Prolotherapy and the Dilemma of Finding the Right Diagnosis

If Prolotherapy is really as successful as always reported why is there only such a small group of experts existing all over the world? Dr. Hemwall, one of the pioneers of Prolotherapy once replied, “because it is too simple.”

I agree with him on this point. Giving the precise injections is not the main problem for a well trained doctor. The most serious problem is to get a really secured diagnosis before the treatment can be started. Otherwise his results will be doomed to fail, while the patient will be disappointed about missing the benefits he expected. The best public relation campaign for Prolotherapy is by word of mouth from content patients.

Getting a good diagnosis depends not only on the doctor’s knowledge and skills. One day he will find out that even a sure manual diagnosis test can lead to a wrong result. Every specialist knows this play of trial and error, especially with chronic shoulder injuries which give you a good example for this statement.

The directions for the shoulder diagnosis from the Dutch Council of practitioners in 1990 are based on the Cyriax advice and techniques which are still the golden standard. Today 20 new different shoulder tests exist, but the consensus between three shoulder experts was not better than 50 percent. (Banji et al in 1996). Multiple positive signs will confuse the Cyriax purists especially. (Dorman, Ravin, USA 1991)


An X–Ray or even an MRI is not the solution to the problem, because signs of degeneration in a tendon or arthrosis of a joint must not be the reason for the actual pain. To get out of this dilemma of the shoulder diagnosis (Extracta orthopaedica, Germany 1999) there is (in my personal opinion) only one way. A test injection with a local anaesthetic is able to secure the diagnosis. If you get a positive answer on an isometric shoulder test, you can always secure this result by using this simple method.


A patient who comes into the office and points to the shoulder roof as the source of his pain usually does not present a diagnostic problem. If there is no referral pain running down into his arm this can only be a lesion of the AC joint of the shoulder. But if the test injection in this case is negative and there is no sign of bursitis subacromialis, no capsular pattern, and no signs of tendon damage in the shoulder area, we really will have a severe diagnostic problem.

In this special case, I would order an MRI study to get a new idea. If this study shows a tendinosis of the supraspinatus muscle this can be a true result but this is should not be taken for granted. Radiologic studies, for example, showed that many people over 50 years of age showed degenerative signs in this tendon without suffering from any pain. The only solution to solve this diagnostic problem is the test injection into the supraspinatus tendon.

In 2004, patient C.B. stepped into my office with exactly these symptoms of an AC-Joint lesion and after the test injections I had the special diagnostic problem, as described, with both shoulders.

My patient had been suffering for a long time and no prior treatments could help her. She had received lots of cortisone injections into the shoulder joints which gave her some relief for a short time. There were only typical clinical signs of an AC-Joint lesion on both sides when she came in, but the test injection was negative. The MRI, which I ordered in July 2004, showed a partial rupture of the supraspinatus tendon on the right side and degenerative signs of the supraspinatus tendon on the left side. The test injection into this tendon was positive on both shoulders.

I treated both tendons with Prolotherapy using the peppering technique of Cyriax just at the osseo-tendinous junction and was successful on both shoulders. We needed five treatments on both sides (using proliferant: 3 ml. of Glucose 15% mixed with lidocaine, a local anaesthetic.)

She was doing well with both shoulders three months after the last treatment! Three years later she came back with shoulder pain on the left side. After five new treatments given in intervals of 14 days, she was well again. Now she is without pain on both shoulders for years. Today, the 28th of March 2011, the patient informed me by phone that she still is doing well and I am convinced, without this special diagnostic path, my Prolotherapy treatment would have been a failure.