Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2019;-:-------

ORIGINAL RESEARCH

Added Value of Gluteus Medius and Quadratus

Lumborum Dry Needling in Improving Knee Pain and
Function in Female Athletes With Patellofemoral Pain
Syndrome: A Randomized Clinical Trial
Hanieh Zarei, MSc, PT,a,b Soha Bervis, PhD, PT,a,b Soraya Piroozi, PhD, PT,a
Alireza Motealleh, PhD, PTa,c
From the aPhysical Therapy Department, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz; bStudent Research
Committee, Shiraz University of Medical Science, Shiraz; and cRehabilitation Sciences Research Center, Shiraz University of Medical Sciences,
Shiraz, Iran.

Abstract
Objective: To compare the effects of exercise therapy alone and exercise therapy plus gluteus medius (GM) and quadratus lumbarum (QL) dry
needling on pain and function in female athletes with patellofemoral pain (PFP).
Design: Single-blind randomized controlled trial with follow-up.
Setting: Physiotherapy clinic.
Participants: Convenience sample of female athletes with PFP (NZ40), who were randomly assigned to the exercise therapy (Ex group) or
exercise-therapyþdry needling (ExþDN group) group.
Interventions: The Ex group received exercise therapy for 4 weeks, and the ExþDN group received exercise therapy in combination with dry
needling directed at GM and QL trigger points for 4 weeks.
Main Outcome Measures: In all participants, pain intensity, function (Kujala score, modified star excursion balance test, step-down test), and QL
and GM pressure pain threshold (PPT) were recorded at baseline and at 4 and 6 weeks after the start of treatment. Analysis of variance
(2 groups3 times) was used to compare within- and between-group differences.
Results: The group versus time interaction effect was significant for all variables (P<.05). Both groups showed significant improvements in pain,
function, and PPT at weeks 4 and 6 compared to baseline (P<.05). Between-groups comparisons showed significantly greater improvements in
pain, function, and PPT in the ExþDN group (P<.05).
Conclusions: Targeting intervention to treat trigger points in the GM and QL muscles combined with exercise therapy had superior beneficial
effects compared to exercise alone in managing PFP. Therefore, adding GM and QL muscle dry needling to exercise therapy may be advisable to
enhance the effects of PFP rehabilitation.
Archives of Physical Medicine and Rehabilitation 2019;-:-------
ª 2019 by the American Congress of Rehabilitation Medicine

Patellofemoral pain (PFP) is a highly prevalent knee problem that
is often observed in female athletes.1 People with PFP typically
complain of diffuse retropatellar or peripatellar pain, which may
Supported by the Shiraz University of Medical Sciences, Vice Chancellery for Research Af-
fairs (contract no. 96-16373).
Clinical Trial Registration No.: IRCT20120411009440N20.
Disclosures: none.
impair functional activities such as stair climbing, running,
squatting, prolonged sitting,2 and static and dynamic balance.3,4
Patellar maltracking and increased patellofemoral joint stress
are among the accepted theoretical causes of PFP.5 These condi-
tions may be related to inappropriate vastus medialis and vastus
lateralis neuromuscular control.6,7 Recent studies have evaluated
the function of core muscles in people with PFP. These studies
identified differences in core muscle function between those with

0003-9993/19/$36 - see front matter ª 2019 by the American Congress of Rehabilitation Medicine
https://doi.org/10.1016/j.apmr.2019.07.009
2 H. Zarei et al
and without PFP. Altered core muscle recruitment patterns,8,9
decreased trunk strength,10,11 and lateral trunk muscle cross-
sectional area12 have been reported in people with PFP. In addi-
tion, the altered trunk and hip kinematics and postural control11,13
noted in other studies suggested that these factors may be related
to abnormal torque and stress at the patellofemoral joint in
PFP.11,14,15 According to recent PFP management guidelines, core
exercises are beneficial for people with PFP.16-19 Although it was
shown that core manipulation might improve EMG activity of the
knee and hip muscles in people with PFP,13 recent systematic
reviews indicated that this kind of treatment did not improve pain
and function.16,18
Myofacial trigger points (TrPs) are a common impairment in
many musculoskeletal pain conditions20 such as PFP. The exact
prevalence of core muscle TrPs in people with PFP is unknown.
However, a higher prevalence of TrPs in gluteus medius (GM) and
quadratus lumbarum (QL) has been reported in people with PFP
than healthy individuals.21,22 There is evidence that TrPs may alter
muscle strength, tension, activation pattern, and motor con-
trol.23-25 It can therefore be hypothesized that TrPs in the GM and
QL may cause alterations in their functioning. These muscles are
the most relevant core muscles in frontal hip and trunk stability,
and are thus involved in optimal knee mechanics.15,26 In unilateral
PFP, the ipsilateral GM and contralateral QL provide this frontal
stability and prevent hip adduction, which may increase the load
on the patellofemoral joint.27,28 Optimizing mediolateral control
of the pelvis has been suggested as an important factor in PFP
management.9,15,29 It is therefore possible that targeting in-
terventions to treat GM and QL TrPs may have beneficial effects
in PFP rehabilitation.
Dry needling (DN) is one of the most common methods of TrP
deactivation.30,31 There is no consensus on the effectiveness of
TrP therapy in PFP managements.16 However, this view was based
on studies focused only on TrPs in quadriceps muscles. To our
knowledge, no study to date has evaluated the effects of GM and
QL DN on pain and function in people with PFP.
Therefore, the aim of this study was to compare the effects of
exercise therapy plus GM and QL DN versus exercise therapy
alone on pain, function, and dynamic balance in female athletes
with PFP. We hypothesized that adding GM and QL DN to
exercise therapy would lead to greater improvements than exercise
alone in (first) pain and (second) function and dynamic balance.
Materials and methods
Study design and participants
This study was a parallel-group, single-blind randomized clinical
trial with an allocation ratio of 1:1. It was approved by the local
institutional review board and registered in the Iranian Clinical
Trials database as IRCT20120411009440N20.
List of abbreviations:
DN dry needling
GM gluteus medius
mSEBT modified star excursion balance test
PFP patellofemoral pain
PPT pain pressure threshold
QL quadratus lumborum
TrP trigger point
Participants with a diagnosis of PFP who were referred from
orthopedic clinics at centers affiliated with our university were
screened for eligibility criteria at a physiotherapy clinic. The
inclusion and exclusion criteria are shown in table 1.8,9,32 All
participants provided written informed consent in accordance with
guidelines approved by the local ethics committee.
Interventions
In this study, 1 group received exercise therapy (Ex group) and the
other received the same exercise therapy protocol in combination
with DN (ExþDN group). Both groups performed 2 sessions of
exercise therapy at the clinic and 3 sessions at home per week, for
4 weeks. An experienced physiotherapist taught the exercises to
the participants in each session and supervised them individually
to ensure that the exercises were done correctly. However, the
home exercise program was not supervised. In recent studies, knee
and proximal muscle exercises have been shown to be effective in
the management of PFP, so we selected the exercises specified in
appendix 1.16-18,33
Previous studies indicated a high prevalence of QL and GM
TrPs in persons with PFP21,22 and noted the relation between these
TrPs and knee biomechanics.27,28 Accordingly, the GM ipsilateral
and the QL contralateral to the involved knee were selected for
DN in the ExþDN group. Dry needling was applied once a week
for 4 weeks by an experienced physiotherapist with 0.3050-mm
and 0.30100-mm needles.a Further details are presented in
appendix 2.34,35
During each visit, the participants were monitored for any
related adverse events such as increase in their symptoms, post-
DN soreness, nausea, bruising, bleeding, or symptoms of vaso-
vagal shock, so that suitable interventions could be used if needed.
Patients in both groups did not receive any other intervention
during the study, except for the occasional use of nonsteroidal
anti-inflammatory drugs as needed. The participants were not
allowed to use any nonsteroidal anti-inflammatory drugs 48 hours
prior to measurement of the outcomes.
The duration of each session was approximately 15-40 min (2-
5min longer for DN in the ExþDN group). All participants in both
groups completed all the treatment sessions. When necessary, the
exercises were tailored based on individual symptoms and abili-
ties. No measurements of adherence were recorded in this study.
Outcome measures
All outcomes were measured before (baseline), 4 weeks after
(post-treatment), and 6 weeks after the start of treatment (follow-
up) by a physical therapist blinded to the treatment allocations.
The primary outcome was average knee pain intensity in the
previous week, measured with an 11-point numerical pain rating
scale on which 0 indicated no pain and 10 the worst imaginable
pain. Secondary outcomes were functional level and pain pressure
threshold (PPT). The step-down36 and modified star excursion
balance test (mSEBT)37 along with the Persian versions of the
Kujala questionnaire38 were used to evaluate objective and sub-
jective functional performance, respectively. The validity and
reliability of all measurement tools were verified and reported
previously.36-40 The Persian version of the Kujala Patellofemoral
Scale38 has 13 items and a score range of 0-100, with lower scores
indicating greater pain and disability.
For the mSEBT, participants were asked to stand on their
affected leg, reach in 3 directions (anterior, posteromedial,
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Gluteus medius and quadratus lumborum dry needling and PFPS
Table 1 Inclusion and exclusion criteria
Inclusion Criteria
1. Female athletes (regular sports activity at least 2h per day 3
times per week)
2. Age between 18 and 45 years
3. Unilateral prepatellar or retropatellar pain unrelated to
trauma for at least 3 mo, aggravated with at least 2 daily
activities such as prolonged sitting, kneeling, squatting,
running, hopping, or stair climbing
4. Positive Clarke’s sign
5. Average pain in the previous week >3 on numeric pain
rating scale.
6. Kujala questionnaire score <85 of 100
7. Trigger points in GM on the affected side and in QL on the
nonaffected side
8. Completed consent form
posterolateral) with their other leg, touch their toes as far away as
possible, and return to standing on their stance leg.37 The reach
distance in centimeters was normalized to each participant’s lower
extremity length. The mean of 3 test repetitions was recorded for
each direction. The participants were asked to do the test without
supporting their unaffected leg on the floor, lifting their stance leg,
or losing their balance.
The step-down test was conducted on a 20-cm step by asking
participants to stand on the step with their affected leg, try to touch
the opposite heel to the floor in front of them, and then return to
their previous stance position. The number of completed repeti-
tions of the task in 30 seconds was recorded. The test was per-
formed 3 times and the mean of the 3 measurements was
considered as the final value for analysis.36 A rest interval of 1-2
min was allowed between trials to prevent fatigue.
To measure PPT, a digital pressure algometerb was used with
perpendicular pressure on the TrP. Each point was evaluated 3
times with a 30-second rest between measurements. The mean
algometer reading from the 3 repetitions was used as the final
value for analysis.
Sample size
To detect a mean between-group difference of 2 points in the
numerical pain rating scale score41 with a standard deviation of
1.7, 90% power, and an alpha level of 0.05, the sample size was
calculated as 15 participants per group. A 30% dropout rate was
assumed, so the final estimated sample size was 20 participants
per group.
Randomization and blinding
Of the 50 volunteers, 40 eligible participants based on the inclu-
sion and exclusion criteria were enrolled by a physical therapist,
and 20 participants were randomly assigned to each group. Group
assignment was conducted with random allocation software (block
sizeZ4, block numberZ10) by a biostatistician, and all alloca-
tions were concealed from both the participants and the
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3
Exclusion Criteria
1. Bilateral anterior knee pain
2. Osteoarthritis
3. Ligament or meniscus injury
4. Patellar instability, plica syndrome, Osgood-Schlatter,
Sinding-Larsen-Johansson syndromes
5. Marked structural deformity and known pathological
condition of back, hip, and ankle
6. Any metabolic or neurologic disease such as diabetes or
radicular pain
7. Contraindication for dry needling, such as cardiovascular
and coagulation disease, anticoagulation therapy,
pregnancy, cancer, fear of needles
8. Physical therapy for knee pain within the previous year
physiotherapist who administered the interventions in presealed
opaque envelopes. The participants and physiotherapist in each
asignaciones
group were blinded to group allocations until the treatments were
started. The assessor remained completely blinded to all group
allocations.
Statistical analysis
Descriptive and statistical analyses were done with SPSS version
16.c The 1-sample Kolmogorov-Smirnov test was used to verify
normal distribution of the data for all variables. To compare
within- and between-group differences, analysis of variance
(2 groups3 times) was used. The time variables were baseline,
week 4 and week 6, and the group variables were ExþDN group
and Ex group. If the grouptime interaction was significant,
repeated measures tests were used in each group to evaluate the
effects of time, and independent t tests were used to identify
significant differences between groups in the score changes
between baseline and week 4, baseline and week 6, and week 4
and week 6. Bonferroni correction was used to adjust for multiple
pairwise comparisons over time to prevent alpha inflation.
Moreover, to compare the differences between groups, the P value
was adjusted as 0.05/3Z0.016. The minimal detectable changes in
pain and Kujala score were considered 2 and 8 points, respec-
tively.41,42 The minimal detectable changes in PPT and mSEBT
were reported, respectively, as 0.45 kg force and 3.5% improve-
ment in previous studies.43,44
Results
Participants
Of the 50 volunteers, 40 met the eligibility criteria and were
included in the study; 20 women were randomly allocated to each
group. None of the participants dropped out of the study, and all
20 women in each group received the allocated intervention. None
of the participants was lost to follow-up, and data for all partici-
pants were included in the analysis (fig 1).
4 H. Zarei et al

Fig 1 Flowchart showing numbers of participants in the eligibility and enrollment, allocation, follow-up, and analysis stages.

Demographic characteristics and variables measured at base- Outcomes

line are shown in table 2. Except for minimal soreness, which
resolved in the following visit, no adverse events were reported in The results showed a significant grouptime interaction for all
either group. variables (fig 2). Comparisons of the baseline versus week 4
measures showed significant improvements in pain, Kujala
score, step-down performance, mSEBT performance (all 3 di-
Table 2 Baseline and demographic characteristics of patients in
rections), and PPT in the QL and GM in both groups (table 3).
the Ex group and ExþDN group
Comparisons between baseline versus week 6 yielded the same
Study Group Control Group findings in both groups (see table 3). Comparisons between week
(nZ20) (nZ20) 4 and week 6 in the Ex group yielded significant changes only
Parameter (Mean  SD) (Mean  SD) for pain and Kujala score (see table 3). In the ExþDN group,
Age (y) 22.253.25 25.658.49 comparisons between week 4 and week 6 detected significant
Height (m) 1.590.05 1.610.07 changes in all outcomes except step-down test performance
Weight (kg) 52.106.95 55.707.73 (see table 3).
NPRS (0-10) 5.900.85 6.000.72 Between-group comparisons of the changes in outcomes from
Kujala score (0-100) 73.956.41 72.806.52 baseline to week 4 showed significantly greater improvements in
Step-down test 13.104.26 10.803.42 the ExþDN group in pain, Kujala score, step-down test, PPT in
PPTQL (kgf) 3.680.78 3.690.72 QL and GM, and mSEBT (all 3 directions) (table 4). Comparisons
PPTGM (kgf) 4.120.82 3.710.49 of the changes from baseline to week 6 also showed significantly
mSEBT (anterior) 0.760.12 0.760.14 greater improvements in the ExþDN group (see table 4). Com-
mSEBT (posterolateral) 0.740.12 0.740.12 parisons of the changes from week 4 to week 6 showed signifi-
mSEBT (posteromedial) 0.670.11 0.660.10 cantly greater improvements in Kujala score, GM PPT, and
mSEBT (anterior and posterolateral directions) in the ExþDN
Abbreviations: mSEBT, modified star excursion balance test; NPRS,
numerical pain rating score; PPTGM, pressure pain threshold gluteus
group. For mSEBT performance, the improvement in the poster-
medius; PPTQL, pressure pain threshold quadratus lumborum. omedial direction was greater in ExþDN group than the Ex group,
but the difference was not significant (PZ.05) (see table 4).

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Gluteus medius and quadratus lumborum dry needling and PFPS 5

Kujala score Step-down test

100 25

Mean score (0-100)

80 20

Mean score
60 15

40 P value <0.001* 10 P value <0.001*

20 Intervention 5 Intervention
Control Control
0 0
1 2 3 1 2 3
Time Time

Quadratus lumborum pain pressure threshold Gluteus medius pain pressure threshold

8 8

7 7

Mean score (kgf)

6
Mean score (kgf)

6
5 5
4 4
3 P value <0.001* 3 P value <0.001*
2 2 Intervention
Intervention 1
1 Control
Control
0 0
1 2 3 1 2 3
Time Time

Modified star excursion balance test (anterior) Modified star excursion balance test (postrolat)
0.95 0.9
0.9
0.85
Mean score
Mean score

0.85
0.8
0.8
P value <0.001* 0.75 P value <0.001*
0.75
Intervention 0.7 Intervention
0.7
Control Control
0.65 0.65
1 2 3 1 2 3
Time Time

Modified star excursion balance test (postromed) Numerical pain rating score
0.8 8
Mean score (0-10)

0.75 6
Mean score

0.7 4
P value <0.001* P value <0.001*

0.65 Intervention 2 Intervention

Control Control
0.6 0
1 2 3 1 2 3
Time Time

Fig 2 Effects of grouptime course interactions according to analysis of variance. )Significant grouptime course interaction.

Discussion the 2 groups showed that combined exercise therapy and DN had
significant added beneficial effects in all outcomes.
This study aimed to compare the effects of a combination of ex- In line with previous studies, our results support the beneficial
ercise therapy and DN for the QL and GM muscles versus exercise effects of exercise therapy on pain and function.45-49 Both groups
therapy alone in female athletes with PFP. The results demon- in the present study benefited from exercise therapy. Quadriceps,
strated that both treatment protocols led to statistically significant hip abductor, and external rotator strengthening exercises may
improvements in pain, function (Kujala score, step-down test, optimize pelvic and femur motion and knee alignment, thus ulti-
mSEBT), and PPT after treatment and at 6 weeks of follow-up. mately decreasing patellofemoral joint stress.50-53 Lower extrem-
Based on the minimal detectable changes in pain (2 points), ity kinetics and kinematic improvements after exercise therapy
Kujala score (8 points), PPT (0.45 kg force), and mSEBT (3.5% may enhance tissue healing and subsequently help reduce pain.54
improvement),41-44 the present results in the ExþDN group were The results of pain reduction and biomechanical optimization
clinically relevant for all outcomes. However, in the Ex group only might lead to functional improvements, as seen in the present
the improvements in pain, Kujala score, and mSEBT performance findings. One cause of increased mSEBT scores may be related to
(all 3 directions) were clinically significant. Comparisons between

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6 H. Zarei et al

Table 3 Time course effects in the Ex and ExþDN group according to repeated measures test and Bonferroni correction
Group Variable Changes Baseline (Mean  SD) Fourth Week (Mean  SD) Sixth Week (Mean  SD) P Value
Control NPRS (0-10) 6.000.72 4.100.91 3.501.05 <.001*,y,z
Kujala score (0-100) 72.806.52 78.205.94 80.756.06 <.001*,y,z
Step-down test 10.803.42 13.853.46 14.152.92 <.001*,y
PPTQL (kgf) 3.690.72 3.910.70 4.150.37 <.001*,y
PPTGM (kgf) 3.710.49 3.970.36 3.970.40 <.001*,y
mSEBT
Anterior 0.760.14 0.810.14 0.810.13 <.001*,y
Posterolateral 0.740.12 0.780.12 0.770.11 <.001*,y
Posteromedial 0.660.10 0.690.10 0.700.10 <.001*,y
Study NPRS (0-10) 5.900.85 2.10 1.11 1.40 0.82 <.001*,y,z
Kujala score (0-100) 73.956.41 86.005.31 92.104.41 <.001*,y,z
Step-down test 13.104.26 20.304.31 21.303.42 <.001*,y
PPTQL (kgf) 3.860.78 6.660.78 7.030.72 <.001*,y,z
PPTGM (kgf) 4.100.82 6.940.94 7.420.74 .001*,y,z
mSEBT
Anterior 0.760.12 0.890.11 0.900.11 <.001*,y,z
Posterolateral 0.740.12 0.830.11 0.850.11 <.001*,y,z
Posteromedial 0.670.11 0.770.10 0.780.10 <.001*,y,z
Abbreviations: mSEBT, modified star excursion balance test; NPRS, numerical pain rating score; PPTGM, pressure pain threshold gluteus medius; PPTQL,
pressure pain threshold quadratus lumborum.
* Comparison of baseline versus fourth week P<.05.
y
Comparison of baseline versus sixth week P<.05.
z
Comparison of fourth versus sixth week P<.05.

Table 4 Differences between the ExþDN and Ex groups in changes from baseline to week 4, baseline to week 6, and week 4 to week 6
according to independent t test
95% CI of Mean
Study Group Control Group Mean Difference Difference
Variable Time (Mean  SD) (Mean  SD) (Mean  SD) P Value (Upper/Lower)
NPRS Fourth week-baseline e3.800.61 e0.781.90 e0.221.90 <.001 e1.44 e2.35
Sixth week-baseline e4.500.76 e1.002.50 e0.282.00 <.001 e1.43 e2.56
Sixth-fourth week e0.700.86 e0.990.60 e0.291.00 .74 0.49 e0.69
Kujala score Fourth week-baseline 12.053.45 2.375.40 0.936.65 <.001 8.54 4.75
Sixth week- baseline 18.153.91 3.017.95 1.1010.20 <.001 12.43 7.96
Sixth-Fourth week 6.103.37 1.932.55 0.863.55 <.001 5.30 1.79
Step-down test Fourth week-baseline 7.201.36 1.053.05 4.150.38 <.001 4.92 3.37
Sixth week-baseline 8.201.93 1.493.35 4.850.54 <.001 5.95 3.74
Sixth-fourth week 1.001.74 1.170.30 0.470.70 .14 1.65 e0.25
PPTQL Fourth week-baseline 0.802.98 0.200.21 0.182.77 <.001 3.14 2.39
Sixth week-baseline 0.823.35 0.740.45 0.242.90 <.001 3.40 2.39
Sixth-fourth week 0.320.37 0.720.24 0.170.12 0.47 0.48 e0.23
PPTGM Fourth week-baseline 1.042.81 0.430.25 0.252.55 <.001 3.07 2.40
Sixth week-baseline 0.993.30 0.530.26 0.253.03 <.001 3.54 2.52
Sixth-fourth week 0.560.48 0.280.00 0.170.47 <.001 0.76 0.19
mSEBT anterior Fourth week-baseline 0.030.09 0.010.03 0.000.05 <.001 0.07 0.03
Sixth week-baseline 0.030.14 0.010.04 0.090.02 <.001 0.1 0.07
Sixth-fourth week 0.010.01 e0.010.00 0.000.01 <.001 0.02 0.00
mSEBT posterolateral Fourth week-baseline 0.030.09 0.010.03 0.000.05 <.001 0.07 0.03
Sixth week-baseline 0.030.10 0.020.03 0.000.07 <.001 0.09 0.05
Sixth-fourth week 0.010.01 e0.010.00 0.000.01 <.001 0.02 0.00
mSEBT posteromedial Fourth week-baseline 0.050.09 0.010.03 0.010.05 <.001 0.08 0.03
Sixth week-baseline 0.050.10 0.010.03 0.010.06 <.001 0.09 0.04
Sixth-fourth week 0.010.01 0.010.00 0.000.00 .05 0.01 e0.00
Abbreviations: mSEBT, modified star excursion balance test; NPRS, numerical pain rating score; PPTGM, pressure pain threshold gluteus medius; PPTQL,
pressure pain threshold quadratus lumborum.

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Gluteus medius and quadratus lumborum dry needling and PFPS
improved knee proprioception and neuromuscular control,50,55 and
consequently balance progression56 after closed-chain hip and
quadriceps exercises. Improved neuromuscular control and kine-
matics in the hips and knees, as reported after strengthening ex-
ercises,52,57,58 may be another reason for the better step-down test
scores in the present study. One of our findings was the increased
PPT after exercise therapy. This finding was in line with evidence
indicating that exercise therapy might lead to increased remote
TrPs PPT due to decreased nervous system sensitization.59
The results of our study support the hypothesis that combining
DN for the GM and QL muscles with exercises may have superior
beneficial effects over exercise alone on pain, function, and PPT in
female athletes with PFP. Although QL and GM PPT showed
statistically significant increases in both groups, the changes were
clinically relevant only in the ExþDN group. The greater in-
creases in PPT in our ExþDN group may thus be due to the
addition of DN for the QL and GM muscles. Dry needling can
efficiently treat TrPs by affecting gate control, increasing local
blood flow, oxygen supply, and endogenous opioid release. This
may provide an optimized environment for tissue healing.20
In line with our results, previous studies showed that adding
quadriceps DN in patients with PFP led to earlier or greater im-
provements in pain and function.32,34,60 Although earlier research
used DN for the quadriceps muscles, the improvements in QL and
GM function in the present study may be due to a similar
mechanism. Because of the important roles of GM and QL in
frontal plane hip and trunk stability, these muscles may contribute
to optimal kinetics and kinematic control of the knee joint.15,26 In
addition, optimizing mediolateral control of the lumbo-pelvic-hip
complex has been shown to contribute to biomechanical im-
provements in patients with PFP.9,15,26,29 TrPs in muscles may
alter muscle activation patterns and potentially lead to pathol-
ogy.25 The higher prevalence of TrPs in the GM and QL in people
with PFP compared to asymptomatic people21,22 suggests that the
normal functioning of knee mechanics may be affected. Therefore,
effective treatment with DN for GM and QL TrPs may have helped
to optimize overall knee mechanics. Consequently, this might
have contributed to the added beneficial effects on pain and
functional measures such as Kujala score, mSEBT, and the step-
down test compared to our control group.
In addition to the possible biomechanical effects of treating
TrPs in the QL and GM, central neurophysiological mechanisms
involved in DN may also have contributed to our results. Dry
needling can release analgesic substances in the bloodstream and
cerebrospinal fluid by stimulating A-delta fibers. This in turn may
cause pain relief in remote areas other than the site of treatment.61
This mechanism is thus another potential explanation for the
greater reductions in knee pain in our ExþDN group. Recent
evidence showed local and remote pain sensitization in females
with PFP due to the increased excitability of nociceptive neu-
rons.59 Any approach (including DN) that modulates nervous
system sensitization might thus improve PPT in females with
PFP.62 Moreover, there is evidence that pain catastrophism and
kinesiophobia are increased in patients with PFP, and that changes
in these factors are predictive of improved function and better
outcomes of pain treatments.63-65 Therefore, DN might lead to less
pain and improved function via this mechanism. However, in this
study we did not evaluate these 2 psychological factors. A final
factor is the possible placebo effect of DN, which may also have
contributed in the improvements in our study. Further research is
needed to better understand the mechanisms that account for the
improvements in patients with PFP after GM and QL DN.
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7
The results of this study are in line with the recent consensus
statement on PFP management, which recommends combined
knee and proximal-focused exercise therapy.16,18 In addition, our
main finding suggests that targeting TrPs in proximal muscles
(ipsilateral GM and contralateral QL) relative to the affected knee
is a potentially effective adjunct treatment for unilateral PFP.
However, further studies are needed.
Study limitations
This study had some limitations. First, we did not include men or
persons with unilateral PFP, and this may have limited the general-
izability of the results. Second, we had no Exþplacebo group, so the
patients were not blind to the use of DN. Third, the home exercise
program was unsupervised, so we were not able to verify adherence to
the home exercise protocol. Fourth, the exercise therapy protocol was
limited to 4 weeks and so was not aligned with current best practice
recommendation for PFP management. Finally, our follow-up was
limited to 6 weeks after the start of treatment; studies with longer
follow-up periods are therefore advisable.
Conclusions
Dry needling of TrPs in the ipsilateral GM and contralateral QL
combined with exercise therapy can improve pain, function, and
dynamic balance more than exercise therapy alone. Therefore, adding
GM and QL muscle dry needling to exercise therapy may be advisable
to enhance the effects of unilateral PFP rehabilitation.
Suppliers
a. Needle; Wujiang City Shenlong Medical Health Product Co,
Ltd.
b. Digital pressure algometer; Wagner Instruments.
c. SPSS version 16; SPSS Inc.
Keywords
Exercise therapy; Patellofemoral pain syndrome; Postural balance;
Rehabilitation; Trigger points
Corresponding author
Alireza Motealleh, PhD, PT, Physical Therapy Department,
School of Rehabilitation Sciences, Shiraz University of Medical
Sciences, Chamran Boulevard, Abiverdi Street, Shiraz, Iran, PO
Box 7194633669. E-mail address: motealleh@sums.ac.ir.
Acknowledgments
We thank the Research Consultation Center at Shiraz University
of Medical Sciences for statistical advice. We also thank K.
Shashok (AuthorAID in the Eastern Mediterranean-translator and
editorial consultant) for improving the use of English in
the article.
8 H. Zarei et al

Appendix 1 Exercise therapy protocol

Week Exercises
1 Hamstring stretch
Quadriceps stretch
Quadriceps exercisey
2 Quadriceps exercise
Side-lying straight-leg raises
Side-lying clamshells
3 Quadriceps exercise
Side-lying straight-leg raises
Side-lying clamshells
Plank exercise
Side plank exercise
4 Quadriceps exercise
Side-lying straight-leg raises
Side-lying clamshells
Plank exercise
Side plank exercise
Mini-squats
Mini-lunge
Step-down
* The number of repetitions in each set of exercises increased each week. Also, new exercises were added each week to the previous week’s program.
y
Isometric quadriceps exercise progressed by adding weights (about 1-2.5 kilogram) in each week.
Description*
Supine straight-leg raising (hip flex with knee ext), cyclic stretch, 2 sets15
repetitions10 seconds hold (for all sessions)
Thomas test position (hip ext with knee flex close to the edge of the table), cyclic stretch,
2 sets15 repetitions10 seconds hold (for all sessions)
Supine, isometric terminal knee ext, 3 sets10 repetitions, 5 seconds hold
Supine, isometric terminal knee ext, 3 sets, 15 repetitions in each set, 5 seconds hold
3 sets, 15 repetitions in each set
3 sets, 15 repetitions in each set
Supine, isometric terminal knee ext, 3 sets, 20 repetitions in each set, 5 seconds hold
3 sets, 20 repetitions in each set
3 sets, 20 repetitions in each set
3 sets, 20 repetitions in each set, 5 seconds hold
3 sets, 20 repetitions in each set, 5 seconds hold
Supine, isometric terminal knee ext, 3 sets, 25 repetitions in each set, 5 seconds hold
3 sets, 25 repetitions in each set
3 sets, 25 repetitions in each set
3 sets, 25 repetitions in each set, 5 seconds hold
3 sets, 25 repetitions in each set, 5 seconds hold
3 sets, 25 repetitions in each set
3 sets, 25 repetitions in each set
Exercise on a step with 18-cm height, 3 sets, 25 repetitions in each set

Appendix 2 The procedure of DN techniques

Muscle Locating the TrPs DN Technique
Quadratus lumbarum lateral third of the lumbar transverse processes in For all TrPs, the skin at the site of TrP was cleaned by
side lying position* alcohol.
Gluteus medius TrP1 upper lateral quadrant of the buttock between the A fast-in and fast-out technique was applied while
region proximal to the greater trochanter and the patient was in the side lying position, 3 times
inferior to the iliac crest in side lying position* for each TrP.
TrP2 The region immediately anterior to TrP1 in side lying When the investigator felt the first local twitch
position* response, the needle was moved up/down with no
TrP3 Anterior to the tensor fascia latae muscle by rolling rotation.
the thumb perpendicular to the muscle fibers in For safety considerations DN for QL was performed
side lying position* below the level of the L2 vertebra.
Abbreviation: TrP, trigger point.
* The criteria for TrP identification were taut band, jump sign, and tenderness.

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