Dextrose Prolotherapy Injections for Chronic Ankle Pain
Ankle sprains, especially of the lateral ligaments, are extremely common injuries in the general and athletic populations. Approximately 25,000 people sprain their ankles daily.1 Sprains constitute 85% of all ankle injuries and, of these, 85% are inversion sprains.2 Sprains of the lateral ankle complex make up 38-45% of all injuries in sports.3,4 The recurrence rate for lateral ankle sprains has been reported to be as high as 80%.5 Up to 40% of individuals have residual ankle symptoms due to chronic instability.6 A 2005 study from the University of Bassel in Switzerland found that 70% to 80% of patients with chronic ankle instability end up with arthritic ankles.7 Long term residual symptoms from ankle sprains that do not heal can result in ongoing problems including pain, stiffness, limited range of motion and the inability to exercise or walk long distances.
Options such as medications, physical therapy, steroid shots, bracing and surgery typically leave the patient with residual symptoms.8 While the response to acute ankle sprains is usually quick; treatment for chronic ankle pain has had limited success. According to a 1999 review, there are more than 20 different delayed surgical procedures available for chronic ankle pain and instability. While most of these procedures are reconstructive in nature, none really restore true anatomy.9,10 Because of this, many patients with chronic pain, including ankle pain, are open to alternative treatments. One of the treatments they are receiving is prolotherapy since more physicians are getting trained to perform it.11 Prolotherapy for ankle ligament injuries has even been mentioned in the Mayo Clinic Health Newsletter.12
|Ankle patients n=19|
|Percentage of female patients 63%|
|Percentage of male patients 37%|
|Average age of ankle patients 52|
|Average years of pain 3.3|
|Average number of MD’s seen 3.3|
|Average number of pharmaceutical drugs 1.0|
|No other treatment options available 63%|
|Surgery only treatment option available 11%|
While prolotherapy has been used for decades to treat ankle injuries and chronic ankle pain, no specific studies on the results of prolotherapy on patients with chronic ankle pain have been done.13 Because of this, we decided to measure the response of patients who received dextrose prolotherapy. Not only did we look at pain levels, but we also reported on a host of quality of life measures that are important to those with chronic ankle problems.
PATIENTS AND METHODS
Framework and setting
In October 1994, the primary authors (R.H., M.H.) started a Christian charity medical clinic called Beulah Land Natural Medicine Clinic in an impoverished area in southern Illinois at which the primary treatment modality offered was Hackett-Hemwall dextrose prolotherapy for pain control. Dextrose was selected as the main ingredient in the prolotherapy solution because it is the most common proliferant used in prolotherapy, is readily available, inexpensive (compared to other proliferants), and has a high degree of safety.14 The clinic met every three months until July 2005. All treatments were provided at no cost to the patients.
Patients who received prolotherapy for their unresolved ankle pain in the years 2004 to 2005 at the charity clinic were called by telephone and interviewed by a data collector (D.P.) who had no prior knowledge of prolotherapy. General inclusion criteria were an age of at least 18 years, possessing unresolved ankle pain that typically responds to prolotherapy, and an ability to undergo at least four prolotherapy sessions, unless the pain remitted with fewer prolotherapy sessions. Typical ankle conditions that respond to prolotherapy include ankle instability, ankle ligament sprain, and ankle degenerative arthritis.
The Hackett-Hemwall technique of prolotherapy was used to treat each ankle. Each patient received 20 to 30 injections of a 15% dextrose, 0.2% lidocaine solution with a total of 15 to 30 cc of solution used per ankle. Injections were given into and around the areas on the ankle that were painful and/or tender to touch. The typical areas injected, each with 0.5 to 1 cc of solution, can be seen in Figure 1. Tender areas injected were on the lateral and medial malleolus, talus, calcaneus, and into and around the tibiotalar joint. The tender areas of the attachments of the deltoid, anterior and posterior talofibular, and calcaneofibular ligaments were also injected. As much as their pain would allow, the patients were asked to cut down or stop the pain medications they were taking.
D.P. was the sole person obtaining the patient follow-up assessment information during the telephone interviews approximately 21 months after they were treated. They were asked a series of questions about their pain and various symptoms before starting prolotherapy. Their response to prolotherapy was also detailed with an emphasis on the effect prolotherapy had on their ankle pain, stiffness, and quality of life. Specifically, patients were asked questions concerning years of pain, pain intensity, stiffness, number of physicians seen and medications taken, quality of life concerns, psychological factors, and whether the response to prolotherapy continued after the treatment sessions stopped.
The patients’ responses to the telephone questionnaire were gathered and analyzed before prolotherapy and then compared with the responses to the same questions after prolotherapy. The responses were also analyzed in a subset of patients who answered “yes” to the following statement: “Before starting prolotherapy it was the consensus of my MD(s) that there were no other treatment options that he or she knew of to get rid of my chronic ankle pain.”
Complete data was obtained on a total of 19 ankle patients who met the inclusion criteria. Of these, 63% (12) were female and 37% (7) were male. The average age of the patients was 52 years old. Patients reported an average of 3.3 years (40 months) of pain and on average saw 3.3 MDs before receiving prolotherapy. The average patient was taking 1.0 pain medication. Sixty-three percent (12) stated that the consensus of their medical doctor(s) was that there were no other treatment options for their chronic pain. Eleven percent (2) stated that the only other treatment option for their chronic ankle pain was surgery (see Table 1).
Patients received an average of 4.4 prolotherapy treatments per ankle. The average time of follow-up after their last prolotherapy session was twenty-one months.