Most meniscus injuries occur due to sharp twisting movements often during sports . A tear can also result from a simple movement such as twisting the knee while the foot is caught on something. Other knee injuries, such as torn ligaments, may occur at the same time as a meniscus tear. The meniscus of older individuals, or those who have been previously “scoped” or used steroid injections, contains tissue that has degenerated and may tear more easily, and may occur as a result of even minor “awkward” movements. This degenerative process of the meniscus is usually present with osteoarthritis of the knee – unfortunately often accelerated by “treatments” the patients have received along the course of their injury – NSAIDs, cortisone, arthroscopy etc.
By strengthening structural weaknesses in the body, as Prolotherapy does, pain associated with a torn meniscus may be alleviated permanently and the patient is able to return to full activities and/or sports.
Ross Hauser, MD, medical director of Caring Medical recently published an article in the Journal of Prolotherapy showing the benefits of Prolotherapy as a first line treatment for meniscus tears. If you are trying to manage a torn meniscus but are not having success, feel free to contact Dr. Hauser’s office at drhauser@caringmedical.com.
For a list of other doctors performing Prolotherapy, see www.getprolo.com.
Ross Hauser, MD, Marion Hauser, MS, RD, and Patricia Holian, RN recently released an article on treating wrist pain with Hackett-Hemwall dextrose Prolotherapy published in Practical Pain Management.
The articulation afforded the hand and the upper extremity by the wrist is essential for mobility, strength, and dexterity that most patients need to function in their daily lives. Interestingly enough, primary care physicians frequently see patients in their offices with complaints of wrist pain. The causes of wrist pain are typically related to overuse, as well as repetitive and high impact injuries that may be work or sports related. These injuries often start as an acute tendonitis or ligament sprain and, if not effectively treated, can result in chronic pain due to the formation of degenerative arthritis. Symptoms are frequently gradual at first—with mild aching but full range of motion—and then typically progress to more acute pain along with impaired movement of the hand and upper extremity.
While prolotherapy is commonly taught and used for unresolved wrist pain, no study has been done to date related to effectiveness. This observational study’s purpose was to evaluate the effectiveness of Hackett-Hemwall dextrose prolotherapy—not only on unresolved wrist pain but on quality of life measures, and its ability to reduce or eliminate the need for pain medications.
To read the full article, click here.
| Author: Ross A Hauser, MD
Medical Director, Caring Medical and Rehabilitation Services, Oak Park, IL |
| A B S T R A C T |
| Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used drugs in the world for the treatment of osteoarthritis (OA) symptoms, and are taken by 20-30% of elderly people in developed countries. Because of the potential for significant side effects of these medications on the liver, stomach, gastrointestinal tract and heart, including death, treatment guidelines advise against their long term use to treat OA. One of the best documented but lesser known long-term side effects of NSAIDs is their negative impact on articular cartilage.
In the normal joint, there is a balance between the continuous process of cartilage matrix degradation and repair. In OA, there is a disruption of the homeostatic state and the catabolic (breakdown) processes of chondrocytes. It is clear from the scientific literature that NSAIDs from in vitro and in vivo studies in both animals and humans have a significantly negative effect on cartilage matrix which causes an acceleration of the deterioration of articular cartilage in osteoarthritic joints. The preponderance of evidence shows that NSAIDs have no beneficial effect on articular cartilage in OA and accelerate the very disease for which they are most often used and prescribed. Some of the effects of NSAIDs on the articular cartilage in OA include inhibition of chondrocyte proliferation, synthesis of cellular matrix components, glycosaminoglycan synthesis, collagen synthesis and proteoglycan synthesis. The net effect of all or some of the above is an acceleration of articular cartilage breakdown. In human studies, NSAIDs have been shown to accelerate the radiographic progression of OA of the knee and hip. For those using NSAIDs compared to the patients who do not use them, joint replacements occur earlier and more quickly and frequently. The author notes that massive NSAID use in osteoarthritic patients since their introduction over the past forty years is one of the main causes of the rapid rise in the need for hip and knee replacements, both now and in the future. While it is admirable for the various consensus and rheumatology organizations to educate doctors and the lay public about the necessity to limit NSAID use in OA, the author recommends that the following warning label be on each NSAID bottle: The use of this nonsteroidal anti-inflammatory medication has been shown in scientific studies to accelerate the articular cartilage breakdown in osteoarthritis. Use of this product poses a significant risk in accelerating osteoarthritis joint breakdown. Anyone using this product for the pain of osteoarthritis should be under a doctor’s care and the use of this product should be with the very lowest dosage and for the shortest duration of time. If NSAID use continues, then most likely the exponential rise in degenerative arthritis and subsequent musculoskeletal surgeries, including knee and hip replacements as well as spine surgeries, will continue to rise as well. Journal of Prolotherapy. 2010;(2)1:305-322. KEYWORDS: accelerating articular cartilage degeneration, articular cartilage, cox-2 inhibition, non-steroidal anti-inflammatory medication, NSAID, osteoarthritis, prostaglandin. |
Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used drugs in the world for the treatment of osteoarthritis (OA) symptoms,1 and are taken by 20-30% of elderly people (defined as people over the age of 64 years) in developed countries.2 The worldwide pain management prescription drug market totaled approximately $24 billion in 2002 and passed $30 billion by 2006. Celebrex (celecoxib) led the pack with nearly $4 billion in sales in 2002.3 Each year, over 70 million prescriptions for NSAIDs are dispensed in the United States, 20 million in Great Britain and 10 million in Canada.4-6 These numbers do not include the 30 billion over-the-counter tablets sold each year in the United States alone.7, 8 The most common over-the-counter and prescription nonsteroidal anti-inflammatory drugs are seen in Figure 1.
Treatment guidelines in the United States, Great Britain, and Canada recommend NSAIDs as second-line treatment (after acetaminophen) for mild OA and as first-line treatment for moderate to severe OA.9-11 As baby boomers age, it is estimated that the number of NSAID users will continue to climb, despite the fact that over 100,000 people are hospitalized for gastrointestinal bleeding and of those 16,500 people die from NSAID toxicity each year.12, 13 In 2006, the Osteoarthritis Research Society International formed an international committee to review all guidelines and evidence available on OA. Based on the evidence of potentially serious adverse reactions to NSAIDs, the committee has advised against the long-term use of NSAIDs to treat OA.14 One of the most serious adverse reactions to NSAIDs, that is little appreciated, is that as a class of compounds they cause the breakdown of articular cartilage, thereby accelerating OA, the very disease for which they are most commonly prescribed.
In the normal joint, there is a balance between the continuous process of cartilage matrix degradation and repair. In OA, disruption of the homeostatic state occurs and the catabolic (breakdown) processes of chondrocytes are increased.
| Chondrocytes – the only cells in cartilage tissue responsible for the synthesis of collagen and proteoglycans that makeup the cartilage matrix |
| Cytokines are signaling molecules used extensively in cellular communications. |
The principal cytokines linked to the catabolism of cartilage and to the OA process are interleukin (IL)-1, tumor necrosis factor (TNF)-a, and IL-6. IL-1 is the prototypic inducer of catabolic responses in chondrocytes. This substance causes the increased secretion of proteinases (which breakdown cartilage matrix) including collagenase, the suppression of proteoglycan synthesis leading to the suppression of matrix synthesis, and ultimately the reduction of the number of chondrocytes.15, 16 (See Figure 2.) IL-1 is a potent inducer of prostaglandin (PG) synthesis by inducing PGE2 synthesis in human chondrocytes. The rate-limiting step for the synthesis of PGE2 and other prostaglandins is the conversion of arachidonic acid to prostaglandin endoperoxide by cyclooxygenase (COX), which exists in two isoforms, COX-1 and COX-2. All NSAIDs inhibit both COX 1 and 2 enzymes but most of the NSAIDs that have been developed in recent years show greater activity of COX 2 in order to decrease gastrointestinal side effects. (See Figure 3.) PGs act (among other things) as messenger molecules in the process of inflammation. It was hoped that the use of NSAIDs would decrease the catabolic program in OA, thereby having a disease-modifying effect. Research, unfortunately is showing PGs, like PGE2, stimulate chondrocyte proliferation and subsequent synthesis of cellular matrix components.17 The net result of their blockade and other NSAID effects is the acceleration of articular cartilage degeneration. To show how this occurs and to what extent, a basic understanding of articular cartilage anatomy is needed.
| Figure 1. Common over-the-counter and prescription nonsteroidal anti-inflammatory drugs (NSAIDs). |
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| Figure 2. The catabolic physiology leading to articular cartilage breakdown. Interleukin-1 is one of the principle cytokines that initiates a cascade that leads to chondrocyte cell death and extracellular matrix breakdown. NSAIDs inhibit prostaglandins, such as PGE2, from stimulating chondrocyte DNA matrix synthesis thereby contributing to articular cartilage degeneration. |
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| Figure 3. Inhibition of cyclooxygenase 1 and 2 by NSAIDs. Studies have shown that, although most NSAIDs inhibit both COX-1 and COX-2, it is the inhibition of COX-2 that is responsible for the anti-inflammatory effects of NSAIDS. On the other hand, inhibition of COX-1 by these agents causes damage to the GI tract. This has led to the development of a new generation of NSAIDs that specifically inhibit COX-2. |
 To read the full article by Dr. Hauser, please click here. |
We received the following email from a fellow Prolotherapy physician:
Dr. Hauser: I have been doing Prolotherapy on tendons & ligaments for years. I have, however, stayed out of the knee joint, theorizing that there is no blood supply & healing of the meniscus. I saw your You Tube piece on knee injections and it stirred considerable interest.
What agent and quantity have you been injecting interarticular? What are your results & adverse reactions? Any pearls & suggestions?
Thanks.
Our response:
Dear Dr,
Thanks for your email. It is a good question.
Please note the Journal of Prolotherapy 2:3 will contain a complete review of the meniscus and Prolotherapy, so please at least get that issue! The issue is due out in August 2010.
Regarding your question, I would recommend you either use Human Growth Hormone (2iu) along with the normal Hackett-Hemwall Prolotherapy solution (12.5 to 15% dextrose, 10% Sarapin) or use platelet rich plasma Prolotherapy using the Hackett-Hemwall method, (3.5 or so ccs of solution injected intraarticularly). To be honest with you, I feel it is most important that you make sure you fully treat the knee instability that caused the meniscus issue in the first place!
All in all, the results of Prolotherapy for meniscal degeneration and tears is simply spectacular!
Regards,
Medical Director, Caring Medical & Rehabilitation Services
Ross Hauser, MD, and the staff of Caring Medical are getting ready to publish a paper in 2010 in the Journal of Prolotherapy where we followed 28 patients who had knee pain coming from either meniscal degeneration or meniscal tears. Eighteen had meniscal tears. Realize some of them had very complex tears. When asked the question “did Prolotherapy meet your expectations?” Twenty-seven of the twenty-eight patients said “yes.” When analyzing the one case that said “no,” the person was 80% better after a few visits (upon the last visit). Why this person ended up having surgery, I do not know (he must have reinjured himself and went for surgery instead of Prolotherapy). We recommend that people with meniscal injuries first see an experienced Prolotherapist.
Prolotherapy, in Dr. Hauser’s opinion, will eventually be the treatment of choice for meniscal tears because it is the only treatment that truly stimulates the meniscus to repair and gets rid of the other causes of knee pain that often go along with meniscal tears, including knee joint instability. When a person gets treated for their meniscal tear with Prolotherapy, the ligaments around the knee are typically treated, so this helps not only with the knee pain caused by the meniscal tear, but also for other causes of knee pain.
More to come…
02/08/2010
(February 8, 2010 Oak Park, IL) Can simple sugar (dextrose Prolotherapy) injections help prevent back surgery and joint replacement? One newly published study suggests that the dextrose injections, or Prolotherapy, can eliminate the need for surgery in up 90% of patients.
Lead researcher and chronic pain specialist Ross Hauser, M.D., of Oak Park, IL says that his team followed the progress of 34 patients who had suffered with chronic pain for at least 27 months and who had been recommended to surgery. All 34 patients received dextrose injections in varying number in painful joints and portions of the spine.
“We took some difficult cases,” says Dr. Hauser, “with a long list of surgical procedures including joint replacements and arthroscopic procedures as the prognosis, and started treatment with Prolotherapy to see if we could help these people avoid surgery.
Prolotherapy utilizes the injections of an irritant causing solution into problematic joints and spine. Doctors hope that the irritation leads to an inflammatory response from the immune system, one that would rebuild weakened joints by strengthening ligaments and tendons.
“It is a very simple procedure that works very well,” says Dr. Hauser. “Joints and the spine are held together by a very intricate network of ligaments, tendons, and other connective tissue. When these ligaments and tendons are weakened through injury, overuse, chronic medication or anti-inflammatory usage, they become unstable. Unstable spines lead to pinched nerves, unstable joints lead to “wobbly” conditions that are usually sent to surgery.
Participants in the study were charted about their levels of pain, stiffness, and quality of life. Over ninety percent of the patients reported a significant decrease in their pain (measured at a 50% or more reduction) and over 70% measured their pain reduction at greater than 75%.
“What is important to understand in these patients is that over 90% of the test subjects did not need to go onto surgery and that these results were measured at least 10 months after their last treatment,” says Hauser, “showing that the positive effects of the treatment are long lasting. More far reaching was the improvement these patients showed in quality of life, with pain reduced; these patients suffered less depression, better sleep, and less anxiety. They also showed significant reduction and reliance in the use of medications.”
Dr. Hauser also points out that Prolotherapy is an in-office procedure that does not require the extended recovery time or risks associated with surgical procedure. “These patients can get Prolotherapy in the morning, and go right to work. In these days of economic hardship, this is a special benefit for those worried about their jobs.”
For more information contact Ross Hauser, M.D., at Caring Medical and Rehabilitation Services in Oak Park, Illinois at drhauser@caringmedical.com.
