Prolotherapy for Lateral Ankle Instability: A Promising Non-Surgical Approach
Lateral ankle sprains are among the most common musculoskeletal injuries, particularly in physically active individuals and athletes. While most sprains heal with standard conservative care, a substantial number of cases progress to chronic ankle instability (CAI)—a condition marked by recurrent sprains, joint weakness, and a feeling of the ankle "giving way". In the UK and globally, this leads to significant long-term disability, loss of function, and, in many cases, the early onset of post-traumatic osteoarthritis.
Given the limitations of current treatment options—including bracing, physiotherapy, and surgery—many patients are now exploring prolotherapy, a regenerative injection therapy that is gaining increasing scientific credibility.
What Is Prolotherapy and How Does It Work?
Prolotherapy, short for "proliferation therapy", involves injecting an irritant solution—most commonly hypertonic dextrose (sugar water)—into damaged or weakened ligaments and tendons. The principle is simple but powerful: the injected solution induces a mild, localised inflammatory response, which stimulates the body’s natural healing cascade. This process encourages:
Fibroblast activation and proliferation
Collagen synthesis and tissue remodelling
Strengthening of ligamentous and tendon attachments
Restoration of mechanical stability in joint structures
Histological and pre-clinical studies have confirmed that dextrose prolotherapy increases the cross-sectional area and tensile strength of ligaments, enhancing joint integrity over time.
One of the key targets in CAI is the anterior talofibular ligament (ATFL), the most commonly injured structure in lateral ankle sprains. Prolotherapy aims to restore the mechanical function of this ligament without surgical intervention.
Clinical Evidence for Prolotherapy in Ankle Instability
1. Randomised Controlled Trial Protocol (Hong Kong)
A major trial protocol published in Trials outlined a rigorous, single-centre, randomised controlled trial comparing dextrose prolotherapy (15%) to normal saline injections in patients with CAI. Participants will receive four ultrasound-guided injections over 16 weeks, and outcomes will be tracked over one year using tools like the Cumberland Ankle Instability Tool (CAIT), Star Excursion Balance Test, and Foot and Ankle Ability Measure (FAAM). This study aims to establish prolotherapy as a non-surgical, primary treatment for chronic ankle instability.
2. Case Series in Elite Athletes (UK)
A case series published in Acta Orthopaedica Belgica by Calder et al. examined the use of prolotherapy in elite-level football players suffering from lateral ligament injuries. Using ultrasound-guided prolotherapy to treat isolated ATFL and AITFL (anterior inferior tibiofibular ligament) injuries, the study found an average return-to-play time of 62 days—comparable to conservative treatment timelines, but with no recorded reinjuries during follow-up. This is significant for elite athletes where re-injury can be career-limiting.
3. Neurofascial Prolotherapy Study (Iran)
In a 2022 study by Kazempour Mofrad et al., 25 patients with MRI-confirmed chronic ankle ligament injuries received neurofascial prolotherapy with 12.5% dextrose. The CAIT score improved from an average of 1.88 to 21.84 over six months, and pain levels (VAS) dropped from 6.12 to 1.24, indicating a statistically and clinically significant improvement in both stability and pain.
4. Retrospective Study of Chronic Ankle Pain
A UK-based retrospective study published in Practical Pain Management looked at 19 patients with long-standing ankle pain and instability. After an average of four prolotherapy sessions using the Hackett-Hemwall technique, patients reported an 80% reduction in pain, improved range of motion, and better overall quality of life—even when previous clinicians had said surgery was the only option.
Why Prolotherapy Matters in the UK Context
In the UK, chronic ankle instability remains under-recognised and often under-treated. While surgical reconstruction may be effective, it is expensive, carries risks, and often involves long rehabilitation periods. Moreover, surgery may not fully restore normal anatomy or function.
Prolotherapy offers a cost-effective, minimally invasive alternative with minimal downtime and growing scientific support. It can be especially beneficial for:
Patients with residual instability despite physiotherapy
Athletes needing faster return-to-play timelines
Individuals wanting to avoid surgery or long-term use of ankle supports
Chronic ankle pain sufferers seeking improved function and quality of life
Important Considerations
Training and technique matter: Prolotherapy should be administered by clinicians experienced in musculoskeletal injection therapy, ideally under ultrasound guidance.
Not for everyone: Complete ligament tears or systemic inflammatory conditions may require alternative treatments.
Gradual improvement: It may take several months and repeated sessions to observe full therapeutic benefit.
Conclusion
Prolotherapy represents an emerging frontier in the management of lateral ankle instability. By directly addressing ligamentous laxity and instability through the body’s own repair mechanisms, it bridges the gap between conservative care and surgery.
Whether you're a recreational runner, a professional footballer, or someone dealing with persistent ankle issues, prolotherapy offers a scientifically supported, non-surgical option to restore function and reduce pain.
References
Sit RWS et al. "A protocol for a randomized clinical trial assessing the efficacy of hypertonic dextrose injection (prolotherapy) in chronic ankle instability." Trials 2022; 23:1063. https://doi.org/10.1186/s13063-022-07037-7
Calder JD et al. "Prolotherapy as a treatment choice for lateral ankle ligament injuries in elite athletes: A case series." Acta Orthop Belg 2021; 86(e-Suppl 3):88–93.
Kazempour Mofrad M et al. "Neurofascial Dextrose Prolotherapy for Managing Chronic Ankle Ligament Injury." Anesth Pain Med 2022; 12(1):e118317.
Hauser RA et al. "Dextrose Prolotherapy Injections for Chronic Ankle Pain." Practical Pain Management Jan/Feb 2010: 70–76.
