Dry Needling For Tennis Elbow: Who Needs It?

Dry Needling is a treatment for Tennis Elbow, Golfer’s Elbow and other conditions that involves repeatedly sticking a needle into tissues (usually muscle or tendon) that are not healing properly in the hope of stimulating a healing response.

Or for the purpose of “deactivating” highly-irritable, pain-causing spots in muscles, known as a ‘Trigger Points.’ The needle in question can be either:

1. A Medical Hypodermic needle – used to penetrate the tissues but without injecting anything (also known as ‘Fenestration’)… Hypodermic Version
   
   
2. Or an Acupuncture needle – which is often referred to as ‘Trigger Point Dry Needling,’ ‘Intramuscular Stimulation’ (IMS) OR ‘Motor Point Dry Needling.’ Trigger Point Version


The Acupuncture needle version seems to be the more common practice, by far, and I’ve included a video a little further down, showing the Acupuncture Dry Needle Therapy technique in action.

I think it’s unfortunate, though, that the term Dry Needling has come to refer to two very different treatments – utilizing two very different types of needles – (by at least three different professions.)

After all, there’s a very big difference – an order of magnitude – between a thin, filament Acupuncture needle and a Medical Hypodermic Syringe!

So I’m going to cover separately what I think should be considered two distinct treatments.



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But, first, a little history on where the term comes from. According to Wikipedia,

“The origin of the term “dry needling” is attributed to Janet G. Travell. In her book, Myofascial Pain and Dysfunction: Trigger Point Manual, Travell uses the term ‘dry needling’ to differentiate between two hypodermic needle techniques when performing trigger point therapy.”

https://en.wikipedia.org/wiki/Dry_needling

However, I also came across this reference to the work of Karel Lewit in a Nat. Inst. of Health paper, claiming that Lewit is the originator of the technique, so it’s not clear who it comes from:

“Modern trigger point dry needling has its origins in the work of Karel Lewit of Czechoslovakia. In his classic work, he examined the short and long‐term effects of dry needling in the treatment of myofascial pain in 241 patients with 312 painful MTrP sites.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458928/

At the time Dr. Travell was practicing, (and apparently for Karel Lewit) it seems it was standard practice to interchangeably inject anesthetics via Hypodermic Needles into ‘Trigger Points’ in muscle tissues, or to use the same needle to “probe” and treat Trigger Points without injecting anything, hence the term “Dry Needling”.

Later, other practitioners began to use Acupuncture needles (which are solid and cannot inject anything) to treat Trigger Points and to treat tendon disorders, like Tennis Elbow and Golfer’s Elbow.

(Although, there seems to be some debate over whether Dry Needling is truly a form of Acupuncture and consistent with Traditional Chinese Medicine, as well as controversy about whether Physiotherapists and Physical Therapists are qualified to perform it.)

What Is Trigger Point Dry Needling?



Trigger Point Dry Needling With Acupuncture Needles

Despite the fact that the term Dry Needling or Trigger Point Dry Needling originally referred to the use of a Hypodermic Needle…

It now seems that Trigger Point Dry Needling almost always refers to the use of Acupuncture needles to treat Myofascial Trigger Points and their associated pain patterns.

(But not just by Acupuncturists, a growing number of Physical Therapists and even Chiropractors are training in the technique and offering it as an adjunct treatment.)

According to The International Journal Of Sports Physical Therapy:

“Myofascial trigger point pain is defined as ‘pain arising from one or more myofascial trigger points (MTrPs), which are hyperirritable spots in skeletal muscle that are associated with hypersensitive palpable nodules in taut bands.’”

Dry Needling For Myofascial Trigger Point Pain: A Clinical Commentary

Int J Sports Phys Ther. 2015 Jun; 10(3): 402–418.

For more quotes from this paper see my G+ post below.

Video Demonstrating Dry Needling For Tennis Elbow

Here’s a short video showing the Acupuncture Dry Needle Technique in action (also apparently known as ‘Motor Point Dry Needling’ if things weren’t confusing enough!

What’s The Difference Between Acupuncture And Dry Needling?

Acupuncture and Dry Needling both utilize Acupuncture Needles, they appear to be the same to the casual observer, and many Acupuncturists claim that they are one and the same.

(I already wrote about conventional Acupuncture in the treatment of Tennis Elbow here in this post (and video) – but there is enough of a difference in theory, intent, and practice to warrant a separate look at the technique of Dry Needling Therapy.)

Dry Needling VS Acupuncture: What’s The Difference? 

There is a rapidly growing number of other practitioners, however, who are taking courses in Dry Needling and practicing it under the aegis of Physical Therapy (or Chiropractic.)



Acupuncture for Tennis Elbow

Many of these practitioners regard Dry Needling as a technique that stands on its own and doesn’t necessarily fall under the auspices of Acupuncture.

It doesn’t require any knowledge of Traditional Chinese Medicine, including the Meridian System and its points that Acupuncturists stick needles into.

Rather, it can be said to have originated with Western Medical practitioners like Dr. Janet Travell, MD and Karel Lewit.

There is definitely controversy brewing, however.

Some Acupuncturists – And their State boards – claim Dry Needling is a technique that falls entirely within their scope of practice and no others.

To the layperson, it probably seems like a purely semantic argument – And that may be the case.

But, according to a 2016 news article in The USA Today, by Kim Painter, ‘Dry needling’ For Pain Therapy Is Under Scrutiny…

The U.S. Physical Therapy Association apparently advises members in at least seven states, including California, Florida, Hawaii, Idaho, New York, South Dakota and Washington to avoid using Dry Needling, citing recent regulatory decisions or language in existing Physical Therapy licensing laws.

The article also states that most of the United States’ 200,000 Physical Therapists have not been trained in Dry Needling, and only approx. 6,000 have taken courses in it.

At the same time, this article by Eric Ries, in the American Physical Therapy Association’s website paints a fairly pretty picture of the technique: Dry Needling: Getting to the Point

Does Trigger Point Dry Needling Help With Tennis Elbow?

The question, of course, is whether this Myofascial Trigger Point Dry Needling approach to treating Tennis and Golfer’s Elbow actually works.

There are a few studies, but not a lot to go on yet. According to this paper, published in International Orthopaedics:

“RESULT: …dry needling was significantly more effective than the first-line treatment at six months.” [First line treatment consisting of topical and oral anti-inflammatory drugs, icing, and brace use.]

“CONCLUSION: Because of the low complication rate, dry needling is a safe method, and it might be an effective treatment option for LE” [Lateral Epicondylitis]

Dry Needling In Lateral Epicondylitis: A Prospective Controlled Study

International Orthopaedics – August 2017; DOI: 10.1007/s00264-017-3604-1

I can’t help but think that from my perspective ANYTHING – including doing NOTHING at all and just leaving it alone – would produce a better outcome at 6 months that the standard, “first-line treatment” of anti-inflammatory drugs, icing, and bracing not to mention Cortisone Shots!!

These inflammation-chasing, immobilizing and cooling / circulation-reducing “treatments” do more harm than good and slow the healing process, from what I can see.

And the “average” rate of recovery is all over the map, with no meaningful “healing time!”

For more on the standard approach, see my Tennis Elbow Treatment Page:

The Standard Treatment Protocol And What’s Wrong With It

I also have to point out a problem I often observe in many of these studies: They are rarely double-blind, placebo-controlled.

Without a placebo group in a double-blind study, one technique or treatment may outperform another, but you have no way of knowing how much of that may have to do with the placebo effect.

(Not that I’m claiming any objective medical evidence proving the effectiveness of my self-help treatment programs for Tennis Elbow and Golfer’s Elbow – I’m not.)

(But the point is that my programs cost very little and currently, at the time of this post, have generous 90-day, 100% money-back guarantees behind them.)

(Whereas, Acupuncture treatments are quite expensive and Dry Needling isn’t reimbursable under Physical Therapy, even if your PT visits are otherwise covered under insurance.)

Ultimately, however, how will sticking a needle in a trigger point treat the underlying causes and dysfunctions at the root of Tennis Elbow or Golfer’s Elbow?

From my perspective, and in my experience with treating this vexing conditions over the past 15+ years, trigger points are not the core issue.

I’m not denying the existence of Trigger Points. I just don’t see them as the root cause – Rather as a symptom that causes more symptoms in the dysfunctional chain of cause and effect.

I see the problem of muscular adhesion formation as a closer-to-the-source issue that needs to be corrected in most cases.

These adhesions are like layers of “Velcro” that gradually restrict a muscle’s flexibility and function over time.

(Or it can be a faster process in the advent of an acute muscular trauma, like a tear, which results in scar tissue formation.)

As this progresses, Trigger Points may very well arise in the muscle, and one can start experiencing a lot of pain and other symptoms at this point.

Eventually, the tension, adhesion restrictions, reduced circulation and other muscular dysfunctions takes its toll on the tendon(s) of the muscles, and the tendon starts to break down.

It’s at this point, when the tendon is breaking down (degenerating) that one can be said to have “true” Tennis Elbow.

And although, sticking needles in muscles or tendons may have profound and desirable effects on the nervous system…

(I’m convinced that both Dry Needing and “Conventional” Acupuncture – if there’s a difference – can be very effective for short-term pain relief.)

Those needles are not going to release the adhesions (which are spread out and are usually present in many layers) and restore full flexibility, circulation and function to the muscle.

The only thing that can release stubborn adhesions is some form of deeper manipulation – And I prefer and advocate the hands-on variety.

I believe advanced massage techniques are the best way to accomplish this – whether you use the Self Massage Techniques that I teach here in The Classroom

Or you seek out the help of someone trained in them.

There’s also the issue of the tendon degeneration (Tendinosis) that so often makes up the core of the injury with Tennis and Golfer’s Elbow.

I can’t see Trigger Point Dry Needling helping very much, if at all with that, but that brings us to the other kind of Dry Needling, which may have a lot of potential to reverse it.

What Is Hypodermic Dry Needling / Fenestration?

The goal of the type of Dry Needling that utilizes a Hypodermic Syringe to treat Tennis and Golfer’s Elbow is to inflict new trauma and bleeding in the tendon to initiate a new healing response.

Keeping in mind that the typical case of Tennis or Golfer’s Elbow involves Tendinosis – A degenerative condition marked by an abject failure of the healing / regeneration process.

The objective of driving a Hypodermic Needle repeatedly into a tendon that is in a state of degeneration and traumatizing it, is to set off a new round of inflammation and repair, which will hopefully continue and lead to the full repair of the tendon.

“This is a relatively new treatment which involves the passage of a hollow needle into the abnormal tendon substance under ultrasound guidance.”

“The area needled is one of angiofibrobalstic degeneration of the tendon substance and creates an area of bleeding.”

“This is thought to reset the inflammatory response and allow fibroblastic proliferation and collagen formation leading to tendon healing.”

Treatment of Tennis Elbow: The Evidence British Medical Journal – BMJ 2003;327:330 http://www.bmj.com/rapid-response/2011/10/30/dry-needling-therapy-treatment-lateral-epicondylitis

(This techniques is also known as ‘Fenestration’ and has been used in veterinary medicine, especially with horses, for quite some time.)

“A potential treatment for chronic tendinosis or tendinopathy is percutaneous ultrasound-guided tendon fenestration, also termed dry needling or tenotomy.”

“This procedure involves gently passing a needle through the abnormal tendon multiple times to change a chronic degenerative process into an acute condition that is more likely to heal.”

Ultrasound-Guided Tendon Fenestration Semin Musculoskelet Radiol. 2013 Feb;17(1):85-90 https://www.ncbi.nlm.nih.gov/pubmed/23487340

More commonly, a liquid substance is injected via the Hypodermic Syringe, rather than using a “Dry” needle, but this, by definition cannot be said to be Dry Needling…

However, when the purpose of injecting that substance is to encourage, rather than suppress a healing response (or pain and other symptoms) that goal is certainly in alignment with the goals of Dry Needling…

Whether that injected substance is an innocuous sugar water, (known as Prolotherapy) the patients own blood (Autologous Blood Injection Therapy) or a centrifuged, concentrated mixture of the the patients blood platelets (Platelet-Rich Plasma Therapy.)

And let’s not forget the new kid on the block: Stem Cell Therapy.

All these “kissing-cousin” therapy techniques are very similar, since Dry Needling will still produce bleeding and bring platelets to the area.

Cortisone Shots, in contrast, would be the complete opposite, since their purpose is to suppress inflammation and metabolic activity in the area, and Corticosteroid Injections are known to worsen degeneration – Not help reverse it.

Not to mention the fact that, although it was once common practice, steroid shots are not supposed to be given directly into the tendon, but, rather around it or into its outer layer…

Whereas, Dry Needling involves deeply and repeatedly puncturing the tendon – potentially dozens of times – to cause trauma and bleeding (usually under a local anesthetic – but not always!)

How fascinating that Surgeons and other Doctors refer to these types of treatments as “Minimally Invasive” procedures.

However, no professional operating within their scope of practice would dare to perform these procedures other than an Orthopedic Surgeon.

And surgery is surgery, whether minimally-invasive or not, with all the same risks of infection and unintended consequences.

Does “Hypodermic” Dry Needling Therapy / Fenestration Work In Helping Tennis Elbow And Golfer’s Elbow Heal?

We don’t really know. There isn’t really enough data or studies yet – even if we include the studies on Prolotherapy and Platelet-Rich Plasma Therapy (article and video).

(Since it’s reasonable to lump them all into the same category.)

These therapies do look promising, however.

They are certainly trying to encourage, nudge – or should we say “JAB” things in the right direction.

But I think the question is: Do most Tennis and Golfer’s Elbow sufferers really need to go to this extreme – even if frustrated and desperate?

I don’t think most need the needle – especially when factoring in the attendant risks and high costs.

(Major health insurance providers do not cover PRP and Prolo therapies, claiming they are still “experimental,” which seems to hold true for Dry Needling, as well.)

I believe most Golfer’s and Tennis Elbow sufferers in the mild to moderate injury range can stimulate their healing and reverse their tendon degeneration by using non-invasive, hands-on therapy techniques (which is what I teach Tennis Elbow Classroom students here in the members area.)

And, if one’s injury has progressed to the point where it involves considerable degeneration and/or a moderate to severe tendon tear – significant enough to qualify one for surgery…

Then it will probably make more sense to just have the surgery, since Tennis Elbow surgery has a proven track record of a fairly high success rate IF and when it’s truly called for, which is less than 5% of the time with Tennis Elbow.

Although there are invariably cases that are “on the line” and in those cases maybe Dry Needling (or “wet needling,” like Prolotherapy or PRP) will end up making more sense.

That’s it for now on this topic – But be sure to explore all the other free articles and videos I have here for you, as well as my free video course: Tennis Elbow 101

And check out my premium self-help programs if you have a stubborn injury and want to learn how to treat yourself at home with the most effective advanced self-massage techniques, stretches and exercises.

Learn To Treat And Heal Your Own Tennis Elbow Or Golfer’s Elbow At Home With This Video Program


You’ll get instant access to a complete VIDEO program designed by a professional therapist to help you take charge and break your vicious cycle of pain and frustration!…

I’ll be your personal tutor guiding you through step-by-step video lessons, where you’ll get the therapy techniques, key stretches and essential exercises you need to treat and recover from your injury at home. (Without any special equipment.)

Tennis Elbow sufferers: Learn more about the self-help program here

Golfer’s Elbow sufferers: Learn more about the self-help program here