Picture this: You did exactly what you wanted! You made great use of your training course and safely dry needled your first patient. It was flawless, and you made a change. The patient felt it and you saw it. In the midst of imaginary jump high-fiving yourself, the patient asks the obvious question: “So…. Now What?!”
Since I joined KinetaCore, it is the single most frequent question I get. It is also the most variable and difficult to answer. Have no fear… We’re here to help! Edo reached out and gave me a bit of free canvas (which is dangerous!) to address this topic. More specifically, he was looking to expand upon a good case. Let me disclose, up front, I practice in out-patient sports medicine. The majority of my clientele is higher functioning, and many of mine are repeat and consistent customers. This will come into play later in the commentary.
I received a text about 5 months ago from a good friend, triathlon machine, and general superhuman. She and I had worked previously together on a few things, and (full disclosure) I had needled her previously with fantastic results. She was having proximal hamstring issues, mostly with the running and biking components of her training. She was scheduled to leave in 2 weeks for Alaska for a huge race for which she was helping pace and coach a friend of hers. Needless to say, no time to waste.
She was tender at the origin of her hamstring tendon and at the musculoskeletal junction (slightly biased laterally – think biceps femoris). Interestingly and unknown to her until then, her force output was significantly compromised, both knee extended hip extension and hip flexed knee flexion. Remember, this is an athlete who is incredibly in-tune with her body. Her involved leg was 50% less force output compared to the uninvolved, and she had NO IDEA! Think of the impact on her cycle and running outputs!
I worked through her lower quarter and I would love to report I found all these hip and lumbar clues. Nope, not a single one. I stepped back and did what I should have done initially, and just listened. Turns out, she broke a clamp on her cleat about 2.5 months ago which required a bit of fixing. Naturally, she did it herself being the capable shoe maker she was. I’m kidding… she had no idea but of course did it anyway. She put herself in a few extra degrees of external rotation in her clipped in position. Well, guess what that did? Yep, you guessed it — massive bias on the lateral hamstring and WHAM. Volume-based Tendinopathy.
Nothing novel about this, right? We’ve all seen something like this before. So why am I boring you with it? Fix the cleat and save the day! Exactly right?! Well somewhat…
Let’s not forget what all this has done to her Neurologic System. Of course, I corrected the cleat, but she still had a massive deficit in output. How could we correct that in 2 weeks and what would dry needling have to do with it?
Tendinopathy is a very interesting pathology. It is both broken and repaired by the same medium: LOAD. However, treatment has to be the right kind of load, in the right context, and ultimately in the right dosage. The problem is most tendons are very reactive and are unable to tolerate much load, especially when they are in a reactive and irritable state. The cortical side of things is very inhibitive in tendons, and the patient will be unable to load the tissue due to all of these variables.
The goal for me is always to get patients loading the tendon! Using our periodization brain, we want to expose the tendon to graduated load to improve tendon compliance (as a physiologic tissue level as well as at a cortical sensitivity level). However, what good is all this without turning on the lights and activating the NM system first?
“Turning On The Lights” – The Neuromuscular System (NM)
I needled to first activate the system. Remember she had no idea how limited she was. I needled her multifidi segments: L 4/5 and S 1/2. I completed this circuit with the biceps femoris long and short heads, and attached them both to the neuromuscular stimulation unit. I used ~10 hertz and kept the intensity to very tolerable. It took almost 4 minutes for her hamstring to become consistent in its contraction (I knew I had struck gold). She got up, feeling like a million dollars and was halfway out the door before I stopped her. “Nice try; We’ve still got plenty of work to do!”
I sent her home with concentration holds. Her homework was simple. Start making connections. She had to concentrate and fire her lateral hamstring to <3/10 pain and hold for 10 seconds. She did this 20-30 times for the first 3 days. The goal was to start turning those neuromuscular light switches on and then keep them on. Concentration exercises are fantastic ideas to do so. Simple, open chain, isolated muscle activations in different ranges working from least provocative to intentionally provocative areas.
After 3 days, she returned and we needled her again (in the same format) but with a little higher intensity and hertz and shorter overall duration. I sent her home with the same homework, just with less contractions per day but with higher intensity and duration intervals.
Realistically, it is foolish to think I would be able to physiologically change the tendon matrix or the cross-sectional muscular unit in only two weeks. Instead, we attacked the neuromuscular system; silenced some alarms and turned on the lights. She went on to crush Alaska with almost no symptoms (still doing her HEP throughout) along the way.
Maintenance Programs and Needling:
Athletes ask a great deal of their bodies. Regardless how prepared or fundamentally sound your muscular system is molded, sport is unpredictable and things happen. Did I follow up after Alaska? Absolutely. We encourage athletes and regular exercisers to engage in foam rolling, soft tissue flexibility modalities, and massages all the time. Why is it so far-fetched to do the same with dry needling?
She ultimately worked her way through a very rigorous hamstring loading program and did extremely well. She also was needled around 10 times in total throughout the process. Over the next few months, I would see her once per month for follow-ups and needling to the same areas. Amazingly, she feels that she is stronger now than before. She will tell you that she doesn’t feel like her hamstrings are “bigger”, but rather she feels like she can tap into them and feel them more. “Lights On!”
I’ve attached a program I put together for her specifically based on hamstring strength and load. I have also attached some fun reading on tendinopathy and management.
Enjoy and remember: Needling turns the lights on…. but exercise and reinforcement keep them on!
1. Malliaras P, Cook J, Purdam C, Rio E. Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. JOSPT. 2015;45:887-897.
2. Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015;49(19):1277-83.
3. Goom TSH, Malliaras P, Reiman MP, Purdam CR. Proximal hamstring tendinopathy: clinical aspects of assessment and management. JOSPT. 2016;46:483-493.
4. Scott A, Docking S, Vicenzino B, et al. Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012. Br J Sports Med. 2013;00:1-12.
5. Littlewood C et al. The central nervous system – an additional consideration in ‘rotator cuff tendinopathy’ and a potential bias for understanding response to loaded therapeutic exercise. Man Ther. 2013;18:468-472.
6. Nefeli T, van Dieën JH, Coppieters MW. Central pain processing is altered in people with Achilles tendinopathy. Br J Sports Med. 2016;50:1004–1007.