Ep. 43 Pain Procedures: SIJ Prolotherapy
Episode Summary:
Join hosts Justine Feitelson and Dr. Dan Bates in this episode of 'It's Not In Your Head' as they dive into the details of prolotherapy, a controversial but effective treatment for sacroiliac joint dysfunction. They discuss the mechanism behind prolotherapy, its application, and the differences between using glucose and platelet-rich plasma (PRP) for the procedure. They also cover diagnostic processes, patient selection, potential risks, and outcomes. Whether you're dealing with ligament laxity, hypermobility, or sacroiliac joint pain, this episode offers valuable insights into diagnosing, managing and treating SIJ dysfunction.
Episode Overview:
What is Prolotherapy
Prolotherapy is an injection-based treatment that targets ligaments, aiming to deliberately trigger inflammation so the body lays down new collagen and stiffens lax ligaments, improving joint stability.
This episode focuses on using prolotherapy for sacroiliac (SI) joint dysfunction, especially when the problem is ligament laxity rather than arthritis.
How SI joint dysfunction shows up
SI joint dysfunction pain usually sits below the belt line, often spreading across the buttocks, down the side of the thighs, and sometimes into the groin.
When the pubic symphysis is also unstable, people may have pubic and lower abdominal pain, plus pelvic floor and hip flexor spasm as the body tries to stabilize the pelvis.
Where and how the injections are done
Dan targets the dorsal interosseous ligament at the back of the SI joint using image guidance (X‑ray, CT, or ultrasound) and contrast to confirm the needle is actually inside the ligament.
This is contrasted with “unguided” prolotherapy seen online, where multiple blind injections may act more on nerves than specifically on ligament tissue.
What is injected (sclerosants)
Common options include high‑concentration glucose (often 50% diluted to 25% with local anesthetic), platelet‑rich plasma (PRP), and a third agent Dan notes is more common in the US and not routinely used in Australia.
Glucose works mainly by provoking inflammation, whereas PRP releases growth factors like TGF‑β that stimulate fibroblasts to lay down collagen via a different mechanism.
Evidence and patient selection
Randomized controlled trials for prolotherapy in SI joint dysfunction show, in one study, about 60% of patients achieving at least a 50% pain reduction at 15 months, with follow‑up data in some trials extending out to several years.
Prolotherapy is not used when the main issue is SI joint osteoarthritis without instability; those patients are more likely to be offered radiofrequency procedures instead.
Cost, PRP vs glucose, and Dan’s algorithm
In Australia, Dan notes cost differences between prolotherapy and PRP are small, while in the US PRP can be around the four‑figure range, making it less accessible.
From his experience, PRP tends to hurt less and work faster with a theoretical lower infection risk, but appears less reliable than glucose; glucose hurts more and is slower but gives more consistent results, so he usually starts with glucose and moves to PRP if needed.
Treatment course and rehab
SI prolotherapy is typically done as a series of three injections spaced 4–6 weeks apart, followed by review 8 weeks later; if there is some improvement but not enough, additional injections or a change to PRP may be considered.
Prolotherapy changes ligament integrity, not strength or motor control, so patients still need rehabilitation to retrain pelvic stability muscles once the joint is less wobbly.
Diagnosis and use of belts/shorts
Before committing to prolotherapy, Dan uses diagnostic SI joint blocks with local anesthetic to see if the pain temporarily disappears and also trials an SI belt or shorts to check if external stabilization helps.
If the block helps and the belt reduces pain, that supports a diagnosis of SI joint instability; if the belt makes things worse or the block is negative, he considers other causes such as SI joint arthritis or discogenic pain.
Risks, side effects, and short‑term flare
Usual injection risks include infection, bleeding, bruising, and a predictable pain flare because the treatment is intentionally inflammatory; patients are asked to avoid anti‑inflammatories during treatment and for 6–8 weeks afterward, as these can switch off the desired effect.
A key specific risk is short‑term subluxation (partial dislocation) of the SI joint in the first few days, especially in people who have subluxed before. To reduce this, Dan has patients wear an SI belt or shorts continuously for several days and arrange rapid manual reduction if it slips.
Outcomes, non‑responders, and duration of benefit
Dan summarizes their data roughly as: about 40% respond well and need nothing more, about 30% get enough improvement and are satisfied, about 20% need extra injections beyond the initial series, and around 10% do not respond and may need fusion or other strategies.
For hypermobile / EDS‑type patients, benefit can range from about six months to three or four years, with an average around two years; he now tries to recall people around 20 months for a single “top‑up” before they fully relapse, while trauma‑related instability (like a bad fall) is often a one‑series‑and‑done situation.