Prolotherapy for Tendon Injuries
Chronic tendon injuries (tendinopathies) are notoriously difficult to treat. Prolotherapy offers an evidence-based approach that stimulates tissue repair rather than simply masking symptoms.
Understanding Chronic Tendon Injuries
Chronic tendon injuries, now more accurately called tendinopathies rather than tendinitis, involve degeneration of tendon tissue rather than simple inflammation. Years of research have shown that these conditions involve failed healing attempts, disorganized collagen and changes in the tendon's cellular structure.
This is why anti-inflammatory treatments often provide only temporary relief: they address inflammation that may not be the primary problem. Prolotherapy takes a different approach: it stimulates a controlled healing response that can restart the repair process and strengthen the damaged tissue.
The strongest research evidence for prolotherapy exists for three common tendinopathies: lateral epicondylosis (tennis elbow), plantar fasciitis and Achilles tendinopathy.
Tennis Elbow (Lateral Epicondylosis)
Lateral epicondylosis affects the tendons on the outside of the elbow and causes pain with gripping, lifting and twisting motions. Despite its name, it affects many people who don't play tennis and any repetitive arm activity can cause it.
Tennis elbow has the strongest evidence base of any condition treated with prolotherapy. Multiple randomized controlled trials and a 2022 meta-analysis of 8 studies (354 patients) have demonstrated that dextrose prolotherapy is superior to control treatments.
Research Highlights
2022 Meta-Analysis: Pooled data from 8 RCTs showed prolotherapy superior to active controls at 12 weeks for pain intensity (SMD = -0.44) and DASH functional scores (mean difference -15.04 points, exceeding the clinically meaningful threshold).1
Scarpone 2008 RCT: At 16 weeks, 100% of prolotherapy patients reported pain ≤1 on a 10-point scale compared to 0% of controls. At 52 weeks, 60% of prolotherapy patients had no pain while 80% of controls still had pain affecting daily activities.2
Rabago 2013 RCT: Both dextrose and dextrose-morrhuate prolotherapy improved PRTEE scores by 41-53% from baseline, with 75-78% of patients reporting satisfaction with treatment.3
Plantar Fasciitis
Plantar fasciitis causes heel pain, particularly with the first steps in the morning. It involves degeneration of the plantar fascia where it attaches to the heel bone. While many cases resolve with conservative treatment, chronic plantar fasciitis can be frustratingly persistent.
A 2021 meta-analysis of 8 randomized controlled trials (479 patients) confirmed that prolotherapy effectively reduces pain, improves foot function and even decreases plantar fascia thickness, suggesting actual tissue healing rather than just symptom relief.
Research Highlights
2021 Meta-Analysis: Pooled results showed significant pain reduction at 3 months (mean difference -1.76 on VAS), improved Foot Function Index scores and reduced fascia thickness.4
Double-Blind RCT: 89% of prolotherapy patients achieved meaningful clinical improvement compared to only 33% of controls. Pain scores improved from 7.0 to 3.1 with prolotherapy vs 6.9 to 5.8 with saline.5
Ersen 2018 RCT: Prolotherapy with 15% dextrose showed significantly greater improvement in pain scores than control, with benefits maintained at 1-year follow-up.6
Achilles Tendinopathy
Achilles tendinopathy causes pain in the tendon connecting the calf muscles to the heel. It's common in runners and people who increase their activity level too quickly. The standard treatment is eccentric loading exercises (the Alfredson protocol), but this can take months to work.
A randomized controlled trial published in the British Journal of Sports Medicine compared prolotherapy, eccentric exercises and combined treatment. The results showed that adding prolotherapy to exercises provides faster symptom relief, though long-term outcomes are similar.
Research Highlights
Yelland 2011 RCT: 43 patients randomized to eccentric exercises alone, prolotherapy alone or combined treatment. At 12 months, clinically meaningful improvement was achieved by 73% (exercises), 79% (prolotherapy) and 86% (combined).7
Faster Results: Combined treatment showed significantly better results than exercises alone at both 6 weeks (p=0.005) and 12 months (p=0.007). Pain and stiffness reductions occurred earlier with prolotherapy.
Full Recovery: At 12 months, 71% of prolotherapy patients and 64% of combined treatment patients achieved full recovery (VISA-A score ≥90) compared to 53% with exercises alone.
Treatment Protocol
Sessions
Most tendon injuries require 3-6 treatment sessions. Response varies by condition and severity; some patients improve after 2-3 treatments while others need the full series.
Weeks Apart
Sessions are typically spaced 2-4 weeks apart to allow the healing response to develop between treatments. This timing follows the protocols used in successful clinical trials.
Dextrose Concentration
We use dextrose concentrations consistent with those used in clinical trials, typically 12.5-20% depending on the treatment area and patient factors.
What to Expect
Timeline
- Days 1-3: Mild soreness at injection sites (normal part of the healing response)
- Weeks 2-4: Gradual improvement begins as tissue repair progresses
- Weeks 8-16: Significant improvement typically evident by 3rd-4th treatment
- 6-12 months: Continued improvement; studies show benefits persist long-term
Success Rates from Research
- Tennis elbow: 100% of patients achieved pain ≤1 at 16 weeks in one RCT
- Plantar fasciitis: 89% achieved meaningful improvement vs 33% controls
- Achilles: 79% achieved clinically meaningful improvement at 12 months
- Combined prolo + exercises: 86% achieved meaningful improvement for Achilles
Frequently Asked Questions
What are the side effects of prolotherapy?
The most common side effects are temporary soreness, stiffness and mild swelling at the injection site, typically lasting 1-4 days as part of the normal healing response. Bruising at the injection site is possible. As with any injection, there is a small risk of infection. Serious adverse events are rare and have not been reported in published clinical trials of dextrose prolotherapy. Prolotherapy is not appropriate during pregnancy, with active infection at the treatment site, or for patients on blood thinners without appropriate management.
Will I need to stop exercising during treatment?
No but avoid intense exercise on day of treatment. Return to regular intensity when comfort level allows (day 2 or later).
How does prolotherapy compare to cortisone for tendon injuries?
Cortisone can provide quick pain relief but doesn't address the underlying tendon degeneration. Research has shown that repeated cortisone injections can actually weaken tendon tissue and increase the risk of rupture. Prolotherapy takes longer to work but aims to strengthen the damaged tissue. For chronic tendinopathies where the goal is lasting repair, prolotherapy is often the better choice.
What if I've already had cortisone injections?
It is ok to have prolotherapy 1 week after cortisone injection.
Is prolotherapy effective for partial tendon tears?
Yes. Complete tears can be helped with prolotherapy but take much longer for the body to complete its repair process.
Can prolotherapy help if I've had the problem for years?
Yes, prolotherapy is often used specifically for chronic, long-standing tendinopathies that haven't responded to other treatments. The studies included patients with symptoms lasting 6 months to several years. Chronic conditions may require more treatment sessions, but there's no point at which prolotherapy becomes ineffective simply because the problem is old.
Tired of Chronic Tendon Pain?
If you've been dealing with tennis elbow, plantar fasciitis or Achilles tendinopathy that won't resolve, prolotherapy may be the answer. Schedule a consultation to discuss your options.
Book OnlineReferences
- Zhu M, Rabago D, Chung VC, et al. Effects of Hypertonic Dextrose Injection (Prolotherapy) in Lateral Elbow Tendinosis: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil. 2022;103(11):2209-2218.
- Scarpone M, Rabago DP, Zgierska A, Arbogast G, Snell E. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clin J Sport Med. 2008;18(3):248-254.
- Rabago D, Lee KS, Ryan M, et al. Hypertonic dextrose and morrhuate sodium injections (prolotherapy) for lateral epicondylosis (tennis elbow): a randomized controlled trial. Am J Phys Med Rehabil. 2013;92(7):587-596.
- Lai CC, et al. Efficacy of prolotherapy for plantar fasciitis: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore). 2021;100(51):e28216.
- Kim E, Lee JH. Autologous platelet-rich plasma versus dextrose prolotherapy for the treatment of chronic recalcitrant plantar fasciitis. PM R. 2014;6(2):152-158.
- Ersen O, Koca K, Akpancar S, et al. A randomized-controlled trial of prolotherapy injections in the treatment of plantar fasciitis. Turk J Phys Med Rehabil. 2018;64(1):59-65.
- Yelland MJ, Sweeting KR, Lyftogt JA, Ng SK, Scuffham PA, Evans KA. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med. 2011;45(5):421-428.