McDevitt AW, Snodgrass SJ, Cleland JA, Leibold MB, et al. Treatment of individual with chronic bicipital tendinopathy using dry needling, eccentric-concentric exercise and stretching; a case series. Physiotherapy Theory and Practice.2018;36(3):397-407.
Abstracted by Melissa Lodhi PT, ScD, COMT and Jean-Michel Brismée PT, ScD Fellowship Director
Purpose: The purpose of this retrospective case series was to describe the outcomes of ten individuals with suspected chronic long head biceps tendon (LHBT) tendinopathy treated with dry needling in combination with an eccentric-concentric exercise protocol.
Methods: This study involved ten individuals who were presented with primary shoulder pain averaging from 3-14 months (mean 9.6+1.6 months). Clinical diagnosis was established using patient history, symptoms, palpation, and orthopedic special tests by a physical therapist. Evaluation occurred at baseline and at discharge. The authors described the patient examination of range of motion measured by active/passive motion via goniometry, muscle length of the pectoralis minor/major, latissimus dorsi and the shoulder rotators. Strength was also assessed of the scapular stabilizers and glenohumeral muscles. Special testing included Speed’s test, Yergason’s, Neer impingement test, Hawkins/Kennedy, and palpation of the region of the long head biceps tendon (LHBT). All ten patients exhibited a combination of positive signs and symptoms consistent with pathology of the LHBT. Treatment consisted of all ten patients receiving 3 components of treatment: dry needling to the LHBT, eccentric/concentric exercises, and stretching. Dry needling was performed with .30 x 40 mm Seirin needle into the most painful and/or thickened areas of the tendon, confirmed by palpation. The needling technique was a pistoning motion of 20-30 repetitions up to 3 areas. Eccentric/concentric exercise (ECE) emphasized eccentrics in supine with weight chosen by the physical therapist and the patient moving weight in shoulder extension/elbow extension. Patients moved the arm into flexion and then eccentrically 3-4 seconds. Stretch to the biceps was performed after the eccentric exercise and recommended to perform daily. The outcome measures utilized included the QuickDash and numerical pain rating scale (NPRS), which were completed at baseline and discharge. Patients also completed the Global Rating Change Scale (GROC) at discharge. The patients received a minimum of 2 and a maximum of 8 treatment sessions, ranging from 10 to 42 days.
Results: Ten patients (8 male, 2 female) ages 24-64 (mean=40+13 years) completed the case series. Descriptive statistics, pre- and post-intervention data were analyzed using dependent t tests for the NPRS and QuickDASH. The initial mean NPRS was 6.1+1.6 and the Quick Dash at baseline was 33.61+17.1. The interventions were continued at each follow up treatment session and patients were discharged when they perceived improvement of their function/disability and pain. At the patient’s discharge, NPRS was 2.2+1.3 and QuickDash 7.75+10.8. Patients’ perception of recovery via GROC score improved +5.4+1.3. The authors commented on limitations of the study in the utilization of 4 physical therapists thus limiting the generalizability of the study. Also noted was the definitive location of dry needling intervention without US as other tissues could be pain generators such as the subscapularis. Finally, the author’s acknowledged the lack of a long-term follow up concerning pain and function.
Conclusion: Results indicated that a combination of dry needling, eccentric/concentric exercise, and stretching may improve pain in chronic LHBT tendinopathy.
IAOM/ODNS Commentary: Research suggests that dry needling appears to be effective in relieving pain for the management of musculoskeletal conditions during immediate and up to 6 months follow-up (Nuhmani, 2023, Dolene 2020). Tendon dry needling involves repeated fenestrations of the affected tendon, which is thought to disrupt the chronic degenerative process and encourage local bleeding and fibroblastic proliferation (Stovchev, p. 135). This study provided a treatment guide to utilize dry needling as an adjunct therapy. Several methodology factors may have affected the author’s outcomes. The recruitment process for participants was not specifically described and the actual sample size was very small, only ten participants, likely impacting the power of the study. The authors did not use a control group as all participants received the same treatment approach due to the ethical dilemma of denying treatments to patients with pain. This lack of control group and of a long-term follow-up limited the inference of cause and effect of the treatment.
All patients reported symptoms greater than 3 months with one participant post operative biceps tenodesis. This aspect could pose a challenge with the limited tendon length exposure from his surgery and ability to appropriately needle the tendon. The utilization of an ultrasound might have been useful for diagnostic purposes in locating the LHB tendon for all participants, especially the patient with the biceps tenodesis. The authors did not comment on exclusion criteria for patients participating in the study such as possible rotator cuff tears or labral pathology. Studies have reported an association existing between individuals with rotator cuff disease and LHBT pathology. (Diplock 2023). Therefore, the presence of rotator cuff pathology could impact the recovery of a LHBT issue. The study discussed evaluation methods of tendinopathy but did not address the possibility of an existing Superior Labral Anterior-Posterior (SLAP) tear in their differential diagnosis. They could have used Biceps I and II testing for provocation of pain as they only used Speed’s test, Hawkins/Kennedy (which is used for subacromial/subdeltoid impingement versus a LHBT issue). The existence of the SLAP tear could possibly influence further irritation of the LHBT. Finally, the authors did not consider possible posterior capsule tightness, which could mechanically influence the anterior translation/positioning of the humeral head by increased LHBT tension (Krupp et al, 2009). Authors could have performed joint specific testing to further assess the posterior capsule mobility.
Treatment technique: The protocol for the intervention involved dry needling first followed by eccentric/concentric exercise, and lastly stretching to the biceps (Figures 1 and 2). A comment concerning the eccentric exercise is the inconsistency related to the weight selection for patients as this was based upon the patient’s discomfort, versus a selected weight (varied between 4 to 6 pounds). The weight was increased when they no longer felt discomfort with the exercise, which lacked consistency.
Fig 1. Eccentric exercise
Fig. 2 Concentric Exercise
Similar to other studies, sufficient information about the specific dry needling technique was not provided. The same size needle, 40mm, was utilized for all participants, which may not consider the soft tissue density of each participant. Research describes several studies using variations of needle sizes from 23 gauge needle to 25 gauge acupuncture needle (Stoychev, 2020). Lectures on tendon dry needling by Optimal Dry Needling Solutions (ODNS) recommend ranges of 25x.13 to 25x.25mm length needles, a much smaller needle than the current study. The study recommended needle pistoning but did not describe the needle direction (perpendicular versus angular approach) nor the depth of the needle. ODNS describes needle placement on both sides of the tendon at oblique angles (Figure 3). Precision could be better attained with the utilization of ultrasound in delineating the biceps tendon from other structures such as the subscapularis tendon as well as depth.
The timing of the intervention varied from 2 to 8 treatments total (4.6 average) and 1-2x/week over total duration of treatment ranging from 10 to 42 days. As noted in research, specific criteria do not exist when to end dry needling intervention. But the authors commented on the cessation of the treatment when the patient reported an improvement in their function/disability and pain. The evidence suggests that tendon needling improves patient-reported outcome measures in patients with tendinopathy, but no specific timeline is delineated. (Dolene 2020, Krey 2015, Nuhmani 2023).
Fig 3. Left Anterior Shoulder: LHBT Dry Needling Technique
The lack of a standardized method of applying dry needling is a major concern as many techniques exist in research regarding dry needling (Nuhmani et al 2023). These standards are needed to describe dry needling techniques in such a way that it can be replicated by including thickness, length and inclination of the needle, type of puncture, needle movement, the experience of the clinician, and criteria used to determine when to terminate the intervention (Nuhmani, 2023). Further research is necessary to assist with standardizing dry needling application in the LHB tendinopathy recovery.
References
- Diplock B, Hing W, Marks D. The long head of the biceps at the shoulder: a scope view. BMC Musculoskeletal Disorders. 2023;24(232):1-19.
- Doidge J, Waumsely C, Barker B et al. “Superficial Dry Needling-Tendon Technique”. Optimal Dry Needling (2023).
- Dolene TV, Jelley W. Non-surgical treatment of patellar tendinopathy: a systematic review of randomized controlled trials. Journal of Science and Medicine in Sport. 2020;23:118-124.
- Krey D, Borchers J, McCamy K. Tendon needling for treatment of tendinopathy: A systematic review. Phys Sportsmed, 2015;43(1):80–86. DOI:10.1080/00913847.2015.1004296
- Krupp R, Kevern M, Gaines M, Kotara S, Singleton S. Long head of the biceps tendon pain: differential diagnosis and treatment. JOSPT. 2009;39(2):55-69.
- Nuhmani S, Khan MH, Ahsan M. et al. Dry needling in the management of tendinopathy: a systematic review of randomized control trials. J of Bodywork and Mvt therapies. 2023;33:128-135.
- Stovychev V, Finestone A, Kalichman. Dry needling as a treatment modality for tendinopathy: a narrative review. Current Reviews in Musculoskeletal Med.2020;13:133-140.