Advertisement

Dry Needling as a Treatment Modality for Tendinopathy: a Narrative Review

  • Vladimir Stoychev
  • Aharon S. Finestone
  • Leonid KalichmanEmail author
Hot Topic

Abstract

Purpose of Review

Tendinopathy describes a combination of pain, swelling, and impaired performance of the tendon and around structures. There are various treatment options for tendinopathy with unclear efficacy. Dry needling involves inserting needles into the affected tendon, and it is thought to disrupt the chronic degenerative process and encourage localized bleeding and fibroblastic proliferation. The purpose of this review is to review the use of dry needling as a treatment modality for tendinopathy.

Recent Findings

The effectiveness of dry needling for treatment of tendinopathy has been evaluated in 3 systematic reviews, 7 randomized controlled trials, and 6 cohort studies. The following sites were studied: wrist common extensor origin, patellar tendon, rotator cuff, and tendons around the greater trochanter. There is considerable heterogeneity of the needling techniques, and the studies were inconsistent about the therapy used after the procedure. Most systematic reviews and randomized controlled trials support the effectiveness of tendon needling. There was a statistically significant improvement in the patient-reported symptoms in most studies. Some studies reported an objective improvement assessed by ultrasound. Two studies reported complications.

Summary

Current research provides initial support for the efficacy of dry needling for tendinopathy treatment. It seems that tendon needling is minimally invasive, safe, and inexpensive, carries a low risk, and represents a promising area of future research. In further high-quality studies, tendon dry needling should be used as an active intervention and compared with appropriate sham interventions. Studies that compare the different protocols of tendon dry needling are also needed.

Keywords

Dry needling Tendinopathy Needle tenotomy Tendon fenestration Acupuncture 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Maffulli N, Khan KM, Puddu G. Time to change a confusing terminology. Arthroscopy. 1998;14(8):840–3.CrossRefGoogle Scholar
  2. 2.
    Khan KM, Cook JL, Bonar F, Harcourt P, Åstrom M. Histopathology of common tendinopathies: update and implications for clinical management. Sports Med. 1999;27(6):393–408.CrossRefGoogle Scholar
  3. 3.
    Peters JA, Zwerver J, Diercks RL, Elferink-Gemser MT, van den Akker-Scheek I. Preventive interventions for tendinopathy: a systematic review. J Sci Med Sport [Internet]. 2016;19(3):205–11. Available from:.  https://doi.org/10.1016/j.jsams.2015.03.008.CrossRefGoogle Scholar
  4. 4.
    Maffulli N, Wong J, Almekinders LC. Types and epidemiology of tendinopathy. Clin Sports Med. 2003;22:675–92.CrossRefGoogle Scholar
  5. 5.
    Holmes GB, Lin J. Etiologic factors associated with symptomatic Achilles tendinopathy. Foot Ankle Int. 2006;27(11):952–9.CrossRefGoogle Scholar
  6. 6.
    Milgrom C, Finestone A, Zin D, Mandel D, Novack V. Cold weather training: a risk factor for Achilles paratendinitis among recruits. Foot Ankle Int. 2003;24(5):398–401.CrossRefGoogle Scholar
  7. 7.
    Rees JD, Maffulli N, Cook J. Management of tendinopathy. Am J Sports Med. 2009;37(9):1855–67.CrossRefGoogle Scholar
  8. 8.
    Gunn C. The Gunn approach to the treatment of chronic pain. New York: Churchill Livingstone; 1997. 1997 pGoogle Scholar
  9. 9.
    van Sterkenburg MN, van Dijk CN. Mid-portion Achilles tendinopathy: wWhy painful? An evidence-based philosophy. Knee Surg Sport Traumatol Arthrosci. 2011;19(8):1367–75.CrossRefGoogle Scholar
  10. 10.
    Kellerman R, Bope E. Conn’s Curr Ther. 2018;2018:1.Google Scholar
  11. 11.
    Almeikinders LC, Temple JD. Etiology, diagnosis, and treatment of tendonitis : an analysis of the literature. Med Sci Sports Exerc. 1998;30(8):1183–90.CrossRefGoogle Scholar
  12. 12.
    Lopez RGL, Jung HG. Achilles tendinosis: treatment options. CiOS Clin Orthop Surg. 2015;7(1):1–7.CrossRefGoogle Scholar
  13. 13.
    Goldin M, Malanga GA. Tendinopathy: a review of the pathophysiology and evidence for treatment. Phys Sportsmed. 2013;41(3):36–49.CrossRefGoogle Scholar
  14. 14.
    Langberg H, Rosendal L, Kjær M. Training-induced changes in peritendinous type I collagen turnover determined by microdialysis in humans. J Physiol. 2001;534(1):297–302.CrossRefGoogle Scholar
  15. 15.
    Tipton CM, Matthes RD, Maynard JA, Carey RA. The influence of physical activity on ligaments and tendons. Med Sci Sports Exerc. 1975;7(3):165–75.CrossRefGoogle Scholar
  16. 16.
    Cook JL, Khan KM, Purdam C. Achilles tendinopathy. Man Ther. 2002;7(3):121–30.CrossRefGoogle Scholar
  17. 17.
    Almekinders LC, Banes AJ, Ballenger CA. Effects of repetitive motion on human fibroblasts. Med Sci Sports Exerc. 1993;25(5):603–7.CrossRefGoogle Scholar
  18. 18.
    Sartorio F, Zanetta A, Ferriero G, Bravini E, Vercelli S. The EdUReP approach plus manual therapy for the management of insertional Achilles tendinopathy. J Sports Med Phys Fitness. 2018;58(5):664–8.PubMedGoogle Scholar
  19. 19.
    Andres BM, Murrell GAC. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008;466(7):1539–54.CrossRefGoogle Scholar
  20. 20.
    SANE. Medical Methods of Treatment. SANE Ment Heal Ser. 2018;601.Google Scholar
  21. 21.
    Schepsis AA, Leach RE. Surgical management of Achilles tendinitis. Am J Sports Med. 1987;15(4):308–15.CrossRefGoogle Scholar
  22. 22.
    Kalichman L, Vulfsons S. Dry needling in the management of musculoskeletal pain. J Am Board Fam Med. 2010;23(5):640–6.CrossRefGoogle Scholar
  23. 23.
    Chiavaras MM, Jacobson JA. Ultrasound-guided tendon fenestration. Semin Musculoskelet Radiol. 2013;17(1):85–90.CrossRefGoogle Scholar
  24. 24.
    • Krey D, Borchers J, McCamey K. Tendon needling for treatment of tendinopathy: a systematic review. Phys Sportsmed. 2015;43(1):80–6 The study is the first and the only systematic review that explores if tendon needling is an effective treatment for tendinopathy. The search is limited to high-level randomized trials with control groups. CrossRefGoogle Scholar
  25. 25.
    • Tsikopoulos K, Tsikopoulos I, Simeonidis E, Papathanasiou E, Haidich AB, Anastasopoulos N, et al. The clinical impact of platelet-rich plasma on tendinopathy compared to placebo or dry needling injections: A meta-analysis. Phys Ther Sport [Internet]. 2016;17(2016):87–94.  https://doi.org/10.1016/j.ptsp.2015.06.003 Available from: A meta-analysis compares the tendon needling with injections of platelet-rich plasma with that of placebo or dry needling injections on tendinopathy. CrossRefGoogle Scholar
  26. 26.
    Kesikburun S, Tan AK, Yilmaz B, Yaşar E, Yazicioǧlu K. Platelet-rich plasma injections in the treatment of chronic rotator cuff tendinopathy: a randomized controlled trial with 1-year follow-up. Am J Sports Med. 2013;41(11):2609–15.CrossRefGoogle Scholar
  27. 27.
    Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jensen P, Ellingsen T. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013;41(3):625–35.CrossRefGoogle Scholar
  28. 28.
    Mattie R, Wong J, McCormick Z, Yu S, Saltychev M, Laimi K. Percutaneous needle tenotomy for the treatment of lateral epicondylitis: a systematic review of the literature. PM R [Internet]. 2017;9(6):603–11. Available from:.  https://doi.org/10.1016/j.pmrj.2016.10.012.CrossRefGoogle Scholar
  29. 29.
    • Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S, Vermillion DA, et al. Efficacy of platelet-rich plasma for chronic tennis elbow a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med. 2013;42(2):463–71 A large double-blind, prospective, multicenter RCT compares tendon needling with and without PRP in patients with chronic tennis elbow. The authors report statistically significant change from baseline in both groups, without significant differences between the groups at 12 weeks, but with clinically meaningful improvements in patients treated with leukocyte-enriched PRP at 24 weeks. CrossRefGoogle Scholar
  30. 30.
    Stenhouse G, Sookur P, Watson M. Do blood growth factors offer additional benefit in refractory lateral epicondylitis? A prospective, randomized pilot trial of dry needling as a stand-alone procedure versus dry needling and autologous conditioned plasma. Skelet Radiol. 2013;42(11):1515–20.CrossRefGoogle Scholar
  31. 31.
    • Uygur E, Aktaş B, Özkut A, Erinç S, Yilmazoglu EG. Dry needling in lateral epicondylitis: a prospective controlled study. Int Orthop. 2017;41(11):2321–5 The study compares the results of dry needling with first-line treatments. The interventions were performed by a physical therapist using thin needles. Significant differences were found at the 3-week follow-up in both groups; however, only dry needling was effective at 6 months. CrossRefGoogle Scholar
  32. 32.
    • Rha D, Park G-Y, Kim Y-K, Kim MT, Lee SC. Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease: a randomized controlled trial. Clin Rehabil. 2013;27(2):113–22 A prospective double-blind RCT compares the effects of tendon needling, with or without PRP in patients with rotator cuff disease. The only study with objective sonographic examinations performed in all patients at baseline and in 6-month follow up. CrossRefGoogle Scholar
  33. 33.
    • Bell KJ, Fulcher ML, Rowlands DS, Kerse N. Impact of autologous blood injections in treatment of mid-portion Achilles tendinopathy: double-blind randomised controlled trial. BMJ. 2013;346(apr18 2):f2310–0 A prospective double-blind RCT evaluated the effectiveness of dry needling with or without the use of autologous blood in patients with mid-portion Achilles tendinopathy. Both groups showed clinically meaningful improvement in pain and functions (VISA-A score) by 6 months and there was no significant difference between groups. CrossRefGoogle Scholar
  34. 34.
    • Dragoo JL, Wasterlain AS, Braun HJ, Nead KT. Platelet-rich plasma as a treatment for patellar tendinopathy a double-blind, randomized controlled trial. Am J Sports Med. 2014;42(3):610–8 A prospective double-blind RCT evaluated the effectiveness of dry needling with or without PRP in patients with patellar tendinopathy. The diagnosis was confirmed by MRI. Statistically significant improvement in both groups, significantly more in the PRP group at 12 weeks, while the difference between groups disappeared at 26 weeks. CrossRefGoogle Scholar
  35. 35.
    Jacobson JA, Yablon CM, Henning PT, Kazmers IS, Urquhart A, Hallstrom B, et al. Greater trochanteric pain syndrome: percutaneous tendon fenestration versus platelet-rich plasma injection for treatment of gluteal tendinosis. J Ultrasound Med. 2016;35(11):2413–20.CrossRefGoogle Scholar
  36. 36.
    Housner JA, Jacobson JA, Misko R. Sonographically guided percutaneous needle tenotomy for the treatment of chronic tendinosis. J Ultrasound Med. 2009;28:1187–92.CrossRefGoogle Scholar
  37. 37.
    Housner JA, Jacobson JA, Morag Y, Pujalte GGA, Northway RM, Boon TA. Should ultrasound-guided needle fenestration be considered as a treatment option for recalcitrant patellar tendinopathy? A retrospective study of 47 cases. Clin J Sport Med. 2010;20(6):488–90.CrossRefGoogle Scholar
  38. 38.
    Kanaan Y, Jacobson JA, Jamadar D, Housner J, Caoili EM. Sonographically guided patellar tendon fenestration: prognostic value of preprocedure sonographic findings. J Ultrasound Med. 2013;32(5):771–7.PubMedGoogle Scholar
  39. 39.
    McShane JM, Nazarian LN, Harwood MI. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow. J Ultrasound Med. 2006;25:1281–9.CrossRefGoogle Scholar
  40. 40.
    McShane JM, Shah VN, Nazarian LN. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow: is a corticosteroid necessary? J Ultrasound Med. 2008;27(8):1137–44.CrossRefGoogle Scholar
  41. 41.
    Jacobson JA, Rubin J, Yablon CM, Kim SM, Kalume-Brigido M, Parameswaran A. Ultrasound-guided fenestration of tendons about the hip and pelvis: clinical outcomes. J Ultrasound Med. 2015;34(11):2029–35.CrossRefGoogle Scholar
  42. 42.
    Peck E, Jelsing E, Onishi K. Advanced ultrasound-guided interventions for tendinopathy. Phys Med Rehabil Clin N Am [Internet]. 2016;27(3):733–48. Available from:.  https://doi.org/10.1016/j.pmr.2016.04.008.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Authors and Affiliations

  1. 1.Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health SciencesBen-Gurion University of the NegevBeer ShevaIsrael
  2. 2.Bait Balev HospitalBat YamIsrael
  3. 3.Department of Orthopaedic Surgery, Shamir Medical Center, Zerifin, affiliated to the Faculty of MedicineTel Aviv UniversityTel AvivIsrael

Personalised recommendations