Dry Needling for Epicondylitis
Epicondylitis, whether medial, lateral, or both, can be an amazingly annoying and difficult impairment to deal with and treat, especially when chronic. The primary reason this can be such a difficult thing to treat is that in chronic conditions, Periostitis is present, which is inflammation of the periosteum, and without needles, it is impossible to treat directly. For that matter, everything aside from the skin and internal treatment is indirect, unless you know how to needle. Lucky for us, needling is an easy and effective way to directly treat affected structures, including the periosteum, muscles, tendons, and whatever else may be involved. This is an enormous advantage and leads to exponentially improved results.
Before we get into this, I need to say, “golf elbow” and “tennis elbow” are bad terms. Really bad. Either side of either elbow can be affected with both of those sports. Medial and lateral epicondylitis or epicondylalgia are much more accurate terms. OK, I feel better now. Onward!
Why Epicondylitis is Difficult to Resolve
Both of these impairments are common ones that patients get discharged for then end up right back with the same problem down the road. This should not happen, barring some kind of structural pathology. If this is happening, the cause of the problem is not getting resolved during treatment. The symptoms may reduce to a level the patient is comfortable with and may not even notice, but the actual problem is still there. The root cause could be coming from just about anywhere, but it is most commonly found between the thoracic spine and the hand. Let’s assume that all other possible causative factors have been ruled out, and you are certain the problem is in the arm. If this is the case, and the muscles, joints, and other structures have been properly addressed, and the patient continues to return to the clinic with pain after a little while, there are a few things that may be happening. Remember, we are only talking about the arm now.
Dry needling to treat Epicondylitis
With needles, fast, long, and lasting results are infinitely more attainable. The ability to needle inflamed periosteum is extremely beneficial and is a superpowered treatment.
James Dunning and others have some good papers on periosteal electrical dry needling, and there is also a lot of acupuncture research on the subject. I have included some of the citations below.
Nice, healthy periosteum feels like a steel plate when tapped with a needle, and it usually doesn’t hurt. Inflamed periosteum begins to feel mushy. As tendons pull on their attachments, without sufficient relaxation, the periosteum starts to receive more tension than it can tolerate. The result is incremental inflammation of the periosteum and pain.
With more pain the following happens:
- muscles get tighter
- vasculature get restricted
- range of motion decreases, which causes a decrease in the production of * synovial fluid inside joint capsules and a decrease in blood perfusion
- hypoxia ensues
- periosteum is placed under increased tension
... and the cycle continues.
This whole negative feedback loop needs to be destroyed, not just calmed down. Without needles and without treating the periosteum, this negative feedback loop can be extremely difficult to stop. Even if the muscles are all loosened up and there is no other issue, the periosteum, itself, oftentimes remains inflamed, and this starts the whole cycle over again. By needling the periosteum and creating acute bleeding, microvascular dilation is improved, new blood comes to the area and removes the stagnated blood and chemicals, and the ANS becomes more homeostatic, thus promoting healing.
One thing I find advantageous, and I do this with all of my patients, is to connect whatever area of the body you are working on to the correlating spinal level(s) and connect the two with stim. Again, I like 1-5 Hz.
At the spinal level, I needle the multifidus and leave the needle on the laminar periosteum of the spine, or in the case of cranial nerves, the suboccipital periosteum. The base of C2 spinous is a great spot as well. This significantly improves the efficacy of the treatment and will lead to longer lasting results.
I don’t think anyone knows exactly why this happens. We really understand very little about the human body. I bet it is somewhere between 1-10% of all possible knowledge. We do know a few things, but I’m sure we do not understand far more than we do currently understand. I think this is true in all areas of medicine. This makes it so cool, you guys. If we knew everything, life would be super boring. There are lots of awesome things to discover, and it’s really exciting. What I 100% for sure do know, however, is that I have put hundreds of thousands of needles into people, and using this methodology is extremely beneficial. I never used to do this on a consistent basis, but the more I have read and practiced, the more I have come to understand and observe that using this method works.
While I don’t think the periosteum does not inflame itself, but rather tight muscles and tendons pull on and aggravate the periosteum, it often becomes the final and limiting factor to complete recovery. With the addition of needling, practitioners are able to safely and accurately assess the status of periosteum in many locations and treat it. This is impossible without the utilization of needles. If you find soft, mushy periosteum, hit it with the needle a handful of times, leave the needle point on the pathologic periosteum, and add stim. You will notice a marked and consistent hardening of the periosteum until it feels normal, like steel. If you can accomplish this, you will make immense and easy improvements with your patients.
Dunning, J., Butts, R., Young, I., Mourad, F., Galante, V., Bliton, P., Tanner, M. and Fernández-de-Las-Peñas, C., 2018. Periosteal electrical dry needling as an adjunct to exercise and manual therapy for knee osteoarthritis: a multicenter randomized clinical trial. The Clinical journal of pain, 34(12), p.1149.
Dunning, J., Butts, R., Henry, N., Mourad, F., Brannon, A., Rodriguez, H., Young, I., Arias-Buría, J.L. and Fernández-de-Las-Peñas, C., 2018. Electrical dry needling as an adjunct to exercise, manual therapy and ultrasound for plantar fasciitis: A multi-center randomized clinical trial. PloS one, 13(10), p.e0205405.
Dunning, J., Butts, R., Fernandez-De-Las-Penas, C., Walsh, S., Goult, C., Gillett, B., Arias-Buría, J.L., Garcia, J. and Young, I.A., 2021. Spinal manipulation and electrical dry needling in patients with subacromial pain syndrome: a multicenter randomized clinical trial. journal of orthopaedic & sports physical therapy, 51(2), pp.72-81.
Weiner, D.K., Moore, C.G., Morone, N.E., Lee, E.S. and Kwoh, C.K., 2013. Efficacy of periosteal stimulation for chronic pain associated with advanced knee osteoarthritis: a randomized, controlled clinical trial. Clinical therapeutics, 35(11), pp.1703-1720.
Hansson, Y., Carlsson, C. and Olsson, E., 2008. Intramuscular and periosteal acupuncture in patients suffering from chronic musculoskeletal pain–a controlled trial. Acupuncture in Medicine, 26(4), pp.214-223.
Hsing, W.T., Imamura, M., Weaver, K., Fregni, F. and Azevedo Neto, R.S., 2012. Clinical effects of scalp electrical acupuncture in stroke: a sham-controlled randomized clinical trial. The Journal of Alternative and Complementary Medicine, 18(4), pp.341-346.
Elbadawy, M.A., 2017. Effectiveness of periosteal stimulation therapy and home exercise program in the rehabilitation of patients with advanced knee osteoarthritis. The Clinical journal of pain, 33(3), pp.254-263.
Chen, N., Wang, J., Mucelli, A., Zhang, X. and Wang, C., 2017. Electro-acupuncture is beneficial for knee osteoarthritis: the evidence from meta-analysis of randomized controlled trials. The American journal of Chinese medicine, 45(05), pp.965-985.
Navarro-Santana, M.J., Sanchez-Infante, J., Gómez-Chiguano, G.F., Cleland, J.A., López-de-Uralde-Villanueva, I., Fernández-de-Las-Peñas, C. and Plaza-Manzano, G., 2020. Effects of trigger point dry needling on lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis. Clinical Rehabilitation, 34(11), pp.1327-1340.
Stenhouse, G., Sookur, P. and Watson, M., 2013. 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. Skeletal radiology, 42(11), pp.1515-1520.