Prolotherapy injections for rotator cuff tears and rotator cuff tendinopathy

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

Prolotherapy, as practiced in our office, involves multiple injections of a dextrose-based solution to the various ligament and tendon attachments around the shoulder, as well as inside the joint. Prolotherapy to all of the adjacent structures stimulates a natural inflammatory response in the weakened rotator cuff tissues. This mild, localized inflammatory reaction draws immune cells to the area to regenerate the injured tissues. The increase in blood flow and regenerative cells is the body’s natural healing response. The body also responds by depositing collagen at the site of injury, strengthening the rotator cuff tendons that once were weak.

  • Prolotherapy injections strengthen the ligaments and the tendinous insertions of the rotator cuff and deltoid. This combined with the gradual re-strengthening of the rotator cuff muscles promises an excellent chance for a full recovery and full performance in many patients.

The research

A September 2025 study published in the Indian journal of anaesthesia (1) explored  treating rotator cuff problems with prolotherapy. The researchers examined outcome data from 13 studies involving 936 patients. In this data prolotherapy was compared to interventions such as platelet-rich plasma, steroids, physiotherapy, or placebos.

The analysis showed that prolotherapy significantly reduced pain, improved functional outcomes with no major adverse effects reported, indicating that the treatment is safe.

The researchers concluded “dextrose prolotherapy may be a feasible and effective alternative for rotator cuff disorders, and it can be considered for patients with limited treatment options.”

Corticosteroids, hyaluronic acid, prolotherapy, and platelet-rich plasma [PRP])

A November 2025 study in the Journal of orthopaedic surgery and research (2) gave a broad overview of the effectiveness  of intra-articular injections for rotator cuff injuries. In this review of patient data, the paper  looked at corticosteroids, hyaluronic acid, prolotherapy, and platelet-rich plasma [PRP]) across short- (less than 1 month), mid- (1–3 months), and long-term (more than 3 months) outcomes. One of the problems cited in this paper was the wide-ranging ways these treatments are given to patients and possibly skewing overall outcomes.

Twenty-nine previously published studies and data on 1800 patients were included in this study. These are the observations.

  • For pain relief, prolotherapy consistently ranked highest across all timeframes.
  • PRP also exhibited favorable long-term analgesic efficacy.
  • Corticosteroids showed short-term benefits but inferior long-term efficacy.
  • For functional improvement, hyaluronic acid demonstrated the best short-term results, whereas prolotherapy was optimal for mid-term recovery.
  • Long-term functional outcomes favored hyaluronic acid and prolotherapy.

In our opinion, and more importantly, the paper suggests “evidence supports a shift from using a single injection agent towards a tailored strategy that selects different injections based on the patient’s symptoms and the specific treatment phase to achieve optimal outcomes.” In our clinic we offer PRP prolotherapy a combination treatment to address the different aspect of the complex rotator cuff tear.

The researchers hypothesized dextrose prolotherapy would reduce pain and improve shoulder function in rotor cuff tears

A May 2017 study in the journal Orthopaedics & traumatology, surgery & research : OTSR (3) presented the results of prolotherapy in the treatment of chronic refractory (difficult to treat) rotator cuff lesions. The researchers hypothesized dextrose prolotherapy would reduce pain and improve shoulder function and patient satisfaction.

  • Patients with chronic rotator cuff lesions and symptoms that persisted for longer than 6 months were divided into two groups: one treated with exercise (control group – three sessions weekly for 12 weeks) and the other treated with ultrasound-guided prolotherapy injections.
  • A total of 101 patients (44 controls and 57 in the prolotherapy group) completed all study protocols and were included in the study.
    • Both groups achieved significant improvements over baseline in standard pain, disability and function scoring.
    • Significant differences in outcome were found: In the prolotherapy group, 53 patients (92.9%) reported excellent or good outcomes; in the control group, 25 patients (56.8%) reported excellent or good outcomes.

Comprehensive Prolotherapy treatment for torn rotator cuff without surgery

  • The first injection is intra-articular, directly into the shoulder joint.
  • Next to the acromioclavicular joint. Shoulder osteoarthritis, rotator cuff tendon issues including tears as well as tendinosis, responds well to Prolotherapy.
  • Next are the posterior shoulder structures including the posterior joint capsule as well as the various ligament attachments in the back of the shoulder.
  • Next, the interior structures in the front of the shoulder are done including the ligaments as well as the various rotator cuff tendon attachments including the Supraspinatus tendon.
  • Prolotherapy is effective for rotator cuff tears, labral tears and biceps tendonitis, various tendonitis as well as shoulder instability.
  • Finally treating the acromioclavicular joint, or AC joint as the biceps tendon attachments.

Research on Prolotherapy and supraspinatus tendinopathy 

Prolotherapy is the simple injection of dextrose (sugar) into the shoulder joint. Many studies have documented Prolotherapy treatments’ effectiveness in treating the problems of chronic pain.  We are going to look at two studies here, and then discuss surgical options. Then return to more research on Prolotherapy.

Doctors at Taipei Medical University published a February 2022 study in the Archives of Physical Medicine and Rehabilitation (4) on the effects of Prolotherapy on pain and shoulder disability in patients with chronic supraspinatus tendinosis.

This was a randomized double-blind placebo-controlled trial.

In this study, 57 patients with symptomatic chronic supraspinatus tendinosis were examined. The patients were randomly divided with 29 getting 20% hypertonic dextrose (Prolotherapy) or 5% normal saline (28 patients getting a placebo).

The Prolotherapy group exhibited significant improvements in the visual analog scale (pain measured 0 – 10) and Shoulder Pain and Disability Index scores compared with baseline scores at week two. However, the effect was not sustained to week six.

Flexion ROM (range of motion) increased at weeks 2 and 6 weeks compared with baseline. The thickness of the supraspinatus tendon improved at weeks 6 and 12 compared with the baseline.

Conclusion: Hypertonic dextrose Prolotherapy injection could provide short-term pain and disability relief in patients with chronic supraspinatus tendinosis. Ultrasound imaging at week 6 revealed a changed tendon morphology.

The review of this study revealed familiar findings. Prolotherapy treatment can help BUT prolotherapy treatment will not be as successful if it is one shot one time, the initial success of pain relief and better range of motion and function can be sustained if further treatments are initiated.

In October 2019, doctors at the University of Toronto, McMaster University, and UPMC Center for Sports Medicine in Pittsburg wrote in PM & R: the Journal of Injury, Function, and Rehabilitation (5) of the “Effectiveness of Dextrose Prolotherapy for Rotator Cuff Tendinopathy.”

Here is the learning point of this research:

  • A comprehensive (research study) search was completed to identify randomized controlled trials addressing prolotherapy using hyperosmolar (higher dextrose amounts injected into the shoulder) dextrose solution for rotator cuff tendinopathy.
  • Included studies in this review analyzed a total of 272 participants with a final follow-up ranging from 6 weeks to 12 months.
  • Prolotherapy (application) differed greatly among studies. (The number of injections given varied. One study used cortisone concurrently. In our office, we do not utilize cortisone with Prolotherapy.
    • There was a statistically significant improvement in pain intensity with multi-site injection protocols compared to physical therapy and medical management in both studies.
    • The complication rate was low with only 6/272 participants experiencing adverse events consisting of the transient increase in pain for 1-2 days post-intervention.

The study concludes:

“Prolotherapy with hyperosmolar dextrose solution is a potentially effective adjuvant intervention to physical therapy for patients with rotator cuff tendinopathy ranging from tendinosis to partial-thickness and small full-thickness tears. Further studies are necessary to determine effects in subpopulations as well as optimal technique including dextrose concentration, volume, and location.”

In December 2018, research published in the European Journal of Physical and Rehabilitation Medicine (6) also explored the effectiveness of Prolotherapy treatments in supraspinatus tendinopathy.

These are the learning points of the study:

  • Although patients with symptoms caused by chronic rotator cuff tendinopathy can be treated using conservative treatments, some of them may still experience refractory or difficult-to-resolve symptoms. Hypertonic dextrose Prolotherapy may be another treatment choice for these difficult-to-resolve symptoms.
  • The study group was 31 patients with chronic supraspinatus tendinopathy and shoulder pain for more than 6 months.

The study was conducted with a single injection of Prolotherapy vs. a Placebo

  • The study patients were treated with one dose of an ultrasound-guided hypertonic dextrose injection at the supraspinatus enthesis site, whereas control patients received one dose of 5% normal saline through the same method.
  • Pain and disability improvement scores were noted at 2 and 6 weeks after intervention.

The study group indicated a significant improvement in pain and disability scores including improved range of motion compared with the control group at 2 weeks after the injection. However, the effect did not sustain until 6 weeks after the injection.

This is our treatment, with multiple injections at each visit. The reality of treatment is that months or years of degenerative tendinopathy in the shoulder cannot realistically be expected to be reversed with a single injection of anything.

One Prolotherapy Treatment vs. One Cortisone Injection

A March 2021 study in the journal Advanced Biomedical Research (7) compared the effectiveness of Prolotherapy injections with corticosteroid injections in patients with rotator cuff dysfunction.

In this study:

  • Thirty to sixty-five-year-old patients with chronic rotator cuff disease were divided into two groups. Ultrasound-guided dextrose Prolotherapy of the supraspinatus tendon was done for one group and ultrasound-guided corticosteroid injection in the subacromial bursa was done for the other groups.
  • Visual analog scale (VAS) and Shoulder Pain and Disability Index (SPADI) were evaluated for both groups at baseline, 3 and 12 weeks after injections.

Results:

  • Thirty-three patients were included in the result.
  • Both the groups showed significant improvement in visual analog scale and Shoulder Pain and Disability Index scores in 3 and 12 weeks after injections compared with pre-injection times with no difference between the two groups either in 3 weeks or in 12 weeks after injections.

Conclusion: Both ultrasound-guided dextrose Prolotherapy and cortisone injections are effective in the management of rotator cuff-related shoulder pain in both short-term and long-term with neither being superior to the other. Therefore, Prolotherapy may be a safe alternative therapy instead of corticosteroid injection due to the lack of its side effects.

One item to note is that we typically do not find Prolotherapy to be a one-time treatment. We see its maximum benefit in three to six treatments.

In January 2016, doctors at the University of British Columbia and the University of Kansas (Dean Reeves MD) published in the Archives of Physical Medicine and Rehabilitation (8) a comparison of the effects of dextrose Prolotherapy on pain levels and degenerative changes in painful rotator cuff tendinopathy against 2 saline control injection procedures.

Study points:

  • 73 patients with chronic shoulder pain, examination findings of rotator cuff tendinopathy, and ultrasound-confirmed supraspinatus tendinosis/tear.
  • Three monthly injections either:
    • (1) onto painful entheses (tendon attachment to the bone) with dextrose (Enthesis-Dextrose),
    • (2) onto entheses with saline (Enthesis-Saline), or
    • (3) above entheses with saline (Superficial-Saline). All solutions included 0.1% lidocaine as a pain agent. All participants received concurrent programmed physical therapy.

Conclusion of the research: “In participants with painful rotator cuff tendinopathy who receive physical therapy, injection of hypertonic dextrose on painful entheses resulted in superior long-term pain improvement and patient satisfaction compared with blinded saline injection over painful entheses, with intermediate results for entheses injection with saline. These differences could not be attributed to a regenerative effect. Dextrose Prolotherapy may improve on the standard care of painful rotator cuff tendinopathy for certain patients.”

Doctors at the National Taiwan University Hospital published their findings in the February 2019 edition of the Archives of Physical Medicine and Rehabilitation (9) in which they suggest that for “patients with rotator cuff tendinopathy, corticosteroid plays a role in the short term (3-6 weeks) but not in long-term (over 24 weeks) pain reduction and functional improvement. By contrast, PRP and Prolotherapy may yield better outcomes in the long term (over 24 weeks).

In this video, Danielle R. Steilen-Matias, MMS, PA-C, discusses Prolotherapy for shoulder pain and arthritis and how we determine if someone is a good candidate!

It is not uncommon for us to see patients after shoulder surgery who continue to have shoulder instability issues. Other times, we will see patients after shoulder surgery who have continued pain. It may be the same pain that they had before surgery, or it may be a different type of pain. What we find in many of these people is that even though healing is occurring and the shoulder looks well, the pain they are having is related to the nerves that may have been impacted during the surgery. We treat these patients with Nerve-release injection therapy, or more commonly, hydrodissection.

Published research papers from our doctors at Caring Medical on Shoulder Disorders

Related articles

Prolotherapy injections for the treatment of shoulder impingement syndrome

References

1 Sony S, Kantha M, Shekhar S, Kumar A, Bhandari B, Muthuramalingam KP. Exploring dextrose prolotherapy in rotator cuff disorders: A systematic review and meta-analysis. Indian Journal of Anaesthesia. 2025 Sep 1;69(9):881-98. [Google Scholar]
2 Wu M, Yan C, Xu Y, Yan Z. The evolving efficacy landscape of intra-articular injections for rotator cuff injuries over time: a network meta-analysis of randomized controlled studies. Journal of Orthopaedic Surgery and Research. 2025 Nov 26;20(1):1038. [Google Scholar]
3 Seven MM, Ersen O, Akpancar S, Ozkan H, Turkkan S, Yıldız Y, Koca K. Effectiveness of prolotherapy in the treatment of chronic rotator cuff lesions. Orthopaedics & Traumatology: Surgery & Research. 2017 May 1;103(3):427-33. [Google Scholar]
4 Lin CL, Chen YW, Wu CW, Liou TH, Huang SW. Effect of Hypertonic Dextrose Injection on Pain and Shoulder Disability in Patients with Chronic Supraspinatus Tendinosis: A Randomized Double-Blind Controlled Study. Archives of Physical Medicine and Rehabilitation. 2022 Feb 1;103(2):237-44. [Google Scholar]
5 Catapano M, Zhang K, Mittal N, Sangha H, Onishi K, de Sa D. Effectiveness of dextrose prolotherapy for rotator cuff tendinopathy: a systematic review. PM&R. 2020 Mar;12(3):288-300. [Google Scholar]
6 Lin CL, Huang CC, Huang SW. Effects of hypertonic dextrose injection in chronic supraspinatus tendinopathy of the shoulder: a randomized placebo-controlled trial. European Journal of Physical and Rehabilitation Medicine. 2018 Dec 13;55(4):480-7. [Google Scholar]
7 Nasiri A, Jahromi LS, Vafaei MA, Parvin R, Fakheri MS, Sadeghi S. Comparison of the effectiveness of ultrasound-guided prolotherapy in supraspinatus tendon with ultrasound-guided corticosteroid injection of subacromial subdeltoid bursa in rotator cuff-related shoulder pain: A clinical trial study. Advanced Biomedical Research. 2021 Jan 1;10(1):12. [Google Scholar]
8 Bertrand H, Reeves KD, Bennett CJ, Bicknell S, Cheng AL. Dextrose Prolotherapy versus Control Injections in Painful Rotator Cuff Tendinopathy. Arch Phys Med Rehabil. 2015 Aug 21. pii: S0003-9993(15)01091-6. [Google Scholar]
9 Lin MT, Chiang CF, Wu CH, Huang YT, Tu YK, Wang TG. Comparative Effectiveness of Injection Therapies in Rotator Cuff Tendinopathy: A Systematic Review, Pairwise and Network Meta-analysis of Randomized Controlled Trials [Google Scholar]
10 Hauser, RA, et al. Prolotherapy as an Alternative to Surgery: A Prospective Pilot Study of 34 Patients from a Private Medical Practice. Journal of Prolotherapy. 2010;(2)1:272-281.

 

Get Help Now!

You deserve the best possible results from your treatment. Let’s make this happen! Talk to our team about your case to find out if you are a good candidate.

Tell Us Your Story