Authors: David Ryland, PT, DPT, IAOM-US Residency Program, Richfield, Ohio & Kelly Albers, PT, ATC, ScD, Residency Director, IAOM-US Residency program, Denver, Colorado & Jean-Michel Brismée, PT, ScD, Fellowship Director, IAOM-US Fellowship program

Abstract

Background and Purpose: Osgood-Schlatter’s disease can negatively impact an adolescent’s ability to perform functional and sporting activities due to anterior knee pain. Literature demonstrates that dry needling can assist with pain management in orthopedic conditions. The purpose of this case study is to discuss potential short-term benefits of pain management with dry needling for Osgood-Schlatter’s disease.

Case Description: The patient is a 15-year-old female sub-elite level soccer player with a five-year history of intermittent anterior knee pain. While attending physical therapy for hip adductor tendinopathy, she developed signs and symptoms concordant with Osgood-Schlatter’s disease.

Outcomes: Three sessions of periosteal tibial tuberosity pecking and unilateral needle rotation within the patellar tendon allowed the patient to fully return to soccer without pain. The patient showed improvements from initial to discharge score on the Lower Extremity Functional Scale from a 27/80 to an 80/80 and Self-Rating Scale on the International Knee Documentation Committee – Subjective Knee Form from a 5/10 to a 10/10. The patient was able to return to soccer practice without limitations from her knee pain after dry needling intervention.

Discussion: After three dry needling sessions, the patient demonstrated pain decrease and return to prior level of function and soccer participation without limitations. This case report demonstrates the utilization and potential benefit of dry needling.

Background and Purpose

Osgood-Schlatter’s Disease

In the early 1900’s, Robert Osgood and Carl Schlatter described Osgood-Schlatter’s disease (OSD) as a traction apophysitis that occurs in adolescents.1 Recent literature shows no difference in prevalence between girls and boys; however, age differences are present with more likelihood of OSD in girls between 8-12 years old and boys between 12-15 years old.1,2,3,4 Osgood-Schlatter’s disease is significantly more common in athletic populations.1,3 Although OSD typically occurs unilaterally, there is a 20-30% prevalence of bilateral symptoms.1,3,4 Interestingly, single-sport athletes have four-times more likelihood of developing OSD compared to multi-sport athletes.5

Osgood-Schlatter’s disease etiology has been described as the overuse or repetitive loading on the extensor mechanism.1 Circi et al (2017) describe an “inflammatory response with the end result being patellar tendinitis, multiple subacute microfractures, and irregular ossification of the underlying bone.”1 Others show an abnormal patellar position with an inferior tilt of 13° in OSD individuals compared to asymptomatic individuals.6 The inferior patellar tilt causes an increase in quadricep stress leading to increased force through the patellar tendon on the tibial tubercle growth plate.6 Lucena et al describe another risk factor as the rectus femoris shortening.3

Dry Needling

Throughout the past decade, dry needling has become a popular treatment technique for orthopedic manual physical therapists. Research supports that dry needling causes an immediate reduction in local, referred, and widespread pain, restoration of range of motion and muscle activation patterns, and normalization of the immediate chemical environment of active myofascial trigger points.7 Dry needling utilizes a solid, thin, monofilament needle that can be inserted directly into muscles, connective tissues, and in the vicinity of nervous tissue.7,8

In addition to physiological effects, dry needling may decrease central and peripheral nociceptive input.7 Myofascial trigger points can stimulate a cascade of chemicals, which creates an environment of constant nociceptive input into the dorsal horn of the spinal cord.7 However, if dry needling elicits a local twitch response, there is an immediate decrease in several chemicals involved.7 A local twitch response can be described as a sudden, brisk, powerful muscle contraction that is thought to break the vicious pain cycle that a myofascial trigger point can have on an individual.7 Any skin puncturing with a needle can stimulate a release of endorphins, change pain thresholds, or induce an expectancy of a positive outcome.7 Although significant in its ability to change the chemical milieu, decrease pain thresholds, and rapidly improve function, dry needling should not be a stand-alone intervention and should be enhanced by exercise therapy and other manual techniques.

Deep dry needling (DDN) and superficial dry needling (SDN) comprise trigger point dry needling. Deep dry needling aims to rectify dysfunctional motor units by resolving myofascial trigger points through local twitch responses, while SDN primarily targets peripheral sensory afferents.7 Superficial dry needling can be highly effective for reorganization of connective tissue such as ligaments, scar tissue, tendons, bone, and teno-osseous insertion sites.8,9,10 Tendon and teno-osseus insertion dry needling may assist with an increase in localized vasodilation and collagen proliferation.8,11,12,13

The purpose of this case study is to discuss the potential short-term benefit of using dry needling as a means of pain management for Osgood Schlatter’s disease.

Case Description

The patient was a 15-year-old female sub-elite level soccer player who presented with a 5-year history of recurrent bilateral anterior knee pain (left > right). The pain waxed and waned throughout the years and reoccurred spontaneously two months ago while rehabilitating a left adductor longus tendinopathy. The patient could not recall a specific mechanism of injury; however, she did report that she had been playing soccer for 10 years and had grown three to four inches in the past six months. The patient was otherwise healthy.

Upon evaluation, the patient described her symptoms as bilateral knee pain that was localized to the tibial tuberosity. She reported that her symptoms were mostly aggravated by ascending and descending stairs, walking, prolonged standing, and during and after any high impact activity including running, jumping, hopping, and changing direction. The patient denied taking any anti-inflammatory medications. Patient reported that at the worst, her pain would increase to a 7-8/10 on the Visual Analog Scale (VAS). The patient reported that her pain could be relieved to a 6/10 on the VAS by resting and icing the area. Patient’s initial score on the Lower Extremity Functional Scale (LEFS) was 27 indicating 66% disability, where 100% is equal to complete disability. On a Self-Rating Scale taken from question #10 on the reliable and validated outcome measure, the International Knee Documentation Committee – Subjective Knee Form, she reported a 2/10 where 10 indicates no limitation and 0 indicates an inability to perform daily activities.14

Clinical Examination

The patient demonstrated minimal edema in the region of the tibial tuberosity (left > right), but there was no warmth in the area. Table 1 depicts clinically significant examination findings.

 

Table 1. Clinical examination findings

Clinical Tests Results
Effusion

R: (+) – Minimal in the region of the tibial tuberosity

L: (+) – Minimal in the region of the tibial tuberosity

Warmth

R: Negative

L: Negative

Passive Range of Motion (PROM): Knee Extension

R: – 5° hyperextension; Pain: Negative

L: – 5° hyperextension; Pain: Negative

PROM: Knee Flexion

R: 150°; Pain: “Tightness,” but negative for pain

L: 155°; Pain: “Tightness,” but negative for pain

PROM: Tibial Internal Rotation (IR)

R: Equal motion between sides; No Pain

L: Equal motion between sides; No Pain

PROM: Tibial External Rotation (ER)

R: Equal motion between sides; No Pain

L: Equal motion between sides; No Pain

Ligament Instability Tests (Varus and Valgus at 0° and 30°, Anterior-Posterior Translatory Test, Lachman’s Test, Anterolateral Drawer Test)

R: Negative

L: Negative

Resisted Knee Extension (30°)

R: Strong and painful; Pain: Mild

L: Strong and painful; Pain: Mild

Resisted Knee Flexion

R: Strong and painless

L: Strong and painless

Resisted Knee Extension (0°)

R: Strong and painful; Pain: Mild

L: Strong and painful; Pain: Mild

Resisted Knee Extension (90°)

R: Strong and painful; Pain: Mild

L: Strong and painful; Pain: Mild

Hop Test (Double Leg)

R: Pain: Mild

L: Pain: Moderate

Hop Test (Single Leg)

R: Pain: Moderate

L: Pain: Moderate

Palpation Localized tenderness on the medial and superomedial aspect of the tibial tuberosity bilaterally.

Intervention

Preceding OSD treatment, the patient was attending physical therapy for an adductor longus tendinopathy. Following OSD diagnosis, the physical therapist collected the LEFS initial score. Physical therapy was recommended two times per week for six to eight weeks with each session focusing on decreasing groin and knee pain, a full body dynamic warm up, increasing lower extremity (LE) functional strength, and return-to-sport drills. The patient received education on her diagnosis and prognosis, and collaborative plan of care was developed. The patient was educated in the benefits of adding anti-inflammatory foods to her diet and that anti-inflammatory medication may be used on an as-needed basis. She followed these instructions and increased the amount of anti-inflammatory foods and pain medication approximately 1-2 times per week. The patient was instructed in ice massage, which may assist with pain control.4 Since OSD is a self-limiting condition, the patient’s functional and sport-specific program for her groin was continued and adjusted based on her ability to tolerate the exercises. The addition of soft tissue mobilization to the knees was included to assist with pain control. The physical therapist used the Kennedy Stages of Tendinopathy (Table 2) as a guideline for appropriately regressing and progressing the patient’s activity level.15

Table 2: Kennedy Stages of Tendinopathy15

Stage Description of Stage Reduction in Activity Level
Stage 0 No pain Full return to sport
Stage I Pain only after activity Decrease activity by 25%
Stage II Pain before and after activity Decrease activity by 50%
Stage III Pain before, during, and after, but is NOT affecting performance Decrease activity by 75%
Stage IV Pain before, during, and after and IS affecting performance Complete rest

Treatment included superficial dry needling of the tendon and periosteal pecking, as the therapist was certified in Optimal Dry Needling Solutions (ODNS) Level I, which does not include certification in deep dry needling of anatomy distal to the knee. The patient and parent completed an informed consent form, which outlined that there were no contraindications or relative precautions for dry needling. The patient was placed supine on the treatment table. Bilateral knees were cleaned with soap and water as well as with hand sanitizer. With gloved hands, the physical therapist palpated for the most tender point around the tibial tuberosities, which were marked with a skin marker ensuring that specific needling was performed. Two 15mm needles on each LE were used for the treatment. One needle was used to perform thirty seconds of periosteal pecking at the most tender point on the tibial tuberosity. The second needle was used within the patellar tendon (Figure 1). Based off the study by Langevin, it was inserted, twisted two revolutions, and then left in-situ for 10-15 minutes.12 The needle was removed only if there wasn’t any “catching” from the tissue, indicating that the tissue had relaxed and released. If the tissue “caught,” the needle remained in-situ for another 5 minutes and then attempted to remove again. This process was continued for a maximum of 15 minutes.

After each needling session, the patient was instructed to perform stretching exercises and to increase water intake to assist with the dry needling soreness.

Figure 1. Dry Needling of patellar tendon. The needle shown in the picture was inserted into the patellar tendon, was rotated two revolutions, and was left in-situ for 10-15 minutes.

Outcomes

            After the first dry needling session, the patient reported 75-80% decrease in pain before, during, and after soccer practice. After the second dry needling session, the patient reported 85-90% pain alleviation. After the final dry needling session, the patient reported that she did not have any pain before, during or after soccer practice. Thus, within three dry needling sessions the patient went from a Stage III to a Stage 0 on the Kennedy’s Stage of Tendinopathy (Table 2).15 The patient’s LEFS score increased from a 27/80 on the initial visit to an 80/80 on the final visit. The patient demonstrated a decrease in her Self-Report Score from 5/10 (0 being not able to perform activities of daily living; 10 being no limitations) to 10/10 on the final visit.14

A virtual follow up visit was performed with the patient 6 weeks after discharge. The patient continued to report an 80/80 on the LEFS and a 10/10 on the Self-Report Score.14 The patient was back to playing soccer at her full ability without any limitations due to knee pain.

Discussion

This is the first case study to report the potential short-term benefit of using dry needling for pain management for Osgood Schlatter’s disease in an adolescent soccer player. Literature supports dry needling effectiveness for pain management for various orthopedic conditions and improvement in patient-reported outcomes.7,8,9,10,11,12,13,16,17,18 By inserting a dry needle into a tendon, it is thought to disrupt the chronic degenerative process and instigate a local bleeding response which in turn leads to increased circulation.12,18

Periosteal pecking is a form of dry needling where the tip of the needle contacts the peritoneum.19 In this patient case, tibial tuberosity periosteal pecking was performed to elicit pain relief, due to irritation of the free nerve endings.19,20 The periosteum irritant has been found to activate the large A-delta fibers, which causes a release of endogenous opioids and encourages a pain inhibiting mechanism in the central nervous system.19,21

The rotational component of dry needling winds up and gathers the collagen fibers around the needle.12 Interestingly, by producing two revolutions with the needle in a unilateral direction, it can create a cell-spreading effect on the muscle to a load of 1.96Nm (2 grams).12,18 Within minutes after needle rotation, the tissues stimulate fibroblasts resulting in an active cytoskeleton reorganization up to “several centimeters” away from the needle, an event called “cell-spreading.”12,22,18 Needle rotation may change the tissue environment and provide an opportunity to heal. 

Additionally, dry needling could assist with pain reduction when the needle penetrates the peritendineum.12,18 It has been demonstrated that any type of in-situ needle is likely to demonstrate an increase in the flow of endorphins, induce specific brain responses that change pain thresholds, decrease cortisol, and create an expectancy of positive outcome.7,8,19,21 Thus, the needle insertion into the peritendineum may have caused a chemical sequela that contributed to the decrease in patient’s pain.

The outcomes of this case study potentially show that dry needling for OSD may assist with pain management. However, it is not appropriate to generalize findings based on a single patient with OSD. In addition, the patient was prescribed functional exercises that increased strength (concentric and eccentric exercises), flexibility, and motor control training. She was instructed to perform these exercises at home. They were provided to her in video format to ensure excellent quality when performing at home. One limitation of this case study is that the patient, of her own jurisdiction, added new interventions following the first dry needling session and returned to soccer practice. Interventions included full length compression tights and self-applied Kinesiotape. As a result, it difficult to determine if dry needling reduced the patient’s pain; however, following removal of the compression tights and Kinesiotape the patient continued to report less pain.  It is important for more research to be completed on dry needling as a cost-effective method of pain control to further assess advantages it may offer over traditional physical therapy. 

References:

  1. Circi E, Atalay Y, Beyzadeoglu T. Treatment of Osgood-Schlatter disease: review of the literature. Musculoskelet Surg. 2017;101(3):195-200. doi:10.1007/s12306-017-0479-7
  2. Gholve PA, Scher DM, Khakharia S, Widmann RF, Green DW. Osgood Schlatter syndrome. Curr Opin Pediatr. 2007;19(1):44-50. doi:10.1097/MOP.0b013e328013dbea
  3. de Lucena GL, dos Santos Gomes C, Guerra RO. Prevalence and associated factors of Osgood-Schlatter syndrome in a population-based sample of Brazilian adolescents. Am J Sports Med. 2011;39(2):415-420. doi:10.1177/0363546510383835
  4. Neuhaus C, Appenzeller-Herzog C, Faude O. A systematic review on conservative treatment options for OSGOOD-Schlatter disease. Phys Ther Sport. 2021;49:178-187. doi:10.1016/j.ptsp.2021.03.002
  5. Hall R, Barber Foss K, Hewett TE, Myer GD. Sport specialization’s association with an increased risk of developing anterior knee pain in adolescent female athletes. J Sport Rehabil. 2015;24(1):31-35. doi:10.1123/jsr.2013-0101
  6. Winkle D, Matthijs O, Phelps V. Diagnosis and Treatment of the Lower Extremities: Nonoperative Orthopaedic Medicine and Manual Therapy. Gaithersburg, MD: Aspen Publishers; 1997.
  7. Dommerholt J. Dry needling – peripheral and central considerations. J Man Manip Ther. 2011;19(4):223-227. doi:10.1179/106698111X13129729552065
  8. Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014;19(4):252-265. doi:10.1179/108331913X13844245102034
  9. Lewit K. The needle effect in the relief of myofascial pain. Pain. 1979;6(1):83-90. doi:10.1016/0304-3959(79)90142-8
  10. Introduction to Trigger Point Dry Needling Level I. Tucson, AZ: ODNS – IAOM-US; 2017.
  11. Kubo K, Yajima H, Takayama M, Ikebukuro T, Mizoguchi H, Takakura N. Effects of acupuncture and heating on blood volume and oxygen saturation of human Achilles tendon in vivo. Eur J Appl Physiol. 2010;109(3):545-550. doi:10.1007/s00421-010-1368-z
  12. Langevin HM, Bouffard NA, Churchill DL, Badger GJ. Connective tissue fibroblast response to acupuncture: dose-dependent effect of bidirectional needle rotation. J Altern Complement Med. 2007;13(3):355-360. doi:10.1089/acm.2007.6351
  13. Lee JA, Jeong HJ, Park HJ, Jeon S, Hong SU. Acupuncture accelerates wound healing in burn-injured mice. Burns. 2011;37(1):117-125. doi:10.1016/j.burns.2010.07.005
  14. Higgins LD, Taylor MK, Park D, et al. Reliability and validity of the International Knee Documentation Committee (IKDC) Subjective Knee Form. Joint Bone Spine. 2007;74(6):594-599. doi:10.1016/j.jbspin.2007.01.036
  15. Kennedy JC, Hawkins R, Krissoff WB. Orthopaedic manifestations of swimming. Am J Sports Med. 1978;6(6): 309-322. DOI: 10.1177/036354657800600602
  16. Krey D, Borchers J, McCamey K. Tendon needling for treatment of tendinopathy: A systematic review. Phys Sportsmed. 2015;43(1):80-86. doi:10.1080/00913847.2015.1004296
  17. Mense S, Gerwin RD. Muscle Pain: Understanding the Mechanisms. Berlin, Heidelberg: Springer Berlin Heidelberg; 2010.
  18. Cuñado-González A, Ríos-León M. Ultrasound-guided Dry Needling in Jumper’s Knee: A Case Report. Physikalische Medizin, Rehabilitationsmedizin, Kurortmedizin 2021; 31(01): 53-58. DOI: 10.1055/a-1240-0281
  19. Robertson ME. The relative effectiveness of periosteal pecking combined with therapeutic ultrasound compared to therapeutic ultrasound in the treatment of medial tibial stress syndrome type II. [dissertation]. Musgrave, Berea, 4001, South Africa: Durban Institute of Technology; 2003.
  20. Saylor-Pavkovich E. Strength exercises combined with dry needling with electrical stimulation improve pain and function in patients with chronic rotator cuff tendinopathy: a retrospective case series. Int J Sports Phys Ther. 2016;11(3):409-422.
  21. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150(3699):971-979. doi:10.1126/science.150.3699.971
  22. Stoychev V, Finestone AS, Kalichman L. Dry needling as a treatment modality for tendinopathy: a narrative review. Curr Rev Musculoskelet Med. 2020;13(1):133-140. doi:10.1007/s12178-020-09608-0
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