Optimal Dextrose Concentration for Prolotherapy in TendinopathyA Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

OBJECTIVE: To compare the effectiveness of different dextrose concentrations used in prolotherapy for reducing pain in patients with tendinopathy. DATA SOURCES: PubMed, Cochrane Library, and ScienceDirect were searched from inception to July 2025. STUDY SELECTION: Randomized controlled trials (RCTs) of dextrose prolotherapy in tendinopathy were included; trials reporting 0-10 pain scores at 6-12 weeks against saline were eligible for network meta-analysis. DATA EXTRACTION: Two reviewers independently extracted data and assessed risk of bias (RoB 2.0); certainty of evidence was rated with CINeMA. DATA SYNTHESIS: A frequentist common-effect network meta-analysis estimated mean differences (MDs) with 95% confidence intervals (CIs) versus saline, interpreted against a minimal clinically important difference (MCID) of 1.4 points. RESULTS: Nine RCTs (490 participants) were included; six were at low risk of bias and three had some concerns. Three trials (111 participants) formed the network, each comparison being informed by a single trial. Compared with saline, 15% dextrose (MD -4.66; 95% CI -5.36 to -3.96) and 5% dextrose (MD -3.55; 95% CI -4.24 to -2.86) reduced pain beyond the MCID; both estimates came from one three-arm lateral epicondylitis trial, in which 15% exceeded 5% by 1.11 points (95% CI 0.43 to 1.79). Neither 20% dextrose (MD 0.26; 95% CI -0.22 to 0.74) nor 10.7% dextrose-morrhuate (MD -0.30; 95% CI -1.23 to 0.63) differed from saline. Heterogeneity and inconsistency could not be estimated, and certainty of evidence was low to very low. CONCLUSIONS: Evidence on the optimal dextrose concentration for tendinopathy is limited. The apparent advantage of 5% and 15% dextrose rests on a single trial and may reflect differences in tendon site, injection schedule, and follow-up rather than concentration alone. Adequately powered trials directly comparing concentrations are needed before dosing recommendations can be made.