For centuries doctors have created small injuries in a non-healing wound by “roughing” up the tissues. Physicians still use this concept today for tendons, ligaments, and joint capsules. For example, in a shoulder capsule prolotherapy, a surgeon usually inserts a small catheter that heats up to prompt healing in a damaged shoulder capsule (the covering of the shoulder joint that helps control motion). Surgeons still score ligaments with scalpels and needles in the technique called percutaneous tenotomy, also to prompt a healing response. Another example is micro-fracture surgery to fix a hole in the cartilage; this is where the surgeon pokes holes in the bone to cause the cartilage to heal. Finally, the procedure known as prolotherapy is in this same category. In this procedure, rather than a mechanical injury being initiated, the physician injects a chemical irritant to cause a chemical micro-injury. All of these types of treatment rely on the same concept that we get one bite of the healing “apple” and if something fails to heal completely the first time, we can get more bites at that apple simply by causing a small injury to the area.