Regenerative Injection Therapy

Regenerative injection therapy (RIT or prolotherapy)

is the injection of growth factors or growth factor production stimulants to promote regeneration of normal tissue (Reeves KD. in Pain Management. 2006). Open-label trials have been uniformly positive in outcome, but double-blind trials have been hampered by a needling control that is not a true placebo. Serial musculoskeletal ultrasound imaging offers a means to follow treatment response to RIT.

RIT has been used successfully to treat a large variety of musculoskeletal conditions, including back pain, groin and knee injuries, plantar fasciitis, foot and ankle pain, rotator cuff tendonitis/tendinosis, epicondylitis, TMJ dysfunction, and osteoarthritis. Treatment intervals vary; typically, treatment is repeated every 2-4 weeks until resolution for 4-6 treatments, each treatment involving multiple injections to a particular area or areas. The injections produce only mild pain. Improvement is most commonly noticed by the second or third treatment.

RIT is a durable solution rather than a palliative measure, and should be considered prior to the use of long-term medication or surgery in appropriate patients.

C.Everett Koop, MD, former U.S. Surgeon General, wrote the foreward to Prolo Your Pain Away, by Dr. Ross Hauser. He stated: “Not many physicians are aware of prolotherapy….one wonders why this is so. In my opinion, it is because medical folks are skeptical and prolotherapy, unless you have tried it and proven its worth, seems to be too easy a solution to a series of complicated problems….that have been notoriously difficult to treat….another reason is the simplicity of the therapy….Another very practical reason is that many insurance companies do not pay for prolotherapy, largely because their medical advisors do not understand it, have not practiced it, and therefore do not recommend it…I think it has to be admitted that those in the medical profession, once they have departed from their formal training and have established themselves in practice, are not the most open to innovative and new ideas.”

The definition of RIT/prolotherapy has evolved over the past 15 years from focusing on the injection of inflammatory solutions (e.g. dextrose) to induce growth to the injection of growth factors or growth factor production stimulants to promote regeneration (Reeves KD in Physiatric Procedures in Clinical Practice, 1995). The principle of regenerative injections is most widely practiced in the treatment of anemia due to chronic renal failure or myelosuppressive chemotherapeutic agents with the use of erythrocyte growth factor (erythropoietin) to cause red blood cell proliferation, as well as in preparation for acute blood loss during surgical procedures.

It is well accepted that growth factors work in coordination and cooperation with each other. Insulin-like growth factor-1 (IGF-1) stimulates fibroblast migration and proliferation and increases collagen production. Transforming growth factor beta (TGF-beta) regulates cell migration and collagen binding tendencies. Vascular endothelial growth factor (VEGF) is involved in angiogenesis. Platelet-derived growth factor (PDGF) stimulates IGF-1 production and tissue remodeling. Basic fibroblast growth factor (bFGF) regulates cell migration and proliferation and stimulates angiogenesis. Several growth factors increase the breaking energy of a healing tendon, including IGF-1, TGF-beta, and PDGF. Since growth factors are expressed within 10 days after tendon injury, RIT is ideally performed within this timeframe to minimize the healing time, although it can be used years after the initial problem began, as long as the patient is healthy.