(RECONSTRUCTION OF LAX LIGAMENTS)
THE KNEE BONE CONNECKA TO THE THIGH BONE… NOW HEAR THE WORD OF THE
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.
HEALING AND INFLAMMATION
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
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.
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