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The Effectiveness of Prolotherapy for Recalcitrant Medial Tibial Stress Syndrome: a Prospective Consecutive Case Series.
Nat Padhiar
Centre for Sports & Exercise Medicine, Queen Mary, University of London
Corresponding Author
ORCiD: https://orcid.org/0000-0002-0352-4534
License:
This work is licensed under a CC BY 4.0 License. Read Full License
Background: Medial tibial stress syndrome (MTSS) is one of the most common lower leg injuries in sporting populations. It accounts for between 6%-16% of all running injuries, and up to 53% of lower leg injuries in military recruits. Various treatment modalities are available with varying degrees of success. In recalcitrant cases, surgery is often the only option.
Objective: To evaluate whether ultrasound-guided injection of 15% dextrose for treatment of recalcitrant MTSS decreases pain and facilitates a return to desired activity levels for those who may otherwise be considering surgery or giving up the sport.
Method: The study design was a prospective consecutive case series involving eighteen patients: fifteen male and three female; (mean age=31.2 years) with recalcitrant MTSS. They were referred from sports injury clinics across the UK, having failed all available conservative treatment.
Intervention: An ultrasound-guided sub-periosteal injection of 15% dextrose was administered by the same clinician (NP) along the length of the symptomatic area. Typically, 1 mL of solution was injected per cm of the symptomatic area.
Main Outcome Measures: Pain was assessed using a 10-cm visual analog scale (VAS) at baseline, short-term, medium-term (mean 18 weeks), and long-term (mean 52 weeks) follow-up. Symptom resolution and return to activity were measured using a Likert scale at medium and long-term follow-up. Statistical analyses were performed using SPSS for Mac version 19.0.0 (IBM, New York, NY, US). The Shapiro-Wilk test was used to evaluate the normality of the distribution of data. Friedman's non-parametric test was used to compare the within-patient treatment response over time. Post-hoc Wilcoxon signed-rank tests with Bonferroni corrections were performed to determine VAS average pain response to treatment over five paired periods.
Results: Patients reported a significant (p<0.01) reduction in median VAS pain score at medium and long-term follow-up compared to baseline. Median improvement per patient was 4.5/10. Patients rated their condition as 'much improved' at medium-term follow-up and the median return to sports score was 'returned to desired but not pre-injury level' at medium-term and long-term follow-up. No adverse events were reported.
Conclusions: Ultrasound-guided 15% dextrose prolotherapy injection has a significant medium-term effect on pain in MTSS. This benefit may be maintained long-term; however, more robust trials are required to validate these findings in the absence of controls.
Clinical Relevance: Clinicians should consider the use of ultrasound-guided injection of 15% dextrose as a viable treatment option to reduce pain and aid return to activity for patients with recalcitrant MTSS.
Keywords
Prolotherapy, MTSS, injection, exercise-induced leg pain, dextrose.
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Editorial decision: Minor revision
On 06 Dec, 2020
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On 21 Nov, 2020
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Received 20 Nov, 2020
Reviewer #1 agreed
On 08 Nov, 2020
Editor assigned
On 04 Nov, 2020
Reviewers invited
Invitations sent on 04 Nov, 2020
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On 04 Nov, 2020
Editor invited
On 04 Nov, 2020
No comments provided
Editorial decision: Major revision
On 30 Jul, 2020
Review #1 received
Received 10 Jul, 2020
Reviewer #1 agreed
On 27 Jun, 2020
Reviewers invited
Invitations sent on 26 Jun, 2020
Editor assigned
On 07 Jun, 2020
Submission checks complete
On 06 Jun, 2020
Editor invited
On 06 Jun, 2020
First submitted
On 05 Jun, 2020
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This preprint is under consideration at Journal of Foot and Ankle Research. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research
The Effectiveness of Prolotherapy for Recalcitrant Medial Tibial Stress Syndrome: a Prospective Consecutive Case Series.
Nat Padhiar
Centre for Sports & Exercise Medicine, Queen Mary, University of London
Corresponding Author
ORCiD: https://orcid.org/0000-0002-0352-4534
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Under Review
Version 3
Posted 13 Jan, 2021
No community comments so far
Editor assigned
On 01 Jan, 2021
Submission checks complete
On 01 Jan, 2021
Editor invited
On 01 Jan, 2021
No comments provided
Review #2 received
Received 06 Dec, 2020
Editorial decision: Minor revision
On 06 Dec, 2020
Reviewer #2 agreed
On 21 Nov, 2020
Review #1 received
Received 20 Nov, 2020
Reviewer #1 agreed
On 08 Nov, 2020
Editor assigned
On 04 Nov, 2020
Reviewers invited
Invitations sent on 04 Nov, 2020
Submission checks complete
On 04 Nov, 2020
Editor invited
On 04 Nov, 2020
No comments provided
Editorial decision: Major revision
On 30 Jul, 2020
Review #1 received
Received 10 Jul, 2020
Reviewer #1 agreed
On 27 Jun, 2020
Reviewers invited
Invitations sent on 26 Jun, 2020
Editor assigned
On 07 Jun, 2020
Submission checks complete
On 06 Jun, 2020
Editor invited
On 06 Jun, 2020
First submitted
On 05 Jun, 2020
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
Subject Areas
Orthopedics
License:
This work is licensed under a CC BY 4.0 License. Read Full License
Background: Medial tibial stress syndrome (MTSS) is one of the most common lower leg injuries in sporting populations. It accounts for between 6%-16% of all running injuries, and up to 53% of lower leg injuries in military recruits. Various treatment modalities are available with varying degrees of success. In recalcitrant cases, surgery is often the only option.
Objective: To evaluate whether ultrasound-guided injection of 15% dextrose for treatment of recalcitrant MTSS decreases pain and facilitates a return to desired activity levels for those who may otherwise be considering surgery or giving up the sport.
Method: The study design was a prospective consecutive case series involving eighteen patients: fifteen male and three female; (mean age=31.2 years) with recalcitrant MTSS. They were referred from sports injury clinics across the UK, having failed all available conservative treatment.
Intervention: An ultrasound-guided sub-periosteal injection of 15% dextrose was administered by the same clinician (NP) along the length of the symptomatic area. Typically, 1 mL of solution was injected per cm of the symptomatic area.
Main Outcome Measures: Pain was assessed using a 10-cm visual analog scale (VAS) at baseline, short-term, medium-term (mean 18 weeks), and long-term (mean 52 weeks) follow-up. Symptom resolution and return to activity were measured using a Likert scale at medium and long-term follow-up. Statistical analyses were performed using SPSS for Mac version 19.0.0 (IBM, New York, NY, US). The Shapiro-Wilk test was used to evaluate the normality of the distribution of data. Friedman's non-parametric test was used to compare the within-patient treatment response over time. Post-hoc Wilcoxon signed-rank tests with Bonferroni corrections were performed to determine VAS average pain response to treatment over five paired periods.
Results: Patients reported a significant (p<0.01) reduction in median VAS pain score at medium and long-term follow-up compared to baseline. Median improvement per patient was 4.5/10. Patients rated their condition as 'much improved' at medium-term follow-up and the median return to sports score was 'returned to desired but not pre-injury level' at medium-term and long-term follow-up. No adverse events were reported.
Conclusions: Ultrasound-guided 15% dextrose prolotherapy injection has a significant medium-term effect on pain in MTSS. This benefit may be maintained long-term; however, more robust trials are required to validate these findings in the absence of controls.
Clinical Relevance: Clinicians should consider the use of ultrasound-guided injection of 15% dextrose as a viable treatment option to reduce pain and aid return to activity for patients with recalcitrant MTSS.
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5