Prolotherapy and Prolozone

Prolotherapy and Prolozone are used for treating:

  • Neck, Upper and Lower Back Pain
  • Sacroiliac Joint Pain
  • Shoulder (Rotator Cuff) Injury
  • Regional Pain Syndrome (RSD)
  • Degenerative Disc Disease  (DDD)
  • Tennis / Golfer’s Elbow
  • Wrist and Hand Pain
  • Osteoarthritis Pain
  • Cervicogenic Headaches
  • Myofascial Pain Syndromes
  • Tendinosus
  • Hip or Groin Sprain
  • Knee,  Foot or Ankle Pain
  • Sciatica and TMJ
  • Spondylosis (Spinal Arthritis)


The term prolotherapy is derived from the word prolo, short for proliferation, as the therapy is intended to proliferate tissue growth in the damaged area. This is also called Regenerative Injection Therapy (RIT), since it is recognized that it extends beyond the proliferative stage-now understood as only the second stage of regenerative healing process. Prolotherapy is an injection technique that has been shown to cause growth of cells and tissue to stabilize and strengthen weakened joints, cartilage, ligaments and tendons. It rebuilds and strengthens the complete joint structure even in patients with no cartilage. This therapy may eliminate the need for joint replacement which usually takes three or more months to recover and costs thousands.* This therapy can be effective because it addresses and eliminates the cause of chronic pain arising from connective tissue such as ligaments, tendons and cartilage.

*Results may vary; no guarantee of specific results

Prolotherapy works by causing a temporary, low grade inflammation at the injection site, activating fibroblasts to the area, which, in turn, synthesize precursors to mature collagen and thus reinforce connective tissue. It has been well documented that direct exposure of fibroblasts to growth factors (either endogenous or exogenous) causes new cell growth and collagen deposition. Inflammation creates secondary growth factor elevation. The inflammatory stimulus of prolotherapy raises the level of growth factors to resume or initiate a new connective tissue repair sequence which had prematurely aborted or never started. Animal biopsy studies show ligament thickening, enlargement of the tendinosseous junction, and strengthening of the tendon or ligament after prolotherapy injections (Alderman, 2015).



Prolozone therapy involves injected ozone into the tendon which increases the blood supply and flow of healing nutrients also stimulating the deposition and activity of fibroblasts and chondroblasts. These cells synthesize the collagen and cartilage that the body uses to repair damaged ligaments and joints. This increase in cellular repair activity strengthens and tightens the injured tissues; thereby stabilizing the area, and removing the cause of the pain. Ozone is a naturally-occurring highly reactive molecule consisting of three atoms of oxygen. Because ozone is so reactive, it is able to heavily stimulate fibroblastic and chondroblastic activity. This high level of reactivity, combined with the innate safety of oxygen, makes ozone a highly therapeutic molecule.


Of note, Dr. Hughes’ primary rationale for use of injected ozone, alongside its benefits to mitigate pain, is its safe and very potent antimicrobial effects as part of sterile technique.  

This means you should not be taking any anti-inflammatory or narcotic medications, which inhibit the immune system and inflammation. Tylenol, muscle relaxers, and Ultram are okay. These help decrease pain, but do not inhibit the inflammatory response. Herbs, enzymes and vitamins are also very helpful, but avoid ginger as this inhibits prostaglandin synthesis which is needed for proper inflammation.

How It Works:

1. The injection is placed into the damaged ligament or tendon at the point where it attaches to the bone.

2. The injection produces an inflammation, which increases blood flow, swelling, and pain.

3. The body then launches a course of repair and healing. The inflammation tricks the body into thinking another injury has occurred, so it sends in macrophages, which are cells that ingest and destroy the irritant solution. These cells clean up the area.

4. The body then sends in fibroblasts, which are cells that help build fibrous tissue.

5. The fibroblasts excrete collagen, a protein that makes the ligaments denser and stronger. The stronger ligaments provide more support for the joints and alleviates the pain.*

*Results may vary; no guarantee of specific results

“Dr. Hughes helped heal my shoulder with ultra sound guided injections. He improved my performance with as little down time as possible. He understands the importance of speedy recovery.”*

Lucas - Aspen, CO

*Results may vary; no guarantee of specific results

Frequently Asked Questions:

How to prepare for the procedure?

You should relax.  The shots can be a little painful, but Dr. Hughes or an associate will give you a sedative (if necessary) and pain killers before and after the shot.  Do NOT take Naproxen (Alieve), Aspirin, or Ibroprofen for at least 2 days before the shot.  You may take Tylenol, Trammadol, Vicoden, Norco, Percocet or anything natural before the shot.  (However, cut back on fish oil for 2 days before the shot).  If you need a pain medication stronger than Tylenol, Dr. Hughes can provide it for you.

You may also want to set up for an acupuncture, massage, physical therapy, or rolfing session on the day of the shot or the day after the shot. Dr. Hughes often brings a therapist to assist during the injections, especially when large tendons, joints, necks, backs are injected.  If you do not want to have a therapist during the injections, please tell Dr. Hughes in advance. Most insurance companies will pay for the therapist to assist with massage or acupuncture during the shots. Patients without insurance usually pay an average of $60.00 to have the therapist during the injection.

Do I need to take any medication before the procedure?

Depending on your age and level of activity, you may require more than just standard prolotherapy if your injury has existed for a long time. Dr. Hughes often must break up some of the scar tissue, bone spurs, or fibrotic tendons or ligaments before protherapy can work best. Most tendons and ligaments do not fully heal to 100% tensile strength unless that fibrotic tissue has been removed. Nerve fibers, however, get imbedded in the scarred up ligaments and tendons and thus patients will often feel a shooting pain that may be nerve like for a second or two as the needle breaks up this scar tissue. Even when a full or partial regional nerve block is done (which Dr. Hughes may do), this pain can feel almost as bad as the pain elicited by a dentist. While Dr. Hughes always uses a generous amount of local anesthetic for every procedure, this does not always reduce the nerve pain because the nerve has often been trapped in the scar tissue, preventing the local anesthetic from getting to it for a second before it breaks down. When the scar tissue is removed, the nerve “wakes up,” often with a little shock. This shock is quickly tempered by the local anesthetic as it bathes the nerve so that the pain discontinues rapidly. The best analogy for this type of nerve tissue that is covered by scar tissue is snow laying over a power line in a way that prevents the flow of electricity. When the “snow” is removed by the needle of Dr. Hughes (see the skier in the photo), the electrical signal begins to work again, often with a tiny little jolt. That little jolt is the life of your nervous system sending power and sensation again to the area of injury along with surround tissues.

Dr. Hughes recommends that any patients with all patients with the such fibrotic scar tissue take a little sedative and pain medication before he performs any procedure on the ligament, tendon, or joint.

What to expect during the procedure?

The injections performed by Dr. Hughes most often are guided by ultrasound imaging.  The ultrasound allows for injections to be incredibly precise.  With the ultrasound visualization, Dr. Hughes addresses what is most critical for the patient on the day of the injection.  Sometimes, the ultrasound allows Dr. Hughes to see and inject a torn ligament or tendon (for example with a rotator cuff tear).  At other times, Dr. Hughes must inject a bone spur or scar tissue.  Torn ligament injections may feel different than that of an injection into scar tissue.  Dr. Hughes always gives each patient a healthy dose of local anesthesia during the injection; however, this local anesthesia may not prevent the shocking type of pain that occurs for only seconds after a lesion or scar tissue is injected.

Also note, sometimes injections cause bruising for days or even a few weeks afterwards.  Warm water and gentle motion followed by ice packs for inflammation can reduce the swelling and bruising that may occur during or directly after the injections.

How many procedures are necessary?

 A standard series of injections for most prolotherapy patients is between 2-5 visits. Each injection is separated by a maximum of 2 weeks unless there is significant pain or inflammation after the first procedure. Patients may feel significantly better after the first visit and fail to come back soon enough for the benefit of a second visit to help them. It is recommended to come back sooner than later for a 2nd, 3rd, and 4th set of injections. Some injections, including bone spurs and scar tissue removal, may take up to 8 visits. Please ask Dr. Hughes about your prognosis and how many visits may be necessary for you.

What to do after the injections?

For most patients, following a healthy diet with plenty of protein, along with adequate rest is the key to recovery after the injections.  A lot of patients make the mistake of exercising too aggressively after the injections and then end up slowing down or even impeding the healing process and collagen remodeling that is described above. Dr. Hughes recommends that patients spend at least 2 days resting the injected body part, treating it as if it had been acutely sprained. For the next 2-3 weeks, patients should be careful about aggressive, or long sports activities (aka skiing moguls, basketball, hiking downhill, even high level Yoga) and jerky motions.

Most patients benefit from adding heat to the injected area and following it with ice packs and elevation (for limbs) for about 2-3 days to reduce the inflammation. Patients may take pain killing medications or natural substances with the exception of Ibruprofen, Aleve, Motrin, Aspirin or other NSAIDs (including Celebrex). Dr. Hughes may prescribe either a muscle relaxer or a light narcotic medication for patients with acute pain. Patients may use anything natural to help their pain (including Traumeel, Arnica, Capzacin cream, etc) but should avoid or decrease direct prostagladin inhibitors such as fish oil from approximately 2 weeks after the injections. In order to stimulate healing more rapidly, Dr. Hughes recommends that all patients consider adding the following supplements to their regimen:

Vitamin C (3000mg 2x/day) or a natural form (such as Cataplex C 4 pills/2x day)

Collagen (Neocell):  2scoops/ 2x day  (okay to mix with Vitamin C and fruit juice but take at least 30minutes away from other food)

Many patients benefit from physical therapy, massage, acupuncture, chiropractic care, Yoga, osteopathic manual medicine directly after the injections as well. Please discuss your plans with Dr. Hughes during or before the injections so that his staff and associated clinics can handle your concerns.

Will prolotherapy increase my inflammation?

Regarding inflammation, your body is already chronically inflamed. It needs to finish the healing process by resting and potentially utilizing controlled proliferative shots to bring the attention of the growth factors, cytokines, oxygen, and overall blood flow to the precise points of injury in the ligaments and tendons. This healing process may shift the chronic inflammation to an acute state as the body heals. That’s why some patients feel more pain for a few days (or longer) after the initial prolotherapy shots.

You will likely want to rest for 2 days after each series of shots, doing light activities with minimal lifting or any kind of extreme sports. Then you need to go easy over the course of the next 2-4 months as your back heals. The level of activity varies for each person. It is you that heals your back ultimately…the same way you heal any other injury.

Will prolotherapy lock up my back muscles?

A common reason your back muscles get chronically tight and may not function properly (“lock up”) is likely because of the damaged ligaments, which have become more like rubber bands or frayed ropes, than the cables that they should be. Without rest, your ligaments may get worse. Think of it like this: Your back is like a suspension bridge (eg Golden Gate Bridge). The hardware of the bridge are the bones along with some of the cushioning of the discs. The software of the bridge are the muscles, tendons, and ligaments. The muscles are backup support and for extreme activities (like skiing, or running, etc). Otherwise, the ligaments with some tendons do most of the work. If they fail, the bridge (your hardware and software) starts to swing and more pressure gets put on the discs and the muscles fire more frequently. Then your discs may herniate or first bulge and then herniate. Physical therapy is great to help you recover but over-strengthening and stretching the muscles before you’ve healed the ligaments usually is just a band-aid or at worse, more damaging than good. Trying to make these overworked muscles fire more than they want to is just asking for more injury.

Prolotherapy works by stimulating your body’s natural ability to heal the ligaments and tendons which ultimately will allow your muscles to relax.  Your bridge is no longer swinging the wind and the muscles will only need to tighten down on those moments when you are catching big air on your mountain bike or snowboard or maybe just running up and down your favorite trail.

Can the Injections be billed to my insurance company?

The prolotherapy injections are not billed to insurance because they are not covered by insurance, and we expect payment at the time of service. However, if an ultrasound is used or any other type of injections are used, those can be billed to insurance.

How much does prolotherapy cost?

The cost depends on the body area, complexity, and number of injections needed. Typical prolotherapy procedures range from $350-$700.


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