Iatrogenic Nerve Injury Following Dry Needling For Foot Pain: Case Challenge
A 48-year-old man reported left plantar heel/foot pain. His symptoms began 20 years ago while playing basketball. At the initial onset of plantar heel pain, he reported burning and tearing pain when first getting out of bed in the mornings, which would typically resolve during the day and between basketball sessions, but which was always present and most intense after playing basketball. Since then, the symptoms have continued on and off for months at a time. The plantar heel pain returned in January 2010 after jogging up a small incline approximately 10 times over a 3-week period. The patient reported he was exercising in “poor quality running shoes” to get in shape. These symptoms have continued since that time without spontaneous resolution.
In the United States, the incidence of heel pain is approximately 10%, ranging from 8% to 15%, accounting for 11% to 15% of healthcare provider service visits.1-4 In adults, plantar fasciitis is the most common source of heel pain.3,4 When pain is associated with foot and ankle conditions, it results in disturbances in gait and difficulties in balance.5 In fact, older adults suffering from plantar heel pain are at higher risk for falls.5 Heel pain is considered to be a self-limiting condition that often takes between 6 to 18 months to spontaneously resolve.3,6 In fact, 80% of plantar heel pain cases spontaneously resolve in 12 months.3
Etiology of Plantar Heel Pain
The plantar fascia consists of three bands: the central, medial, and lateral. The medial and lateral bands originate off the abductor hallucis and the abductor digiti minimi, which may play a role in the etiology or at least a potential role in treatment.2 The thick and fibrous connective tissue of the plantar fascia performs a twofold purpose—a static support of the longitudinal arch and a dynamic shock absorption for the foot and lower leg.2,3,6 Present research has identified many possible risk factors for planter heel pain (Table 1).3,6-8
Travell and Simons have suggested that myofascial trigger points (MTrPs)—hyperirritable spots with hard hypersensitive palpable nodules located in taut bands within the muscles that can cause predictable patterns of pain spontaneously or when manually compressed—in lower extremity muscles are involved in plantar heel pain.9 When stimulated, MTrPs found in the gastrocnemius, soleus, and tibialis posterior muscles refer pain to the plantar heel and may play a part in the development of plantar heel pain symptoms. Site specific musculature that may have pain-causing MTrPs include the abductor hallucis, flexor digitorum brevis, and quadratus plantae (QP) musculature.9
Invasive and non-invasive management strategies for plantar heel pain vary greatly and lack consensus. Table 2 highlights various non-surgical options for treating plantar heel pain.1-6 Acupuncture has been proposed as a treatment option, but acupuncture studies vary in needle placement, sometimes using acupoints at the symptomatic site and sometimes at distal acupoints traditionally used for general pain control.3,10 Traditional acupuncture theory has not specified a particular acupoint for treating heel pain.10
Healthcare providers in Europe have performed dry needling for many years. Dry needling is an invasive procedure in which an acupuncture needle is inserted into the skin and muscle.11,12 Although the pathophysiology and mechanism of action are not completely understood, the knowledge base regarding dry needling is growing for musculoskeletal and myofacial pain conditions.11,13-18 Adverse events include local soreness, bruising, bleeding, pain, and, rarely, pneumothorax. However, the literature supports the safety of this procedure when performed by a trained clinician.13,19
In research studies, needling procedures for MTrPs have been efficacious.13,20 However, Cotchett et al performed a systematic review of the effectiveness of MTrP dry needling and injections associated with plantar heel pain. They found limited evidence, with methodological inadequacies.21
Dry needling is not intended to be a stand-alone treatment procedure. Rather, it is used as an adjunct to standard orthopedic manual physical therapy services, including soft tissue mobilization, joint mobilization/manipulation, and therapeutic exercises. At this time, there is no established dosage for dry needling application. The needle can be inserted and remain in place from seconds to minutes. It can remain stationary, be pistoned up and down, or twirled or spun clockwise and/or counterclockwise. Various electrical stimulation devices can be attached to the needle in some form or fashion to electrically stimulate the targeted muscle. The needle can be inserted superficially (superficial dry needling) to a depth just before penetration of the actual MTrP or it can be inserted deeply (deep dry needling) directly into the MTrP.
Current Case: Medical History
The patient’s past medical history included extensive knee surgeries bilaterally, as well as a history of low back pain. The surgical history of the patient's right knee included arthroscopic debridement in 1984, anterior cruciate ligament (ACL) repair with patellar tendon and calcium excision at graft donor site in 1994, and meniscal resection in March 2009. The surgical history of the left knee included ACL repair with hamstring graft in 1998, arthroscopic debridement in 1999, followed by a Maquet procedure several months later in 1999. The patient reported intermittent low back pain in the late 1980s and 1990s, and worsening of symptoms in 2000, culminating in left lower extremity radiating pain with numbness and tingling that lasted 5 to 6 months. The pain and numbness gradually resolved without intervention. Currently, he reports rare incidences of localized stiffness and low back pain. The referring physician did not provide any objective diagnostic findings, such as high-resolution ultrasound imaging of the fascia, needed to truly document whether there was fasciopathy, and there were no electrodiagnostic findings despite the long history of back symptoms.
The patient was recruited for dry needling treatment at a local hospital and signed informed consent. The patient was initially seen on April 25, 2011, for assessment and dry needling treatment with follow-up assessment sessions on May 9, 2011, and July 17, 2011. No other interventions or life changes were recommended or prescribed for the patient. The data and examination items were chosen primarily based on the clinical practice guidelines regarding heel pain–plantar fasciitis.22