Danielle R. Steilen-Matias, MMS, PA-C
Caring Medical Florida

Many people with chronic low back pain have already undergone an MRI, completed physical therapy, tried massage, modified their activities, or received pain-management injections. Yet they may still have sharp pain when twisting, difficulty standing long enough to cook a meal, or pain while walking at work.

For some patients, the problem may not be fully visible when they are lying still inside an MRI scanner. Their symptoms occur during movement or weight-bearing because a spinal or pelvic segment moves more than it should. This is one reason our evaluation at Caring Medical may include dynamic imaging and an assessment for lumbar instability.

In this article, we present the case of an active man with chronic low back pain, dynamic L5–S1 spondylolisthesis, and bilateral sacroiliac (SI) joint instability. Following a series of comprehensive Prolotherapy and platelet-rich plasma (PRP) treatments, followed by a progressive strengthening program, he reported 85% overall improvement. Repeat motion imaging also showed less abnormal movement.

This is one patient’s experience. It should not be interpreted as proof that every person with low back pain will have the same diagnosis or response. Rather, the case demonstrates why identifying the pain-generating structures—and examining what happens when the patient performs the movements that provoke pain—can be important.

When a conventional MRI does not explain movement-related pain

An MRI can provide valuable information about discs, nerves, stenosis, arthritis, tumors, infection, and other pathology. It is an essential test in many clinical situations. However, most lumbar MRIs are obtained while the patient is lying down and remaining still. A static study may therefore show anatomy without fully demonstrating how the spinal segments behave during standing, bending, extension, or rotation.

Recent research continues to examine the role of functional radiographs in patients with suspected lumbar instability. A 2025 Global Spine Journal study (1) found that flexion and extension radiographs were not necessary in every patient with low-grade spondylolisthesis, but they provided additional information about translational instability in selected or borderline cases. Other research (2) has found that standard standing flexion-extension films can sometimes underestimate motion when compared with differences between standing and supine imaging.

The practical message is not that every patient needs every type of X-ray. Imaging should be selected according to the history, examination, symptoms, and clinical question. When pain is strongly positional or movement-dependent, carefully obtained functional views may reveal information not apparent on a recumbent MRI.

The patient: low back pain interfering with work and martial arts

The patient was a man in his late 40s who worked as a realtor and wanted to maintain an active lifestyle, including practicing jiu-jitsu. His low back pain had become chronic. Twisting or rotating his spine produced sharp pain. Sitting was generally more comfortable, while standing aggravated his symptoms.

These limitations affected ordinary daily life. Cooking became difficult because he could not stand comfortably. Walking and standing while showing homes interfered with his work. He was also unable to participate in jiu-jitsu at the level he wanted.

His symptom pattern raised an important question: what was happening in his lower lumbar spine and SI joints while he was standing and moving?

Dynamic X-rays showed instability in more than one region

Motion studies were obtained while the patient rotated, flexed, and extended his lower spine. The rotational views showed excessive opening across both SI joints, with greater motion on the left. The left-sided measurements were approximately 5 to 6 mm in the views reviewed at the clinic.

The flexion-extension study also demonstrated an L5–S1 spondylolisthesis. In a neutral standing position, the offset was approximately 4.5 mm. With flexion it increased to about 5.6 mm, indicating additional translation at that spinal segment. In extension, the vertebra settled closer to its expected alignment.

Spondylolisthesis simply means that one vertebra has slipped relative to the vertebra below it. Some slips are stable and cause few or no symptoms. A slip that changes with motion may be more clinically relevant, particularly when the movement reproduces the patient’s pain. Still, imaging findings must always be correlated with the examination and symptom history; an X-ray measurement alone does not establish the source of pain.

Why the lumbar spine and SI joints should be evaluated as a connected unit

The lumbar spine, sacrum, pelvis, and hips share forces during standing, walking, bending, and rotation. The SI joints transfer load between the spine and lower extremities. Their surrounding ligaments contribute to stability, while the abdominal, spinal, gluteal, pelvic-floor, and hip muscles provide active control.

When one region loses stability, nearby tissues may compensate. A patient may therefore hurt more on one side even when imaging shows greater motion on the other. Over time, repeated compensation may produce a broader pattern involving the lumbar facet capsules, iliolumbar ligaments, lumbosacral attachments, and posterior SI-joint ligament complex.

This helps explain Caring Medical’s comprehensive approach. We do not automatically assume that every case of chronic low back pain arises from one disc or one isolated injection target. The purpose of the examination is to identify the pattern of instability and determine whether several interconnected structures may need to be addressed.

You can learn more in our detailed discussion of sacroiliac joint dysfunction, ligament injury, and SI-joint pain.

Prolotherapy and PRP: the treatment approach used in this case

Based on his health history, examination, symptoms, and dynamic imaging, this patient was considered a candidate for comprehensive Prolotherapy with PRP. He underwent six treatment sessions at intervals of approximately four to six weeks.

Prolotherapy commonly uses a dextrose-based solution injected at selected painful or unstable ligament, tendon, joint-capsule, or joint attachments. The goal is to stimulate a localized reparative response in tissue that has not adequately healed. PRP is prepared from the patient’s own blood and contains a concentration of platelets and their associated signaling proteins. At Caring Medical, these treatments may be used together when the examination suggests that a broader ligamentous stability problem and selected areas requiring a stronger biologic stimulus are present.

Learn more about Prolotherapy for lumbar instability and low back pain and PRP treatment for lumbar back pain.

What does the research say about Prolotherapy for low back and SI-joint pain?

The evidence should be interpreted by diagnosis rather than treating “low back pain” as one condition.

A randomized controlled trial (3) involving patients whose SI-joint pain was confirmed by diagnostic anesthetic block compared intra-articular dextrose Prolotherapy with steroid injection. Both groups improved initially, but the study reported a higher cumulative rate of at least 50% pain relief at 15 months in the Prolotherapy group—58.7% compared with 10.2% in the steroid group. The authors also stated that further research was needed to confirm safety and define the best protocol.

In a 2018 cohort study (4) of SI-joint instability, 103 patients received three Prolotherapy injections over three months. Approximately half achieved a clinically meaningful functional improvement, and the authors found that early improvement after the first injection helped identify likely responders.

Our research lead by Ross Hauser, MD, discussed how ligament injury may contribute to lumbar instability and chronic low back pain and examined Prolotherapy as a treatment intended to address this proposed mechanism.(5) A broader 2021 review of 12 studies concluded that Prolotherapy may have a role in selected chronic low back pain patients after conservative care has failed, while also emphasizing variation among studies and protocols.(6)

At the same time, older Cochrane evidence found that Prolotherapy injections alone were not consistently more effective than control injections for nonspecific chronic low back pain. Some positive trials combined injections with spinal manipulation, exercise, and other care, making the independent effect of Prolotherapy difficult to determine.(7) This limitation remains relevant: correct diagnosis, patient selection, injection target, technique, rehabilitation, and the specific cause of pain can all influence outcomes.

What does the evidence say about PRP for SI-joint pain?

PRP research for spinal and SI-joint pain is still developing, and individual trials have produced conflicting findings.

A 2023 systematic review identified only four clinical trials and two case reports evaluating PRP for SI-joint dysfunction. It concluded that PRP appeared beneficial, but there was not enough evidence at that time to support it over steroid treatment.(8) A rigorous 2022 randomized trial of 26 patients found that both PRP and steroid groups improved, but the steroid group had lower pain scores and more responders during the six-month study.(9)

More recently, a 2026 meta-analysis pooled 10 randomized or quasi-randomized trials involving 392 patients with facet- or SI-joint pain. PRP did not provide a statistically significant pain advantage at one month, but it was associated with greater pain reduction than corticosteroid at three and six months. Disability differences were not statistically significant, and the authors rated the overall evidence as inconclusive because of limited certainty, heterogeneity, and a need for standardized PRP protocols.(10)

Thus, current evidence supports PRP as a promising option, not a settled or universally superior treatment. The case presented here involved comprehensive treatment of a documented motion pattern; it should not be equated with an isolated intra-articular PRP injection studied in every trial.

Repeat imaging and the patient’s reported improvement

After six rounds of Prolotherapy with PRP, repeat dynamic radiographs were obtained. On the clinic’s measurements, the SI-joint opening seen during rotation was now under 4 mm bilaterally. The neutral L5–S1 offset had decreased from approximately 4.5 mm to 2.75 mm, and the additional translation previously observed during flexion was no longer apparent to the same degree. Extension remained stable.

After the injection series, the patient took a treatment break and began Pilates and progressive muscle activation. At a five-month follow-up, he reported being approximately 85% improved. He could stand without the previous pain, making cooking and his work as a realtor much more tolerable, and he was preparing to return to jiu-jitsu.

Both parts of the outcome mattered: the patient reported meaningful functional improvement, and repeat imaging provided an objective way for the treating clinician to monitor motion. However, this remains an uncontrolled clinical case. It cannot prove that the injections caused the imaging changes, establish which part of the combined program produced the improvement, or predict another patient’s result.

Rehabilitation remains an essential part of restoring function

Ligaments provide passive restraint; muscles provide active stabilization. Even when injection treatment is selected, rehabilitation is important for retraining movement, restoring strength, and gradually increasing load tolerance.

In this case, Pilates and targeted muscle activation were introduced after the patient had gained enough stability and symptom improvement to progress. The timing and type of exercise must be individualized. A program that is appropriate for a stable spine may aggravate a highly irritable or unstable segment if advanced too rapidly. Conversely, prolonged avoidance of activity may contribute to weakness, fear of movement, and deconditioning.

The objective is not merely to reduce a pain score. It is to help the patient stand, walk, work, exercise, and return safely to valued activities.

Who may be considered for this type of evaluation?

An instability-focused assessment may be considered when a patient has:

• chronic localized low back, lumbosacral, buttock, or SI-joint pain;
• sharp pain with twisting, bending, transitions, prolonged standing, or walking;
• a feeling that the back or pelvis is “giving way,” catching, shifting, or repeatedly needing to be adjusted;
• symptoms that are not adequately explained by a conventional recumbent MRI;
• temporary or incomplete improvement with physical therapy, manipulation, bracing, massage, or injections; or
• known low-grade spondylolisthesis with symptoms that appear movement-dependent.

Prolotherapy or PRP is not appropriate for everyone. Evaluation should also look for fractures, progressive neurologic deficits, infection, malignancy, inflammatory disease, severe stenosis, high-grade or progressive spondylolisthesis, and other conditions that may require different or urgent care. New bowel or bladder dysfunction, saddle numbness, rapidly progressing weakness, fever with severe back pain, or major trauma requires prompt medical assessment.

The Caring Medical perspective

Chronic low back pain can persist when the diagnosis describes degeneration but does not identify why a person hurts during a specific movement. In selected patients, the missing factor may be abnormal motion involving the lumbar spine, the SI joints, or both.

At Caring Medical, the history comes first: what movement causes the pain, what position relieves it, and which activities have become impossible? The physical examination and imaging are then used to test the working diagnosis. When instability is identified and the patient is an appropriate candidate, comprehensive Prolotherapy—with PRP in selected cases—may be considered alongside progressive rehabilitation.

The favorable outcome described here is encouraging, but it is not a promise of results. The published evidence is evolving and remains limited by small studies, inconsistent protocols, and varying diagnoses. A careful evaluation is necessary to determine whether instability is truly present and whether a regenerative injection strategy makes sense for the individual patient.

To learn more about the clinic and its approach, visit The Caring Medical Difference.

References

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This article is for educational purposes and is not a substitute for an individualized medical evaluation. Results vary, and no treatment can be guaranteed.