Case study 1

Candidate Name: 20 yr Female wrestling player( cannot share her name as she is an international
athlete, will result breach of ethical code of confidentiality of the patient.)
Body type endomorphic

Condition: Upper cross syndrome

History: patient is an international wrestling player currently going through Rehabilitation after her
right shoulder injury.
She had a chronic shoulder pain since 3 year which was ignored from the very first episode of pain.
She used to take pain killer and used to do her regular wrestling but unfortunately she injured her
right shoulder while playing Olympic style Haryana state wrstling 3 month back., however she
managed to win the bout even after the injury. From the last episode of injury she took an rest for 3
to four weeks and was taking pain killer as advised by doctor (a local doctor in Rohtak) and her
physiotherapist (dr vidya kumara Olympic gold quest). At that time first MRI was taken which shows
grade 2 tear of supraspinatus tendon with tendonitis and laxity in GH joint capsule.) After that the
pain did not get resolved. As did get resolved she went to show Dr D pardiwala ( kokilaben hospital
Mumbai ) where again She was advised to get an MRI done which findings suggest of Supraspinatus
muscle tendonitis and lax capsule of the GH joint. There was evidence of inflammation at AC joint
as well. Although there was no tear in the supraspinatus muscle (suggestive of healing over the
period of time). Here again the doctor advised her to go for rest for another 10 days and start with
basic rehab of the shoulder joint after 10 days. After that she went into India camp where she took
relative rest and passive physiotherapy which involve IFT ,Tense, cold pack and ultrasound massage
at the right shoulder joint. She was also taking enzoflam (antiinflamatry). But even after 10 days she
still had pain and this time pain was even worse. She came me as i am a senior Physio at Olympic
gold quest.
On examination
18/05/2018 I accessed her shoulder where i found she had upper cross syndrome where her b/l
shoulder are protracted ( tight pec major and weak rhomboids and midle traps) and she had
forward head posture. All the ROM was limited R>>>L due to pain. I knew that all we need to correct
her posture. There was marked anterior tilting of scapula suggestive of tight pects minor as well
She had very weak shoulder girdle muscle. Very week scapular stability
On palpation there was very rigid trigger point at both the upper traps and rhomboids muscle.
Treatment given on 18/05/2018
 We couldn’t do any exercise as pain was very much and was likely going towards central
sensitization.

 I did dry needling of her Right upper Trapizious muscle in side lying position with 0.25 x 30
mm needle and got aprox 25 twiches.

 Dry needling of right pects minor with 0.25x 60 mm needle and got aprox 5-6 twiches. She
felt little easy on shoulder but her pain was no better in the GH joint.

 After the dry needling session we applied cold pack and ultra sound therapy.

 I asked her to continue with her medication and cold pack compression and see me after
two days.

 After two days also there was no difference in pain level 9/10 in vas scale. The reason that
dry needling did not worked here was because 1) pain was chronic in nature and it was not
 because of MTrP. Actually MTrP was formed secondary to the injury of her GH joint capsule
and tendon. Also her posture is another factor which was actually contributing to the
formation of MTrP om the respective muscle.

 After that on 22nd June we we again go to Dr D pardiwala at kokilaben hospital.where i

asked if we could get an intra-articular steroid injection so that we get window of
opportunity to strengthen her shoulder girdle muscle and work on her posture. So we get an
intra-articular steroid injection after which her pain on VAS was reduced to 1 from 9.5 out of
10. She was gain advised rest for two weeks (that was till 4th of july) post treatment by
doctor. During the rest period she was treated by Dr Vidya Of OGQ with ice ultrasound and
and relative rest to the joint.

 She come to again on 5th of july 2018 where i again accessed her.

 This time she has full ROM but mild pain at end range 1/10 on VAS scale.

 Limited ROM of B?L Neck side flexion and neck extension.

 However on MMT she had only

o 3/5 of muscle strength in Flexion and Ab-duction of GH joint.

o 4/5 adduction of GH joint
o 2.5/5 External rotation of GH joint
o 3/5 internal rotation of GH joint.
o 4/5 scapular retractors
o 4/5 protacctor
o Very poor seratus anterior stability as there was winging at scapula on wall push.
o Weak core muscle as well.
o 4/5 b/l upper trapizious Neck side bending

 On palpation we have MTrP on

o B/L Upper trapsizius muscle
o Right rhomboidus
o Infratus muscle
o Supraspinatus muscle

 Line of treatment decided was to first get her scapular stability back before starting
strengthening of her GH joint muscle and for that it was decided apssice treatment of soft
tissue manipulation using dry needle twice a week and supervised exercise for scapular
stabilty 6 days a week.
 Treatment given on 5th of july.
o SDN for B/L upper traps with two separate 0.25x30 mm needle for each time
o SDN for B?L pectorals Minor and Major with 00.25x40 mm needle using two
separate needle for each side.
o Passive stretch to b/L upper traps, b/l Levater scalpule, b/l scaline and SCM muscle .
3 stretches for each muscle with 10sec hold.
o Stretching for Pects major and minor. 10 sec hold x 3 times.
o Prone line shoulder blade retraction 3 sets of 25 reps into 3 sets.
o Rowing exercise with Green colour theraband 3 sets of 25 rep.
o Single hand lower traps and lats puldown with green theraband.
o Post treatment taping was done for scapular stability.
 o She was asvisedto do cold compression irrespective of the pain two to three times in
a day.
Similar session are continued everyday without dry needling.dry needling was done only twice a
week ie on 8th july 2018, 11th july 2018, 15th july 2018 and 18th july 2018 21st july 2018.
 8th july
o SDN for B/L upper traps withtwo separate 0.25x30 mm needle for each time
o SDN for B?L pectoralis Minor and Major with 00.25x40 mm needle using two
separate needle for each side.

 11th july
o SDN for B/L upper traps withtwo separate 0.25x30 mm needle for each time
o SDN for B?L pectoralis Minor and Major with 00.25x40 mm needle using two
separate needle for each side.

 15th july
o SDN for B/L upper traps withtwo separate 0.25x30 mm needle for each time
o Didnot felt any tought band in pects so only MFR and stechuing was given

 18th july
o SDN for B/L upper traps with two separate 0.25x30 mm needle for each time
o SDN for right rhomboidus with 0.25x30 mm needle in a oblique direction along the
length of the fiber in semi side lying position.

 21st july.

o SDN for right rhomboidus with 0.25x30 mm needle in a oblique direction along the
length of the fiber in semi side lying position.

Now we have started her rehab its been three weeks that i am working on her posture where she
showed remarkable improvement in scapular stability. MTrP size is reduced to ¼ in upper traps and
there is no MTrP in Pects muscle anymore. Her shoulder move is easy and pain free.
We have a protocols bring her back into play by next 4 month. From next week we will start with GH
joint muscle strengthening.
The reason that i have choose to needle here not because we are treating pain but to supliment
her postural correction exercise and to reverse the muscle memory in patient get her back into
normal posture.
Case Study 2
Patient name: Amit Dhiya 22 yr M Physical education student with long jump as main sports.
Condition: Patello femoral pain syndrome/chondromlacia patelle
Body Type endomorphic

Patient come to me on 14/06/2018.

Chief complain pain underthe patella while assending as well as dedending down the staisrs
Also pain increases when he runs and jumps.
History of present illness: patient has first of episode of this pain 1 year back while he was giving
physical examination where he has run jump and do severalactivites. He took physiotherapy after
that all pain got vanished. He got his recent episode of pain two days back. The nature of pain was
insidus in onsed the pain grow gradually so thta he cant run and climb stairs.
Presenting signs and symptoms (use diagram):
On Examination:

left
rt

IR limited

Tight quadriceps with MTrp weak hamstring but hyperactive

Painful knee cap

B/L over pronation tight calf rt>lt

Pain under the knee cap. 8/10 on Vas scale

Restricted hip ROM IR more then exernal rotation
Slump negative.
bL over pronation
Tight calf muscle solius and gastro rt >>lt
On palpation MTrPin qudricepas and ITB and TFL
Ristrited Knee flexion.

Treatment given
14/06/2018:
Examination before needling : pain in semi squat position and jumping 8/10 on vas scale.
Dry needling was done at MTrP of
 Rectus femoris and Vastus latralis with 0.25x50 mm needle. Two separate needle were
used to get 30to 40 twich reponse
 TFL with 0.25 x40 mm needle in supine position. 4 twich
 ITB with 0.25x 40 mm needle in side lying position. 35-40 twiches were obtained.
 VMO activation with 0.25x40 mm needle.
Post needling examination
Pain in semi squat position 2/10, pain in jumping 2/10.
MFR given for facia covering the quadriceps.
Exercises given after needling and was advised for home as well was.
  Static quards with VMO activation
 Squationg gainst wal 20 sec to be progresseded till 3 min.
 Toe curl toe times a day
 Quadriceps stretching standing position 10sec x 3 rep two timesa day.
 Passive hip internal rotation exercise 10 rotn clockwise twotimes a day
 Heel drops
 Hamstring curl.
 Foam rolling for ITB ,TFL,vastus latralis and rectus femoris

Follow up after a week

20 june 2018
Pain in semi squat 1/10 and full squat 4/10 jumping 4/10
Treatment given
Dry needling was done at MTrP of
 VMO activation with 0.25x 40 mm needle
 Rectus femoris and Vastus latralis with 0.25x50 mm needle. Two separate needle were
used to get 30to 40 twich reponse
 TFL with 0.25 x40 mm needle in supine position. 4 twich
 ITB with 0.25x 40 mm needle in side lying position. 35-40 twiches were obtained.
Post needling examination
Pain in semi squat position 0/10, full squat 2/10 pain in jumping 2/10.
Same treatment continued with same home execises.
Follow up After a week 26th june
Pain before dry needling 2/10 full squat position , jumping 2/10
 VMO activation with 0.25x 40 mm needle
 Rectus femoris and Vastus latralis with 0.25x50 mm needle. Two separate needle were
used.
 TFL with 0.25 x40 mm needle in supine position.
 ITB with 0.25x 40 mm needle in side lying position.
Post needling response. 0/10 in full squat position. 1/10 in jumping.
Patient was advised with same home exercises along with to start CKC and PKC knee execises as
well.
Patient was advised to see me after two weeks
After two weeks that is on on 4th july 2018 no dry needling was done patient has no knee pain in any
of the activity. Patient was advised to follow gym get it reviewed ever two months.

Discussion: the choice of dry needling here was based on problemlist. As VMO was inactive that
why the patient was getting severe pain. With belle i worked on all muscle contributing to cause
anterior knee pain were treted andf give very good result.
Case Study 3
Patient name: Dhruv goyal 16yr/Female, Basket ball player
Condition: OSD (osgood slater disease )
Body Type mesomorphic.

Patient come to me on 17/06/2018.

Chief complain: pain and swelling at right tibial tibrosity.
Pain get agrevated by jumping.and while playing basket ball.
She is playing basket ball since the age of 9.
History of present illness: pain started two days back when she was playing basket ball. There was no
history of any fall or any impact on bone.
Presenting signs and symptoms (use diagram):
On Examination:

left
rt

Er/IR limited weak gluteus maximus and medius

Tight quadriceps with MTrp weak hamstring but hyperactive

Painful knee tibial tubrosity

B/L over pronation B/L very tight calf rt>lt

Pain and swelling over the tibial tubrosity. 7/10 on Vas scale
Restricted hip ROM IR> ER
bL over pronation
Tight calf muscle solius and gastro rt >>lt
On palpation MTrPin qudricepas and ITB and TFL
Ristrited Knee flexion due to pain.
Weak VMO
Tight ITB
Treatment given
17/06/2018:
Examination before needling : pain in semi squat position and jumping 9/10 on vas scale.
Dry needling was done at MTrP of
 Rectus femoris and Vastus latralis with 0.25x50 mm needle. Two separate needle were
used to simultaneously. The needling was dynamic in nature knee flexion and extion with
needle already inside the muscle.
 ITB with 0.25x 40 mm needle in side lying position.
 VMO activation with 0.25x40 mm needle.
 B/L gastronimius and solius muscle needling with 0.25x40 mm and 0.25x 50 mm
respectively for gastro and solius muscle.
Post needling examination
Pain in semi squat position 4/10, pain in jumping 6/10.
MFR given for facia covering the quadriceps. And arounf the patellar retinaculam.
Cold pack for 10-15 min post needling.
Taping above tibial tubrosity done for home.

Exercises given after needling and was advised for home as well was.
 Static quards with VMO activation
 Squatting gainst wall 20 sec to be progresseded till 3 min.
 Quadriceps stretching standing position 10sec x 3 rep two timesa day.
 Passive hip internal rotation exercise 10 rotn clockwise twotimes a day
 Heel drops with extended knee and slightly bend knee
 Hamstring curl.
 Buttuck clinches
 Glute medius actication by clamp shel exercise.
 Foam rolling for ITB ,,vastus latralis and rectus femoris
 Cold compression for 7 min followed by 7 min of gap and repeating it for another 7 mind and
another gap of 7 min. And re applying gain for 7 min so that there are three episode of 7 min
of cooling and 3 episode of 7 min of relative heating at the tibial tubrosity.

Follow up after two days

19 june 2018
Examination reduced swelling around the tibial tunrosity
Pain in semi squat 5 /10 and jumping 6/10
Treatment given
Dry needling was done at MTrP of
 Rectus femoris and Vastus latralis with 0.25x50 mm needle. Two separate needle were
used to simultaneously. The needling was dynamic in nature knee flexion and extion with
needle already inside the muscle.
 ITB with 0.25x 40 mm needle in side lying position.
 VMO activation with 0.25x40 mm needle.
 B/L gastronimius and solius muscle needling with 0.25x40 mm and 0.25x 50 mm
respectively for gastro and solius muscle.
 Dry needling at patellar tendon with 0.25x15 mm needle just above the tibial tubrosity.

Post needling examination

Pain in semi squat position 2/10, pain in jumping 2/10.
Same treatment continued with same home execises.
Follow up After 2days
21st june 2018
Markedly reduced swelling and zero tenderness at tibial tubrosity
Pain before dry needling 2/10 full squat position , jumping 2/10
Dry needling was done at MTrP of
 Rectus femoris and Vastus latralis with 0.25x50 mm needle. Two separate needle were
used to simultaneously. The needling was dynamic in nature knee flexion and extion with
needle already inside the muscle.
 ITB with 0.25x 40 mm needle in side lying position.
 VMO activation with 0.25x40 mm needle.
 B/L gastronimius and solius muscle needling with 0.25x40 mm and 0.25x 50 mm
respectively for gastro and solius muscle.
 Dry needling at patellar tendon with 0.25x15 mm needle just above the tibial tubrosity.
Post needling examination
Pain on jumping 1/10 and squatting 1/10
Patient was asked to continuewith home exercises and cold compression and reviewwit me after a
week.
Follow up after 29th june.
No swelling present.
Pain on deep squatting 1/10, no pain in jumping
Dry needling was done at MTrP of
 Rectus femoris and Vastus latralis with 0.25x50 mm needle.
 ITB with 0.25x 40 mm needle in side lying position.
 VMO activation with 0.25x40 mm needle.
 B/L gastronimius and solius muscle needling with 0.25x40 mm and 0.25x 50 mm
respectively for gastro and solius muscle.
Post needle examination: no pain in any activity.
Needling was done not to treat pain but the do VMO activation.
Patient was advised to continue with home exercises see if pain reoocurs.

Discussion: the choice of dry needling here was based on problemlist. As VMO was inactive that
why the patient was getting severe pain. With needle i worked on all muscle contributing to cause
anterior knee pain.
Case Study 4
Patient name: Amit Srivastva 42yr/male, Ful marathon runner.
Condition: outer side knee pain. Hamstring strain.
Body Type: endomorphic

Patient come to me on 17/07/2018.

Chief complain: pain left latral side of left knee.
Pain get agrevated everytime he runs.
Pain comes ever time when he get inside car and when he come out of car.

History of present illness: patient is a marathon runner.Pain started a month back on his left knee
when he was doing practice run for upcoming marathon. He also feel strain in and tightness in
outer part of hamstring as well.
Presenting signs and symptoms (use diagram):
On Examination:

left
rt

Er/IR limited weak gluteus maximus and medius

B/L Tight ITB with MTrp spasmodic hyperactive hamstring

Painful knee outerside left >right

B/L over pronation weak tight calf

Pain and swelling over the left fibular head 9/10 on Vas scale when he moves the knee no pain in
static position.
Restricted hip ROM IR> ER
SLR :Left ,< right side.. Tight hamstring
b/L over pronation
Tight calf muscle solius and gastro lt>>rt
On palpation MTrPin ITB, Biceps femoris and vastus latralis.
Ristrited Knee flexion due to pain
Tight ITB
Nobel compression and obers test positive
Treatment given
17/07/2018:
Examination before needling : nobel compression test 7/10 on vas scale.
Dry needling was done at MTrP of
 ITB with 0.25x 40 mm needle in side lying position. Side lying position
 VMO activation with 0.25x40 mm needle. supine
 Biceps femoris needling with 0.25x60 mm needle procimaly and 0.25x 40 mm distlay in
side lying position
Post needling examination
Nobel compression test. 03/10 on vas scale.
No reduction in swelling.
Obers test knne faal down to bed completly.
After the treatment patient was advised to do ITB stretching, hamstring stretching and cold pack
compression over the ITB insertion and biceps femoris insertion.
MFR given for facia covering the ITB. Abicepa femoris and vastus latrlais.

Kinesiology taping for ITB syndrom.

Exercises given after needling and was advised for home as well was.
 Static quards with VMO activation
 Squatting gainst wall 20 sec to be progresseded till 3 min.
 Hamstring and ITB stretching lying down position 10sec x 3 rep two timesa day.
 Passive hip internal rotation exercise 10 rotn clockwise twotimes a day
 Heel drops with extended knee and slightly bend knee
 Buttuck clinches
 Glute medius actication by clamp shel exercise.
 Foam rolling for ITB ,,vastus latralis and biceps femoris(latral compartment of thigh)
 Cold compression for 7 min followed by 7 min of gap and repeating it for another 7 mind and
another gap of 7 min. And re applying gain for 7 min so that there are three episode of 7 min
of cooling and 3 episode of 7 min of relative heating at the fibular head

Follow up after two days

21 july 2017
Examination reduced swelling around left febular head
Obers test negative nobel comprsion test 2/10
Treatment given
Dry needling was done at MTrP of
 ITB with 0.25x 40 mm needle in side lying position. Side lying position
 VMO activation with 0.25x40 mm needle. supine
 Biceps femoris needling with 0.25x60 mm needle proximally and 0.25x 40 mm distally in
side lying position
Post needling examination
Nobel compression test. 0/10 on vas scale.
Obers test knne faal down to bed completly.
After the treatment patient was advised to do ITB stretching, hamstring stretching and cold pack
compression over the ITB insertion and biceps femoris insertion.
MFR given for facia covering the ITB. Abicepa femoris and vastus latrlais.

Kinesiology taping for ITB syndrom.

He was asked to follow up after a week.

Discussion on dry needling: patient has Itb syndrome with biceps femoris strain which responded
very well with dry needling. Before this dry needling i used treat such patiend with manual release
technique which was taking lot time and many session to recover but with dry needling patient
hardly need 4-5 sessions of dry needling.
Case Study 5
Patient name: divya , 21 year female table tennis player
Condition: Piriformis
Body Type: mesomorphic

Patient come to me on 11/07/2018.

Chief complain: pain radiate down to rt calf while walking forward bending. 9/10 on vas scale.
Consistant Burning pain in lower calf.9/10
Dullness in the lower back and buttuck.

Pain get agrevated everytime she sits on buttuks. Walks.

History of present illness: patient is a recreational tennis player.Pain started two weeks back when
she was playing tennis. It was long rally game after this she was very tight in general from the whole
body. Next day morning she had burning pain in calf while coming off the, turning on the bed sitting
to standing and standing to sitting all these activities cause pain to shoot down to the calf.
Presenting signs and symptoms (use diagram):
On Examination:

left
rt

sore buutuck and tender piriformis mussle

SLR positive for right side negative for left side.

Contralatral SLR negative
Slump negative both the sides.
Tenderness present at piriformis muscle
Limbar paraspnal muscle, gluteus medius are in spasm.
Diadnosis piriformis syndrome.
Treatment given
11/07/2018:
Examination before needling : SLR test for radiation 9/10
Burning pain in calf muscle vas scale 9/10
Dry needling was done at MTrP of
 Rt Piriformis with 0.25x 75 mm needle in side lying position.
  RT Glutius medius muscle with 0.25x 60 mm needle side lying position.
 Lumbar paraspinals erecter spinae 0.25x25 mm needle
Post needling examination
SLR. Marked reduction in radiation of pain 4/10
There was no burning in calf immediately after the treatment. However paitent has numbness and
dullness at the same spot in calf.

Exercises given after needling and was advised for home as well was.
 Foam roller release for piriformis and lower back muscle.
 Piriformis stretch.
 Makenze extension exercises
 Cat and camel
 Loin exercises
 Sciatic nerve flossing exercises
 Cold compression for 7 min followed by 7 min of gap and repeating it for another 7 mind and
another gap of 7 min. And re applying gain for 7 min so that there are three episode of 7 min
of cooling and 3 episode of 7 min of relative heating at the needled areas.

Follow up after two days

14 july 2017
Examination
SLR 2 /10
No burning sensation in calf
No muscle spasm in lower back mucle
MTrP at gluteus medius and piriformis.
Treatment given
Dry needling was done at MTrP of

 Rt Piriformis with 0.25x 75 mm needle in side lying position.

 RT Glutius medius muscle with 0.25x 60 mm needle side

Post needling examination

SLR 0.5or negligible intensity of radiation/10

Patient was asked to continue with same exercise and follow up after a week.
21st july 2017
O/E
Slump Negative.
SLR negative no radiation with SLR
No burning sensation in calf
No muscle spasm in lower back muscle
No MTrP present in piriformis and gluteus medius muscle.
Patient was advised to start with gym and do basic strengthening of core lower back hips thigh and
legs.