As more patients seek physical therapy services without a medical referral, many physical therapists are turning to diagnostic ultrasound imaging to more accurately evaluate and monitor tissue healing in musculoskeletal conditions.1, 2 Over the past decade, dry needling (DN)3, 4 and instrument-assisted soft tissue mobilization (IASTM)5 have become popular interventions among physical therapists due to their ability to stimulate healing in a variety of musculoskeletal conditions. In the following case report, diagnostic ultrasound was used to monitor tissue healing before and after conservative treatment with IASTM and electrical DN in an active duty soldier with an acute calf injury.
ELECTRICAL DRY NEEDLING: EFFECTIVENESS & MECHANISMS
Dry needling and acupuncture with electric stimulation has been shown to significantly reduce pain and disability associated with a number of neuromusculoskeletal conditions.6, 7 After reviewing 39 clinical trials totaling 20,827 patients, Vickers et al concluded that acupuncture is a reasonable option for patients that suffer from chronic pain, as the results seem to persist over time and cannot be explained by placebo effects.7 However, the use of monofilament needles without injectate to treat acute musculoskeletal issues is more limited.8, 9 Nevertheless, Fan and Wu found that electroacupuncture significantly improved the rehabilitation and regeneration of the force displacement value and temperature index of paraspinal muscles in patients with an acute lumbar sprain.10 Electroacupuncture has also been found to increase the strength, number and organization of collagen fibers in an animal model of an acute Achilles tendon tear.11-13
Trigger point DN is a type of DN used to specifically treat myofascial pain syndromes by targeting trigger points and eliciting localized twitch responses.14 However, needle pistoning has been shown to cause excessive damage to neural, muscle and connective tissue,15 which may be counterproductive for patients with acute conditions.16 Yet, acupuncture and DN have also been shown to elicit unique peripheral and central biochemical, biomechanical, endocrinological, and neurovascular changes, which may facilitate healing.4, 17, 18 Electroacupuncture leads to the release of Substance-P and CGRP, which may help reduce inflammation by providing negative feedback onto autoreceptors.19 The increased substance-P may also autoregulate the concentration of peripheral CGRP. Given that CGRP has an anti-inflammatory effect in low concentrations,20, 21 this may be advantageous in patients with an acute injury. Even in the absence of a localized twitch response,22, 23 acupuncture and DN have been shown to significantly increase vasodilation by 72%23 for up to 60 minutes following treatment,22 which may help “wash-out” factors of inflammation. The increased microcirculation may also deliver additional opioids, nutrients and raw materials required to facilitate healing.24-26 In addition, needle stimulation (i.e. winding) elicits tissue mechanotransduction, which facilitates tissue remodeling via Rho and Rac kinase production.27, 28 Electroacupuncture also promotes tissue healing by mobilizing mesenchymal stem cells to stimulate cytokines and differentiate into fat, bone and cartilage tissue.29
INSTRUMENT-ASSISTED SOFT-TISSUE MOBILIZATION: EFFECTIVENESS & MECHANISMS
Instrument-assisted soft tissue mobilization (IASTM) has been shown to improve pain and function in patients with neuromusculoskeletal conditions.5 Despite a lack of heterogeneity and methodological consistency, a recent systematic review of 6 controlled trials demonstrated clinically meaningful reductions in pain for musculoskeletal conditions.30 However, a consensus on the clinical standards regarding the use of IASTM presently does not exist; therefore, clinical practice guidelines have not yet been established for this modality.31 Nevertheless, Graston treatment has been shown to improve both pain and function in patients with chronic Achilles tendinopathy32 and chronic low back pain.33 A number of case studies also suggest that IASTM may be useful for decreasing pain and improving ROM after more acute, sports-related injuries.34, 35
A number of studies suggest that IASTM may facilitate the reduction of adhesions secondary to fibrosis and scar tissue, which may block oxygen and nutrients and interfere with collagen synthesis and tissue regeneration.5, 36, 37 IASTM has been found to increase blood to injured tissue while facilitating fibroblast recruitment and activation,36 which may ultimately lead to collagen synthesis and reorganization.36, 38 After performing IASTM to the medial collateral ligament, Loghmani and Warden reported increased arteriole-sized blood vessels and blood perfusion compared to the contralateral, untreated lower extremity.39 Portillo-Soto et al also found increased vasodilation in the calf muscle where IASTM was applied.40 In addition, Loghmani et el reported a 3-fold increase in mesenchymal stem cells in tissue treated with IASTM, which may be paramount to rehabilitation and recovery.41
EVALUATION OF CALF INJURY
A 34-year-old, male active duty soldier reported to the physical therapy clinic with the primary complaint of calf pain following a jump onto an obstacle. Notably, the patient had not previously seen a medical physician for this condition and the day of the evaluation was the same day as the injury. The patient reported the acute onset of sharp pain in his right calf as he was attempting to jump, which initially felt like a cramp. He attempted to stretch and massage the area independently before continuing with his training. He successfully jumped onto the obstacle but reported significant pain as he was trying to jump down. Afterward, the patient noted a sharp pain in the calf with each step and was unable to walk normally.
During the initial evaluation, the patient presented with a “pegleg” gait pattern. That is, he attempted to hold his right knee in full extension and hip in external rotation with no ankle dorsiflexion / plantar flexion during the stance phase of gait. The patient reported significant pain over the right medial aspect of his mid-calf at rest and when trying to walk. Although he maintained full AROM of the hip, knee and ankle, any use of the calf reproduced 8/10 pain on the numeric pain rating scale (NPRS). Manual muscle testing revealed 5/5 strength of the right lower extremity muscles; however, the right gastrocnemius was graded as 3/5 compared to the contralateral lower extremity. He was tender to palpation over the right distal third of the medial gastrocnemius with no obvious defect or ecchymosis. During initial evaluation, the patient’s Lower Extremity Function Scale (LEFS) score was 22/80. Diagnostic ultrasound imaging revealed a small defect in the muscle fibers in the distal third of the right medial gastrocnemius with edema throughout the surrounding tissue. See Figure 1 below.
TREATMENT FOR ACUTE MUSCLE INJURY
On the same day as the evaluation, the patient received 5-minutes of gentle IASTM and dynamic cupping to the site of injury and surrounding tissue, to include the distal musculotendinous junction and medial head of the gastrocnemius. In addition, he performed 2 sets of 10 repetitions of active dorsiflexion and plantar flexion. Afterward, he was instructed to ice his medial gastrocnemius for 20-minutes 3 times per day for 3 days. In addition, the patient was given a 1-inch heel lift in his right shoe, and he was instructed to gradually decrease the lift by ¼ inch as the pain subsided.
On day 4 post-injury, the patient reported to physical therapy with 2/10 pain and was using a ¼ inch heel lift. Treatment was the same as the initial visit; however, electrical DN was added around the site of the medial gastrocnemius tear. Four 0.25 x 40 mm needles were placed in the normal tissue (i.e. tissue that was pain free to palpation) adjacent to the tear at an angle that was perpendicular to the skin and a depth of approximately 30 mm. Following insertion, needles were manipulated uni-directionally to elicit a sensation of aching, tingling, deep pressure, heaviness or warmth.3, 42, 43 The needles were then left in situ for 20 minutes with electric stimulation set to a continuous, biphasic waveform at a frequency of 2 Hz and a pulse duration of 250 microseconds. The electric stimulation traveled between pairs of needles such that the current passed through the injured tissue at an intensity described by the patient as mild or moderately uncomfortable.44, 45
Immediately following the patient’s initial treatment with electric DN, he was able to walk out of the clinic with a relatively normal, pain-free gait. After 3 sessions of electric DN (4 treatments total) over a 2-week period, the patient reported no pain (i.e. 0/10 on NPRS). His LEFS improved to 68/80, and he reported a GROC score of +6. In addition, repeated US imaging of the right distal medial gastrocnemius seemed to show a decrease in the size of the defect and reduction of fluid in the area. See Figure 2 below.
Figure 1: Longitudinal image – initial evaluation (day 1)
Figure 2: Longitudinal image: 2-weeks post-injury
This case report suggests that the combination of electric DN and IASTM may be a useful treatment strategy in patients with an acute calf muscle tear. However, no cause and effect claims can be made from a single case study, as in the absence of a comparison or control group, the natural history or time course of the healing may account for the improvements shown regardless of the particular intervention provided. As such, well-designed controlled trials are required to fully determine the additive potential of IASTM and electrical DN for this patient population.
Andrew Beach, PT, MS, OCS, ECS, Dip. Osteopractic
Fellow-in-Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Fort Bragg, NC
Raymond Butts, PhD, DPT, MSc (NeuroSci), Dip. Osteopractic
Senior Faculty, AAMT Fellowship in Orthopaedic Manual Physical Therapy
James Dunning, PhD, DPT, MSc (Manip Ther), FAAOMPT, Dip. Osteopractic
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
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