Ultrasound-guided dry needling with percutaneous paratenon decompression for chronic Achilles tendinopathy

Analysis of Research Trends in Ultrasound-Guided Acupuncture and Dry-Needling: A Scoping Review

Background: This study aimed to summarize the current status of research on ultrasound-guided acupuncture and dry-needling treatment and the specific treatment methods applied to patients. Methods: A scoping review was conducted, surveying three English databases (PubMed, Embase, and the Cochrane Library) for studies published up to May 2024. All studies related to ultrasound-guided acupuncture and dry-needling treatment were considered. Literature was selected using selection and exclusion criteria, and extracted and organized using EndNote. Results: A total of 107 eligible studies were included. Among the 107 studies, non-comparative studies accounted for the largest proportion (n = 47, 43.9%), followed by randomized controlled trials (RCTs; n = 41, 38.3%). Diseases of the musculoskeletal system or connective tissue (15 diseases of the musculoskeletal system or connective tissue) accounted for most (n = 48, 55.8%) of the 86 diseases studied, followed by symptoms, signs, or clinical conditions not otherwise classified (n = 17, 19.8%). Conclusions: Ultrasound-guided acupuncture and dry-needling have been actively studied and applied for the treatment of various diseases. However, higher-quality studies are needed for further applications in research and clinical practice.

The Heel Complex: Anatomy, Imaging, Pathologic Conditions, and Treatment

The differential diagnosis for heel pain is broad but primarily involves abnormalities of the Achilles tendon, calcaneus, and plantar fascia. Achilles tendon disorders include tendinosis, tendinitis, and partial or complete tears. Tendinosis refers to tendon degeneration, while tendinitis is inflammation after acute overload. Untreated tendinosis can progress to partial or complete tears. Tendon disorders can be accompanied by paratenonitis or inflammation of the loose sheath enclosing the tendon. Initial management involves rehabilitation and image-guided procedures. Operative management is reserved for tendon tears and includes direct repair, tendon transfer, and graft reconstruction. The calcaneus is the most commonly fractured tarsal bone. The majority of fractures are intra-articular; extra-articular fractures, stress or insufficiency fractures, medial process avulsion, and neuropathic avulsion can also occur. Posterosuperior calcaneal exostosis or Haglund deformity, retrocalcaneal bursitis, and insertional Achilles tendinosis form the characteristic triad of Haglund syndrome. It is initially managed with orthotics and physiotherapy. Operative management aims to correct osseous or soft-tissue derangements. The plantar fascia is a strong fibrous tissue that invests the sole of the foot and contributes to midfoot stability. Inflammation or plantar fasciitis is the most common cause of heel pain and can be related to overuse or mechanical causes. Acute rupture is less common but can occur in preexisting plantar fasciitis. Conservative treatment includes footwear modification, calf stretches, and percutaneous procedures. The main operative treatment is plantar fasciotomy. Plantar fibromatosis is a benign fibroblastic proliferation within the fascia that can be locally aggressive and is prone to recurrence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Percutaneous ultrasound-guided needle tenotomy for treatment of chronic tendinopathy and fasciopathy: a meta-analysis

OBJECTIVES

To systematically assess the efficacy of percutaneous ultrasound-guided needle tenotomy (PUNT) in the treatment of chronic tendinopathy and fasciopathy.

METHODS

A comprehensive literature search was performed with the following search terms: tendinopathy, tenotomy, needling, Tenex, fasciotomy, ultrasound-guided, and percutaneous. Inclusion criteria consisted of original studies evaluating pain or function improvement after PUNT. Meta-analyses investigating standard mean differences were performed to assess the pain and function improvement.

RESULTS

Thirty-five studies with 1674 participants (1876 tendons) were enrolled in this article. Of which 29 articles were included in meta-analysis and the remaining 9 articles without enough numeric data were included in descriptive analysis. PUNT significantly alleviated pain with the standard mean difference of 2.5 (95% CI: 2.0-3.0; p < 0.05), 2.2 (95% confidence interval (CI): 1.8-2.7; p < 0.05), and 3.6 (95% CI: 2.8-4.5; p < 0.05) points in short-term, intermediate-term, and long-term follow-up intervals, respectively. It was also associated with marked improvement in function with 1.4 (95% CI: 1.1-1.8; p < 0.05), 1.8 (95% CI: 1.3-2.2; p < 0.05), and 2.1 (95% CI: 1.6-2.6; p < 0.05) points, respectively in short-term, intermediate-term, and long-term follow-ups.

CONCLUSION

PUNT improved pain and function at short-term intervals with persistent results on intermediate- and long-term follow-ups. PUNT can be considered an appropriate minimally invasive treatment for chronic tendinopathy with a low rate of complications and failures.

CLINICAL RELEVANCE

Tendinopathy and fasciopathy are two common musculoskeletal complaints that can cause prolonged pain and disability. PUNT as a treatment option could improve pain intensity and function.

KEY POINTS

• The best improvement in pain and function was achieved after the first 3 months following PUNT and was continued to the intermediate- and long-term follow-ups. • No significant difference was found between different tenotomy methods in terms of pain and function improvement. • PUNT is a minimally invasive procedure with promising results and low complication rates for treatments of chronic tendinopathy.

One fifth of patients with Achilles tendinopathy have symptoms after 10 years: A prospective cohort study

Patients with midportion Achilles tendinopathy (AT) are thought to experience a gradual symptomatic improvement over time. The aim of this study was to prospectively investigate if patients with midportion AT have symptoms at 10-year follow-up. Patients withmidportion AT were invited to complete an online questionnaire 10 years after inclusion in an intervention trial. The primary outcomewas the presence of AT symptoms. Secondary outcomes were: the Victorian Institute of Sports Assessment-Achilles tendinopathy (VISA-A, 0-100) score and sports activity level. Of the 54 patientsincluded, 43 (80%) completed the questionnaire at an average follow-up of 10.4 years. Persisting symptoms were reported by 19%. The mean (standard deviation-SD) VISA-A score improved from 52 (17) at baseline to 79 (21) at 10-years follow-up with a mean change of 27 points (95% confidence interval: 21; 35, p < 0.001). Of the 38 active patients, 16 (42%) returned to their pre-injury level sports,of whom 14 (37%) performed them pain free. One-fifth of patients with conservatively treated midportion AT still have symptoms after 10years. One-third of patients were able to perform sports pain-free atpre-injury level. Patients should be adequately counselled to giverealistic expectations. Trial registration number: clinicaltrials.gov (identifier: NCT00761423).

Ultrasound-guided dry needling versus traditional dry needling for patients with knee osteoarthritis: A double-blind randomized controlled trial

Objective

To compare the effect of ultrasound (US)-guided dry needling (DN) with traditional DN in the treatment of pain and dysfunction for patients with knee osteoarthritis (KOA).

Design

A double-blind, randomized controlled trial.

Methods

Patients (25 male and 65 female), age 50–80 years diagnosed with KOA were recruited and randomly assigned to one of three groups in a 1:1:1 ratio for intervention: real US-guided DN with exercise therapy (G1), placebo US-guided DN with exercise therapy (G2), and exercise therapy solely (G3). G1 and G2 were blinded to the application of real or placebo US guidance by turning the monitor of US imaging out-of-view from participants’ vantage points. The effectiveness of blinding was evaluated by asking the participants whether they had received real-US guided DN. The responses were assessed by Chi-square test. Visual Analogue Scale (VAS), Knee injury, and Osteoarthritis Outcome Score (KOOS) subscales (KOOS-pain, KOOS-symptoms, KOOS-quality-of-life (QoL)) were collected at baseline, 4 weeks, and 8 weeks by a blinded assessor. Data were analyzed by mixed model analysis of variance (ANOVA) with Bonferroni correction.

Results

Eighty-four participants (61.26±5.57 years) completed the study. G1 achieved significant improvement in VAS at 8 weeks compared to G2 and G3 (G1 vs. G2: MD = -15.61, 95% CI [-25.49, -5.51], p = 0.001; G1 vs. G3: MD = -19.90, 95% CI [-29.71, -10.08], p< 0.001). G1 achieved significant improvement in KOOS-pain at 8 weeks compared to G2 and G3 (G1 vs. G2: MD = 9.76, 95% CI [2.38, 17.14], p = 0.006; G1 vs. G3: MD = 9.48, 95% CI [2.31, 16.66], p = 0.010). KOOS-symptoms and KOOS-QoL were not statistically significant between groups. G2 had no significant difference of the perceptions as G1 with p = 0.128. G2 were successfully blinded to placebo US-guided DN.

Conclusion

US-guided DN with exercise therapy may be more effective than traditional DN with exercise therapy or exercise therapy alone in reduce pain of KOA.

The Effectiveness of Dry Needling Combined With Therapeutic Exercises in Treating Tendinopathy Conditions: A Systematic Review

CONTEXT

Approximately 70,000 Americans miss work annually due to tendinopathies causing pain, disability, and lower quality of life. Various conservative treatments have been demonstrated to improve outcomes in these conditions. Dry needling (DN) and therapeutic exercise are 2 such interventions that have been proposed to be a positive intervention for addressing tendinopathy.

OBJECTIVE

To summarize the best available evidence on the use of DN and exercise combined to treat tendinopathy.

EVIDENCE ACQUISITION

PubMed, EBSCOHost, and Web of Science were systematically searched from inception to March 2021. Articles were assessed to determine eligibility and evaluated for methodological quality using the PEDro scale. The PRISMA guidelines were used for this review. Inclusion criteria consisted of use of DN in combination with therapeutic exercise, human participants, and active tendinopathy pathology.

EVIDENCE SYNTHESIS

Seven studies met the inclusion and exclusion criteria, which averaged 6/11 on the PEDro scale. The level of agreement of evaluators was 94%. Current evidence supports the use of DN combined with therapeutic exercises, especially those including eccentric exercises, can improve pain and function for various tendinopathies. However, limited evidence exists regarding specific therapeutic interventions to be combined with DN.

CONCLUSION

There is moderate, level B evidence to suggest the use of DN techniques targeted at the tendon and combined with eccentric therapeutic exercise to improve pain and functional outcomes for tendinopathies.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy

BACKGROUND

Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated.

OBJECTIVE

To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains.

DESIGN

Systematic review.

DATA SOURCES

Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series.

RESULTS

9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain.

CONCLUSION

233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures.

PROSPERO REGISTRATION

CRD42020156763.

A Comparative Study of Treatment Interventions for Patellar Tendinopathy: A Randomized Controlled Trial

OBJECTIVES

To determine the additional effect of dry needling (DN) or percutaneous needle electrolysis (PNE) combined with eccentric exercise (EE) and determine which is the most effective for patients with patellar tendinopathy (PT).

DESIGN

Blinded, randomized controlled trial, with follow-up at 10 and 22 weeks.

SETTINGS

Recruitment was performed in sport clubs. Diagnosis and intervention were conducted at San Jorge University.

PARTICIPANTS

Patients (N=48) with PT with pain for at least 3 months between the ages of 18 and 45 years.

INTERVENTIONS

Three interventions were carried out: DN and EE, PNE and EE, and EE with sham needle as the control group.

MAIN OUTCOME MEASURES

Disability was measured using the Victorian Institute of Sports Assessment Questionnaire, patellar tendon. Visual analog scale was used to measure pain over time, the Short Form-36 was used to measure quality of life, and ultrasound was used to measure structural abnormalities.

RESULTS

A total of 48 participants (42 men, 6 women; average age, 32.46y; SD, 7.14y) were enrolled. The improvement in disability and pain in each group between baseline and post-treatment and baseline and follow-up was significant (P≤.05), without differences among groups.

CONCLUSION

DN or PNE combined with an EE program has not shown to be more effective than a program of only EE to improve disability and pain in patients with PT in the short (10wk) and medium (22wk) terms. Clinical improvements were not associated with structural changes in the tendon.

Molecular and Structural Effects of Percutaneous Interventions in Chronic Achilles Tendinopathy

Achilles tendinopathy (AT) is a common problem, especially in people of working age, as well as in the elderly. Although the pathogenesis of tendinopathy is better known, therapeutic management of AT remains challenging. Various percutaneous treatments have been applied to tendon lesions: e.g., injectable treatments, platelet-rich plasma (PRP), corticosteroids, stem cells, MMP inhibitors, and anti-angiogenic agents), as well as percutaneous procedures without any injection (percutaneous soft tissue release and dry needling). In this review, we will describe and comment on data about the molecular and structural effects of these treatments obtained in vitro and in vivo and report their efficacy in clinical trials. Local treatments have some impact on neovascularization, inflammation or tissue remodeling in animal models, but evidence from clinical trials remains too weak to establish an accurate management plan, and further studies will be necessary to evaluate their value.

Lower Limb Tendinopathy Tissue Changes Assessed through Ultrasound: A Narrative Review

Tendinopathy is a common disease that affects athletes, causing pain and dysfunction to the afflicted tendon. A clinical diagnose is usually combined with imaging and, among all the existing techniques, ultrasound is widely adopted. The aim of this review is to sum up the existing evidence on ultrasound as an imaging tool and guide for treatments in lower limbs tendinopathy. Using three different databases—PubMed, MEDLINE and CENTRAL—a literature search has been performed in May 2020 combining MeSH terms and free terms with Boolean operators. Authors independently selected studies, conducted quality assessment, and extracted results. Ultrasound imaging has a good reliability in the differentiation between healthy and abnormal tendon tissue, while there are difficulties in the identification of tendinopathy stages. The main parameters considered by ultrasound imaging are tendon thickness, hypoechogenicity of tendon structure and neovascularization of the tendon bound tissue. Ultrasound-guide is also used in many tendinopathy treatments and the available studies gave encouraging results, even if further studies are needed in this field.

Orthobiologics

Use of orthobiologics in sports medicine and musculoskeletal surgery has gained significant interest. However, many of the commercially available and advertised products are lacking in clinical evidence. Widespread use of products before fully understanding their true indications may result in unknown adverse outcomes and may also lead to increased health care costs. As more products become available, it is important to remain judicial in use and to practice evidence-based medicine. Likewise, it is important to continue advances in research in hopes to improve surgical outcomes. This article reviews clinical evidence behind common orthobiologics in the treatment of foot and ankle pathology.

Surgical Strategies for the Treatment of Insertional Achilles Tendinopathy

Insertional Achilles tendinopathy is one of the most common Achilles tendon disorders and often results in substantial heel pain and functional disability. There is consensus that treatment of insertional Achilles tendinopathy should start with nonoperative modalities. Surgery should be reserved for patients who fail exhaustive conservative treatment for a period of 3 months to 6 months and include débridement of insertional calcifications. Intratendinous degenerative tissue should be débrided and any Haglund deformity resected. Different surgical techniques have been described for reattachment of the distal Achilles tendon. The authors' preferred surgical technique includes the knotless double-row footprint reconstruction. Postoperative complications are not rare.

Platelet rich plasma compared to dry needling in the treatment of non-insertional Achilles tendinopathy

OBJECTIVES

The efficacy of platelet rich plasma in the treatment of Achilles tendinopathy is controversial. Despite positive results observed in open studies, randomized controlled trials failed to show difference against saline or rehabilitation. Aims of this retrospective observational study were to compare the efficacy of platelet-rich plasma and dry needling and to assess possible differences age and sex-related.

METHODS

Groups of 46 and 38 patients with non-insertional Achilles tendinopathy were treated with platelet-rich plasma and dry needling (once a week for 3 weeks), respectively. At baseline, 3 and 6 months, pain and function scores and the percentage of satisfactory outcomes were evaluated. Sub-group analyses were performed according to age and sex.

RESULTS

At 3 and 6 months no differences in terms of pain and function between groups were observed, but the percentage of subjects reporting satisfactory results, at 6 months, was higher in platelet rich plasma group. Better results were observed in younger subjects, with a greater reduction of pain, improvement of function, and accordingly of the percentage of positive outcomes. A trend toward better results was also observed in males.

CONCLUSION

Beneficial effects of platelet rich plasma and dry needling in non-insertional Achilles tendinopathy have been observed only in some subjects, but not in others; platelet rich plasma shows a slight superiority against dry needling, mainly in younger persons; finally, a gender difference in the therapeutic response can be hypothesized.

A critical overview of the current myofascial pain literature - July 2018

In the current issue of this clinical overview, we are pleased to include several basic research studies ranging from the differentiation of radicular and non-radicular low back pain based on the presence of trigger points (TrPs) to the role of TrPs in patients with osteoarthritis, the diagnostic criteria of TrP, the accurate placement of needles in the piriformis muscle with dry needling (DN), and the reliability of TrP identification, among others. As usual, there are many new DN studies, but also several review papers, and manual TrP research. Contributing authors come from as many as 15 different countries!

ACR Appropriateness Criteria® Chronic Ankle Pain

Chronic ankle pain is a common clinical problem whose cause is often elucidated by imaging. The ACR Appropriateness Criteria for chronic ankle pain define best practices of image ordering. Clinical scenarios are followed by the imaging choices and their appropriateness. The information is in ordered tables with an accompanying narrative explanation to guide physicians to order the right test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to midportion Achilles tendinopathy. J Orthop Sports Phys Ther 2018;48(5):A1-A38. doi:10.2519/jospt.2018.0302.