Regenerative Medicine
Regenerative Injection Therapy (RIT) is a minimally invasive injection procedure that stimulates the body’s natural healing mechanisms to repair chronically damaged ligaments and tendons. RIT includes prolotherapy, platelet rich plasma and other injections that help regenerate tissues. RIT is not a new technique. The concept of irritating tissue to promote healing dates as far back as the ancient Greeks. Hippocrates treated Olympic javelin throwers with unstable shoulders by touching what he described as a “slender hot iron” to the ligaments holding the shoulder joint together. The heat would irritate the ligament capsule, causing it to tighten up. (Interestingly, modern-day orthopedic surgeons use heat probes and lasers to do the same thing surgically!) Prolotherapy was used in France to treat hernias before modern surgical techniques became available. The techniques we use today were developed in the 1930’s by G.S. Hackett, MD, a surgeon from Ohio, along with other MD’s and DO’s. The same techniques subsequently have been used successfully for pain relief from ligament laxity for nearly sixty years. Hackett coined the term “prolotherapy” because his initial work demonstrated that the new tissue laid down during the healing process was new healthy tissue, not scar tissue. (This distinguishes prolotherapy from a related treatment known as “sclerotherapy.) “Prolo-” stands for proliferative, implying that new cells and collagen fibers are proliferating and growing.
The term “Regenerative Injection Therapy” is fairly new and is an attempt to portray more accurately what is actually taking place physiologically.
Basic Science Evidence
George Hackett was the first to demonstrate clinically and scientifically a method of strengthening ligaments. He showed that by creating controlled inflammation, permanent increases in ligaments size (35-40 %) resulted. More recent studies have confirmed his initial studies. In 1983, Liu et al. injected a proliferative solution (Sodium Morrhuate) into rabbit MCL’s (medial collateral ligaments of the knee). The ligaments showed a significant increase in ligament mass, thickness, ligament-bone junction strength and weight-to-length ratio compared to controls. This effect was confirmed by Maynard et al. in 1985 in his study on Achilles tendons in rabbits. In a human study in 1989, Klein et al. documented cellular evidence of new collagen growth when comparing pre- and post-injection sacroiliac ligament biopsies. In a clinical study in 1988, Ongley used an established and reliable computerized instrument to demonstrate decreased ligament laxity and improved patient function after injecting P2G into ACL, PCL, MCL, LCL ligaments of the knee
Clinical Science Evidence
RIT is gaining wider acceptance for the treatment of painful musculoskeletal conditions due to its effectiveness and long lasting results. In one study reported in 1987 in Lancet, the prestigious British medical journal, Ongley et al. gave 40 low back pain patients six RIT injection treatments using P2G.16 At six months, 88% (35/40) of the treatment group (as compared with 39% (16 /41) controls) reported at least a 50% improvement in disability scores and reduction in pain. Furthermore, 15 patients in the experimental group were disability-free, compared to 4 in the control group. In 1991, Schwartz and Sagedy reported a retrospective study of a series of patients treated with just a 3 injection series with P2G.17 Overall, 91% (39/43) of patients reported at least 50% improvement. 47% (20/43) reported 95% improvement, 26% (11/43) reported 75% improvement, 9% (4/43) reported 66% improvement, 9% (4/43) reported 50% improvement, 1 reported 33% improvement, and 3 reported no improvement.
The effects of RIT appear to be long lasting. Hackett reported an 82% patient reported cure rate of backache in a series of 1,600 patients treated with RIT. His final examinations were performed from 2-12 years following the conclusion of injection therapy thus indicating the permanency of the treatment.
RIT is a safe technique for treating those ligament and tendon injuries that have failed appropriate conservative treatment. The literature reports an 80-90% response rate, which is consistent with the results we see in our practice. Permanent repair appears to occur in at least 75% of the cases. The technique is somewhat painful but is tolerated well by the vast majority of patients, and it is effective in decreasing the pain of abnormal joint movement, ligament laxity, and tendinosis.
