Document Type : Original Articles


Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.


Background: Tennis elbow syndrome (TES) is mainly known by having pain in the external side of the elbow. Physiotherapy plays an effective role in the treatment of this syndrome. Dry needling is a less invasive, novel, and inexpensive method that shows its therapeutic effects in a shorter time in comparison with the other physiotherapy methods. Effect on tough bands, circulation, and environmental and central neurophysiological effects are some mechanisms by which dry needling poses its effects. The aim of this study was to study the effect of adding dry needling to routine physiotherapy methods in order to improve grip strength and function and reduce pain, as well as to decrease costs and treatment duration for treating tennis elbow syndrome.
Methods: Forty four athletes aged 18 to 40 years old who had exercise or match for at least 3 sessions per week (for a sum of 6 hours per week), and were detected to have tennis elbow syndrome lasting more than 3 months were recognized and classified into two groups. The first group received physiotherapy including ultrasound, deep friction massage, and muscle stretching and strengthening exercises. The second group received dry needling in addition to physiotherapy treatment. Therapeutic duration was 3 weeks in each group and 3 sessions in each week. The patient rate elbow evaluation questionnaire (PREE) was completed at the beginning of treatment and the beginning of the second and third weeks, as well as at the end of the third week; grip strength was measured at the mentioned times as well. One week after the end of the therapeutic period, patients were re-evaluated for the reliability rate of the treatment outcomes. For analysis of data obtained for the study, repeated measure test, Mixed ANOVA, and Paired T-test statistical tests were used.
Results: Results showed that all evaluated variables (including pain, function, and grip strength) were improved in the patients of both groups after completion of the therapeutic period (P<0.0001). Comparison of the two groups showed a significant difference in the pain variable at the seventh session with P<0.0001, the ninth session with P=0.006, and one week after the end of treatment with P<0.001, and the performance variable at seventh sessions with P<0.0001, ninth sessions with P=0.006, and one week after the end of treatment with P<0.0001, respectively. The pain reduction and function increase rates were higher in the group that received dry needling in addition to physiotherapy in comparison with the group that received physiotherapy after the seventh session. Regarding grip strength variable, the mean of groups was different, though the effect of these two methods in the enhancement of grip strength was not statistically significant (P=0.09). Moreover, regarding the results obtained for the group that received physiotherapy in addition to dry needling, the pain variable reduced in a shorter time in comparison with the other group.
Conclusion: With regard to the results mentioned above, both therapeutic methods resulted in an improvement in the studied variables in a comparison that was performed before and after treatment. Moreover, in comparison with the single physiotherapy, using dry needling in addition to physiotherapy had a more powerful effect in improving the studied variables. Therefore, it could be said that using dry needling in addition to other therapeutic methods results in the facilitation of treatment process in the patients, and can reduce their therapeutic costs.


  1. Childress MA, Beutler A . Management of chronic tendon injuries. American family phisicion.2013; 87 (7): 486-90.
  2. 2.Chesterton LS, Mallen CD, Hay EM. Management of tennis elbow. Open access journal of sports medicine. 2011;2:53.
  3. De Smedt T, de Jong A, Van Leemput W, Lieven D, Van Glabbeek F. Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment. British journal of sports medicine. 2007;41(11):816-9.
  4. De Smedt T, de Jong A, Van Leemput W, Lieven D, Van Glabbeek F. Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment. British journal of sports medicine. 2007;41(11):816-9.
  5. Finestone HM, Rabinovitch DL. Tennis elbow no more. Canadian Family Physician. 2008;54(8):1115.
  6. . Chourasia AO, Buhr KA, Rabago DP, Kijowski R, Lee KS, Ryan MP, et al. Relationships between biomechanics, tendon pathology, and function in individuals with lateral epicondylosis 2013;43(6):368-78.


  1. Naseri, N. (2003). Physiotherapy in orthopedic disorders (assessment, diagnosis, treatment). tehran, sobhe saadat.2016; 350-364.
  2. Dhakal S, Acharya T, Gautam S, Upadhyay N, Dhakal S. Diagnosis and management pattern of lateral epicondylitis in a tertiary care center. Journal of Nepal Medical Association. 2016;53(200):231-4.
  3. Wingfield C. Integration of physiotherapy and acupuncture in the management of lateral epicondylitis. AACP acupuncture. 2014;71-72.
  4. Chou L-W, Kao M-J, Lin J-G. Probable mechanisms of needling therapies for myofascial pain control. Evidence-Based Complementary and Alternative Medicine. 2012;2012:705327.
  5. Dines JS, Bedi A, Williams PN, Dodson CC, Ellenbecker TS, Altchek DW, et al. Tennis injuries: epidemiology, pathophysiology, and treatment. Journal of the American Academy of Orthopaedic Surgeons. 2015;23(3):181-9.
  6. Manias P, Stasinopoulos D. A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy. British journal of sports medicine .2006; 40 (1):81-85.
  7. Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDermid JC. Rehabilitation for patients with lateral epicondylitis: a systematic review* 1. Journal of Hand Therapy. 2004;17(2):243-66.
  8. Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. British journal of sports medicine. 2005;39(7):411-422.
  9. Cagnie B, Dewitte V, Barbe T, Timmermans F, Delrue N, Meeus M. Physiologic effects of dry needling. Current pain and headache reports. 2013;17(8):1-8.
  10. Sukumar S, Lawrence Mathias, Srivastav LMS. Effects of static dry needle insertion and trigger point deactivation combined with eccentric exercises in women with unilateral tennis elbow, a single blinded RCT, global journal of multidisciplinary studies2014;4(1), 411-422.
  11. Uygur E, AKTAŞ B, ÖZKUT A, Erinc S, YILMAZOGLU EG. Dry needling in lateral epicondylitis: a prospective controlled study. International orthopaedics. 2017;41(11):2321-5.
  12. Stenhouse G, Sookur P, Watson M. Do blood growth factors offer additional benefit in refractory lateral epicondylitis? A prospective, randomized pilot trial of dry needling as a stand-alone procedure versus dry needling and autologous conditioned plasma. Skeletal radiology. 2013;42(11):1515-20.
  13. Dones VC, Grimmer K, Thoirs K, Suarez CG, Luker J. The diagnostic validity of musculoskeletal ultrasound in lateral epicondylalgia: a systematic review. BMC medical imaging. 2014;14(1):10.
  14. Mansouri A, Vosoghi O. Evalutaion of validity and reliability of the Persian version of patient rate elbow evaluation questionnaire (PREE), [dissertation]. Shiraz: university of rehabilitation siences; 2014.
  15. Gündüz R, Malas FÜ, Borman P, Kocaoğlu S, Özçakar L. Physical therapy, corticosteroid injection, and extracorporeal shock wave treatment in lateral epicondylitis. Clinical rheumatology. 2012;31(5):807-812.
  16. Struijs P, Kerkhoffs G, Assendelft W, van Dijk CN. Conservative treatment of lateral epicondylitis brace versus physical therapy or a combination of both—A randomized clinical trial. The american journal of sports medicine. 2004;32(2):462-469.
  17. Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S, Vermillion DA, et al. Efficacy of Platelet-Rich Plasma for Chronic Tennis Elbow A Double-Blind, Prospective, Multicenter, Randomized Controlled Trial of 230 Patients. The American journal of sports medicine. 2013؛42 (2):463-471.
  18. Marcolino AM, Neves LMS, Oliveira BG, Alexandre AA, Corsatto G, Barbosa RI, et al. Multimodal approach to rehabilitation of the patients with lateral epicondylosis: a case series. SpringerPlus. 2016;5(1):1718.
  19. Hassan SM, Hafez AR, Seif HE, Kachanathu SJ. The Effect of Deep Friction Massage versus Stretching of Wrist Extensor Muscles in the Treatment of Patients with Tennis Elbow. Open Journal of Therapy and Rehabilitation. 2016;4(01):48.
  20. González-Iglesias J, Cleland JA, del Rosario Gutierrez-Vega M, Fernández-de-las-Peñas C. Multimodal management of lateral epicondylalgia in rock climbers: a prospective case series. Journal of manipulative and physiological therapeutics. 2011;34(9):635-42.
  21. Shellock FG, Prentice WE. Warming-up and stretching for improved physical performance and prevention of sports-related injuries. Sports medicine (Auckland, NZ). 1995;2(4):267.
  22. Sukumar S, Mathias L, Rai S. Early Effects of Dry Needling and Low Level Laser Therapy in Chronic Tennis Elbow-An Experimental Study. International Journal of Health Sciences and Research (IJHSR). 2015;5(1):187-96.
  23. Shanmugam S, Shetty K, Mathias L, Santhumayor R. Dry needling on tendons and myofascial trigger points in post-traumatic stiffness of elbow: a case report. International Journal of Research in Medical. 2015;3(6):1529-1532
  24. Mcdevitt A, Krause L, Leibold M, Borg M, Mintken P. A novel treatment of dry needling and eccentric exercise for patients with chronic bicipital tendinopathy: A case series. Manual Therapy. 2016;25:e61.
  25. Wymore M, Blackington D. Dry Needling: A Case Study in Treating Tennis Elbow. Journal of Hand Therapy. 2018;31(1):153.
  26. Kalichman L, Vulfsons S. Dry needling in the management of musculoskeletal pain. The Journal of the American Board of Family Medicine. 2010;23(5):640-6.
  27. Cagnie B, Dewitte V, Barbe T, Timmermans F, Delrue N, Meeus M. Physiologic effects of dry needling. Current pain and headache reports. 2013;17(8):1-8.
  28. . Kibler W, Chandler T. Musculoskeletal adaptations and injuries associated with intense participation in youth sports. The Effect of Intense Training on Prepubescent Athletes Rosemont, AAOS. 1993:203.
  29. Dommerholt J, Mayoral del Moral O, Gröbli C. Trigger point dry needling. Journal of Manual & Manipulative Therapy. 2006;14(4):70-87.