Prolotherapy for Inguinal Pain Letters to the Editor
BioMechanics Archives:: September 2005 Contact Point
Prolotherapy results inspire practitioner's curiosity
By Jerry Hesch
Reading the news article on prolotherapy ("Prolotherapy relieves groin pain in study of soccer, rugby players," June, page 11), I felt compelled to share some comments. Though limitations of the study cannot be adequately ascertained given the brevity of the article, the short-term results are very impressive. Prolotherapy, using lidocaine for analgesia and dextrose as a proliferant, over the course of 17 months resulted in significant reduction in pain and return to painfree sports participation at full capacity in 20 of 24 participants. Two subjects were not able to return full capacity and two had pain when participating. The use of lidocaine with a proliferant is supported by the results, but the lack of a control group means we cannot separate the different mechanisms of action. The athletes who did not achieve a successful outcome may experience some degree of disability, which is likely to spill into other facets of their lives. I have firsthand knowledge of abdominal neuropathies, having sustained a pelvic fracture and multiple ANs due to a severe motorcycle accident. I submit that the possibility of such neuropathies is worth considering for those who have lasting disability and unresolved groin pain. Successful ablation of the genitofemoral and accessory obturator nerves has not resulted in sensory loss in my personal experience, yet did provide substantial pain relief, along with improvement in function. (In researching my own neuropathies I have not had any success locating studies on the use of fibrinogen/fibrin glue for prolotherapy, yet the mechanism of action appears to be consistent with the goals of prolotherapy. I would be grateful to hear if anyone is performing research with this application.) Extreme pain, even if a screen for inguinal hernia is negative (no bulge), can imply an ilioinguinal neuropathy. Pressure above the inguinal ligament may refer to the medial calf and is easily confused with a coexisting S1 radiculopathy when in fact the dysesthesia may be mediated by the terminal saphenous portion of the femoral nerve. Response to the same pressure can skip the proximal thigh and cause a diffuse sense of warmth in the foot. Cautious digital pressure on the scrotal contents can be revealing in the presence of genitofemoral AN. Other-less common-hernias, such as at the obturator foramen, should be ruled out. Referral to a genitourinary or surgical specialist is warranted for recalcitrant groin pain. The proximity of the hip joint mandates traditional screening and a standard medical workup to rule out common and occult pathologies for patients with chronic groin pain. The concluding quote of the news article: "Treating immature athletes (for Osgood-Schlatter disease with prolotherapy), who in the past have been asked to stop playing for two months, for the first time will emphasize healing the cartilage attachment and patellar tendon prior to the formation of an ossicle," seems rather ambitious, given that the study is presently in search of funding. Although briefly mentioned in that final paragraph, I would like to request elaboration on how the goals of prolotherapy are different from other standards of care for Osgood-Schlatter disease, such as those of the American Academy of Orthopaedic Surgeons or the American College of Sports Medicine. I thank the authors for sharing their impressive study, which motivates me to express my gratitude to all authors and inquisitive clinicians, to dialogue, review the literature, and, lastly, to remain hopeful.
Jerry Hesch, MHS, PT Henderson, NV
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