Ross Hauser, MD; Danielle Matias, PA-C; Demi Foster, APRN

In our clinical observations, we have seen Prolotherapy offer good results as a frozen shoulder treatment at getting the shoulder more motion, eliminating pain, and restoring the structures of the joint.

• Prolotherapy is the simple injection of dextrose (sugar) into the shoulder joint. Many studies have documented Prolotherapy treatment’s effectiveness in treating the problems of chronic pain.

In the image below Prolotherapy of the shoulder. Frequent sites of injection are demonstrated including the coracoid process, the subscapularis tendon, and the greater tuberosity also seen are the transverse humeral ligament the bronchial plexus.

After we do a physical examination to access the amount of damage from osteoarthritis and the possibility of bone spurs causing limitations in range of motion, we may also perform an ultrasound to look for rotator cuff tear. Then we typically inject a shoulder capsule with a large amount of Prolotherapy numbing solution to stretch out the shoulder joint. The numb shoulder can then be gently manipulated. Often several sessions of this treatment regimen are needed to achieve the shoulder’s original full range of motion.

Prolotherapy combined with physical therapy

An October 2022 paper in the American Journal of Case Reports (1) examined the effectiveness of Prolotherapy combined with physical therapy versus physical therapy only for frozen shoulder. In this paper, doctors detailed the cases of two patients with frozen shoulder. Here is what they wrote: “Prolotherapy injects certain compounds into articular spaces, ligaments, and/or tendons to relieve pain and disability around joint spaces and to stimulate a proliferation cascade to enhance tissue repair and strength. This case report aims to describe functional outcome changes in 2 patients with frozen shoulder, comparing prolotherapy combined with physical therapy vs physical therapy only.”

In the first patient, doctors described treatment outcomes in a 66-year-old man with right shoulder pain and limited ROM that had worsened in the past three months. The patient complained his shoulder problems disrupted his daily life and he reported a visual analog scale (VAS) of 6 out of 10. The patient underwent prolotherapy combined with physical therapy and had significantly improved ROM after 2 weeks, with relieved pain and improved shoulder function.

In the second patient, the doctors described treatment outcomes in a 65-year-old man with right shoulder pain and limited ROM that had worsened in the past two months. The symptoms affected his general quality of life, with a VAS of 5 out of 10. Patient B underwent physical therapy only and showed similar ROM and no significant pain improvement.

The doctors concluded: “Initial treatment with prolotherapy combined with physical therapy for patients with frozen shoulder achieved a fast improvement of active and passive ROM, significantly decreased pain, and improved quality of life compared to physical therapy intervention only.”

Manipulation Under Anesthesia and Prolotherapy

A case report in the Journal of chiropractic medicine (2) was presented by doctors at the Natural Wellness and Pain Relief Center in Grand Blanc, Michigan. In this case the doctors described treatments for a 50-year-old man who had a 6-month history of chronic shoulder pain. They noted that the patient had a “markedly reduced” range of motion.  His shoulder pain was not responding to traditional treatments or medications including chiropractic manipulation, physical therapy, and steroid injections. Further he was taking hydrocodone 5/325 every 8 hours for pain without pain relief.

An MRI revealed adhesive capsulitis and distal (in the shoulder away from the scapula) infraspinatus partial-thickness tendon tear.

During treatment the the patient received a 3-day serial Manipulation Under Anesthesia. He participated in a course of post-Manipulation Under Anesthesia therapy for 4 weeks and thereafter received 6 total dextrose-based prolotherapy injections of the infraspinatus tendon over the subsequent 8 weeks. His self-rated pain rating scale dropped from a 77 out of 100 (extreme pain) to 11 out of 100. His range of motion returned to within normal limits. The doctors summarized: “This patient with adhesive capsulitis and rotator cuff tear responded favorably to Manipulation Under Anesthesia and dextrose-based prolotherapy. Results were maintained 7 years after treatment.”

Prolotherapy, frozen shoulder, diabetes mellitus and hypertension

An April 2023 paper (3) cited the cases of three patients with frozen shoulder treated with Prolotherapy. The main focus was on the comorbidities of diabetes mellitus and hypertension present in two of the patients and if Prolotherapy could help the patient’s frozen shoulder with these two diseases. Physical therapy was also added to the treatment regiment.

• Patient A.
  • This patient was a fifty-eight-year-old female who suffered from shoulder pain for three months. She had a limited range of motion at the initial evaluation and no crepitus (noisy shoulder) on movement, the pain had slowly started in the shoulder and spread gradually to the neck and elbow. Shoulder discomfort while exercising.
• Patient B with diabetes mellitus.
  • A sixty-one-year-old male, who suffered from right and left shoulder pain for four months. The pain had slowly started in the shoulder and spread slowly to the neck with cramping of the fingertip at the time of the initial evaluation. He had a limited range of motion and no visible crepitus on movement. The patient complained of difficulty doing everyday tasks and nighttime pain awakening. The patient was previously diagnosed with type II diabetes mellitus (DM). Patients with diabetes may get frozen shoulder at an incidence of 10.8% to 30%, with a tendency toward more severe symptoms and treatment resistance
• Patient C with hypertension.
  • A fifty-nine-year-old woman with right shoulder pain which first appeared 3 months ago. The symptoms started gradually, but with time, they started to impact his general quality of life. The patient’s range of motion was restricted, and there was no palpable crepitus when the shoulder moved. Her pain increased while working and cooking, interfering with her nighttime sleep. Hypertension was previously identified as the patient’s condition.

All three patients were treated with Prolotherapy. “The injection point on the rotator cuff includes the supraspinatus, infraspinatus, teres minor, and subscapularis. Intraarticular injection of the glenohumeral joint, subacromial bursa, long head biceps tendon, and acromioclavicular joint (were also given). Injections were administered four times every other week. ”

Summary findings: “The presence of comorbidities in the frozen shoulder causes a worsening prognosis in the treatment process. Using prolotherapy in a patient with comorbidities has been shown to reduce pain and increase the quality of life, which is almost the same as in patients without comorbidities. . . In a patient with a comorbid frozen shoulder, prolotherapy, and physical therapy exhibited the same potential benefits for improved range of motion, dramatically reduced discomfort, and improved quality of life. A patient with a comorbid frozen shoulder may benefit from prolotherapy, which has effects that last till full recovery. However, it takes longer to complete recovery compared to non-comorbid patients.”

References

1 Sam N, Yusuf I, Idris I, Adnan E, Haryadi RD, Hamid F, Usman MA, Johan MP, Zainuddin AA, Bukhari A. Effectiveness of Prolotherapy Combined with Physical Therapy Versus Physical Therapy Only for Frozen Shoulder: A Case Report. The American Journal of Case Reports. 2022 Oct 12;23:e936995-. [Google Scholar]
2 Morningstar MW, Strauchman MN. Manipulation Under Anesthesia and Prolotherapy for Adhesive Capsulitis and Rotator Cuff Tear: A Case Report With 7-Year Follow-Up. Journal of Chiropractic Medicine. 2022 Dec 1;21(4):327-30. [Google Scholar]
3 Sam N, Yusuf I, Idris I, Adnan E, Haryadi RD, Hamid F, Usman MA, Johan MP, Zainuddin AA. A Case Series: Effect of Comorbidities on the Outcomes of Prolotherapy Injection for Frozen Shoulder Patients. International Medical Case Reports Journal. 2023 Dec 31:257-63. [Google Scholar]