Introduction

Exercise-associated muscle cramps (EAMC) present a persistent and often frustrating clinical hurdle in elite athletics, particularly within the high-velocity, high-stochastic environment of National Collegiate Athletic Association (NCAA) Division I basketball. EAMC are defined as painful, involuntary, and sustained contractions of skeletal muscle occurring during or immediately following physical activity [1, 2]. Traditionally, these contractions were attributed to simple dehydration-electrolyte imbalances; however, recent literature has shifted the focus toward the altered neuromuscular control theory [1, 3]. This framework suggests that localized muscle fatigue leads to a critical imbalance between excitatory drive from muscle spindles and inhibitory feedback from Golgi tendon organs (GTOs) [4, 5]. The result is a localized state of alpha motor neuron hyperexcitability that manifests as a cramp.

In the context of rebounding and lateral deceleration in this case, the adductor magnus (AM), specifically its ischiocondylar or ‘hamstring’ portion, serves as a primary stabilizer of the pelvis [6, 7]. When the tissue is subjected to abrupt eccentric loading, the muscle spindle’s afferent response can become exaggerated, while the GTOs’ inhibitory influence is diminished by neuromuscular fatigue, in an environment heavily influenced by hydration and electrolyte balance [1, 3]. This can result in EAMC of the AM. While standard sideline care typically involves passive static stretching, neurodynamic glides, and thermoregulating modalities and hydration, they often fail to downregulate the underlying motor endplate irritability and excitability [5]. This leads to the risk of recurrent spasms and incomplete resolution of symptoms, especially in the acute phase. Recurrent spasms are often reported to become more intense per episode [8–10].

This report details the successful and safe integration of dry needling (DN) to resolve acute AM spasms in an elite athlete, facilitating a symptom-free return to competition within 24 hours post-injury to participate in the subsequent scheduled competition.

Timeline

The timeline of events and management of the athlete is provided in Table 1.

Narrative

A 23-year-old male Division I basketball player presented with EAMC secondary to a strain of the AM (hamstring portion) during a single-leg landing. The athlete jumped to grab a rebound, and upon landing on the right lower extremity, he was observed with significant right lateral trunk lean and near terminal knee extension with the hip in neutral. This case was complicated by the nature of the event, the conference championship weekend, which called for the athlete to be able to play 3 basketball games in 3 days. The mechanism of injury matched an adductor strain in a closed kinetic chain. Within seconds of the landing, the athlete grabbed for the posteromedial portion of the leg, right at the ischial tuberosity. The athlete was able to bear weight and hopped off the court to be evaluated. Observation revealed a visible and palpable muscle cramp of the AM. The athlete was placed in supine for a static strength test of the hamstring: the straight leg raise (SLR) variation. This was discontinued due to the increased intensity of symptoms reported by the athlete. Sciatic nerve flossing in supine, with manual compression of the attachment at the ischial tuberosity. The athlete was observed with a lack of sweat (this is an athlete who typically sweats profusely). Symptoms included a local cramping sensation, with tenderness to palpation. Symptoms were worsened with prolonged contraction of the hamstring or adductors during strength testing, and with passive leg raise strength testing. Subjectively, the athlete reported the symptoms were reduced and tolerable, electing to continue play. The irritability of the symptoms remained constant. The athlete returned to play and had a recurrence of injury after about 10 minutes. The athlete reported the same symptoms and presentation but reported the intensity of the discomfort to be 10× worse. The athlete was removed from play for the remainder of the competition.

Within 5 hours of the injury, the athlete was treated with trigger point dry needling (TrP-DN) of the AM (hamstring portion). The athlete was also treated with muscle energy techniques, sciatic nerve flossing, active release technique, and reciprocal inhibition via quad isometrics. The athlete completed multiple rounds of 10–15-minute-long duration low-load stretching in the supine position, with both heels placed on a wall near 90 degrees of hip flexion. Kinesiology tape was placed above and below the site of cramping, along with down the belly of the hamstrings. Compression shorts were worn over top. The athlete reported a significant decrease in pain and an increase in function post TrP-DN. Later that night, within 12 hours of injury, the athlete completed a second round of the manual therapy and therapeutic exercise techniques noted above. From initial onset to the 12-hour mark, the athlete was placed on a rehydration regimen with electrolyte replacement beverages and water. The next morning, the athlete reported feeling local stiffness in the AM region, with some residual muscle soreness. No other complaints were noted.

TrP-DN was performed using a 0.25 × 60 mm needle, piston technique. 3 needles were used, one at a time, in 3 different locations of the AM. All locations formed a triangle pattern, no more than 1 inch away from each other. Each needle was placed and removed before the next needle was placed for TrP-DN. Total of 3 insertions. Multiple local muscle twitch responses were elicited. Hemostasis was applied. No adverse reactions at the time of treatment. The number of repetitions was not standardized; the clinician terminated needling upon cessation of local twitch responses (LTRs). The clinician performing the DN is a physical therapist, board-certified as a sports clinical specialist, with a certification in DN.

The athlete was cleared for participation, with close monitoring of the warm-ups before a final decision. Observation during warm-ups revealed avoidance of single-leg stance weight-bearing on the right lower extremity in some movement patterns. Compensations with increased double-leg movement patterns noted. The athlete was shying away from loading the right lower extremity. The athlete was able to perform all basketball movements and was cleared to play the game. As the game went on, the athlete began to sweat within their normal limits and worried about the right lower extremity less and less as the game went on. The compensation patterns began to fade, and the athlete was able to finish the entire game without reinjury.

After the second game, the athlete reported feeling good once the game got started. A few hours later, he reported similar stiffness and soreness to the morning. The athlete received another round of TrP-DN in the AM, along with the previously mentioned manual therapy, therapeutic exercise, and taping/compression techniques. The athlete again tolerated TrP-DN well with a significant reduction in symptoms and increased function. The morning of the third game, the athlete noted slight tightness and minimal soreness. The athlete was again cleared to play and was able to play game 3 without any compensation, decrease in performance, or increase in symptoms. Upon the conclusion of the tournament, when returned to the university, the athlete did not complain or show signs of continued injury. The pain rating reported by the athlete throughout the timeline of the case is shown in Figure 1.

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Figure 1. Numerical pain rating over timeline.

Diagnostics

The diagnostic results of the initial sideline evaluation for the athlete are represented in Table 2. From the results of the sideline evaluation, the differential diagnosis list was made to include EAMC, or AM (hamstring portion) strain. In the brief, approximately 2-minute evaluation, it was concluded that the signs and symptoms fit EAMC. Imaging was not available or used in this case. There were no signs of swelling or bruising. No obvious deformities. The athlete’s symptoms were provoked by prolonged contraction of the AM. The reported cramping sensation was the limiting factor in range of motion and strength testing. Diagnosis was also limited due to no loss of function. Athlete performance of basketball-related tasks was only affected by the presence of the cramping/pain sensation. The lack of functional decline (outside of pain) limited useful outcome measures, as did the time frame in which this case took place.

Patient perspective

The athlete expressed great satisfaction with the outcome of this case. His motivation to return to play (RTP) was high post initial sideline evaluation, as it was concluded that the injury would not prevent him from returning. Following the recurrent injury, the athlete was slightly discouraged due to not finishing the game. His motivation to play the next 2 games remained high; thus, he was very open to treatments and techniques to facilitate such a quick return. The athlete noted the most helpful intervention was the DN, and the patient showed great compliance with the other adjunctive treatments in this case. The athlete was very happy when cleared to play the 2 contests post initial injury. The athlete expressed great gratitude for the treatment and care provided. The athlete felt good about their athletic performance in the final 2 contest, both leading to team wins, a conference championship, and a bid to the NCAA tournament.

Discussion

This case report highlights the successful application of DN as an acute intervention for recurrent EAMC in a Division I basketball athlete. The importance of the case lies in the rapid resolution of a ‘tenfold’ increase in symptom intensity, despite the failure of initial manual therapy and the presence of systemic thermoregulatory imbalance, with 3 full contests in 3 days, 24 hours apart. Current clinical practice guidelines for the management of EAMC include gentle stretching, resting in a position of comfort, oral rehydration, and gentle massage. May also include intravenous fluids [11]. DN may provide added value as a complementary strategy due to the mechanisms described below.

Conclusions

This case demonstrates that DN is a safe and highly effective intervention for the acute management of recurrent EAMC in elite athletes, performed in conjunction with traditional acute management. By directly addressing the neuromuscular and biochemical drivers of the muscle spasms, clinicians can facilitate a faster and more stable return to competition, versus traditional manual therapy and rehydration alone. The successful resolution of symptoms allowed the athlete to participate in high-stakes competition without a decline in performance or high risk of reinjury. Future research should explore the efficacy of early intervention DN in athletes exhibiting signs of EAMC, potentially exploring immediate intervention and its effect on returning to the same competition. Limitations of this study include a single-patient design, absence of a control condition, possible spontaneous recovery, multimodal interventions, lack of imaging in diagnostics, no use of thermoregulatory measurements, and the possibility of observer bias.