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Ligaments are plastic, semi elastic, cable-like structures made up of  interwoven “collagen” threads connecting bone to bone to form  joints. All joints are structured this way: the knee, shoulder, back  and neck, wherever. Ligaments bend, but do not really stretch very  well. They have within them nerve endings capable of transmitting  pain impulses. These nerve endings are sensitive to stretching,  tearing, pressure, etc. For example, when you sprain your ankle, one  or more of those ligaments may be injured. The injury consists of  tearing of the ligaments, the extent varying from microscopic fraying  of a few fibers to total disruption. The ankle then swells, the  ligaments are further distracted, stimulating the pain receptors and  producing inflammatory changes as described below. The same mechanism will occur with shoulder injuries, particularly those related to swimming and pitching and with knee injuries.  Subsequently, in order to protect the injured joint, the surrounding  musculature goes into spasm, perpetuating the injury by restricting  motion in an aberrant arrangement, impairing circulation, movement,  and resulting in pain. In the instance of the lower back and sacroiliac joints, poor  posture, injuries and shrinkage of the discs (and of the vertebrae  themselves) as we age cause these ligaments to be stretched and weak.  They fail to provide adequate support to the joints. Among other  things including destabilization of the vertebral column, this allows  the sacrum between the pelvic (iliac) bones to become relatively displaced horizontally and locked in a non-physiologic relationship with the pelvic bones on each side. Movement is either restricted or excessive and always painful. The surrounding muscles contract, locking the sacroiliac and vertebral joints and causing more pain, in turn, further restriction of motion, spasm, PAIN.

The body heals ligamentous tears through a process  called "inflammation". This process is characterized by redness,  swelling, heat, tenderness, and stiffness of the involved joint.  Inflammation takes place in three overlapping stages:  

1. Acute inflammation. (Duration approximately four days) In this  phase, beginning directly at the time of injury, the cells are broken  open and their contents spilled at the site of the tear. Leukocytes,  white blood cells, whose job it  is to clean out the injured area, flood the region. Many chemicals  are released which act as messengers, telling other cells what to  do. "Macrophages" are attracted to the site, beginning the second, 

2. Granulation phase: (duration 10 days to two weeks.) The  macrophages and other white blood cells continue the clean up, digesting the broken down cell parts and secreting enzymes and hormones. These latter stimulate the growth of new blood vessels and generate the ground substance in which the cells ”float”. They attract additional types of white blood cells, fibroblasts, to the site of injury. These migrate to the fibro-osseous junction, where the ligament attaches to the bone, and then through stimulation by the macrophages, make massive amounts of the ligamentous building blocks: single, long collagen fibers. This leads to the third phase of healing:

3. "Wound contraction": (Duration 3 to 6 Weeks) These new collagen fibers are organized through a complex process into ligaments, the collagen fibers winding about each other and contracting, expressing fluid, becoming shorter and tightening the support of the joint. The fibroblasts remain at the injury site after all the other clean-up cells are reabsorbed, continuing to secrete collagen and strengthening the joint for several months. 

When the inflammatory process is successful, the ligaments are returned to their normal length and strength and the joint to its normal function. Should the injury be too severe, or the disruption perpetuated by abnormal activity or too much swelling, the ligaments will heal in an elongated, disorganized fashion. The result will be an excessively mobile joint, poorly supported by its ligaments and now dependent on muscles to maintain stability. Unfortunately, the principal function of muscles should be joint movement and only incidentally joint stabilization. 

TRIGGER POINTS (q.v. www.bonesdoctor.com)
Muscles required to act as support structures, are unable to fulfill their obligations as motion agents, since they wind up in a state of perpetual contraction or spasm. The trigger points (pain receptors) in the now "stretched" ligaments, are sensitized. This is further complicated by the sensitization of trigger points in the tightened muscles, setting up myofascial pain syndromes, often referring pain to more distant sites and locally resulting in more muscle spasm, restriction of motion and pain.

What's the solution? Exercise won't do it. You can’t strengthen a muscle whose contractions are inhibited by pain. Ligaments will not strengthen or tighten with exercise. Medication won't do it. Repeated osteopathic or chiropractic manipulations not only won’t help, but may be a perpetuating factor of ligamentous laxity contributing to joint instability. Surgery may do it in certain cases, but this is obviously fraught with its own dangers and risks, both immediate and long-range. In fact, the only rational answer is:

As we have seen, a significant proportion of back and joint pain is caused by chronic ligamentous laxity. This is a result of the failure of the body’s effort to heal the torn ligaments through inflammation. Ligament injection therapy simply stimulates a controlled, gentler inflammatory process. This involves the deposition of natural chemical and physical irritants at the bony connection of ligaments, to stimulate their repair. In my practice, I use dextrose (sugar), glycerine, lidocaine (a local anaesthetic, commonly employed in dentistry),a small amount of phenol (as a chemical irritant, anaesthetic and antiinfective agent). Occasionally this is supplemented by an infinitesimal amount of an extract of cod liver oil, sodium morrhuate. This stimulates the local production of prostaglandins, the messengers of inflammation, which draw to the site the agents we discussed earlier. Although the process is artificially stimulated, it is entirely natural. Prolotherapy can be useful in the treatment of ligamentous laxity in joints other then the sacroiliac, such as the vertebral joints in all parts of the spine, the hip, knee, foot, ankle, shoulder, elbow, wrist. 

Following injection, there is normally swelling, heat, redness, tenderness and pain. This tells us that the inflammatory process we have deliberately induced is under way. The pain will gradually, but irregularly decrease, and as it does, normal movement and activity can safely be progressively resumed to tolerance. Normal movement will further enhance the laying down of collagen into ligamentous fibers. These injections are repeated as necessary, depending on the healing progress, every 3 to 6 weeks, (or even more frequently in some cases) until such time as the subjective and objective indications for them no longer pertain. That is, pain and function have normalized to the point that the patient feels he has achieved a satisfactory level of stability, and the physician no longer detects the objective signs of instability and joint dysfunction. In my experience, this end-point has been reached in as few as one treatment session and as many as 18.

Although you will be asked to sign a standard informed consent form, the true risks are relatively minor. The injection may be a bit more painful than anticipated, but after all, the intent of the technique is to create an inflammatory reaction which is characterized normally by pain, swelling and redness. 

This reaction usually does not last for more than 3 to 7 days, and most frequently is over after two days. Local infection is another possibility, but I have never seen that and the reports in the literature of same are very scanty. The phenol in the solution acts to sterilize the injection site. Very occasionally there may be some temporary bruising of a nerve, but I have never seen any permanent adverse consequences as a result. There have been no reports of any deaths directly related to prolotherapy in the last 25 years, during which time the number of prolotherapy treatments administered around the world has increased exponentially as has the number of people benefiting from this procedure.

In summary, prolotherapy is a minimally invasive technique utilizing the injection of, for the most part, organic substances into the site of the junction between ligaments and bones, thereby stimulating growth and tensile strength. With care in selection of subjects, and administration by well-trained, knowledgeable physicians, the treatment, although painful, is highly successful, safe and effective in relieving pain due to abnormal joint movement secondary to ligamentous laxity.

Should you be interested in further information, many patients have completed the procedure successfully and would be glad to talk to you about it. Just call my office, say you're interested, leave your name and phone number and I’ll have them get in touch with you. For more, see the following websites:

These sites are, like the material you have just read, for educational and informational purposes only and should not be regarded or interpreted as anything else. Diagnosis and treatment of disease, injury, pain or disability is the province of your health professional who should be consulted in regard to medical symptoms or conditions before adopting any course suggested in these or any other websites.

Thanks to Michele Fecteau, D.O.and Tom Ravin, M.D. upon whose monograph, written for the American Association of Orthopedic Medicine, I have based much of the above.

The information contained in this website is for educational and informational purposes only and should not be regarded or interpreted as anything else. Diagnosis and treatment of disease, injury, pain or disability is the province of your health professional who should be consulted in regard to any medical symptoms or conditions before adopting any course suggested in this website. By proceeding to the table of contents page, you agree to accept the provisions of this disclaimer.

Copyright © 1996-2006 Dr. Richard M. Bachrach
317 Madison Avenue, NY 10017 - 212-685-8113

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