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Dry Needling Combined with Spinal & Extremity Manipulation to Quickly Achieve Post-Operative Terminal Knee Extension

Dry Needling Combined with Spinal & Extremity Manipulation to Quickly Achieve Post-Operative Terminal Knee Extension

Terminal knee extension deficits, getting the knee fully extended, can be a difficult and frustrating impairment to treat. Terminal knee extension deficits are most frequently observed following some type of knee surgery. Post-ACL repair, for example, since the body is being sliced open by a scalpel, all of the muscles surrounding and crossing the knee get tight. Tight muscles crossing any joint is one of the most detrimental things you can do to your joints. It leads to hypoxia, pain, collagen degeneration, and a lot of joint compression.

When joints are compressed, the joint capsule does not move normally. To stimulate production of new synovial fluid (joint oil) and to replace the old fluid in the knee joint, which is produced by the synovial tissue on the inside of the joint capsule, the joint needs to move through normal range of motion (ROM). Poor synovial fluid production leads to a situation similar to driving a car with old, gritty, sludgy oil. If the knee joint lacks ROM following surgery, it leads to all sorts of problems. Slow / incomplete healing, hyperalgesia, nutritional deficiencies in the menisci secondary to lack of clean synovial fluid, and low back pain, to name a few.

I typically find the popliteus to be the main culprit limiting full knee extension following surgery. The popliteus is the deepest muscle in the back of the knee and its function is to unlock the screw-home mechanism, internally rotating the tibia on the femur. Remember, the screw-home mechanism involves external rotation of the tibia on the femur during the last 10 or so degrees of extension. This approximates the tibial plateau and the femoral condyles, essentially locking the knee into stable extension. Unfortunately, if you are not using needles and manipulation, it can be next to impossible to properly treat the popliteus and the knee joint. You have to get through the thick gastroc, and potentially the soleus as well.

Remember, most of the popliteus sits below the knee joint. The tendon is really the only thing crossing the joint, which attaches underneath the LCL and lateral hamstring tendons. Without needles, the only popliteus treatment one can perform is indirect. With needles, it is super easy to directly treat just about the entirety of the muscle; origin, belly (mid-belly is covered by neurovasculature) and insertion. Needling allows us to directly touch / treat most muscles in the body, popliteus included. The deeper the muscle, the harder it is to treat without needles. The multifidus, piriformis, psoas, and popliteus are all deep muscles that, oftentimes, simply do not respond to typical, indirect treatment. Once needles are added to the equation, direct treatment becomes possible and life gets way easier for the patient and practitioner, with rapid, easy improvements in ROM.

The knee consists of a few different joints. Tibia-fibula, tibia-femoral & patellar-femoral. All three of these joints need to move normally to allow for normal knee ROM. To achieve normal, full knee extension, the patella has to slide cephalic in the femoral groove, the tibial plateau needs to tilt posterior, the entire tibia needs to externally rotate, and the fibula needs to be freely moving against the tibia. The tib-fib joint does not move much, but it is vital that it move normally if your goal is achieving full, fluid knee ROM. For example, most people dorsiflex the ankle when extending the knee. To dorsiflex the ankle, the fibular head needs to move cephalic on the tibia. Regardless of how an individual may extend their knee, all those joints need to move normally to allow for normal overall knee motion.

I always needle first, then manipulate. Needling improves muscle length, induces significant increases in blood perfusion and has an overall relaxing effect on the joint. This makes for an easier, more comfortable and lasting manipulation. If only needling or only manipulation is performed, half of the problem still remains. Any deviation in one will lead to a deviation in the other, and treating only one is asking for the impairment to return and become chronic. Manipulation and needling have synergistic effects on depressing sympathetics and elevating parasympathetics, pushing the ANS / CNS towards homeostasis. Remember, any post-surgical patient, and just about all PT patients in general, present with sympathetic hyperactivity. I won’t go into detail about how to specifically manipulate the knee. Suffice it to say, you will never achieve maximal patient outcome potential without combining needling with manipulation. This holds true for the entire body.

Aside from pathology of the knee joint itself, the ankle, hip and pelvic joints are probably the next most common causers of knee pathology and lack of terminal knee extension. For this reason, the knee, just like every other joint or structure in the body, should never be treated alone. The entire body must always be addressed to achieve your patients’ potential.

Think about anterior and or medial ilial rotation, the most common SIJ deviations. Let’s assume we have a patient with anteromedial ilial rotation on one side, which is super common. If the ilium is in anterior rotation on one side, that leg is going to be “longer.”

Related: Check out this video on Leg Length Discrepancy

If the ilium is also medially rotated, the femur is likely going to be in either internal or external rotation, depending on specific compensatory patterns. The compensation for this conversation doesn’t matter. Any deviation in any joint, especially from the low back down, is going to cause abnormal knee position and deficits in ROM.

Consider how deep a lot of the low back, hip and knee musculature is. Again, the deeper the muscle, the harder it is to treat, without needles. It is basically impossible to treat many of the deep muscles in the body without needling. This makes affecting a successful, lasting manipulation, or any other treatment, seriously difficult to achieve. If both the muscles and the joints are not properly addressed, arriving at maximum patient potential is simply not possible.

Thanks for reading everyone. Let me know if anyone has any questions about anything or if you would like to sign up for one of our four needling or 3 manipulation courses. Talk to you soon.



Blood Perfusion

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Muscle Contraction

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  • Stern, M.D., Pizarro, G. and Ríos, E., 1997. Local control model of excitation–contraction coupling in skeletal muscle. The Journal of general physiology, 110(4), pp.415-440.

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  • Hernández-Ochoa, E.O. and Schneider, M.F., 2018. Voltage sensing mechanism in skeletal muscle excitation-contraction coupling: coming of age or midlife crisis?. Skeletal muscle, 8(1), pp.1-20.

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  • Rassier, D.E., 2017. Sarcomere mechanics in striated muscles: from molecules to sarcomeres to cells. American Journal of Physiology-Cell Physiology, 313(2), pp.C134-C145.

  • Powers, J.D., Malingen, S.A., Regnier, M. and Daniel, T.L., 2021. The sliding filament theory since Andrew Huxley: multiscale and multidisciplinary muscle research. Annual review of biophysics, 50, pp.373-400.

  • Nishikawa, K., Dutta, S., DuVall, M., Nelson, B., Gage, M.J. and Monroy, J.A., 2020. Calcium-dependent titin–thin filament interactions in muscle: observations and theory. Journal of Muscle Research and Cell Motility, 41(1), pp.125-139.

  • Bernstein, H.G., Dobrowolny, H., Bogerts, B., Keilhoff, G. and Steiner, J., 2019. The hypothalamus and neuropsychiatric disorders: psychiatry meets microscopy. Cell and tissue research, 375(1), pp.243-258.

  • Roschina, O.V., Levchuk, L.A., Boiko, A.S., Michalitskaya, E.V., Epimakhova, E.V., Losenkov, I.S., Simutkin, G.G., Loonen, A.J., Bokhan, N.A. and Ivanova, S.A., 2021. Beta-Endorphin and Oxytocin in Patients with Alcohol Use Disorder and Comorbid Depression. Journal of Clinical Medicine, 10(23), p.5696.

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  • Lu, Y., Ann, L. and McCarron, R., 2021. Steroid-induced psychiatric symptoms: What you need to know. Current Psychiatry, 20(4), p.33.

  • Maslov, M.Y., Foianini, S., Orlov, M.V., Januzzi, J.L. and Lovich, M.A., 2018. A novel paradigm for sacubitril/valsartan: beta-endorphin elevation as a contributor to exercise tolerance improvement in rats with preexisting heart failure induced by pressure overload. Journal of cardiac failure, 24(11), pp.773-782.

  • van der Venne, P., Balint, A., Drews, E., Parzer, P., Resch, F., Koenig, J. and Kaess, M., 2021. Pain sensitivity and plasma beta-endorphin in adolescent non-suicidal self-injury. Journal of Affective Disorders, 278, pp.199-208.

  • Furness, J.B., 2000. Types of neurons in the enteric nervous system. Journal of the autonomic nervous system, 81(1-3), pp.87-96.

  • McCullough, J.E., Liddle, S.D., Close, C., Sinclair, M. and Hughes, C.M., 2018. Reflexology: a randomised controlled trial investigating the effects on beta-endorphin, cortisol and pregnancy related stress. Complementary therapies in clinical practice, 31, pp.76-84.

  • Maslov, M.Y., Foianini, S., Orlov, M.V., Januzzi, J.L. and Lovich, M.A., 2018. A novel paradigm for sacubitril/valsartan: beta-endorphin elevation as a contributor to exercise tolerance improvement in rats with preexisting heart failure induced by pressure overload. Journal of cardiac failure, 24(11), pp.773-782.

  • Cui, L., Cai, H., Sun, F., Wang, Y., Qu, Y., Dong, J., Wang, H., Li, J., Qian, C. and Li, J., 2021. Beta-endorphin inhibits the inflammatory response of bovine endometrial cells through δ opioid receptor in vitro. Developmental & Comparative Immunology, 121, p.104074.

Electrical Needling

  • 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., Zacharko, N., Fandry, K., Young, I., Wheeler, K., Day, J. and Fernández-de-Las-Peñas, C., 2021. Spinal manipulation and perineural electrical dry needling in patients with cervicogenic headache: a multicenter randomized clinical trial. The Spine Journal, 21(2), pp.284-295.
  • Ghaffari, M.S., Shariat, A., Honarpishe, R., Hakakzadeh, A., Cleland, J.A., Haghighi, S. and Barghi, T.S., 2019. Concurrent effects of dry needling and electrical stimulation in the management of upper extremity hemiparesis. Journal of acupuncture and meridian studies, 12(3), pp.90-94.
  • Brennan, K., Elifritz, K.M., Comire, M.M. and Jupiter, D.C., 2021. Rate and maintenance of improvement of myofascial pain with dry needling alone vs. dry needling with intramuscular electrical stimulation: a randomized controlled trial. Journal of Manual & Manipulative Therapy, 29(4), pp.216-226.
  • Fernández-Carnero, J., 2021. Effectiveness of Dry Needling with Percutaneous Electrical Nerve Stimulation of High Frequency Versus Low Frequency in Patients with Myofascial Neck Pain. Pain physician, 24, pp.135-143.
  • WALSH, S., GOULT, C. and GILLETT, B., 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), p.73.
  • Dunning, J., 2019. Effectiveness of Electrical Dry Needling for Lower Extremity Pain Disorders.
  • Hadizadeh, M., Tajali, S.B., Moghadam, B.A., Jalaei, S. and Bazzaz, M., 2022. Effects of Intramuscular Electrical Stimulation through Dry Needling on Pain and Dysfunction Following Trigger Points in Upper Trapezius Muscle: A Double-blind Randomized Controlled Trial. Journal of Modern Rehabilitation.
  • Ahmed, A.F., Elgayed, S.S. and Ibrahim, I.M., 2012. Polarity effect of microcurrent electrical stimulation on tendon healing: biomechanical and histopathological studies. Journal of Advanced Research, 3(2), pp.109-117.
  • Yazdan-Shahmorad, A., Kipke, D.R. and Lehmkuhle, M.J., 2011. Polarity of cortical electrical stimulation differentially affects neuronal activity of deep and superficial layers of rat motor cortex. Brain stimulation, 4(4), pp.228-241.
  • Gentzkow, G.D., 1993. Electrical stimulation to heal dermal wounds. The Journal of dermatologic surgery and oncology, 19(8), pp.753-758.
  • Hayashi, K. and Ninjouji, T., 2004, September. Two-point discrimination threshold as a function of frequency and polarity at fingertip by electrical stimulation. In The 26th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (Vol. 2, pp. 4256-4259). IEEE.
  • Demir, H., Balay, H. and Kirnap, M., 2004. A comparative study of the effects of electrical stimulation and laser treatment on experimental wound healing in rats. Journal of rehabilitation Research & development, 41(2).
  • Balakatounis, K.C. and Angoules, A.G., 2008. Low-intensity electrical stimulation in wound healing: review of the efficacy of externally applied currents resembling the current of injury. Eplasty, 8.
  • Ashrafi, M., Alonso‐Rasgado, T., Baguneid, M. and Bayat, A., 2016. The efficacy of electrical stimulation in experimentally induced cutaneous wounds in animals. Veterinary dermatology, 27(4), pp.235-e57.
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  • Asadi, M.R., Torkaman, G. and Hedayati, M., 2011. Effect of sensory and motor electrical stimulation in vascular endothelial growth factor expression of muscle and skin in full-thickness wound. J Rehabil Res Dev, 48(3), pp.195-201.
  • Deriu, F., Tolu, E. and Rothwell, C., 2003. A short latency vestibulomasseteric reflex evoked by electrical stimulation over the mastoid in healthy humans. The Journal of physiology, 553(1), pp.267-279.
  • Wang, J., Wang, H., Thakor, N.V. and Lee, C., 2019. Self-powered direct muscle stimulation using a triboelectric nanogenerator (TENG) integrated with a flexible multiple-channel intramuscular electrode. ACS nano, 13(3), pp.3589-3599.
  • Nussbaum, E.L., Houghton, P., Anthony, J., Rennie, S., Shay, B.L. and Hoens, A.M., 2017. Neuromuscular electrical stimulation for treatment of muscle impairment: critical review and recommendations for clinical practice. Physiotherapy Canada, 69(5), pp.1-76.
  • Asadi, M.R. and Torkaman, G., 2014. Bacterial inhibition by electrical stimulation. Advances in wound care, 3(2), pp.91-97.
  • Snyder, A.R., Perotti, A.L., Lam, K.C. and Bay, R.C., 2010. The influence of high-voltage electrical stimulation on edema formation after acute injury: a systematic review. Journal of sport rehabilitation, 19(4), pp.436-451.
  • Feger, M.A., Goetschius, J., Love, H., Saliba, S.A. and Hertel, J., 2015. Electrical stimulation as a treatment intervention to improve function, edema or pain following acute lateral ankle sprains: A systematic review. Physical Therapy in Sport, 16(4), pp.361-369.
  • Hamid, S. and Hayek, R., 2008. Role of electrical stimulation for rehabilitation and regeneration after spinal cord injury: an overview. European Spine Journal, 17(9), pp.1256-1269.
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  • Hwang, I.H. and Thompson, J.M., 2001. The effect of time and type of electrical stimulation on the calpain system and meat tenderness in beef longissimus dorsi muscle. Meat science, 58(2), pp.135-144.

Orthopedic Conditions

  • Clark, N.G., Hill, C.J., Koppenhaver, S.L., Massie, T. and Cleland, J.A., 2021. The effects of dry needling to the thoracolumbar junction multifidi on measures of regional and remote flexibility and pain sensitivity: A randomized controlled trial. Musculoskeletal Science and Practice, 53, p.102366.
  • Navarro-Santana, M.J., Gómez-Chiguano, G.F., Cleland, J.A., Arias-Buría, J.L., Fernández-de-Las-Peñas, C. and Plaza-Manzano, G., 2021. Effects of Trigger Point Dry Needling for Nontraumatic Shoulder Pain of Musculoskeletal Origin: A Systematic Review and Meta-Analysis. Physical Therapy, 101(2), p.pzaa216.
  • Ma, Y.T., Li, L.H., Han, Q., Wang, X.L., Jia, P.Y., Huang, Q.M. and Zheng, Y.J., 2020. Effects of trigger point dry needling on neuromuscular performance and pain of individuals affected by patellofemoral pain: a randomized controlled trial. Journal of Pain Research, 13, p.1677.
  • Carusotto, A.F., Hakim, R.M., Oliveira, R.G., Piranio, A., Coughlan, C.P. and MacDonald, T.J., 2021. Effects of dry needling on muscle spasticity in adults with neurological disorders: a systematic review. Physical Therapy Reviews, pp.1-6.
  • Haser, C.H.R.I.S.T.I.A.N., Stöggl, T.H.O.M.A.S., Kriner, M.O.N.I.K.A., Mikoleit, J., Wolfahrt, B., Scherr, J., Halle, M. and Pfab, F., 2017. Effect of dry needling on thigh muscle strength and hip flexion in elite soccer players. Med Sci Sports Exerc, 49(2), pp.378-383.
  • Ceballos-Laita, L., Jiménez-del-Barrio, S., Marín-Zurdo, J., Moreno-Calvo, A., Marín-Boné, J., Albarova-Corral, M.I. and Estébanez-de-Miguel, E., 2019. Effects of dry needling in HIP muscles in patients with HIP osteoarthritis: a randomized controlled trial. Musculoskeletal Science and Practice, 43, pp.76-82.
  • Geist, K., Bradley, C., Hofman, A., Koester, R., Roche, F., Shields, A., Frierson, E., Rossi, A. and Johanson, M., 2017. Clinical effects of dry needling among asymptomatic individuals with hamstring tightness: a randomized controlled trial. Journal of sport rehabilitation, 26(6), pp.507-517.
  • Osborne, N.J. and Gatt, I.T., 2010. Management of shoulder injuries using dry needling in elite volleyball players. Acupuncture in medicine, 28(1), pp.42-45.
  • Albin, S.R., Koppenhaver, S.L., MacDonald, C.W., Capoccia, S., Ngo, D., Phippen, S., Pineda, R., Wendlandt, A. and Hoffman, L.R., 2020. The effect of dry needling on gastrocnemius muscle stiffness and strength in participants with latent trigger points. Journal of Electromyography and Kinesiology, 55, p.102479.
  • 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.
  • Segura-Ortí, E., Prades-Vergara, S., Manzaneda-Piña, L., Valero-Martínez, R. and Polo-Traverso, J.A., 2016. Trigger point dry needling versus strain–counterstrain technique for upper trapezius myofascial trigger points: a randomised controlled trial. Acupuncture in Medicine, 34(3), pp.171-177.
  • Charles, D., Hudgins, T., MacNaughton, J., Newman, E., Tan, J. and Wigger, M., 2019. A systematic review of manual therapy techniques, dry cupping and dry needling in the reduction of myofascial pain and myofascial trigger points. Journal of bodywork and movement therapies, 23(3), pp.539-546.
  • Mullins, J.F., Nitz, A.J. and Hoch, M.C., 2021. Dry needling equilibration theory: A mechanistic explanation for enhancing sensorimotor function in individuals with chronic ankle instability. Physiotherapy theory and practice, 37(6), pp.672-681.
  • Cagnie, B., Castelein, B., Pollie, F., Steelant, L., Verhoeyen, H. and Cools, A., 2015. Evidence for the use of ischemic compression and dry needling in the management of trigger points of the upper trapezius in patients with neck pain: a systematic review. American journal of physical medicine & rehabilitation, 94(7), pp.573-583.
  • Sánchez-Infante, J., Bravo-Sánchez, A., Jiménez, F. and Abián-Vicén, J., 2021. Effects of Dry Needling on Muscle Stiffness in Latent Myofascial Trigger Points: A Randomized Controlled Trial. The Journal of Pain.
  • Alaei, P., Ansari, N.N., Naghdi, S., Fakhari, Z., Komesh, S. and Dommerholt, J., 2020. Dry Needling for Hamstring Flexibility: A Single-Blind Randomized Controlled Trial. Journal of Sport Rehabilitation, 30(3), pp.452-457.
  • Dommerholt, J., 2011. Dry needling—peripheral and central considerations. Journal of Manual & Manipulative Therapy, 19(4), pp.223-227.
  • Tough, E.A., White, A.R., Cummings, T.M., Richards, S.H. and Campbell, J.L., 2009. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials. European Journal of Pain, 13(1), pp.3-10.
  • Ansari, N.N., Alaei, P., Naghdi, S., Fakhari, Z., Komesh, S. and Dommerholt, J., 2020. Immediate effects of dry needling as a novel strategy for hamstring flexibility: a single-blinded clinical pilot study. Journal of sport rehabilitation, 29(2), pp.156-161.
  • Mason, J.S., Crowell, M., Dolbeer, J., Morris, J., Terry, A., Koppenhaver, S. and Goss, D.L., 2016. The effectiveness of dry needling and stretching vs. stretching alone on hamstring flexibility in patients with knee pain: a randomized controlled trial. International journal of sports physical therapy, 11(5), p.672s