Effect of dry needling on cubital tunnel syndrome

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Physiotherapy Theory and Practice
An International Journal of Physical Therapy
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Effect of dry needling on cubital tunnel syndrome:
Three case reports
Sudarshan Anandkumar & Murugavel Manivasagam
To cite this article: Sudarshan Anandkumar & Murugavel Manivasagam (2018): Effect of dry
needling on cubital tunnel syndrome: Three case reports, Physiotherapy Theory and Practice, DOI:
10.1080/09593985.2018.1449275
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Published online: 12 Mar 2018.
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CASE REPORT
Effect of dry needling on cubital tunnel syndrome: Three case reports
Sudarshan Anandkumar, DPT, M.Sc PT, C-OMPT, CAFS, Cert. (DNT)a and Murugavel Manivasagam, BPT, DYT,
COMT, FSR, DNP, CESb
aRegistered Physiotherapist, CBI Health Centre, Chilliwack, British Columbia, Canada; bRehabilitation department, Pantai Jerudong Specialist
Centre, Brunei Darussalam
ABSTRACT
This case series describes three patients who presented with right medial elbow pain managed
unsuccessfully with conservative treatment that included medication, massage, exercise therapy,
ultrasound therapy, neurodynamic mobilization, and taping. Diagnosis of cubital tunnel syndrome
was based on palpatory findings, a positive elbow flexion test, and a positive Tinel’s sign.
Conventionally, the intervention for this entrapment has been surgical decompression, with success-
ful outcomes. This is potentially a first-time description of the successful management of cubital
tunnel syndrome with dry needling (DN) using a recently published DN grading system. The patients
were seen twice aweek for 2 weekswith immediate improvements noted in all the outcomemeasures
after the first treatment session. At discharge, they were pain-free and fully functional, which was
maintained up to a 6-month follow-up.
ARTICLE HISTORY
Received 25 August 2016
Accepted 20 August 2017
Revised 8 July 2017
KEYWORDS
Cubital tunnel; cubital
tunnel syndrome; dry
needling; entrapment;
intramuscular stimulation;
intramuscular therapy;
neuropathy; neurodynamics;
neural mobilization; physical
therapy; ulnar nerve
Background
Peripheral nerve entrapments typically occur atmechanical
interfaces in the upper extremity. The most common
entrapment is of the median nerve at the carpal tunnel
(Ibrahim, Khan, Goddard, and Smitham, 2012). Ulnar
nerve entrapment is the secondmost common entrapment
neuropathy and may occur at the wrist, thoracic outlet, or
elbow (Elhassan and Steinmann, 2007). In the elbow, ulnar
nerve entrapment occurs at the cubital tunnel and was
described as “cubital tunnel syndrome” cubital tunnel syn-
drome by Feindel and Stratford in 1958 (Wojewnik and
Bindra, 2009). Other nomenclatures that have previously
been used to describe this entrapment are “ulnar nerve
entrapment syndrome,” “sulcus ulnaris syndrome,” and
“tardive ulnar neuritis” (Assmus, Antoniadis, and
Bischoff, 2015; Qing et al., 2014).
The cubital tunnel is an anatomical space containing the
ulnar nerve and ulnar collateral artery and extends from
the medial epicondyle of the humerus to the olecranon
process of the ulna (Shen, Masih, Patel, andMatcuk, 2016).
The floor is formed by the joint capsule and medial collat-
eral ligament of the elbow and the roof is formed by
Osborne’s ligament (also known as cubital tunnel retina-
culum), a fibrous band running between the two heads of
flexor carpi ulnaris (FCU) (Green and Rayan, 1999). After
the ulnar nerve exits the cubital tunnel, it penetrates
between the ulnar and humeral heads of the FCU and
passes through the flexor–pronator aponeurosis (which
forms the common origin of the flexor and pronator mus-
cles) (Amadio and Beckenbaugh, 1986). Multiple sites of
ulnar nerve entrapment around the elbow have been
described in the literature and include the Arcade of
Struthers (about 8 cm proximal to the medial epicondyle),
medial intermuscular septum, medial epicondyle (with
osteophytes irritating the nerve), cubital tunnel, and deep
flexor aponeurosis of the FCU (5 cm distal to the medial
epicondyle) (Kroonen, 2012) (Figure 1).
Cubital tunnel syndrome occurs more commonly in
men and has an incidence estimated to be about 24.7 cases
per 1,00,000 persons per year (Assmus, Antoniadis, and
Bischoff, 2015). It affects about 1% of the population in
the United States (Wojewnik and Bindra, 2009), and the
causes may broadly be classified as either primary (idio-
pathic) or secondary (Palmer and Hughes, 2010). Primary
causes include anatomical variants such as the presence of
the epitrochlearis-anconeus muscle or subluxation of the
ulnar nerve (Assmus et al., 2011). Secondary causes are
either extraneural (like elbow arthritis or trauma) or
intraneural (like lipoma or ganglion) (Assmus et al.,
2011; Kurosawa, Nakashita, Nakashita, and Sasaki,
1995). Further, systemic conditions like hemophilia and
diabetes have been associated with cubital tunnel syn-
drome (Cutts, 2007; Mortazavi, Gilbert, and Gilbert,
CONTACT Sudarshan Anandkumar M.Sc PT anandkumar.sudarshan@gmail.com Registered Physiotherapist, CBI Health Centre, Chilliwack, V2R 0M6,
British Columbia, Canada.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iptp.
PHYSIOTHERAPY THEORY AND PRACTICE
https://doi.org/10.1080/09593985.2018.1449275
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2010). Various risk factors include elbow flexion contrac-
tures, repetitive or prolonged upper extremity use, over-
head activities, obesity, and smoking (Bartels and
Verbeek, 2007). Elbow flexion reduces the geometry of
the cubital tunnel and increases the intraneural pressure
of the ulnar nerve (Gelberman et al., 1998; Kuschner,
Ebramzadeh, and Mitchell, 2006). The pathophysiology
of ulnar nerve entrapment leading to pain is provided in
Figure 2 (Anandkumar, 2013).
Interventions for cubital tunnel syndrome can broadly
be classified as either surgical or nonsurgical (Cutts,
2007). Surgical interventions include a decompression
procedure, medial epicondylectomy, and transposition
of the ulnar nerve (Boone, Gelberman, and Calfee,
2015). Nonsurgical options for cubital tunnel syndrome
include anti-inflammatory medications, injections, splint-
ing, electrotherapy, neurodynamic mobilization, exercise,
and manual therapy (Harder et al., 2016; Lund and
Amadio, 2006; Oskay et al., 2010).
Dry needling (DN) is a treatment tool used by physical
therapists in the management of myofascial pain syn-
drome (Unverzagt, Berglund, and Thomas, 2015). It has
been shown to be effective for reducing pain, improving
range of motion, and enhancing function (Boyles, Fowler,
Ramsey, and Burrows, 2015; Gattie, Cleland, and
Snodgrass, 2017). This case series describes the manage-
ment of cubital tunnel syndrome using DN at the
mechanical interface with three patients.
Case description and clinical findingsPatient A
Patient A was a 50-year-old male, right-hand-dominant
accountant who presented with complaints of constant
right medial elbow pain along with tingling in the 4th
and 5th digits for 6 months. The onset of pain and
tingling was insidious, increasing in its intensity over
time, limiting him at work (primarily desk job) and
functional activities like bathing, driving, and dressing.
The pain and tingling was initially intermittent, located
about 2 cm below the right medial epicondyle and over
the dorsum of the 4th and 5th digits. Symptoms
became constant after 1 month of onset, aggravated
by gripping or desk work. Patient A did not identify
any relieving factors, indicating a high irritability and
no changes were noted in the 24-h pattern of his
symptom behavior.
Patient A denied any history of neck, shoulder and
thoracic spine pain, with absence of clicking or snap-
ping, stiffness, hypersensitivity, or discoloration of the
elbow and hand. He reported normal bowel and blad-
der functioning, with no gait abnormalities, unexpected
weight loss, or sleep disturbances. Previous lab studies
and radiographic images for the neck, thoracic spine,
Figure 1. Anatomy of the cubital tunnel along with sites of
ulnar nerve entrapment.
Figure 2. Pathophysiology of nerve entrapment leading to pain
(reproduced from Anandkumar, 2013).
2 S. ANANDKUMAR AND M. MANIVASAGAM
and elbow were normal. Further, medical history for
patient A was unremarkable.
Patient A was diagnosed as having cubital tunnel
syndrome by his family physician and was initially
managed by rest, ergonomic advice, anti-inflammatory
medication, bracing, and icing, with no improvements.
He was referred for massage therapy and physical ther-
apy, and received these therapies twice a week for
8 weeks. Physical therapy consisted of ultrasound ther-
apy, stretching for the common wrist flexors and ulnar
nerve neurodynamic mobilization. The patient reported
minimal improvement and continued to have limita-
tions at work.
On observation, no postural dysfunctions were noted.
Patient A had equal muscle bulk, normal alignment of
the medial epicondyle, lateral epicondyle and olecranon
processes, and a normal elbow-carrying angle. There
were no skin color changes, atrophy, swelling, or trophic
changes. Myotome and reflex testing was unremarkable
with a negative Hoffman’s sign. However, sensory test-
ing revealed reduced sensation to touch (tested with
cotton), pain (tested using a safety pin), and temperature
(tested using hot and cold test tubes with water) over the
right 4th and 5th digits in the ulnar cutaneous nerve
distribution.
On palpation, concordant symptoms were reproduced
2 cm below the right medial epicondyle over the FCU on
sustained pressure (Wojewnik and Bindra, 2009).
Further, Tinel’s sign was positive at the same site, worsen-
ing the tingling in the digits. Range of motion testing was
normal for the cervical spine, thoracic spine, shoulder
complex, elbow, forearm, wrist, and hand with a normal
end feel. Resisted isometrics testing was unremarkable
and did not worsen the symptoms.Manual muscle testing
revealed no weakness in the upper quarter muscles.
Valgus stress testing did not reproduce the medial elbow
pain. The elbow flexion test (sustained right elbow flexion
with forearm supination and neutral wrist position) wor-
sened the tingling after 7 s (Wojewnik and Bindra, 2009).
Furthermore, upper limb neurodynamic testing biasing
the ulnar nerve (Nee, Jull, Vicenzino, and Coppieters,
2012) reproduced the patients’ pain and tingling.
Patient B
Patient B was a 35-year-old male, right-hand-dominant
carpenter who presented with complaints of intermittent
pain in the right medial elbow and tingling in the
hypothenar eminence and the 4th and 5th digits. Onset
of pain was gradual over 3 weeks; however, it worsened
in the three days prior to examination due to a high
workload. Aggravating factors were gripping at work
with immediate relief of symptoms with rest, indicating
a mild irritability. No changes were noted in the 24-h
pattern of symptom behavior.
Patient B had no issues with gait, sleep, weight loss,
bowel or bladder functioning, and had normal lab and
imaging studies. No pain was reported in other areas of
the upper quarter, and he denied clicking or popping in
his right elbow. He had a history of neck pain that was
successfully treated by acupuncture. He believed that he
would benefit from “needling therapy.”
Upon examination, no impairments were noted in pos-
ture, gait, elbow-carrying angle, muscle strength, and range
of motion testing. Further, there were no atrophy, swelling,
or trophic changes. Sensory testing of the ulnar cutaneous
nerve distribution revealed reduced sensation to touch
(tested with cotton), pain (tested using a safety pin), and
temperature (tested using hot and cold test tubes with
water) over the hypothenar eminence and the 4th and
5th digits. On palpating the cubital tunnel between the
rightmedial epicondyle and olecranon process, concordant
symptoms were reproduced on sustained pressure.
Further, Tinel’s sign was positive at the same site and the
upper limb neurodynamic test biasing the ulnar nerve
(Nee, Jull, Vicenzino, and Coppieters, 2012) and elbow
flexion test (Wojewnik and Bindra, 2009) immediately
worsened the tingling in his wrist and digits. The elbow
valgus stress test did not reproduce the symptoms.
Patient C
Patient C was a 45-year-old female, right-hand-dominant
secretary who presented with complaints of constant pain
in the right medial elbow and intermittent tingling over
the ulnar side of the dorsum of the hand. Onset of pain
was gradual, worsening in its intensity over 3 months,
aggravated by computer work and resting the right elbow
on a table for about 5 min. Patient C noticed tingling only
when she gripped objects. Relieving factors included
removing the elbow from contact surfaces (such as desk
or dining table) but taking up to 35 min for the pain to
settle down indicating a high irritability. Patient C did not
note any changes in the 24-h pattern of her symptom
behavior.
Patient C denied pain at other locations in the upper
quarter and had an unremarkable medical history. Lab
results and radiographic findings were normal, and
patient C had no symptoms indicating a systemic pro-
blem (unexplained weight loss, gait disturbances, sleep
problems, bowel and bladder functioning). Patient C
had previously received 8 weeks of ergonomic advice,
icing, ultrasound therapy, manual soft tissue mobiliza-
tion, neurodynamic mobilization, and kinesio taping
with no reported improvements in pain.
PHYSIOTHERAPY THEORY AND PRACTICE 3
On observation, no abnormalities were noted in pos-
ture, gait, elbow-carrying angle, muscle strength, and
range of motion testing. Sensory testing of the ulnar
cutaneous nerve distribution revealed reduced sensation
to touch, pain, and temperature over the ulnar side of the
dorsum of the hand. Valgus stress test for the elbow was
negative. Like patient A, concordant symptoms were
reproduced 2 cm below the right medial epicondyle over
the FCU on sustained pressure. Further, Tinel’s sign was
positive at the same site, reproducing the tingling over the
ulnar side of the dorsum of the hand. Also, the elbow
flexion test (Wojewnik and Bindra, 2009) worsened the
symptoms after 5 s. Upper limb neurodynamic testing
biasing the ulnar nerve (Nee, Jull, Vicenzino, and
Coppieters, 2012) did not reproduce the concordant
symptoms.
Outcome measures
The Numeric Pain Rating Scale (NPRS), Patient-
Specific Functional Scale (PSFS), JAMAR handheld
dynamometer for pain-free grip strength, and Global
Rating of Change (GROC) were used as outcome mea-
sures in this case series. NPRS, PSFS, and JAMAR
handheld dynamometer measurements were taken at
baseline and at the beginning of each treatment session.
The GROC was measured starting from the second
treatment session.
The NPRS is a reliable tool to measure pain intensity
(Childs, Piva, and Fritz, 2005). The patients rated theirleast pain, worst pain, and average pain from 0 (no
pain) to 10 (worst imaginable pain) over the preceding
24 h. A change of NPRS score of two points is con-
sidered to be clinically meaningful (Childs, Piva, and
Fritz, 2005). NPRS scores are provided in Figure 3.
The PSFS is a valid and reliable scale used to evalu-
ate functional limitations with a minimum clinically
important difference of 2 points (Cleland, Fritz,
Whitman, and Palmer, 2006). It is an 11-point self-
reported scale where “0” indicates inability to perform
the activity and “10” indicates the ability to perform
without difficulty (Cleland, Fritz, Whitman, and
Palmer, 2006). PSFS scores are provided in Figure 4.
Good reliability and validity for grip strength testing
has been found with the JAMAR dynamometer
(Mathiowetz, 2002). All three patients in this case series
were positioned seated with the forearm in neutral and
elbow flexed to 90°. Three attempts were given to
measure the pain-free grip strength with a 20-s rest
interval between the measurements (Stratford and
Levy, 1994). Pain-free grip strength values are pre-
sented in Table 1.
The GROC is a self-reported outcome measure used
to gauge the patient’s perceived change of improvement
after treatment (Jaeschke, Singer, and Guyatt, 1989). It
is a 15-point scale ranging from “–7” (a very great deal
worse) to “+7” (a very great deal better), with a mini-
mum clinically important difference of three points
(Jaeschke, Singer, and Guyatt, 1989).
Figure 3. Graph showing improvements in Numeric Pain Rating
Scale (NPRS) scores for pain intensity.
Figure 4. Graph showing progression of Patient-Specific
Functional Scale (PSFS) scores.
Table 1. Progression of pain-free grip strength (in kg) measured
at baseline and at the beginning of each treatment session.
Pain-free grip strength (kg)
Patient A Patient B Patient C
Treatment sessions Right Left Right Left Right Left
Baseline 8 46 7 49 5 34
First session 8 46 7 49 5 34
Second session 36 46 40 49 15 34
Third session 40 46 49 49 34 34
Fourth session 52 46 55 49 38 34
4 S. ANANDKUMAR AND M. MANIVASAGAM
Evaluation and diagnosis
Normal radiographic findings helped rule out bony
abnormalities and unremarkable blood work findings
along with absence of fever, malaise, weight loss, and
bowel and bladder disturbances helped rule out a sys-
temic cause for the pain. Normal range of motion and
muscle strength testing helped in excluding the cervical
spine, thoracic spine, shoulder complex, and wrist and
hand as sources of the patients’ symptoms (e.g., C8-T1
radiculopathy, thoracic outlet syndrome, Guyon’s canal
syndrome, and golfer’s elbow).
All the patients in this case series had a positive elbow
flexion test (sensitivity: 0.75, specificity: 0.99), Tinel’s sign
(sensitivity: 0.70, specificity: 0.98), and a pressure provoca-
tion test (sensitivity: 0.89, specificity: 0.98) (Novak, Lee,
Mackinnon, and Lay, 1994). High specificity values helped
rule in the diagnosis of cubital tunnel syndrome. In patients
A and C, positive Tinel’s sign and tenderness over the FCU
2 cm below the medial epicondyle indicated the site of
nerve entrapment. In patient B, positive palpatory findings
and Tinel’s sign between the medial epicondyle and ole-
cranon process showed that the cubital tunnel was the site
of mechanical interface. In all three patients, absence of
clicking, popping, or snapping at the elbow suggested that
ulnar nerve subluxation was not occurring.
A negative valgus stress testing helped in ruling out the
medial collateral ligament contributing to cubital tunnel
syndrome in patients A–C. Although patient C had a
negative upper limb neurodynamic test, the other find-
ings suggest a false negative result with the neurodynamic
test in this case.
Treatment
Based on the clinical diagnosis of cubital tunnel syndrome,
physical therapy management consisted of DN for patients
A–C. An information sheet describing DN was provided,
and consent obtained after contraindications was ruled out.
The procedure was carried out with a clean technique
following precautions for infection control. The patients
were positioned in right side lying with the shoulder
abducted and elbow flexed to 90°. The needles were left
in situ for 15 min. The patients were advised to apply ice to
manage any post-needling soreness. Ulnar nerve neurody-
namic slider exercises were reviewed, and they were
advised to do three sets of 15 repetitions once a day. All
three patients were seen twice a week for 2 weeks. The
Sudarshan and Murugavel Dry Needling Grading Scale©
(Anandkumar andManivasagam, 2017) was utilized in the
treatment sequence as described below.
Treatment for patient A
Using a flat palpation to isolate the right FCU 2 cm
below the medial epicondyle, a “grade 6” DN procedure
was carried out with a single solid monofilament needle
measuring 0.20 mm in diameter and 30 mm in length
inserted perpendicularly (Table 2). The needle was
directed toward the FCU where it reproduced the med-
ial elbow pain (Figure 5). As the needle was rotated in a
clockwise direction engaging the tissue bind, the patient
reported tingling in the 4th and 5th digits and heavi-
ness in the elbow, forearm, and hand. Because the
tissues were highly irritable, the needle was not rotated
further and did not lock. Further, “pistoning” the nee-
dle (also known as “thrusting,” “in and out,” “sparrow
pecking”) (Dunning et al., 2014) was not carried out
due to the proximity of the ulnar nerve as a precaution
to prevent iatrogenic damage.
At the second treatment session (3 days later), patient
A noted significant improvements in pain, tingling, and
functional activities. At the beginning of the third treat-
Table 2. Sudarshan and Murugavel Dry Needling Grading Scale (SMDNGS©)*.
Grading levels Needling intensity Target tissues
1 Superficial insertion with no needle rotation and tissue bind. Skin and into superficial
fascia2 Superficial insertion with needle rotation (unidirectional or bidirectional) and engaging tissue bind.
3 Superficial insertion with needle rotation (unidirectional or bidirectional) and engaging tissue bind until
needle locks.
4 Deep insertion with no needle rotation and tissue bind. No “pistoning,” “in and out,” or “sparrow pecking”
performed.
Deep fascia and beyond
(such as muscles,
ligaments, tendons,
bones, nerves and,
myofascia)
5 Deep insertion with no needle rotation and tissue bind. “Pistoning,” “in and out,” or “sparrow pecking” performed.
6 Deep insertion with needle rotation (unidirectional or bidirectional) and engaging tissue bind. No
“pistoning,” “in and out,” or “sparrow pecking” performed.
7 Deep insertion with needle rotation (unidirectional or bidirectional) and engaging tissue bind. “Pistoning,”
“in and out,” or “sparrow pecking” performed.
8 Deep insertion with needle rotation (unidirectional or bidirectional) and engaging tissue bind until needle
locks. No “pistoning,” “in and out,” or “sparrow pecking” performed.
9 Deep insertion with needle rotation (unidirectional or bidirectional) and engaging tissue bind until needle
locks. “Pistoning,” “in and out,” or “sparrow pecking” performed.
*Anandkumar and Manivasagam (2017).
Depending on tissues SIN (severity, irritability, nature), electrotherapy can be combined with DN for either superficial or deep insertion and the needle can be
flicked in all the grades. The length of needle, angle of needle insertion, and depth of needle insertion varies with the structure being treated.
PHYSIOTHERAPY THEORY AND PRACTICE 5
ment session, he reported only mild elbow pain and
stated there was no tingling. Clinically meaningful
improvements were noted in all the outcome measures
(Figures 3 and 4, Tables 1 and 3). By the fourth session,
he was completely pain-free and had no symptoms with
the elbow flexion test, Tinel’s sign, ulnar nerve neurody-
namic testing, and sustained pressure provocation. A
follow-up after 6 months revealed that the patient was
pain-free and fully functional.
Treatment for patient BA “grade 2” DN procedure (superficial insertion) was
carried out with a single solid monofilament needle mea-
suring 0.20mm in diameter and 30mm in length inserted
perpendicularly between the medial epicondyle and ole-
cranon process (Figure 6, Table 2). As soon as the needle
was inserted, medial elbow pain was reproduced. When
the needle was rotated in a clockwise direction, tingling in
the hypothenar eminence and the 4th and 5th digits was
reproduced, and the patient reported a sensation of heavi-
ness in the whole extremity.
At the second treatment session (3 days later), patient
B noted reduced intensity of pain and tingling with better
functioning at work. Gentle wrist flexor stretches were
added during the second session (30-s hold and eight
repetitions). By the third session, the patient had no
tingling with minimal pain. By the end of the fourth
session, he was pain-free and fully functional. A follow-
up after 4 months revealed that patient B had no recur-
rence of cubital tunnel syndrome.
Treatment for patient C
Using a flat palpation to isolate the right FCU 2 cm
below the medial epicondyle, a “grade 4” DN procedure
with a single solid monofilament needle measuring
0.20 mm in diameter and 30 mm in length was inserted
perpendicularly toward the FCU (Figure 5, Table 2).
This reproduced the medial elbow pain and tingling in
the ulnar side of the dorsum of the hand. As the tissues
were irritable, pistoning or needle rotation was not
carried out. Patient C reported her elbow to feel heavy.
By the second treatment session (3 days later), patient
C noted absence of tingling and a reduction in pain. As
the tissues were less irritable, DN was progressed to a
“grade 8” procedure. The needles were inserted into the
FCU and rotated in a clockwise direction until they
locked, reproducing the patient’s concordant symptoms.
Like the first session, the needles were left in situ for
15 min. At the third treatment session, patient C had
significant improvements in all the outcome measures
and was completely pain-free after the fourth session.
Home exercises and ergonomics were reviewed and a
follow-up after 6 months showed that the patient was
fully functional with no recurrence of cubital tunnel
syndrome.
Discussion
This case series describes the successful management of
cubital tunnel syndrome utilizing DN in three patients
who previously had unsuccessful conservative treat-
ment of cubital tunnel syndrome. It has been shown
that positive expectations and preferences from a
Figure 5. Dry needling of the flexor carpi ulnaris at the
mechanical interface.
Table 3. Progression of Global Rating of Change (GROC) scores.
GROC scores
Treatment sessions Patient A Patient B Patient C
Second “−1” (a tiny bit worse) “−3” (somewhat worse) “−1” (a tiny bit worse)
Third* “+6” (a great deal better)* “+5” (quite a bit better)* “+5” (quite a bit better)*
Fourth “+7” (a very great deal better) “+7” (a very great deal better) “+7” (a very great deal better)
*Minimum clinically important difference for GROC – 3 points.
Figure 6. Dry needling at the cubital tunnel between the right
medial epicondyle and olecranon process.
6 S. ANANDKUMAR AND M. MANIVASAGAM
particular intervention are predictor of beneficial out-
comes (Myers et al., 2008). Hence, response bias toward
DN may have contributed to the improvements, espe-
cially in patient B, who had expressed a belief that
needling would be helpful.
The diagnosis of cubital tunnel syndrome in this case
series was inferred from clinical findings. Based on posi-
tive palpatory findings and Tinel’s sign, it was deter-
mined that patients A and C had the site of entrapment
2 cm below the medial epicondyle over the FCU whereas
patient B had the entrapment interface between the
medial epicondyle and olecranon process. Though all
three patients presented with different pain durations
since onset (patient A – 6 months, patient B – 3 weeks,
patient C – 3 months), cubital tunnel syndrome
occurred on their dominant side (right). The ulnar
nerve is superficial at the cubital tunnel, and it was
speculated that repetitive movements and constant, sus-
tained postures at work could have contributed to the
symptoms seen in these patients.
Dysfunction at the mechanical interface leads to
venous congestion, reduced axoplasmic flow, and can
mechanically irritate the nerve, causing inflammation
(Anandkumar, 2013; Coppieters and Butler). This can
further lead to reduced nerve mobility and mechanosen-
sitivity (sensitivity to mechanical stimulus), leading to
the formation of abnormal impulse generating sites
(Chen and Devor, 1998; Saur, Bove, Averback, and
Reeh, 1999).
Treatment of cubital tunnel syndrome utilizing DN was
based on a working model for mechanical interfaces
(Anandkumar, 2018) (Figure 7). DN is thought to mediate
pain by acting through the gate control theory (pre-synap-
tic and post-synaptic segmental inhibition at the spinal
cord) and assisting in the release of endogenous opioids
(through the descending pain suppression systems)
(Cagnie et al., 2013; Dommerholt, 2011). With controlled
microtrauma, the axon reflex has been shown to be acti-
vated due to the release of vasoactive substances like sub-
stance P and calcitonin gene-related peptide (Cagnie et al.,
2013; Sato, Sato, Shimura, and Uchida, 2000). Also, various
proteins like vascular endothelial growth factor are released
with DN and all these factors cause vasodilatation of vessels
and angiogenesis, ultimately resulting in increased blood
flow (Hsieh, Yang, Yang, and Chou, 2012). Further,
enhanced microcirculation and improvements in nerve
conduction velocities have been shown with the needling
of perineural structures (Dunning et al., 2014; Khosrawi,
Moghtaderi, and Haghighat, 2012; Kumnerddee and
Kaewtong, 2010; Sim et al., 2011; Yang et al., 2009, 2011).
Reduced spontaneous electrical activity in the muscles
has been shown with DN at the end plate zone (Chen et al.,
2001; Hsieh, Chou, Joe, and Hong, 2011). Further, with
needle rotation, it has been demonstrated that the collagen
bundles wind around the needle (Langevin et al., 2002).
This causes an internal stretching of the connective tissue
and, when sustained, stretching may lead to tissue relaxa-
tion, reduced tension, and a positive impact on inflamma-
tion regulation mechanisms due to the reorganization in
the viscoelastic properties (Abbott et al., 2013; Berrueta
et al., 2016; Konofagou and Langevin, 2005; Langevin
et al., 2005). It is possible that any one or more of the
mechanisms discussed above were related to the improve-
ments observed in these cases (Figure 7).
All three patients were treated based on a recently
proposed DN grading system (Anandkumar and
Manivasagam, 2017) and were needled based on the tissue
severity, irritability, and tolerance. The DN grading
Figure 7. Model depicting the mechanisms by which dry needling intervenes for a nerve entrapment interface.
PHYSIOTHERAPY THEORY AND PRACTICE 7
system (Sudarshan andMurugavel Dry Needling Grading
Scale©) used to guide treatment led to subtle differences
in the DN procedures for the three cases. In patients A
and C, though DNwas aimed at the FCU, different grades
were utilized (Table 2). In patient A, “grade 6” technique
was carried out where the needle was inserted into the
FCU and rotated in a clockwise direction engaging the
tissue bind. As the concordant symptoms were repro-
duced, the needle manipulation was discontinued. In
patient C, a “grade 4” technique was initially carried out.
The concordant symptoms were reproduced as soon as
the needle was inserted into the FCU. Hence, needle
manipulation (like flicking or rotation) was not carried
out. As patient C started improving with less irritability of
tissues, she was progressed to a “grade 8” technique; due
to better tissue tolerance, the needle was rotated in a
clockwise direction until it locked.
The techniques used in patients A and C were in sharp
contrast to the DN technique used in patient B. The ulnar
nerve issuperficial at the cubital tunnel region between
themedial epicondyle and olecranon process and hence, a
“grade 2” procedure was carried out. The medial elbow
pain was reproduced with superficial needle insertion.
Because the symptoms of tingling appeared and patient
B felt the extremity to be heavy and irritable, clockwise
needle rotation was discontinued before it locked. For a
home program, gentle ulnar nerve sliders were reviewed
with an aim to improve nerve mobility at the mechanical
interface, increase nerve vascularity, reduce adhesions,
and remove inflammatory products (Coppieters,
Bartholomeeusen, and Stappaerts, 2004; Coppieters and
Butler, 2008). Although favorable results were seen in all
three patients, it is not known if the use of the grading
system was a contributing factor.
Nonoperative management of cubital tunnel syn-
drome has been shown to have high rates of recurrence
(Ehsan and Hanel, 2012; Mowlavi et al., 2000). This case
series had a follow-up varying from 4 to 6 months and
hence, the long-term recurrence of cubital tunnel syn-
drome in these patients is unknown. Though the
patients were diagnosed with cubital tunnel syndrome,
their entrapment site and management with DN varied
depending on the tissues irritability, severity of pain, and
tolerance. It was speculated that DN had a beneficial
effect on the mechanical interface by reducing pain,
increasing blood flow, reducing tension, and resolving
inflammation (Anandkumar, 2018).
Although many clinicians use DN for treatment of
myofascial pain and trigger points, it has been proposed
for treatment of fascia, connective tissues, or nerve entrap-
ments (Anandkumar and Manivasagam, 2017; Patrick,
McGinty, Lucado, and Collier, 2016; Saylor-Pavkovich,
2016). To our knowledge, this case series is the first
description of the use of DN in patients with cubital tunnel
syndrome. Most of the current research and certification
programs are solely based on trigger point DNwith a focus
on “pistoning,” “in and out” or “thrusting” the needle to hit
the trigger point (Dunning et al., 2014). Using the same
technique in a nerve mechanical interface is not advisable
due to the possibility of inducing iatrogenic injury. Hence,
adopting the Sudarshan and Murugavel Dry Needling
Grading Scale© (Anandkumar and Manivasagam, 2017)
may help to guide clinical decision-making depending on
the patient’s response to needling.
Conclusion
This case series describes the successful conservative
management of cubital tunnel syndrome using DN.
DN may be a viable conservative treatment option.
Future research with larger samples is needed to verify
the effectiveness of DN in patients with cubital tunnel
syndrome.
Acknowledgments
The authors thank John Campbell Bsc.Kin, Bsc.PT, MRSC,
and Lori Stevens for their assistance in preparing this
manuscript.
Declaration of interest
The authors report no declarations of interest.
Funding
The authors thank John Campbell Bsc.Kin, Bsc.PT, MRSC,
and Lori Stevens for their assistance in preparing this
manuscript.
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10 S. ANANDKUMAR AND M. MANIVASAGAM
	Abstract
	Background
	Case description and clinical findings
	Patient A
	Patient B
	Patient C
	Outcome measures
	Evaluation and diagnosis
	Treatment
	Treatment for patient A
	Treatment for patient B
	Treatment for patient C
	Discussion
	Conclusion
	Acknowledgments
	Declaration of interest
	Funding
	References