T Nation

Prolotherapy Question


#1

I have a question for some of the guys on this board knowledgable about prolotherapy (Maybe Erasmus, fattyfat, or arcadia fades can chime in here). I sustained what has been diagnosed as a class I AC joint sprain in my left shoulder by 2 doctors via MRI and X-ray in July of last year. At the time I didn't address this injury properly as I had no pain or range of motion loss, simply what I thought was some swelling over my AC joint and the first doctor downplayed this and said there was nothing wrong and if I wanted to be cautious take a couple weeks off from lifting.

So I took two more weeks off and started back up with the weights about 3 weeks after the injury. At this time I had no pain, and ramped the weights back up fairly quickly (dumb). Things just didn't feel right-I had clicking and the shoulder just felt "off," probably from instability. So I scheduled an appointment with the second doctor who was sports orthopedic specialist and he said the injury was just barely a class I sprain going off of the diagnostic imaging.

I am somewhat inclined to disagree, as it is 7 months later and my left AC joint is still very slightly more prominent than my right which I just don't see being possible if the AC ligament isn't somewhat torn. I'm assuming there is some degree of laxity in the joint causing this, as I can't imagine the joint being swollen this long after injury.

My question is this, assuming I started back up too soon/quickly and the ligament didn't heal up to the proper length, do you believe prolotherapy would be an effective method to "tighten" this joint back up? I chatted with Eric Lilliebridge on this matter as he had the same injury, and he said that PRP helped with his class I sprain. However, I was thinking it might be better to start off with microperforation prolotherapy before exploring PRP because of the cheaper cost and that PRP doesn't seem to be proven anymore effective. Thoughts?


#2

Prolo will probably be an epic waste of money, but feel free to try. If you truly have a grade 1 AC separation, then the ligaments holding your clavicle down haven’t been affected. Even if they were stretched slightly, it wouldn’t really matter. You probably have clicking because there are some muscular imbalances and compensation patterns going on. I’d go to a physical therapist first and see what they tell you to do before you start getting injections.


#3

[quote]arcadiafades wrote:
Prolo will probably be an epic waste of money, but feel free to try. If you truly have a grade 1 AC separation, then the ligaments holding your clavicle down haven’t been affected. Even if they were stretched slightly, it wouldn’t really matter. You probably have clicking because there are some muscular imbalances and compensation patterns going on. I’d go to a physical therapist first and see what they tell you to do before you start getting injections. [/quote]

Hey thanks for the responses. I’ll reply to both your posts in this thread to keep things consolidated. Also, congratulations on medical school. I’ve been working at a hospital the past two years and am applying this year to hopefully start next year myself.

What you said about Alvin stein makes sense, the reviews weren’t necessarily bad, just mixed. I guess I was mainly curious if he was the Dr. Who administered your treatment. Can you elaborate on why you think prolo would be a waste of money for someone in my situation? I know in a textbook class I AC sprain there isn’t any damage to the ligaments, but I’m not sure if that’s always the case in the real world. It seems like many who are diagnosed with class I’s have a very small increase in the prominence in the end of their clavicle (and I’ve talked to a lot of people on this) which isn’t supposed to be the case in class I. In my case the difference is small enough that almost no one notices even when I point it out to them directly.
I notice the difference because it’s not the same as it was before.

I may be off base, but in my mind it seems as though this prominence would indicate some laxity in the joint as a result of ligament damage? I’ll give physical therapy a try and see what happens first and then move from there.


#4

Thank you in regards to medical school, and good luck on your applications. Send me a private message if you have any questions about the application process or what medical school has been like for me. And yes, Dr. Stein was the doctor who treated me.

I completely agree with you; you may have been misdiagnosed with a grade 1 AC separation. When I first presented to an orthopedic surgeon complaining about SCJ pain and laxity, the surgeon moved my arm through a limited range of motion and said, “Oh, the joint capsule may be irritated.” When I visited Dr. Stein, he grabbed the medial end of my clavicle and literally pulled it out of the manubrial notch by about 2 cm. There was nothing but stretched out threads of connective tissue holding the clavicle in place. If you have decent insurance and it won’t be too much of a financial burden, I would get a second opinion. Grade II and III shoulder separations can be seen on x-rays as increased space between the lateral end of the clavicle and the corocoid process, compared to the unaffected side. They may have you hold a light weight to better visualize the laxity in the joint.

Even if it IS a mild grade II separation, the small degree of laxity should not affect you at all. I believe the clicking you’re experiencing may be related to faulty compensation patterns in your shoulder. You could also get clicking and grinding from distal clavicular osteolysis, but that would show up on an x-ray. In addition, unless you place your arm in a sling for weeks on end or tape it into a reduced position, gravity will work against you and you will not achieve full reduction of the joint by prolotherapy.

Start conservative and then move forward. Don’t get sucked into the idea that you NEED prolotherapy just because you’ve read several convincing prolotherapy websites. It is NOT a cure all, and that’s coming from both a patient and an author. It will work well if administered by a skilled prolotherapist in a properly selected patient. Don’t take any of this as medical advice, just my opinion based on personal experience and anecdotal evidence.


#5

[quote]arcadiafades wrote:
Thank you in regards to medical school, and good luck on your applications. Send me a private message if you have any questions about the application process or what medical school has been like for me. And yes, Dr. Stein was the doctor who treated me.

I completely agree with you; you may have been misdiagnosed with a grade 1 AC separation. When I first presented to an orthopedic surgeon complaining about SCJ pain and laxity, the surgeon moved my arm through a limited range of motion and said, “Oh, the joint capsule may be irritated.” When I visited Dr. Stein, he grabbed the medial end of my clavicle and literally pulled it out of the manubrial notch by about 2 cm. There was nothing but stretched out threads of connective tissue holding the clavicle in place. If you have decent insurance and it won’t be too much of a financial burden, I would get a second opinion. Grade II and III shoulder separations can be seen on x-rays as increased space between the lateral end of the clavicle and the corocoid process, compared to the unaffected side. They may have you hold a light weight to better visualize the laxity in the joint.

Even if it IS a mild grade II separation, the small degree of laxity should not affect you at all. I believe the clicking you’re experiencing may be related to faulty compensation patterns in your shoulder. You could also get clicking and grinding from distal clavicular osteolysis, but that would show up on an x-ray. In addition, unless you place your arm in a sling for weeks on end or tape it into a reduced position, gravity will work against you and you will not achieve full reduction of the joint by prolotherapy.

Start conservative and then move forward. Don’t get sucked into the idea that you NEED prolotherapy just because you’ve read several convincing prolotherapy websites. It is NOT a cure all, and that’s coming from both a patient and an author. It will work well if administered by a skilled prolotherapist in a properly selected patient. Don’t take any of this as medical advice, just my opinion based on personal experience and anecdotal evidence.[/quote]

Hey thanks for the offer, I appreciate all the help and encouragement I can get! What year are you right now?

I suspected misdiagnosis originally, but my situation is kind of muddy because I’ve already gotten a second opinion. I originally injured the joint by being pushed to bottom by a wave and hitting my shoulder. My experience is slightly atypical because at the time I didn’t experience any pain in my AC joint (if I did, it wasn’t enough that I remember), just mild pain on the lateral edge of my shoulder where I hit along the lines of a pretty minor bruise/sore spot. The soreness was gone in around 2 days, but my shoulder just “felt off” somehow. It sounds kind of silly, but at the time I was more worried about having damaged my posterior deltoid attachment where I hit and did a quick google search as I had never heard of this happening from a minor trauma before.

This lead to me reading about AC joint sprains and realizing my distal clavicle had some swelling over it and was more prominent than I remembered. What ensued was me spending hundreds of hours over the next 7-8 months reading pretty much every case study, forum post, website, and orthopedic textbook I could get my hands on about AC joint sprains and shoulders in general.

Originally, I went to the orthopedics department at the hospital I work at about 5 days after my fall and they took AP bilateral X-rays but I was too wide to fit so they had to take a separate X-ray of each shoulder. We reviewed these on the computer, and the Doctor (who at the time I believed was an orthopedist but I later found out was a PA that just transferred from family medicine) did a physical exam and noted I had no pain or range of motion loss. As such, she said my shoulder wasn’t injured but I insisted that she do a bilateral weighted view just to make sure. Again, she noted no difference and said I may have just had a mild sprain and to take two weeks off from the gym if I thought it was necessary. I was less than convinced because she didn’t even take my shirt off to look at my shoulder. The radiology report came back stating that both AC joints were at the upper limit of normal joint width.

So the next week I scheduled an appointment with a reputed orthopedist that I found online. He reviewed my x-rays and did a slightly more thorough examination, but ultimately agreed with the first doctor stating that I had a class I sprain and the clicking or visual change I saw was probably caused by inflammation, give it time to go down, and I was free to do any weightlifting except overhead work.

I called back a few weeks later with the same symptoms and spoke to the PA on the phone who said he was surprised I wasn’t fully back into working out as I barely had a class I sprain. I requested an MRI, which indicated a slight increase in signal intensity in the AC joint and no other shoulder problems. Again, the orthopedist told me to give it more time as it was still early in the recovery process and continue with the band rehab exercises I had been doing, and not hesitate from lifting as long as I had no pain.

So at this point I returned to lifting as fully as possibly, avoiding any exercise that caused clicking. It’s been 8 months since the injury. I actually spent quite a bit of time learning to read the x-rays and MRI’s which was an interesting task in itself.

I have found other examples of class I diagnoses online with a slight bump and no pain, but these seem to be far and few between. The most logical explanation I can come up with is that the grading of injuries represents a range of tissue damage that can be difficult to cleanly classify into a textbook category so I may have some symptoms of one classification and some of another depending on the quality being assessed.

I agree completely with what you’re saying though, better to start off more conservative than risk wasting money or possibly making a minor situation worse by getting injections into my shoulder. At this point I can still compete in strongman at a high level, so I can live with that. It would just be nice to have my shoulder back to what it once was.

Hopefully it doesn’t sound as if I’m just getting sucked into a well written prolotherapy advertisement as I’ve spent a pretty substantial amount of time researching all of this haha. It’s interesting that you mention I would need to tape or sling the affected side to achieve full reduction. While reading it seems quite a few historical texts as well as more contact sports oriented physical therapists and trainers recommend taping the joint to reduce it while the scar tissue heals for a better outcome. However, most orthopedists today seem to either not recommend this or deny it will have any impact.

The most dramatic example of the effects of taping I have ever seen are visible in this thread:

The guy has a full blown class 5 separation, tapes it beginning on the first day, and after a few weeks you can’t even tell his shoulder was ever separated. I can definitely understand the inconvenience of taping your shoulder for weeks on end, but I still wish I would have known about this sooner. Maybe someone will read this and it will help them.

Anyways, sorry for the excruciatingly long response. It’s just nice to have someone open minded and interested in this kind of stuff to bounce my thoughts and ideas off of. Thanks for the help!


#6

I’m finishing up my first year.

You are obsessing over this shit, honestly. Nothing in medicine is a clean, neat category. You may have stretched out the coracoclavicular ligaments a very slight amount, but not enough for a radiologist to even detect. I’m sure you can notice it, and that’s fine. It’s not going away - not now, not ever. Leave it alone and stop spending your nights browsing PubMed and Ovid. You’re freaking yourself out over nothing.

If you broke your nose fighting and you had a little bump from a calcification, I doubt you’d be going from surgeon to surgeon asking what could be done. You need to accept that the clavicle on that side is slightly higher, but it’s not affecting you in any profound way. My shoulders and all of my friends’ shoulders click too. Go to a good physiotherapist. Get off of the computer - you’ve invested way too much mental energy into something that isn’t a major problem.


#7

[quote]arcadiafades wrote:
I’m finishing up my first year.

You are obsessing over this shit, honestly. Nothing in medicine is a clean, neat category. You may have stretched out the coracoclavicular ligaments a very slight amount, but not enough for a radiologist to even detect. I’m sure you can notice it, and that’s fine. It’s not going away - not now, not ever. Leave it alone and stop spending your nights browsing PubMed and Ovid. You’re freaking yourself out over nothing.

If you broke your nose fighting and you had a little bump from a calcification, I doubt you’d be going from surgeon to surgeon asking what could be done. You need to accept that the clavicle on that side is slightly higher, but it’s not affecting you in any profound way. My shoulders and all of my friends’ shoulders click too. Go to a good physiotherapist. Get off of the computer - you’ve invested way too much mental energy into something that isn’t a major problem. [/quote]

I hate to admit it, but you’re right. I don’t use pub med much though-one of the benefits of working at a major hospital is access to almost any medical resource imaginable haha. A lot of the reading is because I enjoy it and want to go into orthopedics.

I too have always had popping in my shoulders, but the popping now is much more intense. Honestly, I think it may have started before I even went on vacation because I remember on two occasions trying to do some band laterals and having to stop because a pop would occur on every rep in the exact same movement pattern as the shoulder does now. I’ll browse around for a good physio and give that a try.


#8

Shoulder is getting worse and now pain is starting to set in. I don’t understand why a class I ac joint sprain wouldn’t have healed after 9 months. Pretty sure I’m getting distal clavicle osteolysis or some shit and will now need surgery.


#9

bigboy15:

I am in month 3 of a similar AC joint problem, and am currently in the “read everything I can find” phase.

Could you please provide an update on your AC joint? Has it healed completely?

Thanks


#10

What exactly is your injury mechanism and how severe was your separation? Depending on how severe it is unless you tape the joint immediately and aggressively into position after injury I don’t believe you will achieve scarring of the ligament into the exact proper position. AC joint sprains are common, yet I don’t see too many people walking around with their collarbones sticking out so the commonly prescribed sling probably helps too in milder cases.

As for me, I’m over 2 years out from what was diagnosed as a class I separation and barely notice it any longer. I have a small bump on that shoulder that no one can really see except me. During daily life it doesn’t hinder me at all, but with training get periodically sore and it clicks and grinds a little more than my right shoulder. I don’t baby it at all and probably made mine worse in the beginning by jumping back into training pretty early. I wouldn’t say it hinders me at all, but it’s definitely something I’ll always be conscious of.