Ligament Injury and Referred Pain Patterns
Ross Hauser, M.D.

The chief principle of Prolotherapy is that it treats the root cause of chronic pain and sports injuries—ligament and tendon weakness. The chief symptom of ligament and/or tendon injury is pain. The pain is aggravated by activity when tension is placed upon the ligament or tendon and usually subsides when the tension is relieved with inactivity. Often the general activity of the athlete is curtailed because of the pain.

Severe pain from muscle spasm can occur from ligament and tendon weakness because the muscle is trying to stabilize the area. Chronic muscle spasms are almost always an indication of underlying ligament weakness. If the ligaments cannot stabilize the joint, the muscles contract to do it.

This is why treatments such as physical therapy, electrical stimulation, and massage, often help to some degree, by relaxing the muscles, but do not cure the problem because the ligament laxity or weakness continues. Prolotherapy to strengthen the underlying joint and ligament permanently eliminates the pain.

The odd thing is that sometimes the pain will totally dissipate between attacks. During this period a physician can still palpate the region and find the tender areas. When the tender areas are palpated, a female will squirm, but a male will jump because of his lower pain threshold. This is called a positive squirm and jump sign, respectively.

What most athletic trainers, orthopedic surgeons, and physical therapists do not know is that ligaments can refer pain to a distant site. The more severe the injury, the more likely a referral pain pattern will exist. Dr. Hackett determined the referral patterns of the ligaments of the lower back, which refer to the legs, after giving 18,000 intraligamentous injections to 1656 patients over a period of 19 years. (Hackett, G. Ligament and Tendon Relaxation Treated by Prolotherapy. Third Edition. Springfield, IL: Charles C. Thomas, Publisher, 1958.)

He determined that often sacroiliac ligament injury refers pain down the leg into the foot and is the reason for so-called "sciatica." Hip joint ligament injury refers pain down the leg into the big toe. Thus if a person has the respective ligament referral pattern, it helps the Prolotherapist determine which ligaments should be examined. The tender areas, as determined by a positive squirm or jump sign, are then injected. Ligament and/or tendon laxity (weakness) is one of the only conditions in which the diagnosis is confirmed before treatment and verified after each treatment. This one fact may be the reason for Prolotherapy's tremendously high success rate.

The treatment involves a physician palpating the exact site of the injury, reproducing the pain, and then confirming the diagnosis with the actual injections, because an anesthetic is contained in the Prolotherapy solutions. The pain is then usually eliminated immediately after the treatment due to the effect of the anesthetic being injected right into the source of the pain-the fibro-osseous junction. Prolotherapy injections into all the tender areas will immediately eliminate all of the sharp pain and tenderness if enough solution of sufficient anesthetic strength is injected. Some people get so many injections that each injection can only contain a small amount of anesthetic solution (higher levels would be toxic). In such an instance, most of the pain will be immediately eliminated, but not all of it. Relieving the pain immediately after the Prolotherapy gives the athlete and the physician confidence that the injured structures have been treated.

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