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.
Article for the American Journal of Prolotherapy
Treatment of Cowboy and Horse
It was towards the end of 2007 when I experienced persistent hip discomfort on my right side. I ordered an x-ray of my hips in April of 2008. Both joints showed signs of degeneration, the left being more pronounced than the right. I was surprised by the findings because I had never experienced pain in my left joint. The specialist I consulted had no doubt that I would soon need a hip replacement, especially on the left side. Why should I need a new hip on a painless side? I had serious doubts about the value of these findings. I agreed that it would be only a matter of time that this would be necessary on the painful right side.
It was notable that the symptoms which were represented here were completely atypical for an arthrosis patient. I never complained about morning pain in the groin. Instead I had trouble lying on the right side of my trochanter hip bone. Add to this, I never observed typical groin pain radiating down to the knee joint. The passive inner rotation of the hip joints was restricted on both sides but not painful in any way. So there was no capsular pattern after Cyriax as a typical arthrosis sign. A certain stiffness in the hip joints I had known for 40 years. The radiographic findings were therefore not at all consistent with the clinical symptoms, especially since only the radiographically better side made complaints.
In early 2009, horseback riding became increasingly difficult due to the tightness in my hips. In autumn 2009 I stopped riding completely because the horse became suddenly lame. He suffered from a chronic lesion of the horse shoe joint. This is not unusual with those hypermobile Texas cow ponies who are specialised in cutting and working cow horse performances and shows.
You may ask yourself why is a German orthopedist riding an American quarterhorse ?
This is a very special story which has had a major impact on my hip arthrosis, and so it is worth telling.
I liked riding on horseback since I was a boy. When I was 30 years old I found out that my hips were not as mobile as they should be. A radiograph showed that I would likely develop an arthrosis in both hips. I knew then that I had to do something in an effort to prevent this. I bought a horse to train the spreading of my hips in the saddle as a natural prophylaxis. This worked pretty well for 20 years and the hips did not bother me while riding a horse in the small English saddle. After 20 years I considered quitting riding. Perhaps that was sufficient prophylaxis for my hips?
In 1985 I started importing Galloway Cattle from Scotland to the countryside of Lübeck where I live. I was conducting an environmental experiment with these cattle in an attempt to bring back the natural meadows and habitats. In order to make this new ranch work possible, I had to switch to a well trained American Quarter horse. Horseback riding was more fun than ever. My experiment has now become a 600 acre nature reserve and a model of landscape management used around Europe by environmentalists.
Now you know the whole story and why this horse is so valuable to me. I am quite sure without this ranch work, my riding would have been more limited and my arthrosis prophylaxis would have shown less effects over all those years. But back to the horses’problem.
My veterinarian doctor found a chronical lesion with effusion of the distal interphalangeal joint of the horses right foreleg. As I stated earlier, this is not unsual for a high performance cow pony with exceptional movement abilities. My vet, Dr. Feilke, gave him injections into that joint in the autumn of 2009. He took cortisone combined with hyalurone and he was fine for a few months. In my own case, I was considering a hip replacement in the summer of 2010.
The winter 2009/ 2010 was very snowy and cold. There was no riding until spring.
During this break my hip was getting better step by step and to my surprise in April 2010 I was completely free of pain. Immediately after the first great trail ride in the spring there was a big setback for myself and the horse. We were both lame at the same time.
An MRI study of my hips showed multiple degenerative signs but still enough cartilage in both hips and no effusion in the joints. There were no MRI signs for a lesion of the hip tendons. The clinical examination showed no signs for a capsular pattern as a cause of the hip pain.
My friend, Dr. Baehnisch, and I thought a tendinopathy of the gluteus medius and the piriformis muscle in combination with a instability of the right SI-Joint could be a possible cause of my hip pain. A positive infiltration test with a local anesthetic secured this diagnosis.
Results of the treatment of Horse and Rider:
My western horse was successfully treated with 3 Prolotherapy sessions by Dr Feilke, according to my instructions. He had not heard of this therapy until this treatment of my horse.
He injected 5 ml of 20% pure Glucose into the horseshoe joint in intervals of 14 days. In autumn of 2010 the horse got one more injection and stayed healthy for a year. In the autumn of 2011 the horse was lame again briefly. He got one more Glucose injection and has been well for the past year and a half.
In summer 2010 I myself received 7 injections from Dr. Baehnisch in Leipzig, into the trochanteric area for the treatment of the tendons of the piriformis and gluteus muscle. Injections into to the hip joint and the capsular ligaments of the joint he did 4 times. He also treated the SI –Joint on the right side 4 times. In this area he injected the ligamentum iliolumbale and the points A B C D after Hackett. Three months after my last treatment I had no problems with walking, however I could not spread my legs to ride my horse.
I tried physiotherapy before I got the Prolotherapy injections, but without improvement.
Three months after the last treatment I was able to sit in the saddle again after some stretching. After some time riding I regularly got pain in my buttock. I quickly found out that I got relief when I put my leg around the horn of the western saddle and by this way got a friction massage from my walking horse in the painful piriformis area in the buttock. So I was able to ride again. To spread my legs more easily, I made my saddle smaller through a self constructed saddle pad from sheepskin. I put this on the saddle to sit higher up and by this way spread less. Through all these actions and treatments I came down on the Visuell International Pain Scale VAS from 6 to 2. This was my status quo for one year until November 2011.
Then I started training in the medical fitness center of the Asklepios clinic in the nearby town of Bad Schwartau. My fitness trainer, Mr. Schumacher, knew my problems and knew Prolotherapy. He once was treated and cured by me with this therapy.
He gave me special training orders, primarily the use of the cross trainer machine, which helped me train the buttock and low back muscles. After 5 lessons I was down on the VAS scale to an unbelievable zero. Very useful exercises to strengthen the adductor and abductor muscles of the hips were conducted on special machines. Additionally, I was given some very good stretching exercises from Mrs. Tamm, physiotherapeut of the Asklepios orthopedic clinic.
Nowadays, after more than one year of training once a week, I am still without pain and can walk for miles in the rugged country hills of eastern Holstein. I can also ride for an hour without problems. If I want to ride longer I put my right leg around the saddlehorn and continue riding in the old fashioned side saddle.
In conclusion I can say that there is no comparison between my condition today and the one I was suffering from in 2007.
Today if I do too much sport, discomfort can occur but will always disappear within 2 to 3 days. My only problem is putting on my right sock because the hip movement is still reduced. In the thirty years in which I have been using Prolotherapy, many spectacular long term results have been documented. I think this is very amazing and encouraging. Now, as a patient with those results, I am a serious witness to this type of therapy. Sure we have to discuss placebo effects for every alternative therapy. However, I feel certain my fine American horse, Lena Okie Paul, and myself could not have both been cured by a placebo effect.
6. February 2013 Dr.Jörn Funck
A special Review in the year 2018
My article about the treatment of a Cowboy with a hip problem and his lame cowhorse was accepted in 2013 for the print issue of the Journal of Prolotherapy, but it was not published because the magazine closed its usual monthly appearance as a print magazine.Since that time you can find all old articles of mine once published now online and with better pictures in colour than in the past.
In 2011 for example I published an article about chronic shoulder problems of one of my patients which I treated successfully in 2004 with Prolotherapy. Now, in 2018, 14 years later, this patient is still alright. A second article of a treatment of the medial coronary ligament of both knees in another chronic case was even as successful and the patient is still without pain in the year 2018. My own hip problems in the article above about rider and horse was successful for rider and horse until the year 2014. At this time my right hip suddenly produced pain in the groin and a new MRI control of the joint showed ,in this special case , a new hip would be the best choice. My back pain from the right SI-joint in 2008 and my hip problem from the tendon of the gluteus medius ,which we treated in 2010 with Prolo never appeared again.I have treated many patients , even with a perfect new hip, which still suffer from pain in this hip muscle. Even in these chronic cases Prolotherapy of the tendon will solve this very special problem.
My fine quarter horse Lenas Okie Paul never ever showed any signs of irritation in his right horseshoe joint after the treatment with Prolo in 2010. In two short videos (which can be sent by email) you can see, that our Cowboy and this horse now in the year 2018 are still good enough to do ranch work as usual and even can do those quick and powerful cutting movements like in a special ranch cutting show in the past here in Holstein/Germany in the year 2007.These longtime results with Prolotherapy are really convincing,because a horse can not be cured by a placebo effect.
10. August 2018 Dr. Jörn Funck