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

Persistent low back pain can make sitting, walking, bending, and sleeping difficult. Some people have pain mainly in the back. Others also experience hip, buttock, or leg symptoms. A scan may show disc degeneration or arthritis, yet it may not explain why a particular movement hurts or why earlier treatment did not help.

At Caring Medical, our clinical interest includes the supporting ligaments of the lumbar spine and pelvis. These tissues can contribute to pain and abnormal movement in selected patients. However, low back pain has multiple possible causes, and ligament instability should not be assumed to explain every case.

This article examines Prolotherapy, its proposed mechanisms, and the evidence for different spinal injection approaches. Recent research includes a systematic review of chronic spinal pain, a randomized comparison of dextrose Prolotherapy with epidural steroid injections, and newer epidural PRP studies. A case presented by Danielle Matias, PA-C, adds another important question: what does it mean when X-ray measurements improve but the patient’s pain does not?

What can cause low back pain and associated leg pain?

The lumbar spine relies on discs, facet joints, ligaments, muscles, and nerves working together. The sacroiliac joints connect the sacrum to the pelvis. Problems affecting these structures may overlap, making it difficult to identify a single pain source.

Our published review discusses spinal ligaments as a possible contributor to lumbar instability. Ligaments provide passive restraint; muscles provide active control. Injury or degeneration could alter load distribution and increase stress on other structures. This is a clinical and biomechanical explanation, rather than proof that most back pain begins with ligament damage. (1)

Potential contributors include:

• Disc-related pain, including some annular tears or herniations.
• Painful facet joints and their surrounding capsules.
• Sacroiliac joint or ligament-related pain.
• Tendon or ligament attachment pain, called enthesopathy.
• Nerve irritation or compression, sometimes accompanied by weakness or altered sensation.
• Hip disease, muscle-related pain, or other pelvic conditions.

Leg pain also needs clarification. Referred pain is felt away from its source without necessarily reflecting a compressed nerve root. Radicular pain involves irritation of a spinal nerve root. Neither the location of pain nor the presence of a disc bulge alone establishes the diagnosis.

An MRI finding is one part of the explanation

A systematic review of 3,110 people without symptoms found that disc degeneration and bulging were common and increased with age. This does not make MRI unhelpful; it means findings need to correspond with symptoms and examination results. (2)

An MRI may reveal a clinically important nerve compression, fracture, or other abnormality. It cannot, on its own, determine whether every visible degenerative change is painful or whether a soft-tissue injection is appropriate.

What is Prolotherapy intended to do?

Dextrose Prolotherapy uses a sugar solution injected into selected musculoskeletal tissues. Hypertonic dextrose is more concentrated than ordinary body fluids. Proposed effects include a local tissue response that may stimulate collagen production and affect painful connective tissues.

Lower-concentration dextrose has also been studied for pain-modulating effects. Rapid relief after an injection cannot reasonably be explained by new ligament growth occurring within minutes. Biological repair and changes in pain signaling are different proposed mechanisms. (3)

The goal of treating a painful attachment is to address the area where a ligament or tendon meets bone, sometimes called the fibro-osseous junction. This differs from injecting into a disc or the epidural space around spinal nerves. The location and purpose of the injection matter as much as the name of the treatment.

Dextrose, PRP, and cell-based preparations are different treatments

Regenerative injection medicine includes several different approaches:

Our lumbar review discusses dextrose and PRP approaches, but does not establish that one is best for all patients or that every preparation reverses degeneration. (1)

For additional background, see our discussion of platelet-rich plasma for lower back pain.

New 2026 randomized trial: Prolotherapy versus epidural steroid injections

A pragmatic randomized trial analyzed 104 participants with low back and associated leg pain lasting at least 12 weeks and leg pain rated at least 6 out of 10. Fifty-five received dextrose Prolotherapy and 49 received epidural steroid injections. Up to five monthly Prolotherapy treatments or three monthly steroid injections were allowed. (4)

The adjusted average results favored Prolotherapy at six and twelve months after treatment completion:

Lower scores indicate better outcomes. (4)

This supports consideration of Prolotherapy for selected patients, but the trial was unblinded and treatment schedules differed. Average pain persisted in both groups. No adverse events were reported. The trial does not establish ligament regeneration, compare Prolotherapy with surgery, or prove it is preferable for every cause of leg pain. (4)

New 2026 systematic review: What the broader spinal evidence shows

A systematic review included 12 studies: three randomized trials and nine nonrandomized studies. Conditions included chronic low back pain, sacroiliac pain, disc-related pain, coccydynia, persistent pain after back surgery, and lumbar disc herniation with associated symptoms. Most studies reported improvements in pain, function, or quality of life. (3)

However, the review summarized results descriptively without pooling them statistically. Small samples and differences in diagnosis, injection site, concentration, and follow-up limit generalization. Its search ended in June 2025, so the April 2026 randomized trial provides evidence outside that search period. (3)

The review discusses ligament, joint, intradiscal, and epidural injections. These should not be treated as interchangeable procedures. Its observations about longer relief with higher concentrations do not establish a universal dose-response relationship: concentration was intertwined with different conditions and injection targets. Neither pain relief nor absence of reported major complications proves tissue regeneration or excludes rare risks. (3)

What earlier controlled trials found—and why they still matter

New favorable results should be considered alongside studies that found limited or no added benefit.

A foundational review included five controlled studies with 366 participants. Three trials found that Prolotherapy injections alone were not more effective than control injections. Two reported benefit when injections were combined with manipulation, exercise, or other treatments, but those additional interventions made it difficult to isolate the injections’ effects. (5)

A 2023 randomized trial assigned 38 patients to conservative treatment or a glucose-injection group. Both improved during follow-up, and the investigators concluded that no overall effects were attributable to the glucose component or the Prolotherapy protocol. It therefore does not establish that injections added benefit or that improvement demonstrated ligament repair. (6)

These findings differ from the favorable 2026 comparison with epidural steroid injections. Differences in participants, treatments, and comparators help explain why one result cannot settle every question about chronic low back pain.

A 654-patient report using 5% dextrose

A report published online in 2021 evaluated 2,382 people with low back pain or lumbar disc herniation and included 654 for treatment. The authors used diagnostic injections in patient selection and treatment sessions separated by four or six weeks. Average pain scores decreased from 7.2 before treatment to 0.9 at 52 weeks; 620 patients were classified as improved and 34 as having poor results. (7)

The size of this series is noteworthy, but it lacked a randomized control group. Its 94.8% improvement figure is an outcome in a selected population, not a success rate that can be promised to another patient. Selection, concurrent care, and symptom changes over time may influence results.

The report also described pain decreasing to 5.1 after the diagnostic injection. That response should not be equated with confirmed ligament healing or an established predictor for every Prolotherapy approach. The study’s 5% solution and technique also cannot be substituted directly for higher-concentration joint or ligament protocols. (7)

Caring Medical’s published lumbar review and three patient cases

Our published lumbar review presents a clinical perspective on instability and includes individual treatment examples. It is a review with case illustrations, rather than a randomized trial. Cases can show how symptoms and function changed, but cannot establish effectiveness for a wider population. (1)

Case 1: Longstanding back and lateral hip pain

A 78-year-old woman with six years of pain received five injection sessions addressing the spine and left gluteal tendon. Pain decreased from 8/10 to 1–2/10 at two months. At one year, she reported walking without a cane and no pain-medication use. (1)

Case 2: Sacroiliac pain after lumbar surgery

A 67-year-old woman had six months of left sacroiliac pain after lumbar laminotomy. Three sessions of combined Prolotherapy and PRP addressed the SI region. Sitting improved, although pain remained approximately 3–4/10 at three months. (1)

Case 3: Different responses in the back, hip, and legs

An 83-year-old man had five years of back and bilateral leg symptoms. A caudal epidural relieved leg symptoms but left back and hip pain. After six dextrose-and-PRP sessions, he stopped using his walker; back pain was 2/10 at eleven months. (1)

These cases involved combined treatments and selected individuals. They do not isolate dextrose’s contribution. The third case also illustrates that relief of one symptom does not necessarily resolve every coexisting pain source.

When the X-ray looks better but back pain persists

This case concerns a woman in her 70s whose chronic low back pain limited prolonged standing and walking. She reported that previous steroid injections had helped for only one or two days. Pain was not disrupting her sleep at that time, but it was restricting activities important to her quality of life.

This distinction matters. A person may sleep adequately yet still be unable to walk far enough to shop, stand comfortably to prepare a meal, or participate in ordinary activities. Pain intensity, sleep, standing tolerance, and walking tolerance describe different aspects of the same illness.

What the presenter observed on movement X-rays

The presentation shows vertebral slippage, called spondylolisthesis, on lumbar movement images. The presenter reports an offset of 10.65 mm in flexion and 9.42 mm in extension before treatment. After four comprehensive Prolotherapy treatments over five months, the reported measurements were 7.93 mm in flexion and approximately 6.25 mm in extension.

Those treatment counts describe this case. They are not a required number of sessions, a schedule for another patient, or proof that treatment should continue until a particular measurement is reached.

The presenter describes the smaller offsets as encouraging. However, after those four treatments, the patient was not feeling better. That unresolved clinical outcome is central to the case and should remain alongside the imaging changes.

Vertebral offset and dynamic instability are different measurements

An offset describes the relative position of two vertebrae on an image. Dynamic translation describes how much that relationship changes between positions. The two should not be labeled interchangeably.

The final imaging row is simple subtraction of the transcript’s values, not an independent radiological interpretation. It shows why the reported findings support a smaller offset in each selected image, but do not, by themselves, demonstrate a smaller flexion–extension difference. They also do not establish increased instability: the complete study, measurement reliability, positioning, and movement captured would be needed to assess that.

A systematic review of lumbar instability definitions distinguishes dynamic translation from static alignment and describes variation in measurements and thresholds. A radiological threshold is not a universal pain threshold or a guarantee of response to treatment. (8)

The video suggests that a smaller residual offset might eventually correspond with relief. That is a possible explanation proposed for this patient, not evidence that everyone becomes comfortable when an offset reaches 2–4 mm. The transcript cannot establish that ligament strengthening caused the measured change or that further reduction would resolve her pain.

What movement imaging can—and cannot—show

Movement X-rays can illustrate changes in bony relationships during the movements recorded. A static MRI answers different questions, including information about discs, nerves, and canal narrowing. Neither examination automatically identifies every structure responsible for pain.

The presenter discusses using continuous movement to reduce the effects of muscle guarding. Guarding is protective muscle activity that may restrict movement when a person expects pain. It can affect what an examination captures. However, continuous imaging does not necessarily eliminate guarding or guarantee a “true” measurement independent of effort, positioning, technique, and interpretation.

Seeing an abnormal movement is different from establishing that it is the main source of symptoms. Likewise, a change between examinations needs to be distinguished from direct evidence of repaired ligament tissue. X-ray techniques also involve radiation, which is relevant to decisions about repeated imaging.

Why persistent pain raises other questions

The video presents two possibilities: the original mechanical problem may remain clinically relevant, or another pain generator may be contributing. These possibilities can coexist, and they do not exhaust the differential.

A pain generator is a tissue or process contributing to pain. Potential contributors include the disc, facet joints, supporting ligaments, sacroiliac region, muscles, or nerves. Walking- and standing-related symptoms can also raise questions about spinal stenosis, hip disease, or vascular limitation, depending on the full clinical findings. Older adults may additionally need consideration of fracture and other systemic causes.

A brief response to an earlier steroid injection does not identify every pain source. Nor does lack of a classic nerve-root distribution exclude all nerve-related contributors. The original injection target and medication are not specified in this transcript, so the case cannot be described as a comparison between a known selective nerve-root injection and a later procedure.

The practical learning point is that improvement in one structural measurement can coexist with continuing pain. It is not enough to assume that all remaining symptoms must come from the same structure or must improve with more of the same intervention.

Why a caudal epidural was considered

The presenter describes performing a caudal epidural after considering a possible neural contribution. A caudal epidural accesses the epidural space through the sacral hiatus near the lower end of the sacrum. It targets a different anatomical compartment from ligament-attachment injections. It is not an injection into the spinal cord.

The transcript uses a tree-trunk analogy to contrast a broader epidural approach with a localized target. That can help explain the intention, but injectate does not necessarily reach every lumbar nerve or treat every pain source. Its distribution depends on anatomy, technique, volume, and other factors.

The presentation discusses local anesthetic, 5% dextrose, and sometimes PRP as possible ingredients. It does not clearly document which complete mixture this patient received. It also does not report her outcome after the caudal epidural. We can therefore describe the reasoning and the intervention, but cannot present it as having resolved her pain.

What the short-term caudal dextrose trial found

A small randomized trial compared a single caudal epidural injection of 5% dextrose with saline in 35 people with chronic low back pain radiating to the buttock or leg. The dextrose group had greater short-term pain reduction at measured points through 48 hours. The between-group difference was not statistically significant at two weeks. (9)

This supports investigating a short-term analgesic effect, rather than proving ligament regeneration. The small mixed-diagnosis population and brief controlled follow-up limit conclusions about lasting benefit. It does not establish the effectiveness of a particular local-anesthetic/dextrose/PRP mixture or predict the response of the woman described in the video.

Image guidance improves information but does not eliminate risk

Ultrasound can help identify the sacral hiatus and guide needle entry. Fluoroscopy and contrast can provide other information about placement and spread. These methods have different strengths and limitations.

The video’s reassurance about safety should not be interpreted as absence of procedural risk. Dural puncture, unintended intravascular injection, bleeding, infection, and medication-related complications remain possible. A needle entering through the sacral hiatus is not automatically incapable of reaching or affecting unintended structures. The approach, anatomy, injectate, and procedural safeguards all matter.

The patient’s priorities remain the outcome

This patient wanted less pain and greater activity. At the stage described, those goals had not been achieved despite the reported imaging changes. That is why the case contributes something different from a successful-treatment testimonial.

The same principle applies to considering surgery. The presenter raised surgical consultation, and the patient preferred a nonsurgical option. The transcript does not provide enough information to determine surgical suitability. A preference to avoid surgery does not establish that an injection will work, and an imaging measurement alone does not determine whether fusion is necessary.

Facet joints, ligament attachments, and persistent pain after surgery

Facet joints guide movement between neighboring vertebrae. Their capsules and nearby ligaments help restrain motion. Our clinical perspective considers whether painful supporting tissues contribute to symptoms, but facet pain is not synonymous with instability and instability is not the only explanation for persistent pain.

Our separate article discusses facet joint osteoarthritis and facet arthropathy. Conventional approaches can include medication, rehabilitation, selected injections, diagnostic blocks, or radiofrequency procedures. Each addresses different aspects of pain; it is inaccurate to describe all conventional treatment as merely masking a single ligament problem.

A 35-patient randomized crossover study examined painful enthesopathies, or ligament/tendon attachment disorders. Eighty-six percent had undergone prior lumbar surgery. It compared local anesthetic with anesthetic plus a phenol-glycerol proliferant. Clinical assessments favored the proliferant injections, but relief generally lasted a few months rather than being permanent. (10)

This was not a dextrose or PRP trial, and it does not demonstrate that all postoperative pain is ligament-related. Its value is in showing that painful attachment sites may deserve attention in selected patients, including some with persistent pain after surgery. (10)

For a broader discussion, see causes and treatments of failed back surgery syndrome.

Disc-related pain: Injections inside a disc differ from ligament injections

A 2006 prospective series studied intradiscal dextrose injections in patients with advanced disc degeneration and leg pain, with or without back pain. Participants had been selected using discography and earlier treatment response. About 43.4% achieved sustained improvement; the average pain reduction among those responders was 71% at eighteen months. (11)

The 71% figure was not the average improvement for every participant. This uncontrolled study also does not establish disc regeneration. Injecting inside a disc is anatomically and procedurally different from treating ligament attachments, with a different risk profile. (11)

A separate retrospective series of 21 patients with MRI-confirmed degeneration examined fluoroscopy-guided injections to lumbar and pelvic supporting tissues. Eighteen reported at least 70% improvement in pain and function at one year, while two reported no benefit and one worsened. The small sample, incomplete follow-up information, and lack of a control group limit conclusions. (12)

A four-case clinical report also described substantial improvement after ligament injections, including return to activities or work. Such reports can generate useful questions, but accompanying treatments and the absence of controls prevent reliable estimates of treatment success. (13)

The important distinction is between treating symptoms associated with degeneration and proving that a degenerated disc has been repaired.

What does the PRP evidence add?

A systematic review and meta-analysis included three randomized PRP trials with 131 participants. It reported improved short-term pain and satisfaction compared with controls. These findings support further study of PRP for selected low-back conditions, but the small evidence base and varying treatment targets limit generalization. (14)

PRP results do not establish the effectiveness of dextrose alone. Similarly, improvement after combined PRP and dextrose cannot reveal which component was responsible. Studies must be interpreted according to what was actually injected and where.

New 2026 PRP trial: results depended on follow-up timing

A randomized trial of 107 patients with MRI-confirmed, single-level lumbar disc herniation compared transforaminal PRP with a steroid-and-local-anesthetic injection. Steroid results were better at one and three weeks, while PRP results favored pain and disability outcomes at six and twelve weeks. No complications were reported in the trial. (15)

Follow-up was limited to twelve weeks, and the study concerned a defined disc-herniation population. It does not establish benefit for isolated axial pain, show ligament repair, or demonstrate that PRP should be added to every caudal injection.

October 2026 review: pooled findings remain uncertain

A review published October 22, 2026, included six randomized trials with 406 participants comparing epidural PRP and corticosteroids for lumbar disc herniation. It found no consistent statistically significant difference in pain through six months or a clear functional advantage. Evidence certainty ranged from very low to moderate, with sparse safety reporting. (16)

Its search ended in July 2025, so it did not include the newer trial described above. The findings illustrate why an individual favorable trial should be considered alongside the broader evidence. They neither show that PRP never helps nor establish routine superiority over steroids. Neither study tests combined ligament Prolotherapy and PRP as one complete treatment strategy.

Why exercise and recovery remain relevant

Supporting ligaments and controlling muscles have complementary roles. Strength, endurance, and movement tolerance matter even when pain improves after an injection. A small lumbar series discussed stabilization exercises alongside injections, but did not isolate the contribution of either component. (12)

Exercise is an established part of many nonsurgical back-pain approaches, adjusted to the condition and the person’s tolerance. Extended inactivity can make return to normal activity harder. That does not mean pushing through new weakness or severe escalating pain. (17)

Published injection schedules range from single procedures to repeated sessions. These differences do not establish that everyone needs the same number of treatments. A response to an initial procedure, by itself, does not prove that continuing injections will produce further benefit.

Video: Low back pain and spinal instability

Our video, Low Back Pain Treated with Prolotherapy When Other Treatments Do Not Resolve Spinal Instability, discusses our clinical perspective on supporting tissues and persistent symptoms. It complements the research sections; clinical observations and proposed mechanisms should be distinguished from benefits established in controlled comparisons.

Limitations and safety: What the evidence does not establish

The new studies provide reasons to continue investigating dextrose, but several questions remain:

• Which diagnoses and patient characteristics predict benefit?
• Which injection targets and concentrations are most appropriate?
• How much benefit comes from the injection compared with accompanying care?
• How durable are improvements beyond the studied follow-up periods?
• Can structural repair be demonstrated independently of symptom improvement?

Pain scores, walking tolerance, sitting ability, and disability questionnaires measure meaningful outcomes. They do not directly measure ligament strength, disc regeneration, or prevention of future degeneration.

Risks vary with the procedure. Temporary soreness and bruising can occur; deeper spinal procedures have additional concerns, including infection, bleeding, and injury to nearby structures. Small trials and incomplete adverse-event reporting cannot establish the absence of uncommon complications. Comparisons of risks require attention to the specific injection rather than the label “Prolotherapy.”

When back or leg symptoms need urgent assessment

New loss of bladder or bowel control, inability to urinate, numbness around the groin or saddle region, or rapidly progressive leg weakness requires emergency assessment. These symptoms should not be managed by waiting for an elective injection.

Back pain with fever, unexplained weight loss, significant trauma, or new numbness or weakness also needs prompt evaluation. (18)

Persistent postoperative symptoms can have multiple explanations, including nerve compression, infection, hardware problems, or pain from other structures. Prolotherapy is not a substitute for investigating a serious or surgically correctable cause.

What these findings mean for patients with persistent low back pain

We retain our interest in ligament support and lumbar stability while recognizing that the evidence is diagnosis-specific. The 2026 randomized trial provides a favorable comparison with epidural steroid injections for selected people with persistent back and leg pain. The systematic review offers a broader overview, but combines diverse conditions and procedures.

Earlier negative or mixed trials remain relevant. Our case examples show possible functional improvements, not outcomes that can be guaranteed. The new video also preserves an important unresolved result: the woman’s pain had not improved despite smaller reported vertebral offsets, and her response to the subsequent caudal epidural is not supplied. A meaningful discussion of treatment needs to account for the source of pain, neurological findings, prior surgery, the intervention studied, and its limitations.

For more focused information, see our articles on sacroiliac instability and SI joint pain and alternatives to epidural steroid injections.

Medical disclaimer: This article provides general educational information and does not diagnose the cause of back pain or recommend a particular procedure. Benefits, risks, and suitability depend on the underlying condition.

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