Ultrasound-Guided Percutaneous Tendon Dry Needling for Recalcitrant Distal Biceps Tendinopathy: A Case Series

Int J Sports Phys Ther. 2026 Nov 1;21(11):1144-1158. doi: 10.26603/001c.172557. eCollection 2026.

ABSTRACT

BACKGROUND: Distal biceps brachii insertional tendinopathy occurs in approximately 2.6 per 100,000 individuals per year, more commonly affecting middle-aged males. Dry needling with percutaneous tendon fenestration is a common treatment for insertional tendinopathies. However, little evidence supports this treatment for the distal biceps tendon, likely secondary to difficult access without ultrasound guidance. This case series describes the treatment of two subjects with chronic distal biceps tendinopathy using ultrasound-guided percutaneous tendon dry needling with fenestration and a graded loading program in outpatient physical therapy.

STUDY DESIGN: Case series.

METHODS: Two recreationally active adults with chronic distal biceps tendon pathology underwent clinical and sonographic examination, with images reviewed by clinicians registered in musculoskeletal sonography (RMSK). Subject A (55 years of age) presented with a partial distal biceps tendon tear, and Subject B (46 years of age) presented with distal biceps tendinosis. Both had pain and exercise-related functional limitations, and each participated in a physical therapy plan of care consisting of one visit per week for five weeks, including ultrasound-guided tendon dry needling for the first three weeks and graded isotonic loading of the distal biceps tendon throughout. Each subject transitioned to a guided home exercise program and was reassessed 3 and 6 months from the evaluation date. Subject-reported outcome measures included the Numeric Pain Rating Scale (NPRS), the Upper Extremity Functional Index (UEFI-20), and the Global Rating of Change (GROC) at baseline, 5 weeks, 3 months, and 6 months.

RESULTS: At five weeks, both subjects exceeded the minimal clinically important difference for each outcome measure. These results persisted at six months, with notable tendon healing characteristics visualized with diagnostic ultrasound.

CONCLUSIONS: Percutaneous ultrasound-guided tendon dry needling with fenestration as an adjunct to a graded tendon loading program may have contributed to reduced pain and disability among two individuals with distal biceps tendinopathy.

LEVEL OF EVIDENCE: 4.

PMID:42974606 | PMC:PMC13727011 | DOI:10.26603/001c.172557