In the last article, authors Melzack, Wall and Bowsher helped explain the theory of pain relief through Dry Needling. This is the last article of the series, where we will be listing a few conditions that will benefit from the extensive use of Dry Needling. Also mentioned will be other techniques that could prove useful along with Dry Needling, thus specifying a global approach to treating that particular condition.
1) Headaches: Before treating headaches, it is imperative to know the source of headaches.
A majority of Migraine sufferers actually suffer from Muscular headaches. Once CNS sources are ruled out through MRI techniques, the therapist must evaluate the patient’s cervical spine (A Cervical spine radiograph is a must). Muscular headaches mostly originate from a dysfunctional cervical spine. Treating the Cervical musculature and restoring the normal Biomechanics of the Cervical, and upper thoracic spine will help in alleviating headaches to a large extent. The alignment of the Lower Spinal segments (Lumbar) should never be neglected.
Common sources of headaches are the Upper Trapezius, Splenius Capitis, Splenius Cervicis, Sternocleidomastoid, Levator Scapulae, Rectus Capitis, Frontalis and the Temporalis muscles. Needling these muscles will normally alleviate sources of most muscular headaches. Needling the fascia of the scalp also provides substantial relief to the patient (I.e.: Particularly the origins of the posterior neck musculature on the scalp). It is also helpful to restore mobility at the Atlanto-Occipital and the Atlanto-axial segments of the cervical spine. Graded mobilization (Maitland’s) plays a vital role.
Example: Patient Mr. MP, at our clinic complained of constant headaches for the past 6 years. Upon thorough examination, his cervical spine showed moderate limited mobility in side flexion and tenderness/ pain at the Atlanto-occipital junction during testing. There was no joint laxity at said joint. His history also revealed constant Gastrointestinal upsets and history of sinusitis/ colds and nasal congestion. Treatment involved improving his immunity through Probiotics and Hormonal balancing which decreased the constant occurrence of colds and subsequently provided him relief from congestion and Gastrointestinal upsets. (At our facility, Nutrition plays a big role in improving overall health.)
The second part of the treatment involved treating any postural shifts in his spinal column (Quadratus Lumborum tightness in his case) along with strengthening of the Core musculature and advice on maintaining good posture. The next few sessions focused on Dry needling of active myofascial triggers (MTrP’s) that contributed to his ‘behind-the-head-and-front-of-the-head’ nature of headaches. 4 sittings of Cervical spine mobilization through Maitland’s methods (PA spinous process, medial/cranial and PA glides to B/L facets at involved levels) and release of latent spinal musculature triggers (MTrP’s) through Dry Needling helped the patient to remarkably recover from headaches that had plagued him for years.
During the course of his treatment (and 6-8 months post discharge), his home exercise program involved strengthening of arm/ scapular/ neck and core musculature along with Nutritional advice.
2) Tennis Elbow: What musculoskeletal condition would you think of, if a patient walked in with pain at his Medial humeral epicondyle? Would you check his Forearm extensors, Supinator and Biceps Brachii?
Lateral Epicondylitis can be quite a misnomer when patients suffer from ‘vague arm/ forearm/ elbow pain’ during arm/ forearm movement. Only when the condition gets chronic does the patient pin point to tenderness at the lateral epicondyle. In most cases of Lateral Epicondylitis/ Common extensor origin strain at elbow, active triggers are found in the Supinator, ECRL, ECRB, Biceps Brachii, Brachialis, Brachioradialis, Pronator Teres and Pectoralis Minor muscles of the involved side. The Supinator exacerbates pain in long standing Lateral epicondylitis cases. It is immensely beneficial to address this muscle at the start of treatment. It is also imperative to treat latent triggers in the Triceps and Coracobrachialis muscles.
Mobilization to the head of the radius proves useful in patients who have a minor subluxation of the head of the radius which could easily go unnoticed. Releasing the Biceps Brachii before manipulating/ mobilizing this bone improves treatment outcome. Strengthening of pronators, common extensors of forearm and arm/ scapular musculature can completely rehabilitate the patient.
3) Plantar Fasciitis: COMMONLY HEARD: ‘Gastrocnemius stretches/ Plantar fascia release/ Icing to the plantar fascia and Tennis ball massages to tender points on the sole of the foot can help with Plantar fasciitis, but it cannot be cured.’ OR ‘The patient must try to lose some weight or wear soft inner soles within his/her shoes to decrease pain from plantar fasciitis.’OR ‘Wearing an overnight calf stretch splint will help prevent heel pain in the mornings’
QUESTION: Is Plantar fasciitis really completely treatable? Ever?
MUSCLES TO BE NEEDLED (If your patient doesn’t mind getting needles stuck into his/her sole): Quadratus Plantae, Flexor Hallucis Brevis, Adductor Hallucis, Abductor Hallucis, Gastrocnemius (medial and lateral), Soleus, Tibialis Posterior, EDL, EHL, Peronei and Tibialis Anterior.
It is a very good idea to find the biomechanical fault/event that precipitated the tightening and inflammation of the plantar fascia in the first place. Most causes are proximal to the foot (I.e.: SIJ dysfunction, Postural faults in spine). Treating these biomechanical faults along side the treatment of the plantar fascia will give a better treatment outcome and help in complete resolution of plantar fasciitis.
If the therapist is skilled, then needling of Calcaneal tuberosity through Periosteal pecking (Dry Needling) might be tried in chronic cases of Plantar Fasciitis. However it is advisable not to needle through the Fat pad of the heel. Care must be taken not to needle the plantar arteries. Mobilization of joints of the foot/ankle plays a big role in chronic plantar fasciitis. Refer to Dr. Umasankar Mohanty’s article in Physiotimes (2013) on foot mobilization techniques in Plantar fasciitis.
Myofascial release of Plantar fascia and the Achilles tendon along with daily stretches to the Gastro-Soleus muscles provides immense relief to the patient. Strengthening of Foot intrinsics and Gastro-Soleus should also be incorporated into treatment. Kinesiotaping of the plantar fascia may be tried in chronic cases, in order to support the plantar fascia.
4) SIJ Dysfunction:
SIJ Dysfunction although a common occurrence in most low back pain conditions necessitates thorough assessment, diagnosis and correction of dysfunction through appropriate muscular strengthening and improved posture. It is very difficult to tabulate the permutations and combinations of dysfunctions that could occur at the SIJ and its associated lumbar segments. However after proper evaluation of the dysfunction, the following muscles could be considered for needling (in most cases):
For correction of Anterior rotation of Innominate:
Needling of Active triggers in Adductor Longus, Tensor Fascia Latae, Gluteus Minimus, Iliopsoas, Rectus Femoris, Piriformis, Tibialis Anterior, Vastus Lateralis and Gastrocnemius
Needling of Active/ Latent triggers (Depending on Chronicity of SIJ dysfunction) in Sartorius, Gluteus Maximus, Gluteus Medius and Lumbar Multifidus.
For correction of Posterior rotation of Innominate:
Needling of Active triggers in Latissimus Dorsi, Rectus Abdominis, Gluteus Maximus, Gluteus Medius, Gluteus Minimus, Piriformis, (sometimes other Lateral Rotators of Hip), Peronei, Lateral Hamstrings, Rectus Abdominis and Sartorius. Needling of Active/ Latent triggers (Depending on Chronicity of SIJ dysfunction) in Gastrocnemius, Tibialis Anterior, VMO, Vastus Lateralis and Superficial needling of IT band.
These are the list of muscles that shouldn’t be ignored when treating SIJ dysfunction through Dry Needling. It is important to note that needling all of these muscles in all patients suffering from SIJ dysfunction is not mandated. Needling should be done after proper assessment of Biomechanics and MTrP’s.
5) Ankle sprain:
Example: Mr. PS is a 22 year old male who complained of chronic ankle swelling around the anterolateral part of his Right ankle since 2 years. This swelling was exacerbated by long periods of standing. Mr. PS had sprained his ankle during a political rally when he missed a step. He fell to the ground but felt a sharp pain in his Right ankle immediately and couldn’t get up thereafter. An MRI confirmed that he had a second degree tear to his Right Anterior Talofibular ligament (ATFL). After moderately successful sessions of Ultrasound to the ATFL and strengthening to the Calf musculature at his local Physiotherapy center, the patient stopped Physiotherapy altogether - only to return to Physiotherapy 2 years later complaining of a constant dull aching pain in his ankle during movements and long periods of standing.
After proper assessment, patient was needled for the Tibialis Anterior and Peronei muscles along with the muscles along the Right lateral side (I.e.: Lateral Gastrocnemius, Lateral Hamstrings, TFL, Gluteus Maximus and Gluteus Minimus). The Medial Gastrocnemius and Soleus were also needled. The IT band was released through Myofascial release. Maitland’s mobilization to improve Fibular gliding movement (at Lateral malleolus) and to improve movement at the Talocrural gliding joint were also done. Strengthening of weakened lower extremity musculature (Gluteus Medius, Gluteus Maximus, VMO, Hamstrings, Gastrocnemius) was also incorporated into the treatment program. Kinesiotaping, Core strengthening, Balance training and Agility exercises helped patient to return to normalcy.
6) Trapezitis/ Trapezius spasm:
Most therapists address the weak overloaded condition of the Upper Trapezius muscle as Trapezitis. Strengthening and decreasing the load on the Upper Trapezius may actually improve symptoms of pain, tenderness and headaches in patients complaining of pain around the angle of the neck. It is imperative not to neglect the scapulohumeral rhythm, the core strength, postural anomalies in the spine and pectoral/ arm strength during the treatment of neck related pain. Deep neck musculature should also be palpated for sources of triggers. A cervical radiograph should be considered to rule out any involvement of the joints in the Cervical spine. Cervical spine Mobilisation and Neural mobilization helps treat chronic cases of neck pain. Needling should be done symptomatically. Latent triggers in the scapula shouldn’t be spared since these can seriously alter biomechanical firing/ muscle activation patterns.
Needling to reduce triggers in the Upper Trapezius, Levator Scapulae, Middle/ Lower Trapezius, Rhomboids, Supraspinatus, Infraspinatus, Serratus Anterior, Subscapularis and Pectoralis Minor proves useful. The Sternocleidomastoid shares the same fascia as the Upper Trapezius and should never be excluded during the treatment of ‘Trapezitis’. The Trapezius is a major source of headaches and Vertigo in patients suffering from long standing headaches (? Migraines) and therefore these muscles shouldn’t be ignored in chronic headaches. Scalenes, Deltoid, Biceps and Triceps are other muscles which need to be searched for latent triggers. These may alter the mechanics at the cervical spine and the Glenohumeral joint and therefore shouldn’t be neglected.
7) Osteoarthritis/ Osteoarthrosis of knee:
Presentation of Degeneration and inflammation of knee joint cartilage is a very common occurrence in patients coming in for Physiotherapy. Not all cases necessitate joint replacements. In fact, joint replacements can be postponed long enough with skilled Physiotherapy. Dry Needling can help by not only alleviating pain but also improving blood supply to the Periosteum around the joint.
Periosteal pecking (through Dry Needling) of outer tibial surfaces is advised which although a very painful technique improves pain caused due to faulty compartmental loading within the knee. Needling could also be done into the patellofemoral joint space in cases of Patellofemoral arthrosis. The functioning of the knee joint is improved by needling the muscles that will provide symptomatic relief. This can only be done through proper assessment. However, some muscles that shouldn’t be neglected during needling are the VMO, Adductor Longus, Rectus Femoris, Vastus Intermedius, Vastus Lateralis, Medial/ Lateral Hamstrings and the Gastrocnemius. The Popliteus is never attended to by most therapists. Needling to the Popliteus can help improve knee joint function immensely. The IT band and Bilateral Gluteus Medius/ Minimus/ Gluteus Maximus and the Rectus Abdominis are imperative to proper functioning of the knee joint. Latent Triggers in these muscles should never be missed.
If knee joint pain is largely unilateral, a more proximal or distal source of the problem should be ruled out first. Several patients with unilateral knee pain show variations in their posture which if addressed in time can help improve the outcome of treatment. Kinesiotaping to Popliteus or Baker’s cysts can provide lot of pain relief and support to an otherwise painful posterior knee joint.
Example: Mrs. MJ showed improvement in knee pain with Dry needling into her outer tibial plateau Periosteum and the removal of muscle triggers in her thigh, gluteal and leg muscles. Her joint space improved with the inclusion of other techniques like aggressive Myofascial release of lower extremity, Kinesiotaping, joint mobilization and Strengthening of Core musculature. She still comes in once a month for needling in order to maintain a pain free joint and keep knee replacement surgery at bay.
8) ACL repairs or ACL strains:
Thorough assessment in cases of ACL repairs/ strains is the need of the day. In most cases an MRI will confirm a complete tear/ strain. Most patients with ACL stress/ strains have weak recruitment or lack of strength in their Gluteal muscles on either side. Upping the strength in these muscles (especially Gluteus Medius) will help in providing stability to the knee joint during pivoting motions.
Example: Mr. AD suffered a complete tear to his Right ACL along with bucket handle tear of Medial meniscus and partial tear to his Lateral meniscus during a State level Football match. He underwent an ACL repair and reported to Physiotherapy in 4 weeks. Needling of following muscles (Right limb) was done in the first three sessions: Gluteus Medius, Gluteus Minimus, Gluteus Maximus, TFL, Adductor Longus/ Magnus, Hamstrings, Quadriceps, Popliteus, Tibialis Anterior, Rectus Abdominis, Peronei and Gastro-Soleus. Treatment also included Plyometrics, Balance training and Agility training along with strengthening of Gluteals, Quadriceps, Hamstrings, Calves, Adductors, Popliteus and Core. Kinesiotaping to improve Hamstrings recruitment/ strength helped prevent further stress on the surgically repaired ACL. Mr. AD is currently playing professional football after 7 months of intensive rehabilitation.
9) Temporomandibular joint dysfunction:
The Temporomandibular joint (TMJ) is a difficult joint to treat with regards to the complex vector forces that this joint has to endure. Parafunctional activities (like Bruxism, Clenching) increase the loads placed upon this joint. A large number of TMJ dysfunctions include Masticatory muscles disorders that may or may not be compounded with a TMJ-disc dislocation/displacement. Treatment in such cases always involves treating the Masticatory musculature (Cervical spine muscles shouldn’t be ignored) and balancing out the vector forces placed upon the TM joint. Manipulation along with functional training of the pterygoids is then incorporated into treatment to improve the positioning of the deviated disc on the condyle.
Muscles that shouldn’t be ignored during needling are the Medial and Lateral Pterygoids, Masseter, Temporalis, Digastrics, Scalenes, Sternocleidomastoid, Facial muscles, Occipitofrontalis, Upper Trapezius, Deep Cervical extensors and Pectorals. Strengthening of Masticatory muscles, Scapular/ Arm muscles and the Core should be emphasized as part of the strengthening program. Spinal postural deformities/ faults should be addressed. Rocabado’s exercises can be suggested for prevention, care and maintenance of the TMJ. Advising the patient to chew on soft food and prevent excess mouth opening will help in acute cases of TMJ disorders.
10) Groin pain/ injuries:
Several athletes (runners and football players) complain of Groin pain after training or after extended periods of game time. Running on concrete surfaces, overtraining and improper Biomechanics are some of the reasons behind Groin pain/ injuries. Removing/ reducing the precipitating factor causing stress to the Groin, will help in reducing the stress on the Groin musculature. However Dry Needling helps remove the TrP’s formed in these muscles due to overuse, while improving the muscle activation timing of involved muscles and also improve the prognosis of the treatment. Strengthening of the Groin/ Oblique muscles should also incorporated along side the release of the Groin muscles. Rest from sport is also advised during the course of the treatment in order to prevent repetitive stress injuries to the Groin muscles.
Muscles that need to be addressed in Groin injuries are the Pectineus, Adductor Longus, Adductor Magnus, Lower portion of Rectus Abdominis, Lower portion of Internal Oblique, Piriformis, Iliopsoas, VMO and Rectus Femoris. Superficial needling of the Inguinal ligament should also be attempted. Again, a proper assessment for Triggers should be done before needling is attempted. Postural dysfunctions like Sacroiliac joint dysfunction and spinal postural abnormalities as a possible cause for groin injuries should be ruled out before attempting needling.
Most Neuromusculoskeletal conditions can be treated with skillful and well chosen Dry Needling techniques. Understanding the cause of the dysfunction is paramount. Thereafter needling can be chosen as the mainstay or the adjunct of treatment. Whatever one chooses, proper assessment of the patient is mandated in all cases. Once a physiotherapist gets proficient in locating TrP’s, very little time and physical energy is required in assessment of pathologic TrP’s.
Whether attempting Superficial or Deep Needling of muscles- the Dry Needling skill should be a treatment tool in every physiotherapist’s kitty!