CASE STUDY

Treatment of a Medial Collateral Ligament

Sprain Using Prolotherapy: A Case Study
Ahmet Mustafa, ADA, MD; Ferdi Yavuz, MD

ABSTRACT
Prolotherapy is effective in treating refractory
tendinopathies, but inadequate clinical evidence exists to
recommend its use as a treatment for acute or chronic,
medial collateral ligament (MCL) injuries. The current
case study documents an illustrative case of a rugby player
who had a grade 2 sprain of the MCL and shows the
clinical and radiological outcomes following injections of
15% dextrose combined with 0.2% lidocaine. In his case,

Ahmet Mustafa, ADA, MD, is a sports medicine specialist at

TAF Sport Medicine School in Ankara, Turkey. Ferdi
Yavuz, MD, is a physiatrist at the Clinic of Physical Medicine
and Rehabilitation, Military Hospital of Etimesgut, in
Ankara.
Corresponding author: Ferdi Yavuz, MD
E-mail address: ferdiyavuz@yahoo.com

he collateral ligaments play a major role in mediallateral stability of the knee joint. These structures
are vulnerable to injury from direct trauma,
producing varus and valgus stress.1 The medial
collateral ligament (MCL), which is also known as the tibial
collateral ligament, is the most commonly injured knee
ligament in contact sports such as soccer, rugby, or
hockey. When a valgus force occurs to the knee joint, it
stretches or tears the ligament on the inner side of the knee.2
Depending on the degree of trauma, injuries to the medial
meniscus and the anterior cruciate ligament (ACL) may also
be involved for patients with an MCL injury.
Isolated MCL tears or sprains can usually be treated
conservatively. However, the MCL injury combined with an
ACL tear, a large bony avulsion, or a tibial plateau fracture
68

ALTERNATIVE THERAPIES, JULY/AUG 2015 VOL. 21, 4

the prolotherapy, together with an exercise therapy, lasted

3 wk. At the end of the 3 wk, the patient was pain free,
with a full range of motion (ROM), and he was able to
perform all rugby-specific movements. The mean duration
for recovery with conservative treatment of isolated,
complete tears of the MCL is normally 4-8 wk. (Altern
Ther Health Med. 2015;21(4):68-71.)

may require surgical treatment. Because the rehabilitation

program and treatment methods will be different when those
conditions exist, it is important to rule out an injury to any of
the associated structures in the MCL injury.3
Due to the fact that isolated MCL injuries, including all
degrees of sprains and grade 1 and grade 2 tears, are likely to
heal spontaneously, the treatment is usually conservative.
However, a grade 3 tear or the presence of valgus instability
in 0 degrees of knee flexion may require surgery. Conservative
management consists of ice therapy, anti-inflammatory
medication, use of a hinged knee brace, physical therapy, and
exercise programs. The authors of the current article suggest
that regeneration injection therapy, which is also called
prolotherapy and involves platelet-rich plasma (PRP),
hypertonic dextrose, and platelet-derived growth factor ,
may be appropriate for inclusion in recognized, conservative
standards for therapy for the condition.3,4 Hyperosmolar
dextrose show its treatment effect indirectly by stimulating
the production of some growth factors, whereas PRP and
platelet derived growth factor show their treatment effects
by delivering growth factors directly to lesions.
Prolotherapy is now recognized as one of the most
popular complementary medical therapies used to initiate a
natural wound-healing cascade in soft-tissue injuries by the
stimulation of growth factors. Hypertonic (15%-25%)
dextrose is one of the most commonly used solutions in
prolotherapy. Studies have shown that a hypertonic dextrose
MustafaProlotherapy for MCL Sprain

Figure 1. Grade 2 sprain of the MCL, subchondral bone

marrow edema, and contusion at the corner of the lateral
tibial plateau were seen on a T2-weighted MRI.

Figure 2. Posttreatment MRI at 6 mo shows a well-healed,

relatively homogeneous MCL and no evidence of subchondral
bone marrow edema or contusion at the corner of the lateral
tibial plateau.

Abbreviations: MCL, medial

MRI, magnetic resonance imaging.

Abbreviations: MRI, magnetic

MCL, medial collateral ligament.

collateral

ligament;

solution can lead to an increase in ligament size and strength

and can stimulate the repair of articular cartilage defects.5-7
Some clinical studies8-10 and case series6,11 have suggested
that prolotherapy is effective in treating refractory
tendinopathies, particularly for lateral epicondylitis, achilles
tendinopathy, hip adductor tendinopathy, and plantar
fasciopathy. However, inadequate clinical evidence exists to
recommend the use of prolotherapy as a treatment for acute
or chronic MCL injuries. On the basis of promising results
from animal studies,12-14 the authors decided to treat an MCL
lesion with prolotherapy. This case report documents an
illustrative case that shows clinical and radiological outcomes
following injections of dextrose with lidocaine in a rugby
player who had a grade 2 sprain of the MCL. Written
informed consent was obtained from the patient for
publication of this report.
CASE PRESENTATION
A 21-year-old male rugby player sustained stress trauma
to the knee valgus. Four days after his sports-related injury,
the player was referred to the authors outpatient clinic for
sports medicine. He had severe painover themedial sideof
his rightknee and a swollen knee joint. His pain dramatically
increased with any weight bearing. On physical examination,
notable tenderness was observed over the MCL. Using a
valgus stress test, the authors found a painful opening of the
medial knee joint at 10- to 15-degree flexion, but no laxity
existed at the full knee extension. Swelling around the knee
joint was also found. Anteroposterior and lateral radiographs
did not reveal any abnormalities. Magnetic resonance
imaging (MRI) showed a grade 2 sprain of the MCL,
subchondral bone marrow edema, and contusion at the
corner of the lateral tibial plateau (Figure 1).
MustafaProlotherapy for MCL Sprain

resonance

imaging;

The patient was informed about his diagnosis and gave

consent for treatment with prolotherapy and home-based
exercise. The patient received 3 prolotherapy treatments for
3 weeks at 1-week intervals. During each prolotherapy
session, the femoral and tibial bony attachments of the MCL
and tender points over the lateral tibial plateau were injected
using the peppering technique. After inserting the needle,
the tender area was peppered with 20 to 30 injections using
a 5-mL syringe with a 23-gauge, 5-cm needle. A total of
4 to 5 mL of solution consisting of 15% dextrose and 0.2%
lidocaine were used per injection session.
After the first injection, isometric and active range-ofmotion (ROM) exercises3 sets of 8 repetitions, up to
3 times dailywere given as an initial exercise program. The
rugby player reached 120 degrees for ROM on the fifth day
postinjection and started progressive resistance training. The
patient was able to walk without knee pain at the 10th day
postinjection. He was then instructed to begin light use of an
exercise bicycle.
By day 21 postinjection, the patient was pain free, with a
full, active ROM. The strength of his quadriceps and
hamstrings was within 85% of the unaffected leg, as assessed
by isokinetic testing. The patient was able to perform all
rugby-specific movements, such as sprinting, accelerations,
and decelerations, without any restrictions. After completion
of a full week of group training without symptoms, the player
was able to play in a rugby match 12 weeks after initiation of
prolotherapy, without residual symptoms or functional
deficit. His posttreatment MRI at the sixth month showed a
well-healed, relatively homogeneous MCL (Figure 2).
Subchondral bone marrow edema at the corner of the lateral
tibial plateau had also diminished, as shown on an MRI.

ALTERNATIVE THERAPIES, JULY/AUG 2015 VOL. 21, 4

69

DISCUSSION
The current case study shows the successful repair of an
MRI-confirmed, grade 2 sprain of the MCL in a male rugby
player, using dextrose-with-lidocaine prolotherapy and an
exercise therapy. After the treatment, the patient regained
full knee function and returned to his recreational sports
without any restrictions. A posttreatment MRI at the sixth
month revealed the healing of the MCL sprain.
Sports-related injuries, including those to ligament and
tendon structures, are usually seen in sports medicine. The
recovery time for ligament and tendon injuries varies
according to severity of the injury and the treatment method.
It is very important for the participants in sports to return to
their preinjury level of function, ideally in the shortest time
possible. Because an early return to the sports activity is the
most important expectation for participants in sports, the
treatment methods that provide a shorter time and a more
effective recovery, without compromising tissue-level
healing, have recently been preferred in sports medicine.15
Previous studies results showed that the mean duration of
conservative treatment for isolated complete tears of the
MCL was 4 to 8 weeks.16,17 In the current case, prolotherapy
combined with an exercise therapy lasted 3 weeks. At the end
of the 3 weeks, the patient was pain free with full ROM, and
he was able to perform all rugby-specific movements.
Prolotherapy, which has been recently referred to as
regenerative injection therapy, is presumed to stimulate the
bodys self-healing mechanisms, leading to the reestablishment
of structural integrity and improved function.18 Because
prolotherapy is a treatment modality that may provide a
solution to a patients pain symptoms and a positive
contribution to tendon healing, it may be beneficial for the
acute treatment of tendon or ligament pathologies related to
sports injury.
The use of various injection therapies by medical
practitioners for the treatment of tendinopathies is widespread.
The solutions most commonly injected into peritendinous
areas are often a combination of corticosteroids and anesthetics.
However, some recommendations suggest limiting the use of
the intratendinous injection of corticosteroids due to their
negative mechanical effects, such as reduced tensile strength
and a loss of viscoelasticity in tendons.19-21 Thus, prolotherapy
remains a promising option for the treatment of tendinopathies
due to its regenerative effects.
Prolotherapy is relatively safe, with few adverse reactions,
which can include mild pain or bleeding at the injection site.
The development of a postinjection pain flare is usually selflimited and often resolves within 1 to 2 days.22
Despite some promising animal studies,12-14 clinical
evidence is lacking for the use of prolotherapy as a treatment
of MCL lesions. Those studies have reported significant
biological effects for improvement in MCL healing using a
platelet-derived, growth factor for prolotherapy injections.
Although no clinical trials have investigated the effectiveness
of prolotherapy in the treatment of MCL lesions, 1 recent
case study has reported positive effects for prolotherapy
70

ALTERNATIVE THERAPIES, JULY/AUG 2015 VOL. 21, 4

using PRP on an injured MCL.23 In that case, an individual

with a complete tear of the MCL experienced pain reduction,
had improvement in isometric strength, and was able to
return to unrestricted sports activity at 3 weeks posttreatment.
In the current case, similar results were found using
dextrose-with-lidocaine prolotherapy. Although both
injected solutions are thought to be irritants, hyperosmolar
dextrose delivers its treatment effect indirectly by stimulating
the production of some growth factors involved in tendon or
ligament repair, whereas PRP produces its effect by delivering
growth factors directly to lesions. In either case, a localized
inammatory response at the site of injection begins with
activation of granulocytes and macrophages. Thus, the
wound-healing cascade can be initiated. However, the relative
effectiveness of one prolotherapy solution as compared with
another has not been previously investigated in any clinical
trial. Therefore, the issue of whether the content of one
injected solution is superior to another solution in treatment
efficacy is unclear. Because growth-factor prolotherapy is a
more expensive option than prolotherapy using dextrose
with lidocaine, in the current case, the authors had selected
hyperosmolar dextrose.
CONCLUSIONS
The current case report shows that prolotherapy using
dextrose with lidocaine seems to be effective as an alternative
option for the treatment of MCL lesions related to sports
injury. Further, clinical research assessing prolotherapy as a
treatment for ligament tears is needed to make specic
recommendations including ideal protocols and optimal
indications.
AUTHOR DISCLOSURE STATEMENT

The authors had no conflicts of interest related to the current case study.

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MustafaProlotherapy for MCL Sprain

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