The effectiveness of PROLOTHERAPY for recalcitrant Medial TIBIAL Stress Syndrome: a prospective consecutive CASE series

Abstract

Abstract Background Medial tibial stress syndrome (MTSS) is one of the most common lower leg injuries in sporting populations. It accounts for between 6 and 16% of all running injuries, and up to 53% of lower leg injuries in military recruits. Various treatment modalities are available with varying degrees of success. In recalcitrant cases, surgery is often the only option. Objective To evaluate whether ultrasound‐guided injection of 15% dextrose for treatment of recalcitrant MTSS decreases pain and facilitates a return to desired activity levels for those who may otherwise be considering surgery or giving up the sport. Method The study design was a prospective consecutive case series involving eighteen patients: fifteen male and three female; (mean age = 31.2 years) with recalcitrant MTSS. They were referred from sports injury clinics across the UK, having failed all available conservative treatment. Intervention An ultrasound‐guided sub‐periosteal injection of 15% dextrose was administered by the same clinician (NP) along the length of the symptomatic area. Typically, 1 mL of solution was injected per cm of the symptomatic area. Main outcome measures Pain was assessed using a 10‐cm visual analog scale (VAS) at baseline, short‐term, medium‐term (mean 18 weeks), and long‐term (mean 52 weeks) follow‐up. Symptom resolution and return to activity were measured using a Likert scale at medium and long‐term follow‐up. Statistical analyses were performed using SPSS for Mac version 19.0.0 (IBM, New York, NY, US). The Shapiro‐Wilk test was used to evaluate the normality of the distribution of data. Friedman's non‐parametric test was used to compare the within‐patient treatment response over time. Post‐hoc Wilcoxon signed‐rank tests with Bonferroni corrections were performed to determine VAS average pain response to treatment over five paired periods. Results Patients reported a significant (p < 0.01) reduction in median VAS pain score at medium and long‐term follow‐up compared to baseline. Median improvement per patient was 4.5/10. Patients rated their condition as ‘much improved’ at medium‐term follow‐up and the median return to sports score was ‘returned to desired but not pre‐injury level’ at medium‐term and long‐term follow‐up. No adverse events were reported. Conclusions Ultrasound‐guided 15% dextrose prolotherapy injection has a significant medium‐term effect on pain in MTSS. This benefit may be maintained long‐term; however, more robust trials are required to validate these findings in the absence of controls. Clinical relevance Clinicians should consider the use of ultrasound‐guided injection of 15% dextrose as a viable treatment option to reduce pain and aid return to activity for patients with recalcitrant MTSS.

Keywords

• Prolotherapy
• MTSS
• Injection
• Exercise‐induced leg pain
• Dextrose