Can Dry Needling Accelerate Healing & Return to Function Following Soft Tissue Allograft Repair?

Following tendon or ligament ruptures, surgical repairs may include two types of donor tissue: autograft (i.e., the patient’s own tissue) or allograft (i.e., where tissue is transplanted from another person). 1-2 Allograft procedures provide surgeons with unique complications, including tissue rejection, risk of infection, increased cost, and delayed incorporation of the allograft with the body. 1-2 Allografts have also been associated with a post operative decrease in tissue strength and an increase in re-tear rate. 

Modern processing and storage methods largely minimize the risks of infection or rejection, but chemical sterilization procedures can be detrimental to allograft tendons, often resulting in delayed remodeling and weakened tensile strength.2,3,4 Notably, a consensus of failure rates in allograft vs autograft procedures does not exist in the current literature.5,6,7,8,9 Following surgery, the body begins a 3-stage healing process, that occurs over a 12-week period.10 During this 12-week period, the body’s cells fully incorporate the allograft with host DNA, and completely replace the donor tissue.3 


Interventions such as dry needling can be useful throughout all 3 stages of healing and may provide a way to accelerate tissue healing, improve strength (of the graft and muscle tissue), and increase allograft incorporation with the patient’s host tissue. This has begun to be seen in common sites of allograft repair. Three sessions of dry needling to healthy rat Achilles tendons led to significant increases in Cox2, Mmp2, Col3a1, and Scx genes, all of which are important in collagen regeneration and tissue remodeling.11 These genes are involved in the early inflammatory phase, and typically decrease over the first 7-28 days of healing.11 “This progressive reduction over time suggests that these genes and metalloproteinases participate in the initial (acute) degradation of the extracellular matrix.”11 Long term gene over-expression, as was seen following dry needling, can be vital in accelerating initial tendon healing/extracellular matrix remodeling, allowing for sooner time to loading and ultimate tendon proliferation of the allograft.11 Acupuncture needling effected collagen production and structure, seeing similar improvements in both strength and structure of rat tendons after elicited tenotomy.12


In the shoulder, significant biological and mechanical changes following ultrasound-guided needling of healthy rat supraspinatus tendons have also been found between groups given no needling, mild needling, and moderate needling.13 Color doppler revealed increased blood velocity 24 hours post needling, as well as significant increase in blood “fractional area” (the % area of doppler signal).11 Histological evaluation revealed increased cellularity 1 week post needling, as well as an increase in type III collagen, TNFa, and IL-1b.13 Mechanical evaluations found an increase in cross sectional area, but interestingly an initial decrease in max load in the moderate needling group at 1 week post needling.13 Both mild and moderate groups saw significant increases in max load at 6 weeks compared to the un-needled group.13 These findings indicate that needling early in the healing process may induce more positive environments for healing, by increasing blood flow, and provide an environment for increasing muscle size and strength earlier in the rehab process.


The use of needle manipulation (unidirectional winding) has been found to improve fibroblast cytoskeletal responses as well, and induces changes in gene expression as well as cellular matrix production during tissue healing.14,15,16 Dry needling to the gastrocnemius 24-hours following a bupivacaine induced injury led to “more intact muscle fibers, less inflammatory cell infiltration, and less fractured muscle fibers.”17 Further RNA sequencing confirmed the manipulation and physical stimulation of the needle led to changes in gene expression and acceleration in muscle regeneration.17 These findings are especially important, as this is a common site for allograft repair and is very accessible to dry needling.


The addition of electrical stimulation to dry needling has also been shown to have positive effects on tissue healing and improving strength in various soft tissues. Using electroacupuncture on injured rat tendons produced improved collagen formation, collagen fibril size, and improvements in the quality of the tissue.18,19 The use of electroacupuncture promoted improved skeletal muscle regeneration, improved blood flow, increased muscle diameter and decreased fibrosis of the tissue during healing.20  


Several studies have also shown improvements in muscle production and functional performance post dry needling. Vertical jump height was compared in groups who received dry needling to the gastrocnemius vs a sham group who received no needling.21 Athletes who received dry needling gained 1.2 inches on their jump vs the sham group.21 In another study, a 25% increase in muscle thickness and 30% improvement in 90 deg external rotation strength was found following needling to the infraspinatus.22

The effects of dry needling on thigh muscle strength in 30 elite soccer players found dry needling to “TrP of the front and back of the thigh following detection on palpation” showed significant improvements in both knee extension and flexion isokinetic strength at a 4-week follow up, with further improvements at 8 weeks.23 Knee flexion/extension endurance also improved significantly at 4 and 8 week follow ups.23 


Allograft repairs continue to be widely used when surgeons are presented with more complicated soft tissue and boney injuries. A growing amount of evidence suggests unidirectional needle manipulation during dry needling may reduce graft complications, accelerate tissue healing, help align collagen matrix, and reduce unwanted fibrosis or scarring of tissues following allograft repair.


Konstantinos Mavropoulos, DPT, Cert. DN
Meadowlands Physical Therapy & Wellness, Hoboken, NJ
Fellow-in-Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy

Casey Charlebois, PhD(c), DPT, MSc, FAAOMPT, Dip. Osteopractic
Director of Clinical Research, AAMT Fellowship in Orthopaedic Manual Physical Therapy
PhD Candidate, Nova Southeastern University, Fort Lauderdale, FL

James Dunning, PhD, DPT, MSc, FAAOMPT, Dip. Osteopractic
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Montgomery Osteopractic Physical Therapy & Acupuncture, Montgomery, AL


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