Lets Pie Crust and tenderise… A guest blog by Paul McCarroll

Last weekend I was talking in Northern Ireland about simplifying the shoulder. During part of the weekend I discuss the role of manual therapy and other passive techniques in shoulder complaints and in physiotherapy in general. One of the discussions it created with one of the delegates Paul McCarroll really challenged my thinking. Paul who is a physio but also a final year medical student told me about an orthopedic surgical technique he observed during Total Knee Replacement surgery called ‘Pie Crusting’. This seems to be very, very similar to the Dry Needling techniques used by physiotherapists and it seems to change tissue tension very easily, very quickly. 

Damn it.

Here’s me banging on about how needles poking things don’t affect the tissues significantly and how needling techniques are all about pain inhibition and neuromodulaton, and here are orthopaedic surgeons dry needling ligaments to correct knee valgus/varus deformities, and have been doing it for years. I will let Paul explain a little more about, but if you have any thoughts on Pie Crusting, Dry Needling, or tissue lengthening please comment below, or on Pauls face book site found here.

Pie Crusting by Paul McCarroll

So many discussions and conversations over the weekend spawned this inquisition. Within the realms of musculoskeletal physiotherapy there are divided opinions, conflicting evidence and some outrageous claims about certain treatment techniques. I’m not gonna bore you with such things but something recently challenged my way of thinking.

Recently I added needling techniques to my treatment tool kit, this was through inquisition and through some patient claims of effectiveness. So my ‘spidey’ senses started tingling and decided to do a course in this to satisfy these thought provoking ideas, after the course I still wasn’t convinced so then I started looking at the literature. For every positive paper you could produce a negative paper, the problem with evidence based research is that there’re an awful lot of factors that can influence the results of a paper, but that’s a discussion for another day.

However, I recently was on an orthopaedic placement in an esteemed specialist hospital, and during a Total Knee replacement I witnessed a technique called ‘Pie Crusting’ which involved multiple needle puncturing of the Medial Collateral Ligament of the Knee. This technique is done to alleviate tension in the Medial Collateral ligament, it involved multiple needle puncturing of taut bands of tissue in the medial collateral ligament with a hypodermic needle.

Pie Crusting

Is this a similar technique to dry needling?

Multiple needle incisions to a taut soft tissue, it certainly sounds very similar to dry needling. So here is my question to all the soft tissue gurus in multiple professional capacities, Whats the physiological process behind this ‘Lengthening of Soft Tissues’?!

PS: I’m looking for the peripheral local response, central mechanisms of neuromodulation and pain are for another day, I’m talking back to Guyton and Hall, cold hard physiology!! Please find attached a paper here on this concept in knee surgery.


Paul McCarroll

10 thoughts on “Lets Pie Crust and tenderise… A guest blog by Paul McCarroll

  1. Hypodermic syringes have a curling edge on and are hollow.. So was surgeon performing multiple tiny surgical releases? An acupuncture needle is solid with very fine gauge and point. I was told on my acupuncture training that the needles don’t ‘cut’, that’s why you can needle with no pain, no bleeding. So needles not the same. Not an expert though so looking forward to hearing other responses.

  2. Adam, I do not doubt that some of the more enthusiastic but misguided “dry needlers” are already doing this to various tissues of their long-suffering patients.

  3. Was the original dry needling not described using injection needles? I don’t think the “doesn’t cut” theory has ever been tested – just what people imagin happens. It is much thinner needle though. Yes, I have been using a similar technique (multiple needles in tight bands in muscle) with good results on my patients (if they freely consent) for years. And no they do not find it painful or traumatic…choosing patients may be key to treatment being tolerated.

  4. Very interesting, the most obvious differences from dry needling are: the needle used, as already stated. The multiple puncturing with the intent of a piercing and cutting the tissue structure, producing an almost web like effect to the soft tissue, effecting a release, producing bleeding to promote remodeling, and the biggest difference of all, the patient is asleep. The micro trauma performed on the ligament pales in comparison to the trauma of the knee repalcement, so it would be hard to gauge how painful a technique “pie crusting” is. I wonder what it would feel like if done awake and/or as a single procedure under anesthetic?

    Just my thoughts.

  5. Interesting.
    As mentioned, there are lots of factors to be consider.
    Knee op involve others cuts and so other processes taking place parallel. Those might increase the effect of pie crusting if were any in the first place ?

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