Prolotherapy fixes a problem most people do not know that they have…   My own introduction to the realm of ‘diagnostic issues’ related to pain of connective tissue origin came from my own back.  I injured my back at age 26 by moving a pickup truck load of railroad ties to edge a flower bed.   From this point on, my back would ‘lock up’ half a dozen times a year for a day or two, or a week or two.  This went on for 20 years.  Then, for 5 years, I had symptoms 24/7.  At age 49, I ended up in my own hospital for several days with ‘can’t get out of bed’ back pain.   I had my choice of Orthopedic Surgeons, since I ate lunch with them every day, so I picked the wise old man in the big Orthopedic group.  We looked at my MRI, and he detailed over half a dozen things that were ‘wrong’ with the discs and the bones at several levels.  He summed up by saying that i was looking at a several level fusion in the next few months, and should dramatically curtail my activities in the meantime.

During our discussion, I had not heard something that i, as a surgeon, needed to hear if we were discussing me having a major operation, so I framed the question directly:  “I heard the list of ‘what was wrong’ on the film, but where, exactly, was my pain actually coming from, and what was the proposed spinal fusion going to do to rectify this problem?”  The answer was very candid.  “Mark, there is some debate, some might say confusion, about the actual source of the pain.  But what we do know is that, with this operation, most people feel better, some do not, and some occasionally feel worse, so you want to put off the procedure as long as you can.”

What did he just tell me?  Or, more specifically, what could he apparently not tell me?   WHERE MY PAIN WAS ACTUALLY COMING FROM!  That lack of precision in the diagnosis deeply concerned me, particularly in relation to the recommendation that I undergo a major operation WITHOUT an ironclad diagnosis.  A month later, my flare up had flared down, and I was in Chicago for a weekend.  We happened to meet with an old friend from residency days, Dr. Ross Hauser.  That visit lead to the source of my back pain being accurately diagnosed (ligament damage subsequent to the injury at age 26), and by means of triggering my connective tissue healing system half a dozen times over the next year (Prolotherapy), this 25 year back problem was completely resolved.  Completely.   This was not just a transient improvement in symptoms.  I have had no back pain, except for a few minor injuries, in the last 10 years.  The ligaments were the problem.  And the word ‘ligament’ never occurred in the conversation with my Orthopedic Surgeon.  He was right:  he did not know the source of my back pain.

My wife experienced a related ‘diagnostic problem’.  Around the time that my  back was melting down, Holley was in a serious car accident.  After being struck on the drivers side door by a vehicle that ran a stop sign, impacting her car at 40 mph, she had activity-limiting back and neck pain.  That pain was worsening two years after the accident, after all the medication, exercise, and physical therapy that had been prescribed.  Another round of evaluation by two Orthopedic Surgeons and two Physical Medicine/Rehab physicians, including a CT scan, an MRI, and a 4 limb nerve conduction study, failed to uncover the ‘cause’ of her ongoing, severe pain.  The next recommended stop was a Pain Clinic.    So, rather than ‘something’ seen on film, she had ‘nothing’ seen on film:  she got a blank look, and the gentle inference that this might be more of a psychological issue than a physical issue.  The problem with that scenario is that I am a trained observer and know the physiologic ‘cues’ that someone is, or is not, in significant pain.  Believe me, she was in serious pain most of the time.  How can you explain this failure to diagnose what was CLEARLY a physical problem???  Because the highly trained, experienced, and caring physicians who were evaluating her had no idea that the ligament structure of her cervical and lumbar spine, and pelvic ligaments, were capable of causing the symptoms that she was describing, how to evaluate this possibility, or how to treat such a problem if they became aware of it…in other words, we are back to the ‘diagnostic problem’…

Holley’s neck and back problems were due to unhealed ligament damage from the motor vehicle accident that did not ‘show up’ on imaging.  These problems were, likewise, resolved by a course of Prolotherapy.    While I used imaging studies of all kinds on a daily basis in my Urology practice, I was just beginning to understand how much these studies are NOT the answer in the diagnosis of pain of connective tissue origin.

The source of all of my pain, and the source of all of my wife’s pain, was connective tissue.    What happened when the source of my pain, and my wife’s pain, was correctly diagnosed (by physical examination instead of imaging studies), and correctly treated?  Both of our issues were resolved.  I have not had ANY back pain for the last 10 years, with the exception of a few minor, discrete injuries (which either healed on their own, or received limited Prolotherapy treatment).  In other words, this was not just a transient ‘improvement’, it was a complete repair of the actual problem.  Holley, also, went from being a candidate for a ‘Pain Clinic’, to having a full and very active life without back or neck pain.  This clinical outcome for both of us got my attention as a physician, particularly in light of the discrepancy between the ‘diagnostic results’ of ‘standard’ (imaging based) medical approaches, and a diagnosis based on a simple physical examination.  And the fact that the diagnosis obtained by this exam lead to a common-sense treatment that completely rectified both of our serious problems—a treatment that was completely ‘different than’ the operation proposed to me by a very competent Orthopedic surgeon, and the ‘blank look’, ‘you’ll just have to live with it’ conclusion that Holley received after thousands of dollars worth of testing—this was even more stunning to me…


Prolotherapy uses a patient’s own healing system to stop pain and other symptoms caused by unhealed connective tissue damage.  The same healing process that repairs a surgical incision or a sprained ankle can be triggered using several very safe, non-toxic chemical mixtures, or Platelet Rich Plasma.  These chemicals must be applied directly to the structures in need of healing, by injection.  The ‘big secret’ surrounding Prolotherapy is the number of problems that patients have that are ‘diagnosed’ as being of something OTHER THAN ‘connective tissue damage’ origin, which prove to ACTUALLY BE from this cause, and which can be greatly improved, or completely resolved, using this treatment.

A lengthy list of issues which can be successfully treated by Prolotherapy is included further down in this website.


Prolotherapy teaches us some very important lessons about what is, and what is not, wrong with people who have neck, back, and joint pain.  How?  Because Prolotherapy basically increases tensile strength in each treated structure by adding collagen molecules, courtesy of the Connective Tissue Healing System.  If you can completely resolve a patient’s pain with treatment of a certain set of structures, you can tell which structures were causing the pain, and you can be certain that the symptoms were somehow a function of the tensile strength of these particular structures.

How in the world could strengthening the ligaments stop back pain that a very respected Orthopedic Surgeon assured me was an indication for spinal fusion?  And how can strengthening ligaments completely resolve a knee or hip problem that has been diagnosed as ‘arthritis’ or ‘bone on bone’?  How could the spinal and pelvic ligaments be causing pain diagnosed to be from a ‘bulging disc’ or ‘sciatica’?  Let’s just say that I stayed up nights thinking about that one, because there is NO explanation in the medical literature for such a relationship between pain, pathology, and treatment.….(just as there is no plausible explanation for why a ‘bulging disc’ or thinned cartilage would be able to cause pain) so I wrote such an explanation based on clinical observations made while treating my first fifteen hundred patients.  (read Connective Tissue Damage Syndrome paper)


What is ‘connective tissue’?  It is ligaments, tendons, fascia, periosteum, labrum, meniscus, the tempro-mandibular joint (TMJ), and cartilage.  Ligaments connect two bones at at joint, allowing some motion, with that motion bounded and controlled by the ligaments.  Tendons connect muscle to bone, allowing the muscle to move the bone.  Fascia is the tough envelope surrounding muscles, and also forms tough sheets of tissue that provide fixation and support for the ‘soft tissues’ and which also connect them at points to bone.  Periosteum is the envelope that surrounds each bone.  All connective tissue structures are made almost entirely of ‘collagen’ molecules in a regular array (as opposed to the random array in ‘scar tissue’).


All connective tissue structures have a rich nerve supply (see ‘bone bruise’ for details), particularly ligaments and tendons, which are the third most innervated structures in your body, behind the ‘mucous membranes’, like the surface of your eye, and your skin.  Ligaments and tendons have the third most sensory nerve fibers per volume of any structures in your body.  Nerve fibers have an interesting ‘structure’, which does not allow for any ‘stretching’.  Other than bone, nerve fibers are the least ‘stretchable’ structures in your body.  If you stretch a nerve fiber, you damage it.


Ligaments and tendons are like cables, and the collagen molecules are just like wires in the cable.  Envision taking a 10,000 pound rated steel cable, made of a bunch of little wires, and hanging a 10,000 pound weight from the cable.  Then get a wire cutter and start cutting wires.  You will cut several without anything ‘happening’, since the cable is probably a little ‘over-engineered’.  And you are a little ‘over-engineered’ when it comes to collagen molecules in your ligaments and tendons.  You generally have more than you need to hold the considerable loads that these structures hold without stretching.  But you will cut that one wire, and the cable will begin to sag and ‘give’ a little.  You will cut a few more wires, and the cable will sag further.  In this weakened state, 10,000 pounds just exceeded the ‘loadbearing’ capacity of the cable, evidenced by it beginning to stretch.  Or, your normal body loads may exceed the weakened load bearing capacity of a ligament or tendon, evidenced by that stucture beginning to stretch.

Now, as your ligament or tendon begins to stretch abnormally, what about all those fragile little nerve fibers that live inside the structure?  Can you see this new ‘stretching’ damaging these small nerve fibers?  Can you then see the structure becoming ‘tender’, because when you press on the structure, you are now pressing on damaged nerve fibers?  Can you see these fibers firing nerve impulses into the nervous system, which might show up by affecting muscle function, by causing ‘referred symptoms’ that are ‘felt’ in other locations, or by causing other phenomena, like headaches?  This simple concept is the key to unlocking an understanding of many body aches, pains, and dysfunctions.


And, this explains how increasing tensile strength, by inducing collagen production courtesy of ones own healing system, can completely rectify the problem of the damaged small nerve fibers.   Strengthen and structure, stop the stretch, fix the problem.  And, if we realize that virtually all the ‘problems’ diagnosed on imaging studies—cartilage loss, meniscus and labrum trears, disc deterioration, bony changes around joints—have as THEIR cause laxity (weakness and abnormal stretching) of ligaments (instead of ‘inflammation’, or ‘arthr-ITIS’, ‘degenerative disc disease’, ‘tendonitis’, etc.), and if we realize that MOST OF THE SYMPTOMS are coming from the CONNECTIVE TISSUE STRUCURES that DO NOT look ‘abnormal’ on imaging, instead of the from the damaged structures that DO ‘show up’ on films, we are now armed with an understanding that will allow us to approach these painful problems in an entirely new way.  If we could just figure out how to correctly identify these weakened, pain-causing structures, and if we could figure out how to ‘tighten’ the loose ones so that the joints do not continue to be torn apart as they are used…then we would be able to effectively treat these problems and really help a lot of people who are in serious pain.  There is good news:  we can do just that.  The evaluation is called a ‘Physical Examination’ that simply looks for tenderness in all the connective tissue structures in the vicinity of a patient’s pain. The treatment is called Prolotherapy.  And this diagnostic and treatment approach do not merely ‘make sense’, they produce excellent results in a large and varied patient population.


Most people do not believe that a simple physical examination can find ‘pain sources’ better than an MRI.  That is because they think that ‘tenderness’ is due to some kind of ‘inflammation’, and the ‘real’ pain is due to abnormalities seen on the films. (Even in the case of an injury noted in a connective tissue structure, like a rotator cuff tendon that is partially torn, as noted on film, this is generally  only PART OF the pain sources which will be noted on physical examination, but will be deemed the ‘entire’ problem based on the films.  If you treat only a portion of the actual sources of symptoms, what is the chance that your shoulder will be pain-free following treatment?). But, if you understand that ‘tenderness’ is caused by stretch-induced small fiber nerve damage in these structures, you realize that this tenderness is present because of the abnormal ‘stretchability’ of the structure, and that this tenderness WILL BE PRESENT UNTIL these structures return to ‘load bearing’ status when enough collagen molecules have been added back to them so that you are no longer yanking on the nerve fibers and damaging them every time you use the structure.  Then it occurs to you that you can not only use ‘tenderness’ as a reliable diagnostic tool, but you can even use it as a means of tracking and to assessing the results of therapy.  And, you will find that when you treat ALL the symptom causing structures, your treatment results get better…a lot better, in fact…if you can remedy what is ACTUALLY WRONG, which is a lack of tensile strength in this set of structures.  Now, what is the only treatment that does this non-surgically?  And, if your operation only addresses ‘what is seen on film’, might your patient have a significant probability of continuing to have pain after surgery?  If you have had surgery, and your pain did not fully resolve, might this be the reason?


Again, though, what about the ‘tendonitis’, or ‘bursitis’, or ‘costo-chondrities’, or ‘plantar fasciitis’, or ‘epicondylitis’, or ‘osteoarthritis’, or other inflammatory or degenerative condition that my other doctors have told me that I have?  Everyone ‘knows’ that these structures are tender due to inflammation….except over the last 20 years medical researchers, have proven conclusively that such an ‘inflammation’ does not exist as the cause of pain  They have no other explanation for the tenderness and pain arising from such structures, but they know that inflammation has no role in this scenario.  And there is not study to date where they looked specifically for small fiber nerve damage in such structures (so this remains a ‘theory’ at this point, instead of an ‘established fact’).  But I think I know what they will find if they do look for this kind of nerve damage in these tender, symptomatic structures.


I believe that they will find small fiber nerve damage in these structures for several reasons:  1.)  it explains the tenderness; 2.) It explains the pain; 3.) it explains the associated muscle malfunctions; 4.) it explains the potential for creating ‘distant’ referred sensations; 5.) it explains the potential for creating distant ‘autonomic nervous system’ symptoms, like migraines and voiding dysfunction; 6.) it explains why all of these go away when tensile strength is added back to the structure; 7.) it explains why these symptoms go hand-in-hand with situation where there is obvious ‘stretching’ in the ligament structure around joints, with physical evidence that includes damaged discs (due to abnormal mechanical forces on the disc due to abnormal motion of the bones), cartilage loss (due to abnormal abrasive forces at the joint surface due to ligaments which are not holding the bones in correct alignment), meniscus and labrum tears (which also reflect the humerus or femur moving abnormally and damaging supporting structures in the joint);  8.) it explains why the ‘pain associated with this or that seen on imaging studies’ can go away, while the things seen on these imaging studies do not change at all.  My back probably still has several degenerated, bulging, ruptured discs, foraminal narrowing, spondylolisthesis, bone spurs and bony changes commonly referred to as ‘arthritic’.  But, since my back has not hurt for the last ten years, do I care what these structures look like on my film?  No, i do not.  Do people with thinned cartilage in their knee, but no knee pain, care how thick their cartilage is?  Particularly if the ligament laxity that allowed their knee to be damaged is tightened, and the structure is no longer being damaged by use?

There are a number of scientific studies which call into question the ability of MRI’s to ‘diagnose’ back pain correctly, so my skepticism about the role of those studies is not unique.  But I also have a high degree of confidence in the ability of a physical examination to offer just such correct diagnosis in the back, and in every other joint and area of the body.  How do I know that I can successfully find ‘the actual’ source of symptoms, and ALL of the symptom-causing structures?  Because my treatment solutions all have a numbing medication.  I am numbing, as well as treating, each structure.  If I can make the patient’s symptoms resolve using the numbing medication in the structures that i treat, what would this tell you about WHERE THESE SYMPTOMS WERE COMING FROM?  And, if I can find such symptomatic damage, I can also effectively treat this damage with a high degree of success. Welcome to the world of Prolotherapy.  And now you understand, at least conceptually, WHY I believe such a palpatory examination can be so useful.


Since YOU now understand where pain CAN BE coming from—potentially in any connective tissue structure—as opposed to where people are usually TOLD these symptoms are ‘coming from’, let us revisit the issue of ‘the diagnosis’.  Because while you have now heard that stretch-induced small fiber nerve damage, evidenced by tenderness in connective tissue, is a possible cause of body pain, your family doctor, Orthopedic doctor, Neurosurgeon, Rheumatologist, Neurologist, Physical Therapist, Chiropractor, etc. have no idea that this is possible.  The several physicians who sat across from me and my wife, who were evaluating her severe pain, and coming up with no answer, were not aware of this possibility.  The Orthopedic Surgeon who offered me a ’several level fusion’ was not aware of this possibility.  The word ‘ligament’ was never mentioned in our discussions.  Literally thousands of practitioners who evaluated thousands of our patients before I first saw them have not correctly and completely diagnosed the actual cause of pain prior to those patients’ arrival in our office.


Why am I so confident of this fact?  Because if I have completely remedied a patient’s problem, I know what structures were, and were not, the source of their symptoms, and I know that strengthening their connective tissue structures resulted, not only in relieving their symptoms, but in reducing or eliminating further joint damage.  I have seen over 4200 patients, roughly 18% of whom have one or both knees treated.  Around 40% of our knee patients have been told that they need a knee replacement, and another 10% have been told that they need an arthroscopic procedure.  So I have treated roughly 1000 knees to date (2015), and over 400 of them were told that they were candidates for operation.  I am aware of less than 20 patients who have gone on to have surgery of any kind following Prolotherapy treatment.  You can do the math on how many operations we have allowed patients to ‘avoid’…and this is just the figures in knees.  There are also necks, shoulders, elbows, wrists, hands, low backs, hips, ankles, and feet where our patients have frequently had operative therapy offered, or in whom operations have already been performed, but pain persists.  Across the scope of issues that we treat, we have an around 90% rate of 80% + pain and symptom reduction, and around 50% rate of 100% relief of symptoms.

After studying knee treatment results in our own practice, I was asked to present my results in a meeting of a national physician organization, and to contrast these with research results obtained using ‘typical’ Orthopedic Surgery approaches (using Platelet Rich Plasma, a strong ‘healing trigger’ that was applied to structures based on Orthopedic diagnostic assumptions—attacking the ‘loss of cartilage’ only), and to results obtained by other Prolotherapists.


From my practice, 55 knees were evaluated over a year following last treatment. The results that we obtained, for those completing a course of treatment, were:  for 80% or more symptom improvement—95%.  For 100% symptom relief—45%.  (again, half of these people were offered operations by Orthopedic Surgeons prior to seeing me, so this is a fairly ‘severe’ group of knee problems that were treated).    My average number of treatments needed to obtain these results was slightly under five treatments.  The two research studies with which we compared these results:  Kon et.al., 2011 (an Orthopedic Surgeon), who used PRP in 50 knees, three treatments, who obtained 40% average symptom reduction, and Patterson and Rabago, 2013, (Prolotherapists) who treated 50 knees with up to 5 treatments, and who obtained an average 50% symptom reduction, with a maximum symptom reduction of 65%. Do my results justify my confidence in my ability to correctly diagnose, and to successfully treat, these problems?   And, do we see how different ‘understandings’ of the problem produces different approaches, which produce different results?   (see Dr. Johnson’s full 60 minute presentation).


How do I know that this concept of Connective Tissue Related Pain is not well understood by your other practitioners?  Because I know when, and where, and by whom, this theory was first proposed in medical literature.  I first proposed this theory in print in 2009 in a medical journal that was not widely read by those outside the Prolotherapy community.  This theory has yet to be widely disseminated, or to be confirmed by pathologic biopsy studies.  But it does fit nicely with reality.  It is the only plausible explanation for why Prolotherapy ‘works’, and for dozens of clinical phenomena that I see in my office every day.  The medical community and medical training, remain tethered to theories like ‘inflammation’ in structures—tendonitis, etc.—which came from the 1950’s and were discredited by medical research over a decade ago.   The notion that ‘everything worth knowing’ can be diagnosed on films’ is not implausible, given how beautiful, detailed, and expensive some of these films are, but this notion is simply incorrect.  Imaging for diagnosis, and imaging for guiding of treatment, suffer from the same problem:  you cannot ‘see’ symptomatic damage in many structures on any kind of film.  You can, however, easily demonstrate it on a quick, and ‘free’ physical examination.


But, if you are not aware that connective tissue is a potential pain source (and the  notion that ‘ligaments’ are a potential pain source disappeared in the 1950’s, when physical examinations were abandoned in favor of ‘x-rays’, and ‘rheumatism’ became ‘arthritis’), to what will you attribute the patient’s symptoms?

The tenderness in ligaments that used to be noted on examination in conjunction with joint pain, and which used to be termed ‘rheumatism’, or ‘damage to connective tissue structures around the joint causing joint pain’, was supplanted by the notion of ‘arthritis’, or ‘joint inflammation’, based solely on the fact that the first anti-inflammatory medication, Cortisone, made many people with joint, neck, and back pain ‘feel better’.  This clinical observation suggested that the cause of these pains ‘must’ therefore be ‘inflammation, since an ‘anti-inflammatory’ medication (Cortisone) made them  feel better.  Unfortunately, those who proposed this ‘new’ theory in the 1950’s did not get tissue and look at it under a microscope to see if there was actually inflammation present in these structures.  It took 40 more years for someone to finally examine structures thought to have ‘tendonitis’ with a microscope.  When this was done, in more than 15 separate studies between 1995 and 2005, guess what was found?  No inflammation at all.  ‘Tendonitis’ does not exist.

But by that point, at least in the minds of practitioners, neither did ‘pain coming from ligaments’.  Ligaments, in the interim, literally ‘disappeared’ as a possible source of body pain.  In the current 5000 plus page text series that Orthopedic residents master during their training process (Campbell’s Operative Orthopedics), I do not believe the word ‘pain’ and the word ‘ligament’ occur in the same paragraph…and I looked.) then you will of necessity attribute symptoms reported to you by a person who HAS this pain source to a cause that you HAVE heard of…again usually something you ‘see’ on imaging, or ‘infer’, like a nerve pinch or an inflammation.  Or a Morton’s Neuroma, or a bone spur, or scar tissue, or occipital neuralgia, or spinal stenosis, or dozens of other purported ‘reasons’ for pain.


So, how can one ‘know’ whether or not they have a ‘connective tissue’ pain source?  The answer is simple:  if a person draws a map of the location of their symptoms, and if tender connective tissue structures can be located which correspond to, or ‘make sense’, in light of the location and nature of the patient’s symptoms (keeping in mind the large array of possible symptoms which connective tissue can produce, and the capacity of connective tissue to ‘refer’ symptoms, or for symptoms from a structure to be perceived inches, or feet, from the structure actually producing the pain or symptom, in known patterns of distribution), then a reasonable assumption is that these symptoms might be related to the connective tissue structures.   I am highly skilled at performing, and interpreting, such an examination, and i really cannot determine the answer to this question unless I have the opportunity to examine an individual.  But a patient can get some sense of this on their own:  in the area of their symptoms, if there are ‘sore spots’ noted when the area is pressed upon, or massaged, this likely represents symptomatic connective tissue damage.  This is true whether there is ‘one’ spot, like a sports injury, or body-wide tenderness and pain, as is seen in ‘fibromyalgia’.   It is also true that if a patient cannot ‘find’ such tender structures on their own, I often can.

But, how can we be sure that the located tender structures are actually related to what the patient is complaining of?  Again, the answer is very straightforward.  The ‘healing trigger’ solutions that are employed in a Prolotherapy treatment all contain Lidocaine, a ‘numbing medication’.  While triggering healing, I am also ‘numbing’ each treated structure.  If these structures have this theorized small fiber nerve damage, and if this damage is in fact causing the patient’s symptoms, what should happen if these nerve fibers are ‘numbed’?  The symptoms will all go away immediately, and for the hour or so that the Lidocaine is producing numbness.  Then they will return.  If you see this pattern, what would it tell you about where the pain and referred symptoms are ACTUALLY coming from?  This gets really amusing when patients have numbness and tingling in a leg that they have been told is ‘sciatica’.  While ‘actual’ sciatica exists, most patients who have been told that they ‘have it’ actually have referred symptoms from pelvic and hip ligaments.  It is fun to see patient’s reactions when I make ‘numbness and tingling go away…using a ‘numbing medication’.  An occasional patient asks me if I simply made their symptoms go away by ‘numbing the sciatic nerve’.  What do you think would happen if I ‘numbed’ the sciatic nerve?   The whole leg would go numb and the patient would be unable to walk for an hour or so.  But if I am numbing the small, damaged nerve fibers in the sacroiliac ligament that are producing this ‘referred symptom’, then it would make perfect sense that such numbness and tingling would go away for an hour or so.  In other words, this theory corresponds precisely to phenomena we observe in the office on a daily basis.

And the ‘character’ of numbness and tingling is different depending on whether the cause is actually a pinched nerve, or small fiber nerve damage in connective tissue structures.  In a true nerve pinch, there is loss of the sensation of light touch and pinprick.  The skin is so numb that patients do not ‘feel’ light touch at all, and barely feel a pin pricking the skin.  In referred connective tissue symptoms, the sensation of light touch is maintained, and a pinprick feels ‘normal’…the skin just has weird prickly sensation, and ‘feels’ like it is numb, even though, when tested, it is not actually numb. Then there is the distribution.  The sacroiliac ligament refers symptoms down the lateral thigh and calf.  True sciatica is not felt there.  Each ligament has a defined ‘referral pattern’.  When someone draws a symptom in the distribution of one or more ligaments, you simply check the appropriate possibilities for tenderness.  If one or more are tender, you inject the tender structures.  If the referred symptom ‘goes away’ immediately, you have built a strong case for the actual cause of this symptom.

Unfortunately, on a daily basis we have patients come in who have been informed that the cause of their symptoms is anything but their connective tissue, when it proves to be precisely and only from that source.  We have been, literally, amazed at the percentage of patients in whom this is the case.  This ‘missed diagnosis’, in my opinion, is THE reason that explains the failure of the medical community to do anything other than mask the symptoms of most body pain, and it explains the high incidence of persistent pain after most interventions, including ’curative’ operative therapy.  We emphasize correct understanding of the symptom source in a patient for a very good reason:  correct understanding of the cause is the only way to reliably find an actual solution to the problem.


If we are going to employ the healing system to fix unhealed connective tissue damage, we need to understand how this system works (and what can go wrong with it).


We are trying to get your body to make more collagen. You cannot simply ‘take’ collagen and have it show up where it needs to go.  It is ‘digested’ by the GI tract.  Nor can you ‘inject’ it and have it insert itself into the correct structures.  Your body has to identify a structure as ‘in need of healing’, and cells called ‘Fibroblasts’ (the only cells capable of making collagen molecules) must make these molecules in a way that they are ‘woven into’ the correct structure.  Fibroblasts are everywhere in your body.  I could not take a biopsy any place in your body and not find several.   But they do nothing unless they are ‘told’ to make collagen.  The ‘telling’ consists of a group of chemicals, collectively called ‘growth factors’, which trigger the healing cycle.  These are 40 plus chemicals which ‘run together’ and ‘act in concert’ to trigger healing.

These ‘growth factors’ live in essentially only two places in your body:  your platelets and your white blood cells.  If you have bleeding as a part of the injury, like a sprained ankle or an operation, the platelets are part of the clot, or thrombus, or scab that coats the surface of injured structures.  These then deliver growth factors directly into the injured structures.  If you do not have bleeding, the the white blood cells control and modulate the degree of collagen replacement by measuring out these ‘growth factors’ whenever they sense that tissue damage has occurred.  Prolotherapy, using dextrose or one of the 40 plus chemicals which has been shown through the years to ‘trigger healing’, uses the ‘WBC response/growth factor release’ mechanism.  Platelet Rich Plasma utilizes both the WBC and the platelets as sources of these growth factors to trigger healing.


And guess what impairs the output of these ‘growth factors’ by the WBC’s?   You may have already guessed:  Non-Steroidal Anti-Inflammatory Drugs (NSAID’s) (Advil, Aleve, Mobic, Celebrex, etc.), and Corticosteroids (cortisone shots, epidural steroid treatment, Medrol dose packs, etc.).  These chemicals make you ‘feel better’ after an injury, but they make you heal MUCH WORSE, and should not be used in the context of ANY connective tissue injury, including surgery, in almost all circumstances in my opinion.   There are numerous laboratory and clinical research findings which attest to the harmful effect of these ‘standard’ recommendations for treating injuries, joint pain, back pain, and neck pain.  This is also true of ‘icing’ an area.  Ice should NEVER be used on an injury involving connective tissue.  The only indication for icing an injury is when a muscle may be actually torn.  In terms of connective tissue injuries, the pain of the injury is numbed, swelling is reduced, but healing is impaired.  If unhealed damage is the cause of pain, you might be very interested in actually healing your injuries.  Pain relief that stops healing may not be a good trade-off.


Prolotherapy triggers the ‘healing cycle’.  What is the ‘healing cycle’?  I am a surgeon by trade.  My day used to consist of making a hole in your belly, and rooting around and making a few more holes on the way to doing whatever operation I was doing.  At the end of the procedure, I would sew those holes up, but if we took out the sutures that same day, you would still have a bunch of holes.  But a month later everything would be sealed up and healed up enough for you to resume running, lifting, swimming, or whatever other strenuous activity you desire.  In the meantime, your body has made a vast number of collagen molecules to ‘knit together’ the holes.  Most people are generally familiar with the ‘six week sequence’ of healing following major surgery, or a major injury.  This is precisely the same process that we trigger chemically with Prolotherapy.  Most people think that most of the ‘healing’ happens during the first two weeks of this cycle, but it does not.  By the end of two weeks, you have made about 15% of the collagen you are going to make, and by the end of the fourth week, about 95%.  So you make about 80% of the collagen during the third and fourth weeks following a Prolotherapy treatment.  This is why you are generally seen at monthly intervals, because at this point you have had virtually the entire response that your body is going to provide.


A ‘scar’ is a random array of collagen.  But, if the structure in need of healing is a ligament or tendon, these same molecules are simply arranged in the proper parallel arrangement to match the ‘rest’ of whatever structure is being ‘healed’.   In 1999 a study was done with an electron microscope pre and post treatment to see what kind of collagen architecture was produced by Prolotherapy treatment.  How much was ‘ligament’, and how much was ‘scarring’.  The answer was a bit of a surprise.  What was seen was not only ‘pure ligament’, but the newly made collagen structure had the appearance of the ‘best, strongest’ possible ligament architecture…like marathon-runners tissue instead of ‘average’ ligament structure.  So, we apparently make a very good version of what we are ‘trying’ to make, and nothing that we are ‘not’ trying to make with this treatment.


I was taught during medical school, in the 1970’s, that cartilage does not ‘heal’.  This is because a cartilage defect in a large joint would simply sit there, unchanged, for as long as you wanted to observe it.  It was later discovered that cartilage CAN heal, but this requires that the cartilage cells, called ‘chondrocytes’, morph into a more immature cell form called a ‘chondroblast’.  This more immature cell form will then begin to produce new cartilage.  Prolotherapy with Dextrose, or with PRP, is capable of producing this effect.  Dr. Dean Reeves in 2013 published a study showing that Prolotherapy with dextrose stimulated new cartilage growth in 12 out of 20 patients treated with three dextrose treatments inside the knee capsule.  Platelet rich plasma has also been shown to stimulate cartilage growth, as it not only triggers the WBC portion of the healing system, but utilizes also the platelet portion, which would be expected to add more to the effect.  In addition, in the PRP collection and processing system that I use (Harvest Technologies), there are also about 120,000 stem cells in the injected material.  Stem cells are very well known for their ability to grow cartilage by  differentiating into cartilage cells.


This raises an interesting and important question:  which is better to address ‘arthritic’ knees—stem cells treatments or Prolotherapy treatments.  The answer to this depends on ‘what you think is wrong’.  I see the current move toward stem cell treatments as ‘the’ treatment for ‘osteoarthritis’ of the knee and other joints to suffer from the same problem as joint replacement.  I think that the wrong structures are the primary target of treatment.  I personally think that better results are obtained by addressing the ligament structures, and in addition perhaps growing a bit of new cartilage, as opposed to making a nice, shiny (and expensive) new layer of cartilage because…what happened to the last layer of cartilage that was there?  Oh…it rubbed off because the ligaments were not holding the joint surfaced in proper alignment.  If you do not effectively address the underlying ligament ‘cause’ of joint destruction, what do you think is probably going to happen to the ‘new layer’ of cartilage in a few years?

And, you need to consider precisely what a ‘stem cell’ treatment accomplishes, and what triggering the connective tissue healing system accomplishes at the cellular and structural level.  Stem cells are cells that can ‘differentiate’ into a variety of kinds of ‘mature’ cells, like muscle cells, gland cells, and cartilage cells (chodrocytes).  Therefore, if you want to grow cartilage, you might reasonable put stem cells into the area, and they might reasonably grow a new cartilage.   But, when you are trying to repair DAMAGED LIGAMENTS AND TENDONS, you need something other than ‘progenitor cells’.  There are no ‘ligament cells’ that ‘make’ ligament, nor are there ‘tendon cells’ that make tendon.  Tendons and ligaments are made almost entirely from collagen molecules, and are simply like a cable or a rope.  Collagen molecules are made by only one cell in your body:  a ‘fibroblast’.  Fibroblasts are everywhere.  I could not do a biopsy of tissue anywhere in your body and not find fibroblasts.  And, they are mobile.  When the ‘healing system trigger’ growth factor chemicals are released, fibroblasts migrate to the site of injury in large numbers.  YOU DO NOT NEED MORE FIBROBLASTS.  You have plenty.  What you do need is for the healing system to be triggered by the outpouring of these ‘growth factors’, which is what Prolotherapy accomplishes from the WBC’s, and what Platelet Rich Plasma accomplishes from both the WBC’s and the Platelets.  When there is an outpouring of these growth factors in a structure or structures, the ‘in situ’ fibroblasts begin making collagen to repair the structure.  Other fibroblasts migrate to the structure(s) in large numbers, and also begin to make collagen.  So, if the problem is a lack of collagen/tensile strength in a connective tissue structure, then what is required to repair this deficit is to trigger the connective tissue healing system, or Prolotherapy.

A stem cell treatment, for all intents and purposes, does not rebuild ligament and tendon tissue, nor is it intended to do so.  And, even if it did, if it is several times the cost of a Prolotherapy treatment, would it not make sense to try a less expensive, yet potentially very effective, remedy first?  We are back to the question of ‘what is wrong’ to determine which treatment makes most sense, in addition to the financial considerations.  If you are an Orthopedic Surgeon, or you are relying on the thought processes spawned by the Orthopedic Surgeons in the 1950’s and 1960’s, and think that the sum of the problem is ‘bone on bone, due to lack of cartilage, caused by an inflammation (osteo-arthritis), leading to pain, then the ‘fix’ is to attack the cartilage lack head-on with stem cells.  This would probably lead to results not unlike the ‘Orthopedic Model’ PRP results (see these results compared to Prolotherapy, and Dr. Johnson’s, results).  However, if you realize that the MAIN problem is lack of tensile strength in the ligament structure, leading to pain, and to destruction of the cartilage layer and other joint surface structures (like the meniscus), and to the bony changes that are associated with what is termed ‘osteo-arthritis’, you will direct your therapy to producing an outpouring of ‘growth factors’ in the specific ligament and tendon structures which are causing the majority of the symptoms, in addition to inducing this same process to refurbish, albeit to a lesser extent, the cartilage surfaces.  PRP has the added advantage of having about 120,000 stem cells in the injected material (perhaps 1/10 of a full stem cell treatment…not the same, but helpful, and generally adequate, for what needs to happen to restore the joint to full function and pain-free status.  It is a matter of choosing the right tool for the job.

Most people who offer stem cell treatments in large joints do not address this ligament issue, and most physicians who offer PRP treatment do not, either.  And, since much of the symptoms are coming from the ligament structures to begin with, a significant percentage of knees and other joints will probably continue to be symptomatic.  And that is precisely what I have seen in our clinic.  I do stem cell treatments, but I need to do them very rarely, and can generally get results that are as good as, and usually better than, the results I have seen in patients who have had stem cell treatments by other physicians—-with MUCH less expense.  I support the right of every American to spend more than they need to spend if that is what they want to do, but why would you want to do that?

I see the root of this situation as physicians who, while trying to trigger healing (to their credit), are still mired in a ‘traditional medical mindset’ that focuses on ‘what is seen on imaging studies’, and tries to make that sum of ‘the problem’.   Let me reiterate:  in examining over 1000 knees, around 40% of which had cartilage loss sufficient to have joint replacement recommended, not ONE of these knees with severe, or even moderate, cartilage damage did NOT have demonstrable laxity of the anterior cruciate ligament.  Not one.  Yet, I have never seen this association made in the Orthopedic literature.  And in knees with this degree of damage on films, there are always many other symptom-generating connective tissue structures.  Unless you effectively treat ALL of them, you knee will still hurt.  I have been asked multiple times through the years if I have x-ray documentation of cartilage growth following Prolotherapy treatment…and my answer is always that I have documentation of dramatic, and long-term, symptom relief in an extremely high percentage of my treated knees (and, yes there is in fact such imaging evidence available in a research study, but that is not the point). If the knees in my patients are virtually, or completely, symptom-free, do I, or the patient, care what the x-ray looks like?  Again, this question assumes a direct correlation between ‘what is seen on films’ and pain—which simply is not the case.  All of this is simple common sense….which is unfortunately, it seems, rather uncommon…

(see Dr. Johnson’s knee results compared with Orthopedic and other Prolotherapists’ research results)


In the rare situations where we cannot trigger healing and get the desired results in joint treatments with Prolotherapy/PRP, and cannot find a healing system problem which can be rectified, a stem cell treatment will be recommended as an option.  We are certainly willing to perform this procedure at any point if the patient desires, and if they have a problem that this treatment might reasonably address.  If we render this treatment, particularly as the ‘first option’, we will make every effort to treat the underlying joint instability as well, to attempt to ensure the best pain relief, functional recovery, and long-term results.  Even in our most affluent patients, though, we will not RECOMMEND this treatment except in the VERY RARE situation where other options, which hold promise of complete relief of symptoms and are MUCH more economical, have been exhausted.


There are basically two ways that connective tissue structures loose tensile strength:   over-injury and under-healing.  Any time there is a significant injury, like a sprained ankle, the body will generally heal about 70% of the tensile strength back during the initial six weeks ‘healing cycle’.  You body also has a ‘maintenance healing’ process, with a more modest pace of collagen production, that works on an ongoing basis to replace the ‘daily attrition’ of collagen molecules.  You break and replace every collagen molecule in a given structure about every seven years, so this maintenance replacement system is actually hard at work every day.  And this is the system that gradually takes the 70% job  to 100% over the ensuing few months…if this system is working and we do not ‘get in the way’ with NSAID’s and ice.   And, since you have a lot of ‘extra’ strength in most of these structures, even if you loose some strength, you often do not ‘feel anything’, at least after the first injury in a structure.

But, if the injury is more ‘severe’, or if your tissues are already ‘abnormally weak’, or if you dramatically impair your healing system after an injury on the advice of a trainer, a family doctor, an Orthopedic Surgeon, or other well-meaning but mis-informed person who thinks that ‘inflammation is the enemy of healing’ (which is a marketing sound-bite with no scientific evidence behind it), by icing your injury and taking a handful of anti-inflammatory medication, or if your healing system is not working well for other medical reasons, like a low Testosterone level, then you might be left with a ‘non-loadbearing tendon or ligament.  If your maintenance healing system is working well and you are not too far ‘over the line’, you may find that your symptoms go away in a month or two, never to return…if you are fortunate.

If you have the misfortune to be left with non-loadbearing structures after an injury, if your maintenance healing system does not finish the repair work, you will have a whole array of possible consequences—possible muscle malfunction, joint instability, cartilage damage, etc.—in addition to pain that is intermittent, or constant.  If your healing system is not doing its ‘maintenance repair work’  what else would you expect to see?   If the daily damage is not being replaced, every connective tissue structure in the body gets progressively weaker.  One by one, thees structures ‘cross’ the line to stretch abnormally under load, and begin causing symptoms.   I refer to this as ‘multi-site connective tissue pain without a trauma history’.  Since there is often no imaging abnormality associated with this condition, and no ‘laboratory test’ that will confirm its presence, the rest of the medical community may refer to this situation as ‘fibromyalgia’ if the tenderness and symptoms are body-wide.  If the symptoms are more scattered, doctors may respond with a look of puzzlement, boredom, a raised eyebrow and the insinuation that the symptoms are somehow not ‘real’, or there may be an extensive attempt to ‘find’ the source of the problem by test after test.  At this point, one of two things happens:  either something is ‘found’ and ‘diagnosed’ as the cause of the pain (arthritis of the spine, for example, or ‘degenerative disc disease’), or ‘nothing’ is found and we are back to the various ‘looks’ that doctors give patients when the doctor has no clue.


The bottom line is, connective tissue healing is not perfect in many situations.  This may present no problem, or might produce enormous pain, deterioration and damage of various other structures, along with mild to severe activity limitation.  Joint pain is the second most common reason for consulting a physician in patients over the age of 40.  Chronic pain, which is defined as pain of over 3 months duration, much of which, based on my patient population, represents undiagnosed connective tissue damage, costs 635 billion dollars per year in treatment and lost productivity.  Back and neck pain, much of which represents unhealed, and undiagnosed, and potentially healable, connective tissue damage, costs 86 billion dollars per year in treatment costs and lost productivity.  And joint replacement, which as we have seen can often be avoided with proper diagnosis and treatment of unhealed connective tissue damage, costs 17 billion dollars per year.  These are not minor issues.   And, when you add the costs of imaging studies upon which diagnosis and treatment may not ‘best’ be based, to say the least, the cost of mis-understanding the role that connective tissue damage plays in body pain and further structure damage soars further.


But the most important cost is in the lives of individual people.  I had 25 years of back pain and increasing activity limitation.  That was a bad situation, and 24 years of it was unnecessary if I had known the correct diagnosis and the correct treatment.  But we have had so many patients with far worse pain, far more life limitations, more ‘not-helpful’ medical interventions, more disability…the vast majority of whom have been able to ‘get their life back’ when this single issue—unhealed connective tissue damage—was correctly diagnosed and properly treated.  Does everyone have this diagnosis who has severe pain?  Of course not.  Does everyone who has this diagnosis get dramatic results from treatment?  Most do, but some do not.  But of all the things that have surprised me during my decade of Prolotherapy practice, this one has stunned me most:  the percentage of patients coming through our door, who have previously had all manner of ‘diagnoses’, who had not only ‘something’ we could treat and improve, but in whom ALL of their symptoms were from this one cause, and who DID get dramatic ultimate results, in contrast to ALL previous attempts at therapy.  This fact is why I am taking the time, on this beautiful Saturday summer afternoon, to try to communicate what I have learned and what I have seen about this very important issue.  This issue affects a lot of people.  It is a huge personal issue, and a huge public health issue.   I want to develop interest in patients, and in practitioners, to learn about this disorder.  There should be people who understand this problem correctly and who offer effective treatment for it, in every community.  Currently there are many states which do not have a single competent practitioner.