradiol Vaginal Tablet Applicaons in the Treatment of Atrophic Vaginis
Premenstrüel Sendromlu Olgularda Tiroid Fonksiyon Testleri
Thyroid Funcon Tests in Cases With Premenstrual Ssyndrome
Acil Serviste Akut Aort Diseksiyonu Tanısı Alan Hastaların Geriye Dönük Analizi
Retrospecve Analysis of Paents Diagnosed as Acute Aorc Dissecon in Emergency Department
Erkan DOĞAN, Akkan AVCI, Müge GÜLEN, Ertan CÖMERTPAY, Begüm Şeyda AVCİ, Salim SATAR
Amniyon Sıvı Embolisi Nedenli Bir Ölüm Olgusu
Amnioc Fluid Embolism as a Cause of Death: A Case Report
Yasemin BALCI, Ümit Ünüvar GÖÇEOĞLU
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A Very Rare Cause Of Ulnar Nerve Palsy: Dorsal Shi of the Ulnar Nerve Aer Distal Radius Fracture
Gürkan YILDIZ, Mesut TAHTA, Eyüp Çağatay ZENGİN, Ahmet SAVRAN
Laparoskopi Sonrası Umbilical Trokar Yeri Hernisi
Umbilical Port Hernia Following Laparoscopic Surgery
The Concurrence three dierent beningn pathologies in one nose
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Full-text available
Background Increasing evidence has supported the use of dextrose prolotherapy for patients with osteoarthritis. However, the real benefits may be affected by differences in injection protocols, comparative regimens, and evaluation scales. Methods PubMed and Scopus were searched from the earliest record until February 2016. One single-arm study and five randomized controlled trials were included, comprising 326 participants. We estimated the effect sizes of pain reduction before and after serial dextrose injections and compared the values between dextrose prolotherapy, comparative regimens, and exercise 6 months after the initial injection. Results Regarding the treatment arm using dextrose prolotherapy, the effect sizes compared with baseline were 0.65 (95% confidence interval [CI], 0.14–1.17), 0.84 (95% CI, 0.40–1.27), 0.85 (95% CI, 0.60–1.10), and 0.87 (95% CI, 0.53–1.21) after the first, second, third, and fourth or more injections, respectively. The overall effect of dextrose was better than control injections (effect size, 0.36; 95% CI, 0.10–0.63). Dextrose prolotherapy had a superior effect compared with local anesthesia (effect size, 0.38; 95% CI, 0.07–0.70) and exercise (effect size, 0.71; 95% CI, 0.30–1.11). There was an insignificant advantage of dextrose over corticosteroids (effect size, 0.31; 95% CI, –0.18 to 0.80) which was only estimated from one study. Conclusion Dextrose injections decreased pain in osteoarthritis patients but did not exhibit a positive dose–response relationship following serial injections. Dextrose prolotherapy was found to provide a better therapeutic effect than exercise, local anesthetics, and probably corticosteroids when patients were retested 6 months following the initial injection.
Full-text available
Objectives. Plantar fasciitis is a self-limiting condition, but can be painful and disabling. Among the different treatments which exist, corticosteroid injections are effective and popular. Extracorporeal shock wave therapy (ESWT) is another treatment modality used for resistant conditions. In this study, the authors evaluated the efficacy of radial ESWT versus corticosteroid injections in the treatment of chronic plantar fasciitis. Design. Randomized clinical trial. Setting. Physical medicine and rehabilitation research center in a university hospital. Subjects. Forty patients with plantar fasciitis who did not respond to conservative treatment. Methods. Patients were allocated to radial ESWT with 2000 shock waves/session of 0.2 mJ/mm ² (n = 20) or local methylprednisolone injections (n = 20). Pain in the morning and during the day based on a visual analog scale (VAS), functional abilities using the foot function index (FFI), and satisfaction were evaluated before treatment and at 4 and 8 weeks after treatment. Results. Patients (average age: 42.1± 8.20) received five sessions of ESWT or single steroid injection. Changes in the VAS in morning and during the day and the FFI throughout the study period were significant in both groups ( P < 0.001). ESWT group had a higher reduction in VAS in morning and better function in FFI, but these changes were insignificant statistically [FFI decreased to 19.65 ± 21.26 points (67.4% improvement) in ESWT vs 31.50 ± 20.53 points (47.7%) in injection group at week 8, P = 0.072)]. Good or excellent results in the opinions of patients were achieved in 55% of ESWT and 30% of corticosteroid injection groups ( P = 0.11). Conclusion. Both interventions caused improvement in pain and functional ability 2 months after treatment. Although inter-group differences were not significant, the FFI was improved more with ESWT and patients were more satisfied with ESWT, thus shockwave therapy seems a safe alternative for management of chronic plantar fasciitis.
Full-text available
Hypertonic dextrose injections (prolotherapy) is an emerging treatment for symptomatic knee osteoarthritis (OA) but its efficacy is uncertain. We conducted a systematic review with meta-analysis to synthesize clinical evidence on the effect of prolotherapy for knee OA. Fifteen electronic databases were searched from their inception to September 2015. The primary outcome of interest was score change on the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Three randomized controlled trials (RCTs) of moderate risk of bias and one quasi–randomized trial were included, with data from a total of 258 patients. In the meta-analysis of two eligible studies, prolotherapy is superior to exercise alone by a standardized mean difference (SMD) of 0.81 (95% CI: 0.18 to 1.45, p = 0.012), 0.78 (95% CI: 0.25 to 1.30, p = 0.001) and 0.62 (95% CI: 0.04 to 1.20, p = 0.035) on the WOMAC composite scale; and WOMAC function and pain subscale scores respectively. Moderate heterogeneity exists in all cases. Overall, prolotherapy conferred a positive and significant beneficial effect in the treatment of knee OA. Adequately powered, longer-term trials with uniform end points are needed to better elucidate the efficacy of prolotherapy.
Full-text available
Introduction: The aim of this review was to identify and evaluate existing research to determine the clinical effectiveness and safety of prolotherapy injections for treatment of lower limb tendinopathy and fasciopathy. Review: Nine databases were searched (Medline, Science Direct, AMED, Australian Medical Index, APAIS-Health, ATSIhealth, EMBASE, Web of Science, OneSearch) without language, publication or data restrictions for all relevant articles between January 1960 and September 2014. All prospective randomised and non-randomised trials, cohort studies, case-series, cross-sectional studies and controlled trials assessing the effectiveness of one or more prolotherapy injections for tendinopathy or fasciopathy at or below the superior aspect of the tibia/fibula were included. Methodological quality of studies was determined using a modified evaluation tool developed by the Cochrane Musculoskeletal Injuries Group. Data analysis was carried out to determine the mean change of outcome measure scores from baseline to final follow-up for trials with no comparative group, and for randomised controlled trials, standardised mean differences between intervention groups were calculated. Pooled SMD data were calculated where possible to determine the statistical heterogeneity and overall effect for short-, intermediate- and long-term data. Adverse events were also reported. Two hundred and three studies were identified, eight of which met the inclusion criteria. These were then grouped according to tendinopathy or fasciopathy being treated with prolotherapy injections: Achilles tendinopathy, plantar fasciopathy and Osgood-Schlatter disease. The methodological quality of the eight included studies was generally poor, particularly in regards to allocation concealment, intention to treat analysis and blinding procedures. Results of the analysis provide limited support for the hypothesis that prolotherapy is effective in both reducing pain and improving function for lower limb tendinopathy and fasciopathy, with no study reporting a mean negative or non-significant outcome following prolotherapy injection. The analysis also suggests prolotherapy injections provide equal or superior short-, intermediate- and long-term results to alternative treatment modalities, including eccentric loading exercises forAchilles tendinopathy, platelet-rich plasma for plantar fasciopathy and usual care or lignocaine injections for Osgood-Schlatter disease. No adverse events following prolotherapy injections were reported in any study in this review. Conclusions: The conclusions of this review were derived from the best available scientific evidence. It is intended that the results of this study will assist clinical decision-making by practitioners. The results of this review found limited evidence that prolotherapy injections are a safe and effective treatment for Achilles tendinopathy, plantar fasciopathy and Osgood-Schlatter disease, however more robust research using large, methodologically-sound randomised controlled trials is required to substantiate these findings.
Full-text available
To compare the effect of dextrose prolotherapy on pain levels and degenerative changes in painful rotator cuff tendinopathy against two potentially active control injection procedures. Randomized controlled trial, blinded to participants and evaluators. Outpatient pain medicine practice. Chronic shoulder pain, examination findings of rotator cuff tendinopathy, and ultrasound-confirmed supraspinatus tendinosis/tear. Three monthly injections either onto painful entheses with dextrose (Enth-Dex), onto entheses with saline (Enth-Sal), or above entheses with saline. (Superfic-Sal). All solutions included 0.1% lidocaine. All participants received concurrent programmed physical therapy. Primary: Participants achieving an improvement in maximal current shoulder pain ≥ 2.8 or not. (Twice the minimal clinically important difference for (Visual Analog Scale) VAS pain. Secondary: Improvement in the Ultrasound Pathology Rating Scale (USPRS) and a 0-10 satisfaction score (10 = completely satisfied). The 73 participants had moderate to severe shoulder pain (7.0±2.0) for 7.6±9.6 years. There were no baseline differences between groups. Blinding was effective. At 9 month follow-up 59 percent of Enth-Dex participants maintained ≥ 2.8 improvement in pain compared to Enth-Saline (37%;p=.088) and Superfic-Saline (27%;p=.017). Enth-Dex participants' satisfaction was 6.7±3.2 compared to Enth-Saline (4.7±4.1;p=.079) and Superfic-Saline (3.9±3.1;p=.003). USPRS findings were not different between groups (p = .734). In participants with painful rotator cuff tendinopathy who receive physical therapy, injection of hypertonic dextrose on painful entheses resulted in superior long term pain improvement and patient satisfaction compared with blinded saline injection over painful entheses, with intermediate results for entheses injection with saline. These differences could not be attributed to a regenerative effect. Dextrose prolotherapy may improve upon standard care of painful rotator cuff tendinopathy for certain patients. Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
Plantar fasciitis is the most common cause of heel pain. Local injection modalities are among treatment options in patients with resistant pain. The aim of the present study was to evaluate the effect of local autologous whole blood compared with corticosteroid local injection in treatment of plantar fasciitis. In this randomized controlled multicenter study, 36 patients with chronic plantar fasciitis were recruited. Patients were allocated randomly into three treatment groups: local autologous blood, local corticosteroid injection, and control groups receiving no injection. Patients were assessed with visual analog scale (VAS), pressure pain threshold (PPT), and plantar fasciitis pain/disability scale (PFPS) before treatment, as well as 4 and 12 weeks post therapy. Variables of pain and function improved significantly in both corticosteroid and autologous blood groups compared to control group. At 4 weeks following treatment, patients in corticosteroid group had significantly lower levels of pain than patients in autologous blood and control groups (higher PPT level, lower PFPS, and VAS). After 12 weeks of treatment, both corticosteroid and autologous blood groups had lower average levels of pain than control group. The corticosteroid group showed an early sharp and then more gradual improvement in pain scores, but autologous blood group had a steady gradual drop in pain. Autologous whole blood and corticosteroid local injection can both be considered as effective methods in the treatment of chronic plantar fasciitis. These treatments decrease pain and significantly improve function compared to no treatment.
Plantar fasciitis is a very common cause of inferior heel pain that can be triggered and aggravated by prolonged standing, walking, running and obesity, among other factors. Treatments are largely noninvasive and efficacious. Supportive treatments, including the plantar fascia-specific stretch, calf stretching, appropriate orthotics and night dorsiflexion splinting, can alleviate plantar fascia pain. While local injections of corticosteroids can help with pain relief, the effects are short-lived and must be weighed against the risk of fat pad atrophy and plantar fascia rupture. Ultrasonographyguided focal extracorporeal shock wave therapy is useful for patients with chronic plantar fasciitis and referrals for this treatment can be made in recalcitrant cases. Activity modification to decrease cyclical repetitive loading of the plantar fascia should be advised during the treatment phase regardless of the chosen treatment modality.
Objective: Plantar heel pain and heel spur are common clinical problems. Non steroidal anti-inflammatory drugs, local steroid injections and physical therapy modalities are the most commonly used treatment choices. The purpose of this study was to compare the efficacy of laser therapy and local steroid injection in patients who had plantar heel pain, tenderness with palpation and heel spur in lateral ankle X-Rays. Materials and Methods: Fifty-four patients were included in this study and were evaluated for the pain intensity and the existence of tenderness with palpation. Visual analog scale (VAS) was used for this purpose. The patients were randomized into two groups; in the laser group (n= 24); Infrared Gallium-Arsenide (Ga-As) laser therapy with 904 nm wavelength was applied for 30 seconds for 10 sessions (5-8), in the injection group (n= 30), patients were treated with local injection of 6.43 mg betamethasone dipropionate and 2.63 mg betamethasone sodium phosphate and 20 mg 2% prilokain. The assessment of pain intensity and tenderness with palpation were made before and 1, 3 and 6 months after the treatment. Results: In laser and steroid injection groups, the improvement was observed in pain intensity and in tenderness with palpation at 1st, 3rd and 6th months after application. There was not a statistically significant difference between the values of the two groups at 1st, 3rd and 6 months after treatment. Conclusion: It was observed that the laser treatment was as effective as local steroid injection in the conservative treatment of epin calcanei, it lasted for 6 months. However, our results showed that none of the groups was superior to each other.
To compare the efficacy of autologous blood-derived products (ABPs), CSs and shock-wave (SW) therapy in the treatment of plantar fasciitis. Electronic databases were searched for studies that compared ABPs, CSs and SW therapy for the treatment of plantar fasciitis, published up to June 2014. The primary and secondary outcomes were reduction in visual analogue scale (VAS) score at 3 and 6 months and odds ratio of treatment success, respectively. Groups were compared by traditional pair-wise meta-analysis and by network meta-analysis. Seven randomized controlled trials and three quasi-experimental studies that included 604 patients were enrolled. Pair-wise meta-analysis indicated a trend favouring ABPs over CSs regarding VAS reduction at 3 months; this benefit was significant in a subgroup analysis of platelet-rich plasma (PRP) vs CSs. There were no significant between-group differences in VAS reduction at 6 months and in treatment success. Network meta-analysis showed that ABPs had the highest probability of being the best treatment at 3 months, but ABPs were slightly inferior to SW for VAS reduction at 6 months. Although SW therapy had the highest likelihood of treatment success, the between-group differences in probabilities were less remarkable than those for pain reduction at 3 and 6 months. ABPs, followed by CSs, were best in providing relief from pain at 3 months. SW therapy and ABPs had similar probabilities of providing pain relief at 6 months, and were better than CSs at that time. Subgroup analysis indicated that an ABP regimen consisting of platelet-rich plasma improves treatment efficacy. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email:
Dextrose injections into the knee can reduce pain and improve a patient's quality of life.