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G Summarize the best available evidence supporting tendon G Background on tendinopathy needling as a potentially effective treatment for tendinopathy. G Physical therapy examination, evaluation and treatment G Describe the histologic response of the tissue contributing to of tendinopathy the theoretical remodeling of chronic pathologic tissue. G Background on dry needling and tendon fenestration G Describe and demonstrate techniques and their proposed integration into the plan of care for the patient with G Video and live demonstration of tendon needling tendinopathy. including ultrasonography G Conclusion, discussion and future directions

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Sànchez-Ibàñez et al. New Treatments for Degenerative Hopkins et al. Critical review on the socio-economic impact of tendinopathy. Tendinopathy. Rheumatology (Sunnyvale) 2016. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2016;4:9-20.

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Chiavaras. Ultrasound-guided tendon fenestration. De Jonge 2011, 2012, Albers 2014, Semin Musculoskelet Radiol. 2013;17:85-90. Vicenzino 2015, Vargas 2015

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Rudavsky & Cook. https://twitter.com/NSurdykaPhysio J Physiother. 2014;60:122-129.

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https://www.physio-pedia.com/Tendinopathy Cook and Purdham. Br J Sports Med 2009;43:409–416. 85:5/-8
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painful, may have lumpy bumpy tendons, remaining tendon is doing G Strength and endurance base pretty well

Reinking. Physical Therapy in Sport. 2012; 13:3-10 Cook JL, et al. Br J Sports Med 2016 Michener and Kulig. J Orthop Sports Phys Ther. 2015;45:829-832.

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Fredberg and Stengaard-Pedersen . Chronic tendinopathy tissue Cook JL, et al. Br J Sports Med 2016 pathology, pain mechanisms, and etiology with a special focus on inflammation Scand J of Med & Sci in Sports, 2008)

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G Underlying tendon abnormality is not directly treated G Temporary symptom relief not completely understood J Altered release of toxins as well as inhibition of collagen,  Injection of corticosteroid inside the tendon has a deleterious extracellular matrix molecules, and granulation tissue effect on the tendon tissue and should be unanimously G Use as an anti-inflammatory is questionable G Injection of corticosteroids directly into a tendon has been condemned. No reliable proof exists of the deleterious effects of shown to weaken tendon and predispose to rupture peritendinous injections. Too many conclusions in the literature G Other potential complications are based on poor scientific evidence and it is just the reiteration J Fat necrosis J Depigmentation of a dogma if all steroid injections are abandoned. –U. Fredburg J Supression of adrenocorticotropic hormone J Increased blood glucose levels in patients with diabetes

Coombes et al. Lancet 2010

Prolotherapy Prolotherapy G Effectiveness and safety of prolotherapy injections for management of G Involves injection of an irritant, lower limb tendinopathy and fasciopathy: a systematic review such as hyperosmolar dextrose, into (Sanderson et al. J Foot Ankle Res. 2015; 8: 57) the area of tendinosis J Limited evidence to support prolotherapy being safe and effective for treatment of G Thought to improve symptoms by: Achilles tendinopathy, plantar fasciopathy and Osgood-Schlatter disease J Causing inflammation, which introduces growth factors that G The effect of sclerotherapy and prolotherapy on chronic painful promote healing OR Achilles tendinopathy-a systematic review including meta-analysis J Acts as a vascular sclerosing agent (Morath et al. Scand J Med Sci Sports. 2017 Apr 27) J Sclerotherapy and prolotherapy may be effective treatments for Achilles tendinopathy and are considered safe Hauser R. Prolotherapy. The Open Rehabilitation Journal, 2013, 6, 69-76 %8-@181@>5/4
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Finoff et al. PM&R 2011;3(10):900–911 James et al. Br J Sports Med 2007;41(8):518–521

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TrPs are physiological contractures characterized by local G Not intended to be a stand alone procedure ischemia and hypoxia, a significantly lowered pH (active TRPs only), a chemically altered milieu (active TRPs only), local and G Therapeutic exercise, neuromuscular re- referred pain, and altered muscle activation patterns. education and functional training G Patient education on self-care Dry needling of myofascial trigger points (TrP) has a different physiological basis versus treatment of connective tissue, G Part of progression to restore movement, fascia etc. return to activity and participation Description of Dry Needling in Clinical Practice: An Description of Dry Needling in Clinical Practice: An Educational Resource Paper, APTA 2013 Educational Resource Paper, APTA 2013

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G 39 patients analyzed G Inclusion: Age 24-65, Symptoms >6 mo. Active TrP in the upper thoracic region G Meta-analysis of TDN vs. sham G 22 received TDN, 17 received placebo 7 6.46.6 J Ikbuldu 2004 – Upper trap 6 5.4 5.3 J Huguernin 2005 – Hamstring pain 5 VAS Scores 4 4 J Itoh 2006 – Chronic LBP Sham 3 J Itoh 2007 – Chronic neck pain 2 2.2 Dry needling  1 …limited evidence that deep needling directly into myofascial P=0.000 trigger points has an overall treatment effect when compared with 0 Before 1st session 6th session standard of care. Treatment *<<1>&A->@1>
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Recommend dry needling compared to sham or placebo for immediate G Dry Needling vs. other reduction of pain (grade A) interventions (injections,
Cautiously recommend dry needling compared to sham or placebo at 4 weeks laser, acupuncture and (grade A) standard rehab)
More research needed to establish efficacy of TDN to to other interventions for upper quarter pain

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120 individuals with nonspecific shoulder pain were randomized to 1) personalized, evidence
Dry needling when compared to control/sham had a statistically significant based physical therapy 2) trigger point dry needling + personalized, evidence based physical effect on functional outcomes but not compared to other treatments therapy
Individuals were assessed at baseline, after treatment and 3 months
Low to moderate evidence that dry needling is more effective than no
Outcomes were pain (VAS), ROM limitations, Constant-Murley score for pain and function treatment and the number of active myofascial trigger points
No difference in functional outcomes when compared to other PT treatment
Dry needling did not offer benefit in addition to personalized, evidence based physical therapy in individuals with shoulder pain

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Description of Dry Needling in Clinical Practice: An Educational Resource Paper, APTA 2013 Tendon Fenestration/ #
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Description of Dry Needling in Clinical Practice: An Chiavaras. Semin Musculoskelet Radiol 2013;17:85–90 Educational Resource Paper, APTA 2013 McShane. J Ultrasound Med 2006;25(10): 1281–1289

Tendon Fenestration/ 2015 Dry Needling G Common extensor tendon of the elbow
Tendon needling improves patient reported outcomes in patients with tendinopathy J 80% of patients had good or excellent outcome
2 studies on lateral epicondylosis; increase in visual analog scale 34% (signif change >25%) G Patellar tendon from baseline to 6 months in one study, 56% increase in another study
Study on tendon needling and eccentrics for Achilles tendinosis, 19.9% increase in Victorian J 72% of patients had good or excellent outcome Institute of Sports Assessment-Achilles (signif change >10%) G Also shown to be effective for Achilles, gluteal, proximal
Study on rotator cuff tendinosis, subjective shoulder pain and disability index showed hamstring and other tendons about the pelvis and hip statistically significant improvements from baseline to 6 months (p<0.05)
Conclusion: tendon needling improves patient-reported outcome measures in patients with tendinopathy; autologous blood products may improve outcomes further Chiavaras. Semin Musculoskelet Radiol 2013;17:85–90 McShane. J Ultrasound Med 2006;25(10): 1281–1289

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Nwaka, OK. Update in Musculoskeletal Research. Chiavaras. Semin Musculoskelet Radiol 2013;17:85–9 Sports Health. 2016 Sep:8(5); 429-437.

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Chiavaras. Semin Musculoskelet Radiol 2013;17:85–9 Jacobson et al. Ultrasound-Guided Fendestration of Tendons About the Hip and Pelvis. J Ultrasound Med 2015: 34:2029-2035.

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G Followed up with therapeutic exercise (ROM followed by gentle theraband resistance into Reproduction of patient s flexion, abduction, ER and IR) familiar symptoms G Day 6 patient reported 50% improvement, Day 10 patient reported full resolution of symptoms

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Bernhardsson et al. Clin Rehabil. 2011;25:69–78.

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Chiavaras. Ultrasound-guided tendon fenestration. Semin Musculoskelet Radiol. 2013;17:85-90.

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G Potential positive effects of ultrasound-guided tendon fenestration. G It is unknown which factors influence the outcome of the procedure G Do some tendons have better outcomes compared to others? G Does increased vascularity, echogenicity, or size of the tendon abnormality at ultrasound influence results? G Chronicity: It is unknown whether chronicity of the symptoms, prior treatments, and patient variables such as age or smoking affects outcome. G Technique: it is unknown whether needle choice or number of needle passes through the tendon has an effect. Lastly, because other percutaneous ultrasound-guided tendon injections such as hyperosmolar dextrose, autologous whole blood, and PRP also involve tendon fenestration during the procedure, does tendon fenestration alone produce similar results compared with these tendon injections?

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1. Chiavaras MM, Jacobson JA. Ultrasound-guided tendon fenestration. Seminars in musculoskeletal radiology. 2013;17(1):85-90. 2. Housner JA, Jacobson JA, Misko R. Sonographically guided percutaneous needle tenotomy for the treatment of chronic tendinosis. J Ultrasound Med. Cacchio, A., F. Borra, G. Severini, A. Foglia, F. Musarra, N. Taddio and F. De Paulis (2012). "Reliability and validity of threepain 2009;28(9):1187-1192. 3. Housner JA, Jacobson JA, Morag Y, Pujalte GG, Northway RM, Boon TA. Should ultrasound-guided needle fenestration be considered as a treatment provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy." Br J Sports Med 46(12): 883-887. option for recalcitrant patellar tendinopathy? A retrospective study of 47 cases. Clinical journal of sport medicine : official journal of the Canadian Cook, J. L. and C. Purdam (2012). "Is compressive load a factor in the development of tendinopathy?" Br J Sports Med 46(3): 163-168. Academy of Sport Medicine. 2010;20(6):488-490. Cook, J. L., E. Rio, C. R. Purdam and S. I. Docking (2016). "Revisiting the continuum model of tendon pathology: what is its merit in 4. Jayaseelan DJ, Moats N, Ricardo CR. Rehabilitation of proximal hamstring tendinopathy utilizing eccentric training, lumbopelvic stabilization, and clinical practice and research?" British Journal of Sports Medicine. trigger point dry needling: 2 case reports. J Orthop Sports Phys Ther. 2014;44:198-205. 5. Krey D, Borchers J, McCamey K. Tendon needling for treatment of tendinopathy: A systematic review. Phys Sportsmed. 2015;43:80-86. Cushman, D. and M. E. Rho (2015). "Conservative Treatment of Subacute Proximal Hamstring Tendinopathy Using Eccentric Exercises 6. Krey D, Borchers J, McCamey K. Tendon needling for treatment of tendinopathy: A systematic review. Phys Sportsmed. 2015;43:80-86. Performed With a Treadmill: A Case Report." J Orthop Sports Phys Ther 45(7): 557-562. 7. Louwerens JK, Veltman ES, van Noort A, van den Bekerom MP. The Effectiveness of High-Energy Extracorporeal Shockwave Therapy Versus Goom, T. S., P. Malliaras, M. P. Reiman and C. R. Purdam (2016). "Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment Ultrasound-Guided Needling Versus Arthroscopic Surgery in the Management of Chronic Calcific Rotator Cuff Tendinopathy: A Systematic Review. and Management." J Orthop Sports Phys Ther 46(6): 483-493. Arthroscopy. 2016;32:165-175. 8. Nagraba L, Tuchalska J, Mitek T, Stolarczyk A, Deszczynski J. Dry needling as a method of tendinopathy treatment. Ortop Traumatol Rehabil. Lempainen, L., K. Johansson, I. J. Banke, J. Ranne, K. Mäkelä, J. Sarimo, P. Niemi and S. Orava (2015). "Expert opinion: diagnosis and 2013;15:109-116. treatment of proximal hamstring tendinopathy." Muscles, Ligaments and Tendons Journal 5(1): 23-28. 9. Saylor-Pavkovich E. Strength Exercises Combined with Dry Needling with Electrical Stimulation Improve Pain and Function in Patients with Chronic Malliaras, P., J. Cook, C. Purdam and E. Rio (2015). "Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Rotator Cuff Tendinopathy: A Retrospective Case Series. Int J Sports Phys Ther. 2016;11:409-422. Challenging Case Presentations." J Orthop Sports Phys Ther 45(11): 887-898. 10. Settergren R. Treatment of supraspinatus tendinopathy with ultrasound guided dry needling. Journal of chiropractic medicine. 2013;12(1):26-29. 11. Settergren R. Treatment of supraspinatus tendinopathy with ultrasound guided dry needling. J Chiropr Med. 2013;12:26-29. McCormack, J. R. (2012). "The management of bilateral high hamstring tendinopathy with ASTYM® treatment and eccentric exercise: a 12. Tsikopoulos K, Tsikopoulos I, Simeonidis E, et al. The clinical impact of platelet-rich plasma on tendinopathy compared to placebo or dry needling case report." The Journal of Manual & Manipulative Therapy 20(3): 142-146. injections: A meta-analysis. Phys Ther Sport. 2016;17:87-94. 13. Yeo A, Kendall N, Jayaraman S. Ultrasound-guided dry needling with percutaneous paratenon decompression for chronic Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc. 2016;24:2112-2118.