Jan 29, 2015Point of Attack
With an emphasis on restoring muscle function, trigger point dry needling ensures the Washington Redskins are always ready to strike.
By Elliott Jermyn
Elliott Jermyn, MS, PT, ATC, CSCI, is Physical Therapist and Assistant Athletic Trainer for the Washington Redskins. He is a Level II Functional Dry Needling Practitioner and can be reached at: [email protected].
The field of athletic rehabilitation includes a never-ending stream of new products, ideas, and treatments for athletic trainers to choose from. In my role with the Washington Redskins, I’ve encountered many diverse modalities, techniques, and therapies. While some of these are now collecting dust in the athletic training room cabinet, others have stuck. Trigger point dry needling (TDN) fits into the latter category and has changed the way I treat my athletes.
A large part of my job involves identifying and correcting players’ asymmetries, whether they are skeletal, muscular, or neurological. An important step in this process is finding and eradicating myofascial trigger points, which are irritated areas of a muscle that manifest as nodules. These hard, palpable knots are often the source of local and referred pain.
TDN is an invasive technique composed of inserting a sterile, solid filament needle into an athlete’s muscle to release these trigger points, generating a neuromuscular response. This method is used to address a variety of soft-tissue issues as well as other injuries and can quickly lead to improved motion and function.
After several Redskins players expressed an interest in it, I started practicing dry needling in 2012. It has helped our athletes return to the field quicker after an injury and stay on it longer. TDN plays a significant role in my treatment program, providing a safe, effective method of removing trigger points.
INTRO TO TDN
Despite its recent emergence in sports medicine, TDN is not new. It has roots in the work of Dr. Janet Travell in the 1950s and originally involved inserting a hypodermic needle into a trigger point with the use of an anesthetic. Dr. Travell and her colleagues were able to observe quality pain relief from this method. Further experimentation was done without injecting a solution, thus the term “dry needling” was born.
Then, and now, the use of needles allows practitioners to reach parts of a player’s tissue that were previously inaccessible with manual therapy or other instruments. However, in modern applications, TDN is completed using solid filiform needles that are one-tenth the gauge of a hypodermic needle, which minimizes secondary tissue trauma.
I was first introduced to TDN in the early 2000s when I was a practicing physical therapist at an outpatient clinic. Though the treatment intrigued me, it wasn’t until I entered the professional sports setting in 2008 that the depths of its benefits became obvious.
At the time, a handful of Redskins were routinely receiving needling treatments from a private clinician, and one player asked me to accompany him to a session so I could communicate the treatment goals for his injury. I was amazed at how quickly the practitioner was able to improve the athlete’s function, and I knew right away that TDN was something I needed to incorporate in my repertoire.
Numerous studies have validated the effectiveness of dry needling on injured muscles, yet its use should not be limited to these ailments alone. I have had equal levels of success in treating ligament and tendon injuries, such as MCL sprains, lateral ankle sprains, patellar tendonitis, and Achilles tendonitis. Additionally, I have needled athletes prior to spinal adjustments because loosening the tissues facilitates movement.
Dry needling sessions vary from two minutes to an hour depending on the type and severity of the injury. For example, if a player comes to me seeking a “quick fix” for an irritated neck, a single needle or two in his upper trapezius can do wonders for restoring motion in his cervical spine. But other ailments need more time and attention. Someone requiring a full-body treatment (incorporating the spine, gluteals, calves, and thighs) would typically have an hour-long session using as many as 150 needles. In general, most injuries require between four to six treatments for maximum benefits.
Regardless of the malady, I begin the process with an evaluation of range of motion and bone symmetry. I always check for pelvic obliquity, as I believe problems here can cause many issues up and down the kinetic chain. Next, I perform a quick strength assessment on the muscles at or around the source of pain. Finally, I use the Functional Movement Screen to highlight any movement flaws and compensations. Once these steps are complete, I build a treatment plan incorporating TDN to hone in on the underlying issue.
To begin a TDN session, I put on sterile gloves and clean areas that will be needled with alcohol prep pads. Then I palpate the muscle to identify any trigger points. Once they are located, I choose the appropriate size needle (ranging from 30 mm to 120 mm depending on the tissue being treated) and begin insertion.
The goal of any TDN treatment is to elicit a rapid local twitch response, which occurs when a trigger point has been hit. For both the patient and the practitioner, this feels like a muscle spasm, but differs in that it only takes place within the “angry” tissue. In most cases, treatment is complete after feeling multiple twitches. However, depending on the athlete’s responsiveness, pain tolerance, and the tissue being needled, it is possible to elicit dozens of these contractions before the tissue loosens.
Following the needling, I then reassess for range of motion and strength within the area that was treated. Lastly, I wrap up each session with some type of functional exercise, such as a single-leg squat or rotational band exercise. This movement helps to maintain the newly generated ranges and allows the athlete to see and feel the results.
A unique aspect of TDN is that it is an excellent adjunct treatment that can be used with other therapies where myofascial restriction and pain are present. Specifically, its use in conjunction with electrical stimulation can open up new doors for practitioners. Using alligator clips on the needles, I am able to connect them to an e-stim machine, which allows me to introduce light or strong currents to the area being treated. This method often results in an initial disorganized, sputtering contraction in the affected muscle. Eventually, it transitions into a strong tetanic contraction. This can take anywhere from 30 seconds to 20 minutes depending on the irritability of the muscle and helps determine the end point of the treatment.
It was interesting to see the Redskins players’ responses when I first began using TDN. Most of our athletes had heard of needling before, if they hadn’t received the treatment themselves, but I still needed to prove its worth through a handful of successful treatments. No one I know likes needles, but clearing the pinch in an ornery hip will go a long way in gaining athletes’ trust and confidence.
As all athletic trainers know, athletes are copycats. If something works for their buddy, they are up for giving it a try, too. Once we started implementing TDN as a treatment option, a hesitant player only had to look to the athletic training table next to him to see it in action. And the results spoke for themselves. After the first few successes, athletes were lining up to ask, “Will TDN work for X?” Quite often, the answer was, “Yes.”
Currently, I use TDN on athletes daily. Roughly 75 percent of the Redskins players have used needling, with about half receiving TDN on a regular basis.
Because TDN is still unfamiliar to many in the sports medicine profession, it occasionally faces resistance. Some detractors take umbrage because athletes frequently have soreness following treatment. I often tell my players to expect a “different kind of pain” following needling, not unlike the muscle soreness experienced after a hard workout. However, this pain is simply a side effect of the modality and shouldn’t be construed as a problem with TDN. In fact, when a player tells me his injured tissue feels sore, I know the treatment is working.
The acute soreness associated with needling often precludes me from performing it prior to weightroom work or practice, so treatments are usually done post-activity. In rare circumstances, where there is no injury that would exclude the athlete from participation, I have needled prior to and during a game.
One complaint that I often hear is that physical therapists do not have enough training in the use of needles to safely administer TDN. However, I believe my seven years of schooling and countless hours in the study of human anatomy and physiology have fully prepared me to practice TDN properly. My Level I certification began with a brush up on relevant anatomy and progressed to developing an understanding for basic needle principles, including clean needle technique, proper use, management, and disposal. I then began to slowly learn the approach to each muscle.
Level II certification provided a deeper understanding on needling theory and principle and ways to further utilize TDN in my practice. To sit for the Level II certification, I applied TDN to the required minimum of 200 patients. I had to document rationale, tissues needled, and outcome responses. I also had to complete roughly 60 hours of course work and lab time.
As sports medicine professionals, we consider ourselves experts in the field of human movement, and TDN should be looked at as another tool in our collective toolboxes. Yet some states have laws restricting who can and cannot practice TDN. For example, in Virginia, where our team facility is located, physical therapists have been approved to perform TDN, but they are required to attend 54 contact hours of training prior to using the treatment independently. Other states limit the practice to physicians, chiropractors, and acupuncturists. With its usage growing, there is an ongoing push to involve more physical therapists, and even athletic trainers, in TDN.
TDN is a modality that I believe will become increasingly popular over the next few years as more physical therapists, athletic trainers, athletes, and coaches recognize its potential as a rehabilitative tool. When used appropriately, this quick, safe, and effective treatment can help our athletes return to form and get back on the field in a timely manner.
To view a list of references for this article, visit: www.Training-Conditioning.com/references.
SIDEBAR: CASE STUDY: HAMSTRING
The athlete reported to the athletic training staff with signs and symptoms consistent with a hamstring strain. The injury occurred during punt coverage practice when the player said he “opened up” and felt a pull. He was examined on the field and removed from practice.
Assessment: Left-side, moderate grade-one strain to mid-belly biceps femoris, accompanied by neural tension. Plan is to treat and reevaluate until restoration of full motion and strength.
Day One Treatment: – Trigger point dry needling (TDN) to palpable trigger points in biceps femoris, semimembranosus/semitendonosis, adductor magnus, and left side gluteus medius/minumus
– Manual therapy and muscle energy techniques to address pelvic asymmetry and leg length
– Manual psoas release to left side
– Light soft-tissue massage to affected areas, followed by microcurrent electrical neuromuscular stimulator (MENS) and compression.
Day One Results: The athlete reported diminished, but still present, soreness in his hamstring. His range of motion (ROM) was still limited by 25 percent.
Day Two Treatment: – TDN to neurosegmental spinal multifidus (L4/5, S1)
– TDN to biceps femoris origin at ischial tuberosity, mid-belly biceps femoris, and muscle/tendon junction biceps femoris, with added percutaneous electrical nerve stimulation for 10 minutes at five pulses per second, moderate intensity
– Light bike ride for 10 minutes with minimal resistance
– Light massage to affected areas
– Core and hip strengthening with bands and physioball
– Treadmill walk for 15 minutes
– MENS and compression.
Day Two Results: The athlete reported global soreness, excellent ROM, improved strength, ability to perform single-leg Romanian dead lift, and a very positive outlook on his injury.
Days Three and Four: We began light agility ladder drills, increased band resistance, and weightroom/eccentric work. By day four, he was running, cutting, and accelerating and passed our return-to-play criteria for practice. After a week, he had no further setbacks.
Notes: Soft-tissue injuries are some of the most common seen by athletic trainers and can often be slow-moving, debilitating setbacks. The athlete’s improvement in two days was astonishing to him. This wasn’t his first hamstring strain, and he anticipated a 10- to 14-day recovery.
SIDEBAR: CASE STUDY: NECK
The athlete reported to the athletic training room the morning after a game complaining of moderate neck pain. He had participated in the entire contest the night before and had no knowledge of any mechanism of injury. In addition, there was no reported radiculopathy or headache.
Assessment: Physical therapy diagnosis showed signs and symptoms consistent with multilevel facet irritation and corresponding muscular dysfunction. Plan is to treat with trigger point dry needling (TDN) until full range of motion (ROM) is restored and the athlete is pain-free.
Day One Treatment: – TDN to bilateral upper trapezius, right levator scapula, bilateral rhomboid major, spinal multifidus of C3-T10, and suboccipital triangle – Muscle energy techniques (METs) to right anteriorly rotated innominate, right leg distraction, and left side elevated first rib
– Posterior to anterior glides and manipulation of costovertebral junction of mid-thoracic spine
– Passive ROM work and METs to improve limited bilateral cervical rotation.
Day One Results: The athlete reported a moderate increase in pain in his bilateral upper trapezius, but full ROM was nearly restored to both rotations. Full forward flexion chin to chest was obtained with tightness felt in both upper trapezii. Cervical extension returned to nearly full but still elicited pinching in right C4 dermatome. Moist heat and gentle massage helped to relieve upper trapezius tightness.
The athlete took home a conventional transcutaneous electrical nerve stimulation unit and was educated in its proper use. He was also instructed on a home-exercise program for self-ROM activities. He presented on the second day with normal ROM in all planes but extension (reduced 25 percent) with continued pinching. Soreness remained in his upper trapezius.
Day Two Treatment: TDN to anterior trigger points in upper trapezius and sternocleidomastoid (SCM) and palpable trigger points in right levator scapula.
Day Two Results: Full ROM was restored, and the athlete no longer felt a pinching sensation. The player was taken through a light resistance band workout and continued to be pain-free. He returned to practice on day two without irritation. He continued with at-home self-motion exercises and checked in daily with the athletic training staff for three days without symptoms returning.
Notes: This case demonstrates how irritated tissue can have a substantial impact on skeletal presentation. Very little manual work was done on this athlete’s cervical spine, and once the trigger points were released, his body instantly allowed an unrestricted return to function. This proved to be a learning experience for me in that I had to search out the remaining causes of his pain on the second day of treatment. His rapid improvement once I hit the SCM and anterior upper trapezius was spectacular.