Dry Needling is a specialized service offered by Sapphire Physical Therapy. I am often asked how dry needling works and how it differs from acupuncture treatment. Due to the success I have personally had with both patients and in treating my own running-related overuse issues, I will explain what dry needling is and how it complements our fundamental physical therapy treatment methods. ~John Fiore, Sapphire PTimage


Dry needling is an effective soft tissue and musculoskeletal treatment technique to reduce pain associated with running-related injuries. Dry needling has been offered by Sapphire Physical Therapy for nearly three years. Licensed physical therapists with additional, specialized dry needling training are now incorporating dry needling into physical therapy treatment plans with impressive results. All dry needling treatment approaches and methods, however, are not alike. Understanding the science behind dry needling and an extensive knowledge of human neuromuscular anatomy is vital to successful dry needling treatment. Dry needling utilizes acupuncture needles as treatment tools, but should not be equated with acupuncture. Acupuncture has been practiced for thousands of years and is a systemic (whole body) treatment approach. Acupuncture is based on the Yellow Emperor’s Canon of Internal Medicine which was written between 206 BC and 220 AD. The Canon integrated various channel theories into one system based upon the limited neuroanatomical knowledge of the time.i Yun-tao Ma, PhD (who trained me in 2013-2014 and who founded the American Dry Needling Institute) has bridged the gap between ancient Chinese acupuncture philosophies and the neuroanatomical knowledge of western medicine to create the integrative dry needling treatment approach. Based on the cellular biology of tissue healing and its relationship with the peripheral and central nervous systems of the body, Dr. Ma has facilitated safe, effective dry needling techniques to reduce pain and stimulate tissue healing in the physical therapy outpatient setting. I was fortunate to receive my dry needling training from Dr. Ma and I now utilize integrative dry needling in my physical therapy practice. If you have struggled with a persistent running injury, suffer from acute or chronic musculoskeletal pain, experience frequent headaches, back or neck pain and are otherwise in good health, dry needling is an effective, virtually pain-free treatment used in conjunction with physical therapy therapeutic exercise and manual therapy techniques.


Various theories have existed for thousands of years for the presence of tender points or trigger points in predictable locations throughout the body. Treating such tender points (acupressure points) released tension and eased pain. What ancient practitioners did not realize, however, is the fact that pressure through a sensitive acupressure point stimulates a sensory nerve ending. The sensitized sensory nerve relays a message to the spinal cord where the central nervous system transmits the information to the brain. Sensory input is processed in the brain and a range of neurobiological events are set into action depending on how the stimulus is perceived. Dry needling, therefore, activates the body’s natural healing potential by specifically targeting and balancing the sympathetic and parasympathetic nervous systems to facilitate healing on a cellular level (at the site of the needle insertion or the injured body area). Dry needling also stimulates parts of the brain (via the hypothalamus) which activate the principle survival mechanisms (the nervous, endocrine, immune, and cardiovascular systems) and normalize the physiological activities of the whole body.ii iii


Dry needling treatment utilizing the Integrated Neuromuscular Acupoint System is painless approximately 80% of the time. While some practitioners “manipulate” the needle upon insertion, pain-free insertion of the needle alone initiates the self-healing process without the unnecessary pain to the patient which occurs during needle manipulation. Integrative dry needling results in complete resolution of symptoms in 28% of cases, resolution of symptoms for six-months or more in 64% of cases, and marginal results in just 8% of cases.iv Dry needling treatment begins with a Quantitative Evaluation to determine the distribution of acupoint sensitivity in two key body areas (lateral forearm H1point & lateral lower leg H4 point). The distribution of sensitive acupoints effectively predicts the number of recommended treatments. Running injuries (acute and chronic in nature), musculoskeletal pain, tendonitis, tendinosis, joint pain, back and neck pain, muscular guarding, delayed onset muscle soreness, cumulative stress (overuse injuries) injuries, and joint stiffness all respond remarkably well to dry needling treatment. Dry needling indirectly improves the effectiveness of running-specific weight bearing strengthening exercise and manual therapy techniques by reducing chronic compensatory movement patterns resulting from stiffness, tightness, and pain.


Following a comprehensive medical history screen and physical therapy objective evaluation (functional testing, range of motion testing, strength testing, video running gait analysis), dry needling may be determined to be an effective component of your treatment. In addition to treating restricted, painful, or injured areas, a sequential series of key body locations (homeostatic points) may be included in the dry needling treatment. Treating of the body’s 24 homeostatic points restores homeostasis in the body and boosts our healing capacity.v When homeostasis declines, homeostatic acupoints are gradually transformed from a latent phase (non-sensitive) to passive or active phase (sensitive with or without palpation). The positive systemic response to dry needling the 24 homeostatic points makes it possible not only to treat the localized injury, but also to prevent running injuries by boosting the healing and recovery response of the body. Treatment frequency varies based upon the degree of restriction or injury and overall health (self-healing potential determinant). Dry needling may be incorporated into your physical therapy exercise and manual therapy treatment to bring about more timely results and functional improvement in running performance. Call or email John Fiore at Sapphire Physical Therapy to learn more about dry needling. Feel free to call and schedule an appointment to see how dry needling can be an effective, efficient addition to your running injury prevention and treatment plan.
John Fiore, PT
Sapphire Physical Therapy

i Ma YT: Biomedical acupuncture for pain management: an integrative approach. Philadelphia, PA. Elsevier Churchill Livingstone. 2005. ii Tracey KJ: The inflammatory reflex, Nature 420:853-859, 2002. iii Wang H, it al: Nicotine acetylcholine receptor alpha7 sub-unit is an essential regulator of inflammation, Nature 420:384-388, 2003. iv Ma YT: Biomedical acupuncture for pain management: an Integrative approach. Philadelphia, PA. Elsevier Churchill Livingstone. 2005. v Dung HC: Anatomical acupuncture, San Antonio, TX, 1997, Antarctic Press.

A September 9, 2015 article in the New York Times brought to the forefront the work of Paul DeVita, a professor of kinesiology at East Carolina University in Greenville, N.C., and president of the American Society of Biomechanics. Dr. DeVita’s research compared the lower leg and ankle function of young runners in contrast to runners over forty years of age. His initial research in 2000 looked at gait changes with age at walking speeds, whereas his 2015 research data was gathered at running speeds. While the results are alarming, incorporating the study finding into your training program will greatly reduce running-related overuse injuries.

The over 40-49 age group has seen a huge increase in numbers in the past decade. As a runner who was once a member of the 40-49 age group, I have experience the changes in running performance associated with age. DeVita’s research confirmed a 20% reduction in running speed per decade beyond forty. Both running stride length and lower leg muscle function decline in a linear manner with age. Calf (gastroc-soleus muscle) and ankle dorsiflexion (tibialis anterior muscle) functional strength both decline with age. A reduction in lower leg muscle strength and function shifts the burden of self-propulsion to our hips and glutes which are already physically challenged by prolonged sitting and tight hip flexor muscles.

Lower leg, foot, and Achilles tendon injuries become increasingly common in runners over forty. Gradual degradation of muscle and tendon tissue integrity and nerve innervation sets the stage for an increase in running-related overuse injuries. On a positive note, the information provided by Dr. DeVita’s research will serve to guide strength and conditioning programs for runners interested in injury prevention and running performance. Stretching the calf and lower leg muscles, Active Release techniques, dynamic warm-up, and rolling are great ways to improve lower leg muscle tissue mobility. Lower leg, ankle, and foot strengthening exercises should be a part of every runner’s training program, not just those in the fourth decade of life and beyond. Strengthening exercises should include single leg heel raises, heel drops, resisted ankle inversion/eversion/dorsiflexion, and intrinsic foot strengthening exercises. Of course, the gluteal musculature and core are not to be forgotten as older runners rely on these inherently weak muscle groups in the absence of full lower leg and ankle strength.

If you have been battling a lower leg, ankle, foot, or Achilles injury, email me your questions to determine how you can not only return to pain-free running, but also prevent future injury recurrence. Strength and muscle/tendon tissue mobility are the keys to running faster beyond your forties!

John Fiore, PT

Sapphire Physical Therapy


Reynolds G, Why Runners Get Slower with Age. New York Times. 2015, Sept 9.
DeVita P, Hortobagyi T. Age Causes a Redistribution of Joint Torques and Power During Gait. J Appl Physiol (1985), 2000, May; 88 (5):1804-11.
DeVita P, Fellin RE, Seay JF, Ip E, Stavro N, Messier SP. The Relationship Between Age and Running Biomechanics. Med Sci Sports Exerc. 2015, Aug 7.

September marks the beginning of the fall running season. Smoke-filled skies will soon give way to clear, frost-covered mornings. While fall offers some of Missoula’s best running conditions, nine months of running miles often results in fall aches and pains. Lower extremity running injuries impact 19% to 79% of runners. Factors which lead to an increased incidence of running injury include a significant increase in running distance, terrain, or pace, a change in overall body composition or strength, and a lack of adequate recovery or rest following a workout or race.

When running-related pain develops, it is important to determine whether the pain symptom is the result of an underlying weakness and/or a mechanical problem located elsewhere in the body. The running body in motion is subjected to multidirectional forces. Our body’s ability to dissipate excess force, minimize impact force, and transfer these multidirectional forces into forward running progress determines our running efficiency. Evaluating a runner’s efficiency through video evaluation is an excellent way to determine potential injury-causing compensations to improve running efficiency.

Sapphire Physical Therapy offers video running evaluation which allows runners to watch themselves run in slow motion. A physical therapist will point out any running gait deviations and explain how such deviations may lead to or be the underlying cause of running-related pain. An August, 2015 study in the Orthopedic Journal of Physical Therapy reviewed 974 studies to determine whether or not visual feedback (in the form of video analysis, visual feedback) and verbal feedback are effective in improving running mechanics. The study confirmed that both visual feedback and verbal cues are effective in modifying running mechanics. The key to an effective and useful running video analysis lies in the ability of the physical therapist to detect running gait deviations and translate those into simple cues to be used while running. Running injury treatment and prevention simply makes more sense when pain, weakness, and running video compensation can be related to one another.

Below are several examples of simple verbal cues which may be utilized based on possible running gait compensations based on a video running evaluation. Contact John with any questions or comments and learn more about our comprehensive running and physical therapy services at www.sapphirept.com.

* Shorten your stride length

* Increase your running cadence

* Land with your foot beneath you

* Allow your hip to extend using your gluts

* Incorporate your big toe while pushing off

* Relax your upper body and breathe

John Fiore, PT
Sapphire Physical Therapy

Agresta C, Brown A. Gait Retraining for Injured and Healthy Runners Using Augmented Feedback: A Systematic Literature Review. J Orthop Sports Phys Ther 2015;45(8):576-585. doi:10.2519/jospt.2015.0503

Knee pain is a common running injury. A rapid increased in mileage, hill training, weakness in the quadriceps, hip, glut, foot, and ankle musculature are contributing factors to knee pain. Lack of stabilization at the hip or lower leg places increased stress on the knee joint. The vastus medialis oblique (VMO) is a key stabilizing muscle during weight bearing knee flexion and extension and warrants further discussion.

What is the VMO?

The vastus medialis oblique (VMO) is one of four quadriceps muscles which extend the knee joint and stabilize the knee in weight bearing. The knee is a modified hinge joint which means it is more complicated than a door hinge. Subtle but important accessory motion occurs with movement in many extremity joints. Accessory rotation in the knee (the femur rotates slightly medially relative to a stationary tibia) occurs during weight bearing, and decreases joint wear and improves patella-femoral joint function. The VMO is the quadriceps muscle responsible for accessory joint motion during the final few degrees of knee joint extension. Building and maintaining strength in the VMO, therefore, is an important component of running without knee pain.

The VMO originates on the intertrochanteric line of the femur and adductor muscle aponeurosis and inserts on the quadriceps tendon and tibial tuberosity via the patellar tendon. The VMO is a difficult muscle to isolate during strengthening exercises due to its diminutive size andspecificity. Without adequate VMO strength, however, patella-femoral (knee cap) tracking shifts in a lateral direction during flexion and extension associated with running. Prolonged lateral knee patella tracking leads to irritation of the patella surface and inflammation of the surrounding tissue (patellar tendon, cartilage). While prior joint trauma, osteoarthritis, meniscus injury, and overtraining can also lead to knee pain in runners, the VMO must be addressed during conservative treatment and injury prevention. Additional treatments such as patella-femoral taping and video running analysis may reveal underlying asymmetries which contribute to knee pain.

VMO-Specific Strengthening

1. Terminal Knee Extension:
Weight bearing terminal knee extension (TKE) isolates the stabilizing VMO and (if done correctly) facilitates the necessary accessory motion of the knee joint. Emphasis should be on straightening the knee using the quadriceps muscles rather than attempting to “lock” the knee.

2. Eccentric Quadriceps Strengthening:
Strengthening the quadriceps in a functional loading position is important for runners. Focus should be on slow, controlled sit-down motion without the knee, hip, and foot turning inward.

John Fiore, PT
Sapphire Physical Therapy

There are 4.1 million runners in the United States which is a 30% increase since 2000.1 Nearly 80% of runners sustain at least one overuse running injury per imgresyear,2 and 70% to 80% of these injuries occur between the knees and the feet.3 The most common running injuries include patellar tendonitis, plantar fasciitis, iliotibial band syndrome, patella femoral pain syndrome, shin splints, Achilles tendon pain, hamstring strain, stress fractures, and ankle sprain. This month’s Runners Edge article will focus on Achilles tendon pain.

The Achilles tendon is one of the largest tendons in the body. It is formed by the gastrocnemius and soleus muscles and serves to attach these lower leg (calf) muscles to the heel (calcaneus) bone. Unique to the gastroc-soleus-Achilles complex is the fact that this muscular-tendon group crosses three joints (knee, talocrural ankle joint, subtalar ankle joint). The Achilles tendon, therefore, is responsible for powering push-off during running and absorbs torsional stress placed upon the associated lower extremity joints. Achilles tendon soreness is common in runners. A rapid increase in running mileage, a drastic change in shoe cushioning or shoe drop, or a significant increase in hill running can all lead to Achilles pain. Poor calf muscle length and mobility as well as poor proximal hip and core functional strength also results in increased Achilles tension during running.

Soreness in the Achilles must not be ignored due to its limited blood supply which can make healing and inflammation reduction challenging. Acute Achilles tendonitis symptoms include pain during the push-off phase of walking or running, tenderness

to palpation a few inches above the calcaneus. Acute symptoms may also include a “squeaky” sensation in the Achilles tendon as you move your foot up and down in to dorsiflexion and plantarflexion. This “squeaky” sensation represents inflammation in the Achilles tendon sheath and warrants immediate rest, ice, and medical treatment to reduce inflammation. Chronic Achilles inflammation and soreness results in the formation of a thickened “knot-like” structure within the

Achilles and is referred to as Achilles tendinosis or Achilles tendinopathy. The thickened tendon represents scar tissue formation which will not resolve with rest alone.

Treatment of Achilles tendonitis in its early stages should include complete rest from running. It is vital to reduce inflammation by modifying activity level. Anti-inflammatory medication may be prescribed, and ice/elevation will aid in pain reduction. Because the blood supply in the Achilles is limited, healing may take some time. A physical therapist will help determine the underlying cause of your Achilles symptoms as proximal weakness or a muscle imbalance which lead to poor running mechanics. If acute Achilles tendonitis is not treated in a timely manner or if symptoms are ignored, then Achilles tendinosis may develop. The associated tendinosis “lump” of scar tissue decreases the elasticity of the Achilles and may lead to bone irritation at the Achilles attachment (calcaneus). Addressing the scar tissue with properly applied physical therapy cross friction massage, instrument assisted soft tissue mobilization (IASTM), and anti-inflammatory modalities such as Iontophoresis are beneficial. If symptoms do not resolve in a timely manner, orthopedic options such as platelet rich plasma (PRP) injections should be considered. Once pain is gone, running mileage and uphill running should be resumed very gradually. Strengthening the Achilles tendon and calf musculature in an eccentric (lengthened) manner will reduce injury recurrence.

Do not ignore Achilles pain. See treatment immediately to expedite your return to running. Because of the unique dynamic musculoskeletal forces and complex synthesis of movement involved in running, treatment of running injuries must not focus solely on static, passive interventions. Physical therapy is a vital component in returning to full running ability following an Achilles tendon injury. Rest and pain relief alone will not insure a full return to running. A physical therapist with experience treating running specific injuries and a firsthand understanding of the mechanics of running will insure a successful return to running. Learn more about our comprehensive running and physical therapy services at www.sapphirept.com.

John Fiore, PT

Sapphire Physical Therapy

1 Wilk B, Muniz A, Nau S. An Evidence-based Approach to Orthopaedic Physical Therapy: Management of Functional Running Injuries. Orthopaedic Physical Therapy Practice. 2010; 22:213-216. 2 Van Gent RN, Siem D, van Middelkoop K, et al. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. J Sports Med. 2007; 41:469-480. 3 Ballas M, Tyrko J, Cookson D. Common overuse running injuries: Diagnosis and management. Am Fam Physician. 1997: 55(7):2473-2484.

Spring in only a few weeks away and the roads and trails are drawing runners out of winter hibernation and winter sports. Whether you are new to running, or have already signed yourself up for a dozen races, spring represents a season of new beginnings. Spring is a great time to assess your running form to maximize your running efficiency while minimizing your injury risk. As running mileage increases, it is important to maintain proper running form. Fatigue associated with less than ideal running efficiency increased overuse injury risk. While overall body fatigue is often obvious, individualmuscle fatigue (resulting in running gait asymmetries) is often undetectable until an injury occurs.

A comprehensive running form analysis should be conducted by a physical therapist experienced in running biomechanics and running injury treatment and prevention. There are a few simple steps, however, which every runner can implement to improve running efficiency in preparation for spring mileage increases.

1. Run Silently

Whether you are a forefoot, mid-foot, or heel striker, it is important to remain light on your feet as your mileage increases. Listen to your foot strike. A silent runner is an efficient runner.Landing quietly on your feet is possible only if your feet, lower legs, quads, hamstrings, hips, gluts, core, and upper body are strong. The less time you spend on each foot, the shorter the impact duration of each foot strike. Shortening each foot strike duration results in a lower impact force through the body over the distance of your run and a higher running efficiency. Work on running quietly on your shorter runs and gradually implement silent running into your long runs.

2. Shorten Your Stride

The longer your stride, the greater the leverage through your hips, knees, and back. Shorten your stride slightly and focus on increasing your turn-over or cadence. Relax your arms, maintain a neutral pelvis (hips beneath you) and drive your knees forward. Running silently is more readily achieved with a shortened stride.

3. Correct Your Posture

Most of us spend a great deal of time sitting each day. Prolonged sitting results in hip flexor tightness, hamstring tightness, abdominal weakness, gluteal weakness, forward shoulder posture, forward head posture, and protracted shoulder posture. Body adaptations secondary to sitting must be addressed to improve running posture. Whenever possible, get up from the sitting position and move your body/joints into positions opposite those found while sitting. Straighten your spine, extend your hips, find and strengthen your gluteal muscles, find your neutral pelvis position, lengthen your hamstrings, stretch your rounded shoulders, and hold your head up.

The experts at Sapphire Physical Therapy can evaluate your running gait, posture, detect underlying form or strength issues, and develop an individualized injury prevention and treatment program to meet your individual needs. Call Sapphire Physical Therapy or see learn more at www.sapphirept.com and let us help you successfully achieve your 2015 running goals.
John Fiore, PT
Sapphire Physical Therapy