ARTICLE

Mulligan’s Mobilization with Movement and Muscle

Trigger Point Dry Needling for the Management of Chronic
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Lateral Epicondylalgia: A Case Report

Josue Fernández-Carnero, PT
Cesar Fernández-de-las-Peñas, PT, PhD
Joshua A. Cleland, PT, PhD, OCS, FAAOMPT
For personal use only.

ABSTRACT. Background: It has been found that trigger points [TrPs] in the extensor carpi
radialis brevis [ECRB] muscle reproduce pain in lateral epicondylalgia [LE]. Trigger point dry
needling [TrP-DN] has not been previously investigated in LE.
Findings: A female LE patient with duration of six years received eight treatments [TrP-DN in
the ECRB muscle and a mobilization-with-movement technique] in a four-week period. The out-
come measures of the patient-rated tennis elbow evaluation [PRTEE], pain-free grip force [PFG],
visual analogue scale, and pressure-pain threshold [PPT] were taken pre- and post-intervention
and at one-month and four-month follow-ups. The PPT increased from 248 to 609 kPa at the end of
the treatment period. Elbow pain showed a substantial improvement from 7/10 at the pre-treatment
to 0/10 after the four-week intervention period. PFG values increased from 12 to 28 kg after the
treatment period. After the treatment, all values of the PRTEE questionnaire were 0, suggesting a
rapid recuperation of elbow function following the intervention.
Conclusions: Our findings suggest that the TrP-DN and mobilization-with-movement combi-
nation may be suitable for the restoration of motor function and the induction of a hypoalgesic
effect in LE.

KEYWORDS. Lateral epicondylalgia, trigger point dry needling, mobilization-with-movement,

pain threshold

Josue Fernández-Carnero, PT, Cesar Fernández-de-las-Peñas, PT, PhD, Department of Physical Therapy, Occu-
pational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain;
and Esthesiology Laboratory of Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.
Joshua A. Cleland, PT, PhD, OCS, FAAOMPT, Department of Physical Therapy, Franklin Pierce College,
Concord, New Hampshire, USA; Physical Therapist, Rehabilitation Services, Concord Hospital, New Hampshire,
USA; and Manual Therapy Fellowship Program, Regis University, Denver, Colorado, USA.
Address correspondence to: Josué Fernández Carnero, PT, Facultad de Ciencias de la Salud, Universidad Rey
Juan Carlos, Avenida de Atenas s/n, 28922 Alcorcón, Madrid, Spain, Phone: + 34 91 488 89 59, Fax: + 34 91 488
89 57. E-mail: josue.fernandez@urjc.es
Journal of Musculoskeletal Pain, Vol. 17(4), 2009
Available online at www.informaworld.com/WJMP


C 2009 by Informa Healthcare USA, Inc. All rights reserved.
doi: 10.3109/10582450903284802 409
 410 JOURNAL OF MUSCULOSKELETAL PAIN
BACKGROUND
Lateral epicondylalgia [LE] is a common soft
tissue injury, which involves the origin of mus-
cles of the wrist and finger extensors. Pain more
often involves the dominant side [63 percent]
and rarely both sides (1). Further, many physical
workers report daily pain in the elbow [35 per-
cent] or pain for longer than one month during
the past year [60 percent] (1). LE is characterized
by lateral elbow pain, mechanical hyperalgesia,
muscle strength changes (2), functional impair-
ments (3, 4), and referred muscle pain (5). The
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aetiology of this condition remains unclear, but
the majority of patients are usually treated with
conservative procedures.
A wide range of aetiologies and risk factors
have been proposed for LE. The most common
hypothesis is that LE involves the muscles of
the forearm, particularly the extensor carpi ra-
dialis brevis [ECRB] muscle (6). Further, motor
control impairments of the forearm musculature
have been identified in LE (7). Simons et al. (8)
For personal use only.
described the referred pain from different mus-
cle trigger points [TrPs] in the forearm muscu-
lature resembles pain features of LE. A TrP is
defined as a hyperirritable spot within a palpable
taut band of a skeletal muscle that is painful on
compression, stretch, or overload, and that elic-
its a referred pain pattern (8). We have found
that TrPs in the ECRB muscle reproduce pain
symptoms in people with LE (5). Therefore, it
seems that TrP may be involved in the genesis
of LE sensory symptoms.
Many interventions have been described for
the management of LE, including ultrasound,
orthotic devices, acupuncture, laser, exercises,
mobilization techniques, or corticosteroid in-
jections. However, evidence for manual ther-
apy, tape, orthotic, and exercise for the manage-
ment of LE is insufficient (9). There is evidence
suggesting that “mobilization-with-movement”
[MWM] interventions, described by Mulligan
(10, 11), applied to the elbow can be bene-
ficial for reducing pain, increasing pressure-
pain threshold [PPT], and pain-free grip in
LE. The MWM treatment for LE involves both
manual therapy and active muscle exercise of
the forearm extensor muscles. Particularly, the
treatment involves the application of a lateral
glide to the elbow joint, which is sustained
while an exercise, activity, or movement is
performed.
Muscle trigger point dry needling [TrP-DN]
is a procedure commonly applied for the man-
agement of TrPs, which has been used in many
scientific studies (12). Hong et al. (13) demon-
strated that TrP-DN is as effective as injection
lidocaine for reducing pain symptoms induced
by TrPs. The Cochrane Review (14) found insuf-
ficient evidence to determine whether acupunc-
ture is effective for LE. Nevertheless, TrP-DN
has not been investigated in this condition (12).
The purpose of this case report is to describe
the outcomes of a patient with LE, suffering from
ongoing pain at the LE region and the dorsal
aspect of the forearm, who was treated with the
combination of TrP-DN in the ECRB muscle and
the MWM technique.
CASE DESCRIPTION
Clinical History and Physical Examination
The patient was a 26-year-old female beau-
tician, which required her to undertake heavy
levels of manual activity. She was right-handed.
At the initial assessment, her main complaint
was an intermittent sharp pain with occasional
aching over the lateral region of the right elbow.
She also reported an intermittent dull burning
sensation over the posterior and lateral elbow re-
gion and occasional stiffness over the wrist. The
pain started six years previously while perform-
ing intensive physical work. The pain forced
her to stop working. The patient rested for sev-
eral months before returning to the job, only to
be forced to stop again due to the increase of
her symptoms. The patient had previously re-
ceived 10 sessions of physical therapy consist-
ing of deep and painful massage to the forearm
muscles, ice therapy, and laser and transcuta-
neous electrical nerve stimulation. An exercise
program was also prescribed, but since it was
painful, exercise was stopped.
The patient had experienced little progress
since the onset of the condition; she sought as-
sistance from another therapist. A period of ap-
proximately five years elapsed from the previous
treatment period to the time the patient entered
our clinic. At the time of the initial examination,
rest seemed to reduce the pain, but resumption
of any activity exacerbated it.
Physical examination revealed the classical
signs and symptoms of LE: Pain on palpation
 Fernández-Carnero et al.
over the lateral region of the elbow, pain on pal-
pation of the common extensor myotendinous
unit, and pain with resisted wrist extension and
with stretching of the wrist extensors (15). She
exhibited marked hyperalgesia to palpation over
an area just distal to the anterior and lateral as-
pect of the lateral epicondyle. Resisted wrist ex-
tension, gripping, and middle finger extension
were extremely painful. Cervical spine, shoul-
der, and elbow joint movements were full and
pain free. The subject was selected for the study
on the basis of this clinical presentation, which
is usually recognized as LE.
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Examination of Trigger Points in the Forearm
Musculature
The patient was examined for the presence of
TrPs in the ECRB muscle. The TrP diagnosis
was performed following the criteria described
by Simons et al. (8) and by Gerwin et al. (16):
(1) presence of a palpable taut band in a skele-
tal muscle; (2) presence of a hypersensitive ten-
For personal use only.
der spot within the taut band; (3) local twitch
response elicited by the snapping palpation of
the taut band; and (4) presence of referred pain.
Active TrPs were considered when the elicited
referred pain reproduced the patient’ elbow pain.
Dry needling has been shown to be more sen-
sitive than manual palpation in the identifica-
tion of active TrPs (12); therefore, dry needling
method was used in the current case report to
induce local twitch responses in the ECRB. The
needling was introduced five times in different
directions within the TrP to induce a clear and
visible local twitch response. The patient was
asked to report the pain referral and pain loca-
tion following each needle insertion.
Function Outcome Measures
Function was assessed with the patient-rated
tennis elbow evaluation [PRTEE], because it
provides a simple, reliable, and valid tool for
the assessment of pain and function in LE (17).
The questionnaire evaluates pain and function of
the affected arm during the preceding week and
is divided into two parts. The first part includes
a scale of rate pain consisting of five questions
scored from 0 point [mildest] to 10 points [most
severe]. The second part deals with the function.
The functional disability scale is subdivided into
411
two parts: the first one evaluating specific activi-
ties, and the second one evaluating general activ-
ities commonly affected by LE. The patient rated
her ability to perform the activity on a scale rang-
ing from 1 point [no difficulty with the activity]
to 10 points [cannot perform the activity at all].
The pain-free grip force [PFG] was also in-
cluded in the functional analysis. For that pur-
pose, a hydraulic dynamometer [Enterprises Inc,
Irvington, NY, USA] was used. The PFG was
calculated with the upper extremity in a stan-
dard position of elbow extension and forearm
pronation (18). Patient was instructed to grip the
dynamometer until the pain was first provoked.
Three measures were recorded with a 20-second
rest interval between each measurement, and the
mean was considered.
Sensory Outcome Measures
A 10-cm visual analog scale [VAS; range: 0 =
no pain, to 10 = maximum pain] was used to
assess the following pain measures (19): (1) cur-
rent level of lateral elbow pain, (2) worst level of
lateral elbow pain experienced in the preceding
24 hours at rest, and (3) worst level of lateral el-
bow pain experienced in the preceding week at
rest. The mean was calculated during the treat-
ment sessions.
Pressure-pain threshold [the minimal amount
of pressure where a sense of pressure first
changes to pain] over the most sensitive area of
the elbow was assessed (20). For that purpose,


a pressure algometer [Somedic ] with a 1-cm2
R
rubber-tipped plunger mounted on a force
transducer was used. The patient pushed a
button to stop the pressure stimulation when the
threshold was reached. Pressure was applied
30 kPa/s. Three trials at intervals of 30 seconds
were obtained, and the mean of these three trials
was used.
Trigger Point Dry Needling
During all treatment sessions, the patient first
received the TrP-DN technique. Since referred
pain elicited by active TrPs in the ECRB re-
produced the pain symptoms of our patient, the
active TrPs in this muscle was needled. The
TrP-DN procedure used was similar to the TrP
injection described by Hong (13, 21). The TrP
was compressed by the index finger or middle
 412 JOURNAL OF MUSCULOSKELETAL PAIN
FIGURE 1. Trigger point dry needling in the extensor capri radialis brevis.
J Muscoskeletal Pain Downloaded from informahealthcare.com by McMaster University on 11/25/14
finger of the non-dominant hand of the therapist
to direct the placement of the needle tip while
inserting the needle [Figure 1]. An acupuncture
needle, 1.5 inches in length, was held by the ther-
apist’s dominant hand. The needle was inserted
into the skin at a point above the taut band over
the TrP. After penetration of the needle into the
skin tissue, it was directed to the muscle TrP until
a first local twitch response was provoked. Then,
the needle was inserted and withdrawn from the
TrP rapidly. With movement of needle, a local
For personal use only.
twitch response can be elicited if the needle tip
encounters a sensitive locus. The needle inser-
tions were repeated to elicit as many local twitch
responses as possible. As soon as the needle was
pulled out of skin, the TrP region and the needle
insertion site were compressed firmly for at least
three seconds.
Mobilization with Movement Manoeuvre
After the application of TrP-DN, the patient
received the MWM intervention. The MWM
FIGURE 2. Mobilization with movement intervention.
technique has been previously described in the
literature (10, 11). This technique is performed
as follows: one hand of the therapist is used to
glide the proximal forearm laterally, while the
other hand fixed the distal end of the humerus
while the patient performed a PFG action. In


R
our case report, a Belt was used to replicate
the lateral manual force across the elbow joint
while the patient conducted a pain-free wrist
extension motion resisted by the therapist
[Figure 2]. Ten repetitions were performed with
an approximate 15-second rest interval between
repetitions (10, 11).
Treatment Procedure
At the first visit, clinical history and physical
examination was recorded by a physical ther-
apist experienced in the management of mus-
culoskeletal conditions. After inclusion into the
study, pre-intervention data of function and sen-
sory outcomes were assessed by an external as-
sessor. The patient received eight sessions of
 Fernández-Carnero et al.
FIGURE 3. (a) Pressure-pain threshold over the elbow region. (b) Pain-free grip force evolution during
the study.
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15 minutes during a four-week treatment period
[two sessions per week] of both TrP-DN and
MWM. Functional and sensory outcomes were
again assessed one week after the last session,
and one- and four-month follow-up. Finally, the
perceived improvement of our patient at one-
and four-month follow-up periods was assessed
with a Global Rating of Change on a 15-point
Liker scale ranging from −7 [a very great deal
For personal use only.
worse] to +7 [a very great deal better] (22). De-
scriptors of perceived worsening or improving
were assigned with values ranging from −1 to
−7 and +1 to +7, respectively.
RESULTS
Sensory Outcomes
The PPT levels over the lateral elbow region
increased from 248 kPa prior to the study to 609
kPa at the end of the treatment period, which
means an increase of 150 percent. Further, PPT
levels also increased at one and four months
after discharge [200 percent and 198 percent,
respectively]. Figure 3(a) summarizes the evo-
lution of PPT levels during the study.
Pain on the lateral elbow region showed a
substantial improvement from 7/10 at the pre-
treatment to 0/10 after the four-week interven-
tion period. This improvement was maintained
during all follow-up periods. The patient re-
ported to be a great deal better [+7] on the Global
Rating of Change at both one- and four months
after discharge.
Function Outcomes
The PFG values on the affected arm increased
from 12 kg prior to the study to 28 kg after the
413
treatment period, which indicates an increase of
116 percent. Further, PFG continued increasing
at one and four months after discharge [175 per-
cent or 185 percent, respectively]. Figure 3(b)
summarizes the evolution of PFG values during
the study.
The PRTEE revealed that our patient reported
a higher level of pain and disability before the
treatment. After the eight treatment sessions, all
values of the questionnaire were 0, suggesting a
rapid recuperation of elbow function. Again, the
improvement was maintained at both follow-up
periods [Table 1].
Relationship between Function and Sensory
Outcomes
We also calculated the relationship between
function and sensory outcomes with the Pearson
correlation coefficient [r]. The PPT levels were
positively correlated to PFG [r = 0.617], and
negatively correlated to both the elbow pain [r =
−0.863] and the function scale [r = −0.525]:
the lower the PPT on the elbow region, the lower
PFG or the higher elbow pain.
DISCUSSION
Our case report described the outcomes of
a patient with chronic recalcitrant LE who re-
ceived a combination of a muscle [TrP-DN] and
a joint technique [MWM]. The results demon-
strated that the patient experienced a dramatic
and sustained improvement in both pain and
function. We also found a relationship between
sensory and functional outcomes, suggesting
that both impairments can be treated at the same
time in LE. Further, the mechanical hyperalgesia
 414 JOURNAL OF MUSCULOSKELETAL PAIN
TABLE 1. Patient-Rated Tennis Elbow Evaluation
Pre-intervention
Specific activities
Turn a doorknob or key
Carry a grocery bag with the handle
Lift a coffee cup or glass to your mouth
Open a jar
Pull up pants
Wring out a washcloth or wet towel
Usual activities
Personal activities [dressing, washing]
Household work [cleaning, maintenance]
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Work [your job or everyday work]
Recreational or sporting activities
present before the intervention was ameliorated
after the intervention period and at four months
after discharge. Our findings suggest that the
treatment combination employed may be suit-
able for the restoration of motor function and
the induction of a hypoalgesic effect in people
For personal use only.
presenting with LE.
We found a hypoalgesic effect following the
intervention [increase of 200 percent in PPT lev-
els] concomitant with an excitation of the mo-
tor system [increase of 175 percent in PFG],
which is similar to results previously found for
other manual procedures (10, 11). A mechani-
cal hypoalgesic effect concomitant with an ex-
citatory response of the motor system resembles
the pattern generated by stimulation of the lat-
eral peri-aqueductal midbrain gray matter (23).
It has been suggested that mobilization tech-
niques activate inhibitory descending systems
(10, 11), which would explain the results of the
current case study. A detailed description on the
possible mechanisms can be found elsewhere
(24).
Although TrP-DN is usually used for the treat-
ment of TrPs, scientific evidence of its effec-
tiveness is limited to case reports or/and a few
clinical studies (12). Further, the exact mecha-
nisms by which TrP-DN may be effective remain
elusive. Simons et al. (8) suggested that the ther-
apeutic effect of TrP-DN might be a mechanical
disruption of TrP contraction knots. An accu-
rately placed needle may also provide a localized
stretch to the contraction knot, which would al-
low the involved sarcomeres to resume their rest-
ing length by reducing the overlap between actin
and myosin filaments (25). Finally, TrP-DN may
One-month Four-month
Post-intervention follow-up follow-up
6 0 0 0
5 0 0 0
3 0 0 0
8 0 0 0
0 0 0 0
7 0 0 0
6 0 0 0
7 0 0 0
8 0 0 0
6 0 0 0
stimulate Aδ fibers and activate serotonergic or
noradrenergic inhibitory systems.
The results in this case report are similar
to other studies showing that MWM for the
management of LE can result in a dramatic
and immediate decrease in PFG force (10,
11). Additionally, similar to our findings, these
studies also demonstrated a reduction in PPT
over the lateral epicondyle following the MWM
technique.
Finally, it is also interesting to note that our
patient experienced a more rapid improvement
on PPT levels and PFG than in previous studies
where authors compared physical therapy with
corticoid injection (9). Perhaps, the combination
of TrP-DN and MWM may be a useful treat-
ment option for LE. However, a cause-effect re-
lationship cannot be inferred from a case report.
Hence, future randomized clinical trials should
investigate the effectiveness of this treatment ap-
proach.
Declaration of interest: The authors report no
conflict of interest. The authors alone are respon-
sible for the content and writing of this paper.
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Submitted: December 10, 2007
Revisions Accepted: January 16, 2008