Dr. Joern Funck in "Journal of Prolotherapy"
(USA, Nov. 2009)
Why I Switched from orthopedic Surgery to Prolotherapy
In 1975, after I finished my clinical education as an orthopedic surgeon, I opened my private office as an orthopedist in Luebeck, Germany. In those days the possibilities to operate were not so good for young orthopedic surgeons. Big operations, like hip replacements, were done only in the large public hospitals. Successful endoscopic joint operations and open shoulder operations did not come about until some years later.
At that time I decided to treat soft tissues with injections, medication, and physiotherapy and not to operate any more. In the beginning, numerous shoulder patients had a problem when medication was not successful. I started studying manual therapy but to manipulate a cervical spine was not the solution of shoulder problems, as my teachers at that times insisted. At last, I remembered a little booklet from Dr. James Cyriax from London who gave me diagnostic and treatment advice for shoulders which turned out to be very successful. So I took extended training in orthopedic medicine by Cyriax, which was not common in Germany at the time.
The only treatment after a secured shoulder diagnosis in those days was a cortisone injection. Cortisone typically helped very quickly, but the problem had a tendency to come back. After several injections with cortisone, the risk of a rupture of the treated tendon was present or the success of the injection diminished.
During those times, one of my teachers in manipulation techniques was Professor Tilscher from Vienna, who introduced me to Prolotherapy for low back pain patients. The same advice was given to me by Dr. Barbor from London.who brought Prolotherapy from the States to Europe.
In 1998,after 20 years of treating only low back pain patients with Prolotherapy,I introduced my colleague orthopedist Dr.Baehnisch from Leipzig,Germany to Prolotherapy. He traveled to the United States several times where he received in depth training from Drs. Ravin and Cantieri.
These doctors used the Cyriax diagnostic and treatment techniques as well,so it was not difficult to follow their advances.Consequently,we were able to set up new standards to our own work back in Germany.I started treating shoulder tendon problems with Prolotherapy and could leave the cortisone path behind with all its associated problems.
From the year 2000 until 2006 I have compiled 1500 cases in which I used Prolotherapy as the primary mode of treatment. The treatments were successful in 88.3% of them.
In Germany, we once believed that Prolotherapy would only work on ligaments and not on tendons. My own success in treating tendinosis of shoulder tendons since 2002 defeated that whole theory in my mind. A tendinosis means a weakness of a tendon accompanied with some signs of inflammation.
My experience with hip pain brings further proof to the efficacy of Prolotherapy, as there is a similar problem with hip pain. Cyriax teaches that a hip has to show a so-called capsular pattern when the doctor moves the joint for diagnostic reasons. The pain is expected in the groin if this joint is really the problem. But many patients show more pain on the outer side of the hip going down to the knee.
The large bone called the greater trochanter, where the gluteal muscles and a bursa (fluid filled sac) attach is often the origin of the pain and typically such a person is diagnosed with trochanteric bursitis (inflammation of the bursa).
Until the year 2000, I typically injected this bursa, like all my teachers before me, with 40 mg Triamcinolon (cortisone) with mostly good, but only temporary relief. So people came back for more injections. At the end, I recall five patients who did not respond any more to this therapy. So I sent them to an orthopedic clinic, where the bursa was surgically removed.
The end result was always negative in my experience. I thought the reason for the pain must be the gluteus medius tendon, one of the big hip muscles, and not the famous bursa. I started treating the tendon of the gluteus medius, which runs to the outer hip point, called the greater trochanter, and got good results with Prolotherapy. From 2002 to 2006, I treated 162 patients with these symptoms and was successful in 140 cases. Finally, I was convinced when I cured five patients with gluteus medius problems after hip replacement surgeries. The surgeons could not determine the reason of their remaining pain. But Prolotherapy was able to rid them of their remaining pain.
One side note that I would Iike to mention: My security in those difficult diagnostic cases is always the test injection with a local anaesthetic. Although the Cyriax techniques are very accurate, they sometimes fail, especially in the important shoulder diagnostic. MRI's are not useful, so I rarely order them. For patients with chronic pain on their long road from expert to expert, test injections provide a hopeful sign to convince them that their diagnosis has really been secured.
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 thorougly secured diagnosis before the treatment can be started.Otherwise results will be doomed to fail and the patient diappointed when the expected benefits do not materialize.The best public relation compaign for Prolotherapy is word of mouth from patients successfully treated.
Getting a good diagnosis depends not only on the doctors knowledge and skills as every specialists have encountered the situation where a positive manual diagnosis lead to a wrong conclusion.This is especially true for chronic shoulder injuries.
The directions for the shoulder diagnosis from the Dutch Council of practitioners in 1990 is based on the Cyriax advices and those techniques which are still the golden standard.
Today there are some 20 new different shoulder tests, but the consensus amongst shoulder experts is no better than 50 percent (Banji et alien in 1996).Multiple positive signs will confuse especially the Cyriax purists.(Dorman,Ravin, USA 1991)
How to get out of this fundamental trap?
An X-Ray or even an MRI is not the solution to this problem because signs of degeneration in a tendon or arthrosis of a joint is not necessarily the reason for the pain.
To get out of this ,,Dilemma of the shoulder diagnosis" (Extracta orthopaedica, Germany 1999) there is, in my opinion, only one way: That is a test injection with a local anaesthetic, which will secure the diagnosis. A positive answer on a isometric shoulder test can always be confirmed by using this simple procedure.
Here is a specific example for trial and error in a shoulder case.
A patient who comes to the office and points to the shoulder roof as the source of his pain usually does not present a diagnostic challenge. If there is no associated pain running down to 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 are no sign of Bursitis subacromialis, no capsular pattern and even no signs of tendon damage in the shoulder area, then we have a serious diagnostic problem.
In this special case, I would order an MRI study to get a more detailed picture.Should this study show a tendinosis of the supraspinatus muscle this could be an accurate identification of the cause, but not necessarily.Radiologic studies for example showed that many people aged over 50 displayed degenerative signs in this tendon without suffering any pain.
The only solution to solve this diagnostic problem is, as I have mentioned before, the test injection into the supraspinatus tendon.
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