Systematic Review

Percutaneous Electrolysis for Musculoskeletal Disorders

Management in Rehabilitation Settings: A Systematic Review
Carmelo Pirri 1, * , Nicola Manocchio 2, * , Andrea Sorbino 2 , Nina Pirri 3 and Calogero Foti 2

1 Department of Neurosciences, Institute of Human Anatomy, University of Padua, 35121 Padova, Italy
2 Physical and Rehabilitation Medicine, Department of Clinical Sciences and Translational Medicine, University
of Rome “Tor Vergata”, 00133 Rome, Italy; [email protected] (A.S.); [email protected] (C.F.)
3 Department of Medicine—DIMED, School of Radiology, Radiology Institute, University of Padova,
35121 Padova, Italy; [email protected]
* Correspondence: [email protected] (C.P.); [email protected] (N.M.)

Abstract
Background: Percutaneous electrolysis (PE) is a minimally invasive procedure that utilizes
galvanic current delivered through a needle. PE is increasingly employed for musculoskele-
tal disorders, despite the scarcity of scientific evidence supporting its use. The aim of this
systematic review is to synthesize the existing evidence and explore the applications of PE
in rehabilitation. Methods: In line with Preferred Reporting Items for Systematic Reviews
and Meta-Analyses guidelines, a systematic search was conducted across the PubMed, Web
of Science, Scopus, and PEDro databases from inception to July 2025. The search strategy
employed the term “Percutaneous Electrolysis” without applying additional filters or time
restrictions, ensuring a comprehensive search. Cited references from screened articles were
also evaluated for potential inclusion. Studies were included if they met the following
criteria: peer-reviewed articles, intervention-based research, relevance to the topic, and
publication in English. Results: Of the 181 papers retrieved, 143 were excluded for various
reasons, leaving 38 studies. The evidence suggests that PE appears effective in reducing
pain and improving function, particularly when combined with exercises such as eccentric
training or stretching, though inconsistencies in protocols and patient characteristics, along
Academic Editor: Philippe Gorce with unclear mechanisms, show that it warrants further investigation. Conclusions: In
Received: 5 June 2025 conclusion, while PE emerges as a promising therapeutic strategy for musculoskeletal dis-
Revised: 16 July 2025 orders, its full integration into rehabilitation practice necessitates further rigorous research
Accepted: 21 July 2025
to standardize treatment protocols, elucidate the underlying mechanism, and validate its
Published: 23 July 2025
cost-effectiveness. These steps are essential to establish PE as a robust and evidence-based
Citation: Pirri, C.; Manocchio, N.;
option within the field of rehabilitation.
Sorbino, A.; Pirri, N.; Foti, C.
Percutaneous Electrolysis for
Keywords: Percutaneous Electrolysis Therapy (EPTE); Electrolysis Percutaneous
Musculoskeletal Disorders
Management in Rehabilitation
Intratissue (EPI); physiatry; electroacupuncture; elbow Tendinopathy; plantar fasciitis;
Settings: A Systematic Review. patellar Tendinopathy; plantar heel pain; muscle injury
Healthcare 2025, 13, 1793.
https://doi.org/10.3390/
healthcare13151793

Copyright: © 2025 by the authors. 1. Introduction

Licensee MDPI, Basel, Switzerland. Percutaneous electrolysis (PE) consists of the application of a galvanic current through
This article is an open access article
an acupuncture needle placed into an affected soft tissue. Being applied with a very
distributed under the terms and
thin needle, PE is considered a minimally invasive technique and thus, albeit being fairly
conditions of the Creative Commons
Attribution (CC BY) license
new, is easily accepted by patients [1]. PE serves as the overarching term that includes
(https://creativecommons.org/ various techniques, such as Electrolysis Percutaneous Intratissue (EPI), percutaneous needle
licenses/by/4.0/). electrolysis (PNE—sometimes associated with higher-intensity currents) and Percutaneous

Healthcare 2025, 13, 1793 https://doi.org/10.3390/healthcare13151793

Healthcare 2025, 13, 1793 2 of 35

Electrolysis Therapy (EPTE) [1]. EPI and EPTE are both specific methods within this
category; EPI tends to use a higher intensity current while EPTE often employs a lower
intensity current [1].
Ultrasound (US) guidance can be used when performing PE to achieve better therapy
efficacy and to ensure that the target tissue is reached [2]. Solid scientific evidence is
still lacking about PE; its effectiveness seems related to a local inflammatory response
caused by a non-thermal electrolytic reaction that stimulates local repair and regeneration
processes; a mechanical effect caused by needle insertion itself has been suggested, similarly
to what happens in acupuncture [3,4]. Papers on murine models have shown an increased
concentration of anti-inflammatory proteins and angiogenic factors alongside a decrease in
pro-inflammatory mediators in tissues treated with PE. Moreover, genes related to collagen
regeneration seem to have higher expression [5]. Another suggested that PE action has
been related to a temporary vasodilation of healthy animal tendons: this could increase the
removal of nociceptive molecule and pro-inflammatory cell arrival, a process crucial for
tendon healing and regeneration [6]. PE’s ultimate goal is to generate an analgesic effect.
PE has been mostly applied for the treatment of musculoskeletal (MSK) pain, mostly
related to tendinopathies, but the literature reports that other applications (e.g., mammary
fistulas) are available, too [7,8]. MSK pain can manifest as either acute or chronic conditions.
Acute MSK pain typically arises suddenly following trauma or overuse and is often self-
limiting. In contrast, chronic MSK pain persists for more than three months, frequently
resulting from failed tissue healing, repetitive microtrauma, or degenerative changes [9,10].
Most of the studies reviewed in this paper primarily address chronic MSK disorders (e.g.,
chronic tendinopathies such as patellar, Achilles, lateral epicondylitis, and plantar fasciitis)
where pain and functional impairment are longstanding and resistant to initial conservative
management. A smaller subset of studies investigates acute conditions, such as acute
whiplash syndrome. The nature of MSK pain (acute or chronic) is an essential factor, as it
influences both treatment strategies and the expected response to interventions.
Tendinopathies arise from a combination of factors, including impaired tendon healing,
increased blood vessel formation (hypervascularization), and changes in the structure of col-
lagen fibers and the surrounding matrix [11]. Among tendinopathies, patellar tendinopathy
is an overuse injury predominantly affecting athletes involved in jumping sports, character-
ized by pain in the patellar tendon that can significantly impair athletic performance [12].
The injury is particularly prevalent in sports such as basketball and volleyball, where
the repetitive loading of the knee is common; current treatment approaches for patellar
tendinopathy emphasize conservative management, particularly focusing on load man-
agement and exercise therapy [13]. Epicondylitis primarily involves the extensor carpi
radialis brevis tendon and is characterized by pain over the lateral epicondyle, affecting grip
strength and overall function [14]. Supervised exercise that combines eccentric and static
stretching was found to significantly outperform other conservative treatments, suggesting
that tailored exercise regimens should be a cornerstone of non-operative management [15].
Subacromial pain syndrome is another common disease, characterized by pain localized
around the acromion and often exacerbated by arm elevation. This syndrome includes
various underlying etiologies, such as bursitis, supraspinatus tendinopathy, and partial
rotator cuff tears [16]. Current treatment modalities for subacromial pain syndrome include
nonsteroidal anti-inflammatory drugs and corticosteroid injections, which provide tempo-
rary relief by reducing inflammation in the subacromial space [17]. There is still a debate
on the optimal treatment for tendinopathies, but physical therapy focused on managing
tendon strain is usually the first approach. If pain lingers, other options like extracorporeal
shock wave therapy or injections with several compounds (i.e., collagen, hyaluronic acid,
Healthcare 2025, 13, 1793 3 of 35

or platelet-rich plasma (PRP)) injections might be explored, although their effectiveness

can vary [18–20].
The management of MSK disorders typically involves a multimodal approach combin-
ing non-pharmacological, pharmacological, and, in some cases, surgical interventions. The
main pillars include patient education and self-management, exercise therapy, pharmaco-
logical treatments (e.g., NSAIDs, acetaminophen, opioids), interventional procedures (e.g.,
injections), and psychosocial and behavioral therapies (to address the multidimensional
nature of pain) [21–29]. PE is emerging as a new therapeutic approach whose effects,
benefits, indications, optimal methods of application, and possible contraindications need
to be understood more thoroughly. The primary aim of this systematic review is to explore
the application of PE for the management of musculoskeletal disorders in the rehabilitation
field. Secondarily, we aim to evaluate the most recent evidence in the literature about the
various methodologies, rehabilitation protocol applied, US guide employment, and “the
grey zones” of PE.

2. Materials and Methods

2.1. Search Strategy
This systematic review was performed in accordance with PRISMA 2020 guide-
lines [30]. A systematic search was performed in the online databases PubMed, Web
of Science, Scopus, and PEDro until July 2025. The protocol for this systematic review has
been duly registered with Open Science Framework registries accessible via the follow-
ing registration link: https://doi.org/10.17605/OSF.IO/CMU9H. The literature search
was structured according to the PICO framework (Population/Problem, Intervention,
Comparison, and Outcome), as detailed in Table 1.

Table 1. Description of the PICO (P = Population, I = Intervention, C = Comparison, O = Outcome) elements.

Patients or Healthy Volunteers who

Population
Underwent Percutaneous Electrolysis for Musculoskeletal Diseases
Intervention Percutaneous Electrolysis
Comparison Not applicable
Pain, function, mobility, thickness, quality of life, and ability to reach the
Outcome
target tissue.

As a search strategy, the term “Percutaneous Electrolysis” was inserted for the search
in all databases. No other specifier was applied, and no time limit was used, to keep the
search as broad as possible. The cited references of the screened articles were assessed for
potential inclusion. In order to provide a review that was as comprehensive as possible,
case reports, case series, and cadaveric studies were included to enhance the depth and
breadth of the research.

2.2. Screening Results and Eligibility

The inclusion criteria for this systematic review were determined through a structured
process to ensure that only studies directly relevant to the research objectives were selected.
The inclusion criteria were developed after clearly formulating the research question and
specifying the objectives of the review, in accordance with PRISMA guidelines. Criteria
were set prior to the formal literature search to minimize selection bias and ensure con-
sistency throughout the screening process. Only peer-reviewed intervention studies were
included. Studies had to involve patients with relevant MSK disorders, and no restrictions
were placed on age, gender, or geographic location. Papers were also included if they
involved the cadaveric evaluation of the potential application of PE. Studies were required
Healthcare 2025, 13, 1793 4 of 35

to report on clinical outcomes relevant to MSK disorders, such as pain reduction, functional
improvement, or safety/adverse effects. The articles were excluded if (1) the article was not
peer reviewed; (2) the publication was a review article on the research topic; (3) the study
was not an intervention; (4) the study was off topic; or (5) the paper was not in English.
Full-text manuscripts of accepted papers were retrieved and screened by two inde-
pendent researchers (N.M. and A.S.); if there was a disagreement, a third author (C.P.)
helped in the decision. After the selection, each title/abstract/full text was independently
assessed by each of the authors. The extracted data were transcribed into standardized
data collection sheets.

2.3. Data Extraction

Data concerning this topic were collected in an appropriate Excel (Microsoft, Redmond,
Washington, DC, USA—version 16.99) spreadsheet and analyzed:
a. General characteristic of the paper: first author, year of publication, study design.
b. Study population characteristics. Human/no human, patients or healthy volunteers,
age, gender, and type of disease.
c. Methods: type of US imaging, setting; use of the US guide; operator performing the
procedure; type of disease; rehabilitation protocol applied.
d. Times during rehabilitation: pre-, during, post-, and follow-up.
e. Outcomes and results.

2.4. Risk of Bias

Two researchers evaluated the study quality, and differences were solved after dis-
cussion. The papers were scrutinized for quality using Risk of Bias Assessment tool for
Randomized Control Trials (RCTs). This tool includes different domains of bias: random
sequence generation, allocation concealment, blinding of participants and personnel, blind-
ing of outcome assessment, incomplete outcome data, selective reporting, and other bias.
Each domain was judged as “low risk”, “high risk”, and “unclear”.
The case–control studies were assessed using Newcastle–Ottawa Scales (NOS) for
case–control studies. The case-report studies were evaluated by Joanna Briggs Institute
(JBI) Critical Appraisal Checklist for Case Reports for case-report studies. Animal studies
were assessed using the Systematic Review Centre for Laboratory animal Experimentation
(SYRCLE) Risk of Bias Table for Animal Studies, while cadaveric studies used the Quality
Appraisal for Cadaveric Studies (QUACS) scale.

3. Result
The study flowchart is shown in Figure 1.
A total of 181 papers were retrieved using the search methods described above. After
duplicate (87) removal, 56 papers were excluded from this review after assessment because
they were off topic (21), reviews (19), study protocols (9), not interventions (3), not in
English (2), or corrections of previously published papers (2). Thirty-eight papers were
thus included in this review and deeply analysed for the variables under examination:
thirty-one were on MSK disorders, two were on animals, and five were cadaver studies.

3.1. Musculoskeletal Diseases

A wide heterogeneity has been observed regarding the application of PE in the field of
musculoskeletal disorders. Among these papers, 29 (94%) were carried out on humans and
2 (6%) on animals (discussed in the relevant section). US guidance was used in 26 (84%)
papers and was avoided in 1 (2%); the remaining 4 (14%) did not provide information
about US application. A discrepancy was evident when sample sizes were analyzed with
Healthcare 2025, 13, 1793 5 of 35

a wide overall range among the studies (min 8–max 102). The same result emerged when
analyzing participants’ age, with an overall range of 16–62 years among the studies; the
lowest reported mean age was 21.03, and the highest was 58 years. Of the 21 studies
reporting operator data, physiotherapists (PT) performed the procedure in 19 (63%) cases,
and 2 (7%) studies used the general term “clinician” without further details; 9 studies did
not report the operator performing the procedure. Notably, only 11 (35%) papers reported
data about adverse events, negative in 10 cases; 20 papers did not provide information on
this topic.

Figure 1. Study flowchart.

In the assessed papers, the most represented pathology for PE use is patellar tendinopa-
thy (six papers, 20%). Abat et al. [31] applied PE on 33 people (29 males, mean age 25.3 years)
affected by insertional patellar tendinopathy. Patients received weekly sessions of PE and
two weekly sessions of eccentric exercise; PE was applied through 3 milliamps echo-guided
punctures (needles from 0.30 to 0.32 mm in diameter and a modified electric scalpel) until
there was clinical improvement or no improvement in the symptomology was seen after
10 sessions; a two-year follow-up period was established. No adverse events were reported.
Notably, like some of the other authors, Abat et al. applied a motor re-educational program
(two weekly sessions of eccentric exercise) alongside PE and found that this combination is
effective in reducing pain and improving functional status assessed via the Victorian Insti-
tute of Sport Assessment for the patellar tendon (VISA-P) scale. The same research group
reported another protocol for patellar tendinopathy on 40 patients (35 males, mean age
25.5 years); a very similar PE application technique (one session every 2 weeks up to a max-
imum of ten sessions, with 0.3 mm in diameter acupuncture needles and intensity of 3 mA)
alongside repeated sessions of eccentric exercise training. In this paper, Abat et al. followed
Healthcare 2025, 13, 1793 6 of 35

up on patients for 10 years and confirmed that the treatment resulted in improvement in
knee function assessed via the VISA-P scale and Tegner score [32]. Lopez-Rojo et al. [33]
reported contrasting findings in their investigation comparing dry needling (DN) and PE
with eccentric exercises for patellar tendinopathy. Forty-eight patients (forty-two males;
mean age, 32.46 years) were divided into three groups: control (sham needling), DN, and
PE (3 mA for 3 s). All groups performed eccentric exercises. A physiotherapist delivered
the interventions. Outcomes were assessed using the VISA-P scale, the Visual Analog
Scale (VAS) for pain, and Short-Form 36 (SF-36) for Quality of Life (QoL). The authors
found that neither DN nor PE combined with eccentric exercises demonstrated greater
efficacy than eccentric exercises alone in reducing pain and improving function at both
short-term (10 weeks) and medium-term (22 weeks) follow-up. Notably, no adverse event
was reported in the previous papers; however, two studies assessing the possible impact of
PE on the autonomic system were retrieved. The first one, by de la Cruz Torres et al. [34],
involved 22 male footballers (mean age 23.5 years) divided into two groups: the control
(evaluation of heart rate variation at rest and during US examination of patellar tendon) and
the experimental group (evaluation of heart rate variation at rest and during PE application
at the patellar tendon by a PT-3 mA needle 0.3 mm). The experimental group showed in-
creased parasympathetic and decreased sympathetic activity, implying the risk of vasovagal
reaction. The same group published another paper in 2018 to assess if the aforementioned
autonomic reaction could be related to the needle puncture alone or more specifically to PE.
In this paper, 36 male footballers were recruited and allocated into three groups: control
(evaluation of heart rate variation at rest and during US examination of the patellar tendon),
PE group, and needle group (evaluation of heart rate variations at rest and during PE or
needle puncture, respectively). The PE group showed significant autonomic reactions com-
pared to the other two, suggesting a strong relation with electric current application [35].
Lastly, one paper analyzed the cost-effectiveness of three patellar tendinopathy treatments:
PE, DN, or sham needling. The authors reported that the total cost per session was sim-
ilar in the three groups, but the PE group presented better cost-effectiveness in terms
of quality-adjusted life years [36]. One paper, by Valera-Carelo et al. [37], analyzed PE
application on patellofemoral syndrome; 15 patients (mean age 25.6 years) were divided
into three groups: high-intensity PE (660 mA for 10 s), low-intensity PE (220 mA for 30 s),
and the DN control group. Both PE procedures seemed effective in reducing pain and
caused less pain during interventions.
Another body area in which PE has been widely applied concerns foot disorders,
particularly plantar fasciitis and plantar heel pain. Iborra-Marcos et al. [38] investigated
the efficacy of PE compared to corticosteroid injections for plantar fasciitis in a study
of 64 patients (35 males, mean age 46.4 years). Patients were divided into two groups:
PE treatment (3 mA for 5 s, administered weekly for up to 10 sessions) or corticosteroid
injections (1 mL mepivacaine and 1 mL betamethasone acetate+betamethasone sodium),
both US-guided. The study did not report the healthcare professional performing the
procedures. At 12-month follow-up, both interventions showed improvements in pain
(VAS) and function (Foot and Ankle Disability Index—FADI). However, corticosteroid
injections required fewer administrations and achieved superior outcomes in both pain
and function.
Fernández-Rodríguez et al. [39] investigated the effectiveness of US-guided PE for
chronic plantar heel pain. They recruited 73 patients and divided them into two groups:
one receiving PE and a control group receiving a placebo puncture. The PE group un-
derwent one session of cathodal PE (28 mC) per week for five consecutive weeks. The
study focused on four main outcomes: pain, function, and disability (21-item activities of
daily living subscale of the Foot and Ankle Ability Measure questionnaire), plantar fascia
Healthcare 2025, 13, 1793 7 of 35

thickness measured by ultrasound, and all these were assessed at baseline (pre-treatment),
12 weeks, and 24 weeks. Patients in the PE group showed significantly better results in
pain, function, and disability at both the 12-week and 24-week follow-ups compared to the
control group. Al-Boloushi et al. compared the effectiveness of PE (1.5 mA) and DN for
pain, function, and QoL in 102 patients (30 males, mean age 48.8 years) with plantar heel
pain. All participants also received a stretching protocol. Both PNE and DN significantly
reduced both mean and maximum pain scores from the first treatment session onwards,
demonstrating long-lasting effects (up to 52 weeks). Notably, the PE group exhibited
significantly better QoL at the 52-week follow-up compared to the DN group [40]. Building
on their prior work, the same group conducted a cost-effectiveness analysis using the same
data to compare PE and DN for plantar heel pain [41]. Their findings suggest that PE may
be a more cost-effective approach compared to DN, particularly at the 52-week follow-up,
where statistically significant differences in cost-effectiveness were observed.
A study by García Naranjo et al. [42] investigated the effectiveness of PE for acute
whiplash syndrome. The researchers recruited 100 patients (36 males, average age
38.1 years) and divided them into two groups: PE and physiotherapy. The PE group
received three weekly sessions of US-guided PE (4 mA) performed by a trained phys-
iotherapist. The physiotherapy group received a combination of treatments including
microwave thermotherapy, analgesic Transcutaneous Electric Nerve Stimulation (TENS)
currents, massage, therapeutic ultrasound, active exercises, and stretching, all delivered
daily for four weeks. Both groups showed similar improvements in pain and neck function
as measured by the Northwick Park Neck Questionnaire and VAS. However, the PE group
demonstrated significantly better results in pain pressure threshold. Notably, physiother-
apy required a significantly longer treatment time, averaging 20 h compared to less than
1 h for the entire PE intervention.
Moreno et al. [43] investigated the effectiveness of PE for adductor longus enthesopathy-
related groin pain in soccer players. They recruited 24 non-professional male athletes (men
age 26.1 years). The participants were divided into two groups: US-guided PE (two sessions
per week, 3 mA for 5 s) combined with active physiotherapy (APT), and a control group
receiving only physiotherapy. The study followed the participants for six months. The
combined intervention of PE and APT resulted in a greater and faster reduction in pain
compared to physiotherapy alone. Additionally, the PE group showed a tendency to-
wards better functional recovery, and these positive treatment effects persisted for at least
six months.
Sanchez-Gonzalez et al. [44] investigated the potential effects of PE on endogenous
pain mechanisms in a study of 46 asymptomatic participants (15 males, aged 18–40 years).
The participants were divided into three groups: sham (PE application without electrical
current), low-intensity PE (0.3 mA for 90 s), and high-intensity PE (three pulses of 3 mA,
each lasting 3 s). All PE interventions were administered under US guidance by a phys-
iotherapist. The researchers assessed widespread pressure pain thresholds, conditioned
pain modulation, and temporal summation bilaterally in four specific areas: the lateral
epicondyle, the bicipital groove, the C5 transverse process, and the tibialis anterior muscle.
Their findings suggest that a single session of PE can mildly stimulate pathways involved in
regulating pain perception (nociceptive gain). Interestingly, no significant differences were
observed between the low-dose and high-dose PE applications. Varela-Rodriguez et al. [1]
also conducted an RCT to investigate whether PE can induce endogenous pain modula-
tion mechanisms and whether these effects are dependent on the dosage of the galvanic
current. Fifty-four asymptomatic participants (thirty-four males, mean age 22.96 years)
were enrolled and allocated into three groups, each receiving a single ultrasound-guided
PE application on the lateral epicondyle tendon. The groups received either sham (without
Healthcare 2025, 13, 1793 8 of 35

electrical current), low-intensity (0.3 mA, 90 s), or high-intensity (three pulses of 3 mA,
3 s) stimulation. Widespread pressure pain thresholds, conditioned pain modulation, and
temporal summation were evaluated in the elbow, shoulder, and leg regions. The study
found that a single PE intervention modulated pain processing in local and widespread
areas, implying an endogenous pain modulation effect. Interestingly, this effect appeared
to be independent of the dosage administered.
Varela-Garrido et al. [45] investigated the effectiveness of a multimodal program for
chronic lateral epicondylitis in 36 patients (19 males, average age 38 years). The program
combined US-guided PE, eccentric exercise, and stretching. The researchers measured
patient outcomes at baseline, at discharge, and during follow-ups at 6, 26, and 52 weeks.
All outcome measures showed significant improvements between pre-intervention and
discharge, indicating that the multimodal program effectively reduced pain and improved
the ultrasound-assessed structure of the tendons. Yildizgoren et al. [46] presented a case
report examining the biochemical and ultrasound features of PE in a 45-year-old woman
with chronic lateral epicondylitis who had not responded to conventional treatments. The
patient received three sessions of US-guided PE (350 µA, 80 s per session). Pain and
functional outcomes were assessed at baseline and four weeks post-treatment using the
VAS and QuickDASH questionnaire. The patient’s VAS score improved from 8 to 2, and
her QuickDASH score improved from 56 to 18. Ultrasound imaging during the procedure
revealed hyperechoic gas formation, attributed to hydrogen gas generated by electrolysis.
No adverse events were observed. These findings suggest that US-guided PE combined
with exercise and stretching is beneficial for managing chronic lateral epicondylitis.
De-la-Cruz-Torres et al. [47] investigated the effectiveness of PE for chronic soleus
injury in dancers. Thirty dancers (twenty-seven males, average age 21.03 years) were
randomly assigned to one of three groups: PE, eccentric exercise, or a combined PE and
exercise program (n = 10 per group). A PT administered the PE intervention, which
consisted of two sessions of US-guided PE (one session per week) with an intensity of
2.5 mA, delivered for 3 s per application and repeated three times per session. The study
found that the combined PE and exercise group showed a significantly greater improvement
compared to the other groups. Dancers in the combined group also reported a greater
perception of improvement.
Jimenez-Rubio et al. [48] carried out a protocol to validate a new, functional on-field
program for the rehabilitation of soccer players after a hamstring strain injury. Nineteen
professional male soccer players (mean age 24.23 years) were recruited for the purpose of
this paper. Following the clinical diagnosis of a hamstring strain injury, players underwent
PE followed by physiotherapy (mobilization and strengthening exercises). Subsequently,
players participated in a progressive, on-field readaptation program consisting of 13 drills.
The mean time to return to play was 22.42 ± 2.32 days.
Rodríguez-Huguet et al. [49] investigated the efficacy of PE on lateral epicondylalgia
in two studies. The first study was an RCT enrolling 32 patients (20 males, mean age of
38.16 years) divided into two groups: a PE group (16) and a DN group (16). A PT performed
the interventions four times, which were administered alongside a daily eccentric exercise
program. Patients were followed up for up to three months. Significant between-group
differences in pain and flexion movement were found after treatment, suggesting that
PT may be more effective than DN for the short- and medium-term improvement of
pain and function in lateral epicondylalgia. The second study compared an integrated
intervention of pulsed negative-pressure myofascial vacuum therapy, PE, and eccentric
exercise to a program of manual therapy mobilization, US therapy, and eccentric exercise.
Forty participants (twenty-five males) with a mean age of 40.1 years were equally divided
between the groups. The PE group received four weekly sessions, while the control group
Healthcare 2025, 13, 1793 9 of 35

received ten sessions over two weeks. Both groups performed daily eccentric exercises at
home. The PE group showed statistically significant improvements in pain intensity and
function compared to the control group after treatment, with these benefits maintained at
the one-month and three-month follow-up [50].
Benito-de-Pedro et al. [51] conducted an RCT to compare the short-term pain reduction
effects of PE versus DN on myofascial trigger points of the levator scapulae in patients
with chronic non-specific neck pain for at least 3 months. Fifty-two patients (sixteen males,
mean age 38.77 years) were enrolled. Pain intensity, pressure pain threshold, cervical range
of motion, and neck disability were assessed. Additionally, post-needling soreness was
evaluated. The study found that PE and DN appear to have similar short-term effects on
pain reduction, although PE was reported as a more painful treatment compared to DN.
Moreno et al. [52] investigated the feasibility of PE as a treatment for rectus abdominis-
related groin pain in professional footballers in a pilot study. Eight professional male soccer
players (mean age 26.8 years) participated in the study and received ultrasound-guided
PE delivered by a PT. Participants received PE only; no other concurrent treatments were
administered. Participants were followed up for up to 6 months. PE was delivered at
3 mA for 4 s during 2 to 6 sessions administered once weekly. PE treatment resulted in
complete pain resolution within one month. Patients achieved excellent functional recovery
for walking and jogging within one week, and for getting out of bed, running, jumping,
and kicking within one month of treatment completion.
Another pilot study on professional footballers was the one by De-la-Cruz-Torres et al. [53].
The authors examined the effects of adding US-guided PE to a specific exercise program
for soleus injury in female soccer players on perceived pain at stretching and at palpation,
ankle dorsiflexion range of motion, muscle fatigue, and sport performance. Twenty female
soccer players (mean age 22.5 years) were allocated into two groups: an experimental
group receiving the exercise program combined with US-guided PE and a control group
receiving the exercise program with sham stimulation. Both groups showed significant
improvements in pain intensity (palpation and stretching), ankle dorsiflexion range of
motion, and heel raise test values between pre-treatment and post-treatment. There were
no significant differences in the curve sprint test results between pre-treatment and post-
treatment within either group or between the groups. However, the percentage changes
favored the experimental group, suggesting a potential benefit of PE that requires further
investigation in larger studies with a higher statistical power.
Two papers were retrieved about subacromial pain syndrome. The first one, by de
Miguel Valtierra et al. [54], was an RCT investigating the efficacy of US-guided PE as an ad-
junct to manual therapy and exercise in 50 patients (23 males; mean age 54 years) diagnosed
with subacromial pain syndrome. Participants were allocated to two groups: one receiv-
ing manual therapy and exercise alone and another receiving the same intervention plus
US-guided PE. The exercise program focused on pain, shoulder disability, function, and
pressure sensitivity, delivered in one session per week for five consecutive weeks. Patients
in the US-guided PE group received the intervention at each treatment session. Subjects
receiving manual therapy, exercise, and US-guided PE demonstrated significantly greater
improvements in shoulder pain and function compared to those receiving manual therapy
and exercise alone at all follow-up assessments up to 6 months. Notably, the addition of
US-guided PE did not yield significant differences in disability scores compared to the
control group. However, significant improvements were observed for pain and function.
This study is noteworthy for reporting adverse events associated with US-guided PE, with
six patients in the intervention group experiencing transient muscle soreness following
the first two treatments, which resolved spontaneously within 24–36 h. The second study,
by Arias-Buría et al. [55], investigated the comparative effects of US-guided PE combined
Healthcare 2025, 13, 1793 10 of 35

with an eccentric exercise program for the rotator cuff muscles in patients with subacromial
pain syndrome. Thirty-six participants (nine males; mean age 58 years) were randomized
into two groups: one receiving US-guided PE alongside an eccentric exercise program and
another receiving the exercise program alone. The exercise program consisted of eccen-
tric exercises performed twice daily for four weeks. Patients in the US-guided PE group
received the intervention at each exercise session. Individuals receiving the combined
intervention demonstrated greater improvement in shoulder pain compared to those in the
exercise-only group. This improvement was statistically and clinically significant for pain,
but the effect on function did not reach the minimal clinically different threshold.
Another common shoulder problem is supraspinatus tendinopathy; two papers were
retrieved on the subject. Rodríguez-Huguet et al. [56] conducted a randomized controlled
trial investigating the effectiveness of PE compared to DN for supraspinatus tendinopathy.
Thirty-six patients (twenty-seven males, mean age 40.04 years) were assigned to receive
either PE (one treatment per week for four weeks, 350 µA for 1.2 min) or DN (weekly session
for four weeks at the upper trapezius muscle towards supraspinatus). Both groups also
performed eccentric exercises. The PE group showed significantly greater improvements
in pain and shoulder range of motion at the one-year follow-up compared to the DN
group. Góngora-Rodríguez et al. [57] employed an RCT design to investigate the effects of
a combined intervention on supraspinatus tendinopathy. The intervention included PE,
percutaneous peripheral nerve stimulation, and eccentric exercises (3 sets of 10 repetitions
of 3 exercises, twice a day for 4 weeks). Fifty participants (thirty-six males; mean age,
44.24 years) were allocated into two groups. One group received four weekly sessions
of PE and PPNS, while the other group received ten sessions of TENS and US. The PE
group demonstrated statistically significant improvements in pain, strength, supraspinatus
electromyographic amplitude, US characteristics of the tendon (including echogenicity,
thickness, and hypervascularization), and shoulder function.
Lopez-Martos et al. [58] conducted an RCT to evaluate the effectiveness of PE and DN
for temporomandibular myofascial pain. Sixty patients (eight males; mean age, 38.8 years)
participated in the study. Patients were assigned to one of three groups: PE, DN, or sham
needling procedure. The PE group received low-dose electrical stimulation (2 mA for 3 s)
delivered via a needle inserted in the lateral pterygoid muscle. The DN group received
a deep needle puncture into the trigger point without any electrical stimulation. The
sham group received a sham procedure where pressure was applied to the skin without
needle penetration. All groups received treatment once a week for three consecutive weeks.
Follow-up assessments were conducted up to 70 days after treatment. The authors reported
that the PE group experienced significantly greater and faster pain relief and improvement
in mouth opening compared to both the DN and SNP groups. Papers on PE applied for
MSK diseases are reported on Table 2.
Healthcare 2025, 13, 1793 11 of 35

Table 2. Papers on the use of percutaneous electrolysis for management of musculoskeletal disorders.
Human/Not US Age: Mean, Type of Rehabilitation Rehabilitation Rehabilitation Follow- Adverse
Authors, Year Title Study Type Sample Size Sex Operator Setting Outcomes Results
Human Imaging (Range) Disease Pre During Post Up Events

Weekly session of
EPI® and
two weekly sessions
of eccentric exercise.
Patients received the
intratissue
percutaneous
Effectiveness of the
Intratissue electrolysis (EPI® ) Victorian
Percutaneous Two weekly technique treatment Institute of Sport
Electrolysis (EPI® ) sessions of until there Assessment for Average
was clinical No
Ferran Abat, technique and Prospective 25.3 years patellar eccentric exercise up to the patellar 35 points
Human YES 33 M: 29; F: 4 / not / improvement or no adverse
2014 [31] isoinertial eccentric Case Series (16–53) tendinopathy using isoinertial two years tendon (VISA-P), improvement in
improvement in the events
exercise in the resistance the Tegner scale, VISA-P
treatment of patellar machines symptomology was Roles and
tendinopathy at seen after Maudsley scale
two years follow-up 10 sessions,
3 milliamps
echo-guided
punctures, needles
of from 0.30 to
0.32 mm in diameter
and a modified
electric scalpel

Treatment with
the US-guided
EPI technique
Clinical results after and eccentric
Session of PNE every
ultrasound-guided YES (2 weekly Victorian exercises
2 weeks up to a
intratissue sessions of Institute of Sport in patellar
maximum of
percutaneous eccentric exercise 3 months, Assessment– tendinopathy
ten sessions. No
Ferran Abat, electrolysis Prospective Patellar training using 2 years, Patella (VISA-P); resulted in
Human YES 40 M: 35; F: 5 25.5 / NOT NOT Acupuncture adverse
2015 [32] Case Series Tendinopathy the resistance 5 years, Tegner score; the a great
(EPI® ) and eccentric isoinertial 10 years.
needles (0.3 mm in
Roles and improvement in
events
exercise in the diameter) with
leg-press Maudsley knee function
treatment of patel- different lengths.
machine) score and a rapid
lar tendinopathy. Intensity 3 mA
return to the
previous level of
activity after
few sessions

Symptoms and
degenerative
Ultrasound-guided Session of PNE per structural
Yes (home VAS, DASH, US
percutaneous needle week over 4 weeks. changes of
Fermín program evaluation,
electrolysis in Intensity of 4–6 mA for chronic lateral No
Valera- Prospective M: 19; F: chronic lateral consisting 6, 26 and patients’
chronic lateral Human YES 36 38 ± 6.4 / NOT NOT 3 s approximately epicondylitis are adverse
Garrido, Case Series 17 epicondylitis of eccentric 52 weeks perceptions of
epicondylitis: three times. A reduced after events
2014 [45] exercise the overall
short-term and 0.3 × 25 mm (1 inch) US-guided PNE
and stretching) outcome
long-term results acupuncture needle associated with
EccEx and
stretching

US-guided
percutaneous
Application of electrolysis
galvanic current combined with
Ultrasound-Guided through eccentric
Percutaneous 36, randomly acupuncture needle exercises resulted
Electrolysis and assigned into Eccentric exercise on each session once Shoulder pain in slightly better
José L Subacromial No
Eccentric Exercises US-guided PE program of a week (total of (NPRS) and outcomes in the
Arias-Buría, RCT Human YES M: 9; F: 27 58 ± 7 clinician Pain / / 1 week adverse
for Subacromial Pain (n = 17) group the rotator 4 sessions), disability short term
2015 [55] Syndrome events
Syndrome: A or exercise cuff muscles acupuncture needles (DASH) compared to
Randomized (n = 19) group of different lengths when only
Clinical Trial (0.3 mm in diameter, eccentric
intensity of 350 µA exercises were
for 1.2 min) applied in
subacromial
pain syndrome
Healthcare 2025, 13, 1793 12 of 35

Table 2. Cont.
Human/Not US Age: Mean, Type of Rehabilitation Rehabilitation Rehabilitation Follow- Adverse
Authors, Year Title Study Type Sample Size Sex Operator Setting Outcomes Results
Human Imaging (Range) Disease Pre During Post Up Events

Personal
Psychological
Apprehension
Scale (PPAS),
heart rate
variability (HRV),
the standard
deviation of the
RR intervals
(SDNN), the
square root
Significant
of the mean of
increase in
the sum of the
parasympathetic
squares of the
Autonomic activity (in
differences Measurable
responses to One session of PNE. keeping with a
between the increase in
ultrasound-guided patellar Intensity of 3 mA. potential
Blanca de la adjacent RR parasym-
percutaneous needle tendon in Acupuncture vasovagal
Cruz Torres, RCT Human YES 22 M: 22 23.5 PT NOT / NOT NOT intervals pathetic
electrolysis of the healthy male needles with 0.3 mm reaction) during
2016 [34] (rMSSD), and the activity
patellar tendon in footballers diameter and application of the
number of (detected
healthy male different lengths US-guided PNE
adjacent RR by HRV)
footballers. technique on
interval (RRI)
healthy patellar
pairs that differ
tendons of male
by >50 ms in the
football players
full register,
divided by the
total number of
RRIs and
expressed as a
percentage
(pNN50). The
reverse axis
(SD1), the
longitudinal
axis (SD2)

Therapeutic
results after
ultrasound-guided
intratissue Treatment with
percutaneous Four (from 2 to 6)
ultrasound-
rectus 24 h, sessions, once a Verbal Rating
Carlos electrolysis (EPI® ) Prospective abdominis- 1 week, week, with a needle Scale (VRS),
guided EPI
Moreno, in the treatment Human YES 8 M: 8 26.8 PT NOT NOT NOT has shown N.A.
Case Series related 1 month, 0.25 × 30 mm in Patient-Specific
2016 [52] of rectus encouraging
groin pain 6 months diameter. Intensity Functional Scale
abdominis-related clinical
of 3 mA for 4 s
groin pain in results for RAGP.
professional
footballers: a
pilot study.

Two sessions a week

PE treatment in
of PNE. Intensity of
association
3 mA. A
with active
0.33 × 50 mm in
physiotherapy
Intratissue diameter of s
ensured a greater
percutaneous acupuncture needle.
and more rapid
electolysis combined Adductor Intensity of 3 mA.
Patient-Specific reduction of pain
with active longus 3 applications
Carlos Functional Scale and tended to No
physical therapy for enthesopathy- every session
Moreno, RCT Human YES 24 M: 24 26.1 PT NOT YES NOT 6 months (PSFS), Numeric promote greater adverse
the treatment of related groin (3 right + 3 left if
2017 [43] Rating Scale functional events
adductor longus pain the ALErGP-
(NRS) recovery in
enthesopathy- (ALErGP) adductor longus
soccer players
related groin pain: a enthesopathy-
with ALErGP
randomized trial related groin pain
compared
was present
to active
bilaterally), with a
physiotherapy
duration of
only.
5 s each
Healthcare 2025, 13, 1793 13 of 35

Table 2. Cont.
Human/Not US Age: Mean, Type of Rehabilitation Rehabilitation Rehabilitation Follow- Adverse
Authors, Year Title Study Type Sample Size Sex Operator Setting Outcomes Results
Human Imaging (Range) Disease Pre During Post Up Events

Patients
receiving the
therapy
Weekly session for
substantially
three weeks
decreased their
(3 sessions) with
pain,
25 × 0.16 mm
pressure-pain
A novel approach in acupuncture needles. VAS, Northwick
threshold and
the treatment of Starting Park Neck
quality-of-life
acute whiplash intensity was Questionnaire
100, divided measures,
García syndrome: acute 2 mAmp, which was (NPQ), pressure
in two groups: M: 36; equally to
Naranjo J, ultrasound-guided RCT Human YES 38.1 PT whiplash NOT NOT NOT 5 Weeks increased on a pain N.A.
physiother- F: 64 standardized
2017 [42] needle percutaneous syndrome 1 mAmp/s speed to 167 threshold
apy and PE physiotherapy
electrolysis. A reach 4 mAmp, (PPT) with
programs.
randomized repeated three times algometric
Distinguishly,
controlled trial. per session, with assessment
PNE protocol
a resting
consists of only
210 interval of
3 application
1–2 min
sessions of
between shocks.
15 min each one,
with no added
interventions

The inclusion of
US-guided PE in
Disabilities of the combination
manual therapy Arm, Shoulder with manual
and exercise: During the and Hand therapy and
Ultrasound-Guided the program follow-up (DASH) exercise resulted
50 randomized
Application of consisted of period, questionnaire. in no significant
into manual
Percutaneous 3 exercises participants Secondary differences for
therapy/
Electrolysis as an focusing on were asked to outcomes related disability
Lorena de exercise 0.30 mm × 25 mm
Adjunct to Exercise Subacromial supraspinatus, continue with included pain, compared with No
Miguel (n = 25) or the M: 23; Up to needle, intensity of
and Manual RCT Human YES 54 ± 7 years PT Pain / infraspinatus, the exercise function the application of adverse
Valtierra, manual ther- F: 27 6 months 350 µA for a total of
Therapy for Syndrome and scapular program and (Shoulder Pain manual therapy events
2018 [54] apy/exercise 90 s
Subacromial Pain stabilizer this was and Disability and exercise
plus
Syndrome: A muscles. Each monitored on Index [SPADI]) alone in patients
electrolysis
Randomized exercise was subsequent pressure pain with subacromial
(n = 25)
Clinical Trial performed in follow-up thresholds (PPTs) pain syndrome.
3 sets of assessments. and Global Nevertheless,
12 repetitions Rating of Change differences were
(GROC) reported for
shoulder pain
and function

Both techniques
were effective in
the treatment of
64 patients:
PF, providing
32 treated G32 needle, 3 mA
excellent VAS
Intratissue with current was
Visual analog pain and FADI
Percutaneous ultrasound- delivered for 5 s.
Álvaro scale (VAS) to results at
Electrolysis vs. guided EPI The treatment No
Iborra- Retrospective M: 35; plantar record pain and 12 months.
Corticosteroid Human YES and 32 with 46.4 ± 8.5 / / / / 1 year was repeated 7 days adverse
Marcos, Case-Control F: 29 fasciosis the Foot and However, CI
Infiltration for the ultrasound- later and then again events
2018 [38] Ankle Disability required fewer
Treatment of guided for up to 10 sessions
Index (FADI) patient visits
Plantar Fasciosis Corticos- at weekly intervals
and appeared
teroid as required
to provide
infiltration
somewhat better
VAS and
FADI results
Healthcare 2025, 13, 1793 14 of 35

Table 2. Cont.
Human/Not US Age: Mean, Type of Rehabilitation Rehabilitation Rehabilitation Follow- Adverse
Authors, Year Title Study Type Sample Size Sex Operator Setting Outcomes Results
Human Imaging (Range) Disease Pre During Post Up Events

VAS, maximum
interincisal
opening (MIO)
greater and
without causing
earlier relieving
pain or
pain and
Randomized, YES discomfort,
improving MIO
double-blind study (two weeks Session of PNE once involvement of
of patients
comparing after each per week, for the TMJ, assessed
Ricardo temporo- treated with
percutaneous procedure, 3 consecutive weeks. by a 100-point No
Lopez- mandibular 28, 42, and percutaneous
electrolysis and dry RCT Human NOT 60 M: 8; F: 52 38.8 (18–62) / NOT / concentric Intensity of 2 mA questionnaire, adverse
Martos, myofascial 70 days needle
needling for the exercises for 3 s. A Tolerability to the events
2018 [58] pain electrolysis
management of with the 0.25 × 40 mm treatment was
compared to
temporomandibular masticatory acupuncture needle evaluated by the
deep dry
myofascial pain muscles) patient and the
needling and
observer using a
sham needling
5-point scale,
procedure
ranging from 0
(very bad) to 4
(excellent)

The application
of the US-guided
PNE technique
Personal
caused a Significant
Psychological
Autonomic One session of PNE, measurable Auto-
Apprehension
Responses to with three increase in nomic
Scale (PPAS),
Ultrasound-Guided applications with parasympathetic Imbalance
Paula Garcìa diameters of the
Percutaneous Prospective patellar needles with 0.3 mm activity (detected (In
Bermejo, Human YES 36 M: 36 24.36 PT NOT NOT NOT NOT Poincare’s plot
Needle Electrolysis: Case–Control tendinopathy diameter and by heart-rate Keeping
2018 [35] (SD1, SD2), stress
Effect of Needle different lengths. variability— with A
score, and
Puncture or Intensity of 3 mA for HRV), which was Potential
sympathetic/
Electrical Current? 3s due to the Vasovagal
parasympathetic
combination of Reaction)
ratio
needle puncture
and electric
current

VAS, 21-item
activities of daily Improved pain
Session of PE once living subscale of and function.
Prospective per week, for the Foot and This treatment
Fernández- Randomized Trial of 73 (PE group chronic 5 consecutive weeks. Ankle Ability may also No
M: 31, 1, 12, and
Rodríguez T, Electrolysis for RCT Human YES or placebo 46 Clinician plantar NOT / YES A 0.35 × 40 mm Measure decrease fascia adverse
F: 42 24 weeks
2018 [39] Chronic Plantar puncture) heel pain acupuncture needle. questionnaire, thickness (but events
Heel Pain. Intensity of 28 mC of and plantar further studies
cathodal PNE. fascia thickness are needed for
measured by this last point).
ultrasound.

The program
proposed for the
rehabilitation
and readaptation
phase following
an injury
Validity of an Aiken’s V for
to the hamstring
On-Field each item of the
muscle complex
Jiménez- Readaptation program and
Prospective Hamstring was determined
Rubio S, Program Following Human YES 19 M: 19 24.23 ± 5.36 / NOT YES / / / number of days N.A.
Case Series Injury to be valid by the
2019 [48] a Hamstring taken by the
panel of experts,
Injury in players to return
given its
Professional Soccer. to play
soccer-specific
context and that
the entire
program was
carried out on
the field.
Healthcare 2025, 13, 1793 15 of 35

Table 2. Cont.
Human/Not US Age: Mean, Type of Rehabilitation Rehabilitation Rehabilitation Follow- Adverse
Authors, Year Title Study Type Sample Size Sex Operator Setting Outcomes Results
Human Imaging (Range) Disease Pre During Post Up Events

EPTE®
percutaneous
electrolysis device
(Ionclinics & A.
Deionic SL, Valencia,
Spain) for 1.2 min at
Ultrasound-
an intensity of
Eccentric exercise guided
350 µA in the
program to be percutaneous
Percutaneous insertional tendon of Numerical pain
32: trigger performed daily electrolysis as an
Electrolysis in the the muscles of the rating scale
Manuel point dry (three series of adjunct to an
Treatment of Lateral epicondyle using a (NPRS), pressure No
Rodríguez- needling M: 20; Lateral Epi- ten repetitions of up to eccentric exercise
Epicondylalgia: A RCT Human YES 38.16 ± 13.89 PT / / 0.3 mm needle pain thresholds adverse
Huguet, (n = 16) and F: 12 condylalgia eccentric work three months program is more
Single-Blind guided by (PPT), SF-12, and events
2020 [49] PE group twice daily effective for pain
Randomized ultrasound (Voluson elbow range
(n = 16) (morning and and range of
Controlled Trial 730 pro, General of motion
afternoon) with movement than
1 kg weights) Electric® , Boston, trigger point
MA, USA) and dry needling
forming an angle of
between 30◦ and
45◦ with the axis.
The treatment was
performed once a
week for four weeks

PE group:
One treatment per
week over
four weeks (four
sessions in total)
using a
percutaneous
electrolysis EPTE®
device (Ionclinics & PE seems to be
Deionic S.L., more effective
Valencia, Spain) at than TDN in
Eccentric an intensity of relieving pain
Effectiveness of Numerical Pain
exercises for the 350 µA for 1.2 min and improving
Percutaneous Rating Scale
36: PE group supraspinatus to was performed. PE ROM and PPT
Manuel Electrolysis in (NPRS) but the
(n = 18) or a be performed was applied on the supraspinatus No
Rodríguez- Supraspinatus 25–60 Supraspinatus shoulder range
RCT Human YES trigger point M: 27; F: 9 / / daily at home / 1 year injured zone of the values in adverse
Huguet, Tendinopathy: A (40.04 ± 9.88) tendinopathy of motion (ROM)
dry needling from the first to supraspinatus patients with events
2020 [56] Single-Blinded and trigger point
group (n = 18) the last day of tendon, which was supraspinatus
Randomized pressure pain
treatment located by tendinopathy,
Controlled Trial threshold (PPT)
(3 × 10 repetitions): ultrasound both right after
treatment and at
Trigger point dry one-year
needling group: A follow-up.
weekly session for
four weeks
(four sessions in
total) of dry
needling of the
upper trapezius
muscle towards
supraspinatus
Healthcare 2025, 13, 1793 16 of 35

Table 2. Cont.
Human/Not US Age: Mean, Type of Rehabilitation Rehabilitation Rehabilitation Follow- Adverse
Authors, Year Title Study Type Sample Size Sex Operator Setting Outcomes Results
Human Imaging (Range) Disease Pre During Post Up Events

Pain (NRS),
ankle
dorsiflexion
range of motion
(DROM)
30 dancers measured using
Two sessions of
randomly the weight- US-guided PE,
Ultrasound-Guided US-guided PE
allocated to a bearing lunge combined with
Percutaneous therapy (one session
PE group test (WBLT), an eccentric
Needle Electrolysis per week),
B De-la-Cruz- (n = 10), an endurance, the exercise program,
in Dancers with 21.03 ± 2.88 Chronic Eccentric acupuncture needle
Torres, RCT Human YES eccentric M: 27; F: 3 PT / / 4 weeks heel raise test, is a useful N.A.
Chronic Soleus (16–26) soleus injury exercise program measuring
2020 [47] exercise the Dance therapeutic tool
Injury: A 0.30 mm × 40 mm,
group Functional for the treatment
Randomized intensity of 2.5 mA,
(n = 10), or a Outcome Survey of chronic
Clinical Trial during 3 s, 3 times
combined (DFOS) soleus injury
(2.5 : 3: 3)
group (n = 10) questionnaire,
and the minimal
clinically
important
difference
(MCID)

Both PNE and

DN were
effective for PHP
Four sessions of DN management,
or PNE once a week; reducing mean
needle from 30 and maximum
Foot Pain
Comparing two to 75 mm in length pain since the
domain of
dry needling and 0.25 to 0.30 mm first treatment
4, 8, 12, the FHSQ, VAS, No
Al-Boloushi interventions for M: 30; 48.8 ± 8.8, Plantar in diameter. session, with
RCT Human YES 102 PT NOT stretching NOT 26 and Quality of life adverse
Z, 2020 [40] plantar heel pain: a F: 72 (24–60) heel pain Intensity of 1.5 mA long-lasting
52 weeks (QoL) was events
randomised (intensity was effects (52 weeks)
assessed with the
controlled trial adapted to patients’ and significant
EQ-5D-5L
characteristics differences
according to their between groups
pain tolerance) in the case of
QoL at 52 weeks
in favour of the
PNE group

DN or PNE
combined with
an EE program
has not shown to
Disability was be more effective
48 (19 for measured using than a program
each group: the Victorian of only EE to
control Institute improve
A Comparative
group, DN of Sports disability and
Study of Treatment An intensity of 3 mA
intervention Assessment pain in patients
María Pilar Interventions galvanic current was
combined patellar up to Questionnaire, with Patellar
López-Royo, for Patellar RCT Human YES M: 42; F: 6 18–45, (32.46) PT / Eccentric exercise / used during the 3 s N.A.
with EE tendinopathy 22 weeks patellar tendon. tendinopathy in
2021 [33] Tendinopathy: A that the
group, or VAS, Short the short (10 wk)
Randomized procedure lasted
PNE Form-36. and medium
Controlled Trial
intervention Ultrasound was (22 wk) terms.
combined used to measure Clinical
with EE) structural improvements
abnormalities were not
associated with
structural
changes in the
tendon.
Healthcare 2025, 13, 1793 17 of 35

Table 2. Cont.
Human/Not US Age: Mean, Type of Rehabilitation Rehabilitation Rehabilitation Follow- Adverse
Authors, Year Title Study Type Sample Size Sex Operator Setting Outcomes Results
Human Imaging (Range) Disease Pre During Post Up Events

PNE treatment
was more
cost-effective
than DN, with
significant
differences
at 52 weeks. In
Cost-Effectiveness of the comparisons
One session a week EQ-5D-5L
Two Dry Needling made according
Secondary of PNE or DN for (EuroQoL), the
Fernández D, Interventions for M: 30; 48.8 ± 8.8, Plantar to the cost-
analysis of Human / 102 PT NOT YES NOT 52 Weeks 4 weeks. Procedure quality-adjusted N.A.
2021 [41] Plantar Heel Pain: A F: 72 (24–60) heel pain effectiveness
RCT not described life years
Secondary Analysis analysis, this
in detail (QALYs)
of an RCT. translated into an
86% probability
that PNE
was more
cost-effective
compared to
DN at
52 weeks

15 equally
randomized
to the
HIPE and LIPE
high-intensity
Myofascial induce PPT
percutaneous
Short-term The HIPE group trigger points changes in
electrolysis
effectiveness of high- received a 660 mA (MTrPs), patellar MTrPs and
(HIPE)
and low-intensity galvanic current for tendon pain patellar
Juan Antonio experimental
percutaneous Patellofemoral 10 s, the LIPE group pressure tendon and No
Valera- group,
electrolysis in RCT Human / / 25.6 ± 1.9 PT pain / / / 1 week 220 mA × 30 s, and thresholds improvements in adverse
Calero, low-intensity
patients with syndrome the Dry Needling (PPTs), and SAKPP and seem events
2021 [37] percutaneous
patellofemoral group received no subjective to produce less
electrolysis
pain syndrome: A galvanic current; anterior knee pain during the
(LIPE)
pilot study 0.30 × 40 needle pain perception intervention
experimental
(SAKPP) compared
group or Dry
with DN
Needling
active
control group

A single PE
54 asymp- Widespread intervention
Endogenous Pain tomatic pressure pain modulated pain
Modulation in subjects thresholds processing in
Response to a Single randomized low-intensity (PPTs), local and
Session of into three (0.3 mA, 90 s), and conditioned pain widespread
Sergio Varela- No
Percutaneous groups: sham M: 34; 22.96 ± 3.63 high-intensity (three modulation areas, implying
Rodríguez, RCT Human YES PT asymptomatic / / / / adverse
Electrolysis in (without F: 20 (18–40) pulses of 3 mA, 3 s) (CPM), and an endogenous
2022 [1] events
Healthy Population: electrical 0.3 × 25 mm temporal pain modulation.
A Double-Blinded current), acupuncture needle summation (TS) The pain
Randomized low-intensity, were assessed in processing effect
Clinical Trial and high- the elbow, was independent
intensity shoulder, and leg of the dosage
administrated
Healthcare 2025, 13, 1793 18 of 35

Table 2. Cont.
Human/Not US Age: Mean, Type of Rehabilitation Rehabilitation Rehabilitation Follow- Adverse
Authors, Year Title Study Type Sample Size Sex Operator Setting Outcomes Results
Human Imaging (Range) Disease Pre During Post Up Events

The total cost per

session was
similar in the
three groups:
EUR 9.46 for the
percutaneous
needle
electrolysis group;
EUR 9.44 for the
dry needling
group; and EUR
8.96 for the sham
group. The
percutaneous
Percutaneous needle
needle
electrolysis
Eccentric Costs, electrolysis group
A comparative (three needle
48 randomly exercise: quality-adjusted presented better
study of treatment insertions
divided into three sets of life years and cost-effectiveness
Daniel interventions 0.25 mm × 25 mm,
Secondary three groups: fifteen repetitions incremental cost- in terms of
Fernández- for patellar patellar up to intensity of 3 mA,
analysis of Human YES PE, dry M: 42; F: 6 32.5 ± 7.14 PT / of single-leg / effectiveness quality-adjusted N.A.
Sanchis, tendinopathy: tendinopathy 22 weeks 3 s), dry needling
RCT needling and squats on a ratio, SF-36 life years and 96%
2022 [36] a secondary (idem as PE), or
sham decline transformed to and 93%
cost-effectiveness sham needling. Four
needling board QoL values using probability of
analysis treatment sessions,
twice a day SF-6D scores being
once every 2 weeks
cost-effective
over 8 weeks
compared to the
sham and dry
needling groups,
respectively.
Percutaneous
needle
electrolysis has
a greater
probability
of being
cost-effective than
sham or dry
needling
treatment

Specific exercise
program
20: an
Ultrasound-Guided (4 sessions per The application
experimental
Percutaneous week during of the US-guided
group Pain intensity,
Needle Electrolysis 4 weeks) based PNE combined
(exercise PE: needle dorsiflexion
Combined with on strength with a specific
program + US- PE: Soleus Injury 0.30 mm × 40 mm, range of motion,
Blanca De-la- Therapeutic Exercise gluteus exercise, exercise program
Prospective guided PNE; 21.30 ± 3.80 in Female intensity of 1.5 mA, knee-flexion heel
Cruz-Torres, May Add Benefit in Human YES F: 20 PT / eccentric / 4 weeks may cause N.A.
Case–Control n = 10) or a Control: Soccer during 3 s, 3 times raise test, curve
2023 [53] the Management of hamstring clinical benefits
control group 23.40 ± 5.98 Players Control: idem sprint test, and
Soleus Injury in exercise, in the treatment
(exercise without current the global rating
Female Soccer eccentric of female soccer
program + sham of change scale
Players: A gastrocnemius players with
stimulation;
Pilot Study exercise, and soleus injury
n = 10)
eccentric soleus
exercise

Pain intensity:
modified visual
Efficacy of Deep Dry
numeric pain
Needling versus
scale (VNPS), PE and DDN
Percutaneous
Single treatment pressure pain appear to have
Electrolysis in 52—
session, needle threshold (PPT), similar
Ana Isabel Ultrasound-Guided intervention non-specific
PE: M: 8 (0.30 mm × 30 or cervical range of short-term No
Benito-de- Treatment of Active (PE; n = 26) 38.77 neck pain
RCT Human YES F: 19–DDN: PT / / / 14 days 0.30 mm × 40), motion (CROM), effects. PE adverse
Pedro, Myofascial Trigger and control (36.15–41.38) lasting more
M: 8 F: 19 3–5 applications of neck disability: proved to be a events
2023 [51] Points of the Levator (DDN; n = 26) than 3 months
5 s at an intensity of Northwick Park more painful
Scapulae in groups
1.5 mA. Pain treatment
Short-Term: A
Questionnaire than DDN
Randomized
(NPQ) and
Controlled Trial
post-needling
soreness
Healthcare 2025, 13, 1793 19 of 35

Table 2. Cont.
Human/Not US Age: Mean, Type of Rehabilitation Rehabilitation Rehabilitation Follow- Adverse
Authors, Year Title Study Type Sample Size Sex Operator Setting Outcomes Results
Human Imaging (Range) Disease Pre During Post Up Events

A 0.3 × 25 mm
acupuncture needle
46 at 45◦ to the skin in
Widespread
(three groups the direction of the
pressure pain
receiving a lateral epicondyle.
thresholds (PPT),
single The sham group did
conditioned pain One session of
ultrasound- not receive any
Effectiveness of modulation PE is able to
guided PE electrical current,
different (CPM), and slightly stimulate
intervention: Sham: M: just the
percutaneous temporal modulatory
Juan L sham 5; F: 11 needle insertion; the
electrolysis protocols summation (TS) pathways related No
Sánchez- (without Low Int: low-intensity group
in the endogenous RCT Human YES 18–40 PT asymptomatic / / / / were bilaterally to nociceptive adverse
González, electrical M: 5; F: 10 received an electrical
modulation of pain: assessed in the gain, particularly events
2023 [44] current), High Int: galvanic
A Double-Blinded lateral pressure pain
low-intensity M: 5; F: 10 current at an
Randomized epicondyle, sensitivity and
(0.3 mA, intensity of 0.3 mA
Clinical Trial bicipital groove, temporal
90 s), or for 90 s, whereas the
transverse summation
high-intensity high-intensity
process of C5 and
(three pulses groups received
the tibialis
of 3 mA, three pulses of 3 mA
anterior muscle
3 s) PE for 3 s each of
electrical galvanic
current

Structural and
pain (NPRS),
Functional Changes 50
strength, elec-
in Supraspinatus randomized Four treatment
Eccentric exercise tromyographic Combined
Tendinopathy in two groups: sessions, one per
program activity, treatment with
through PE + peripheral week, intensity:
consisting of ultrasound PE, Peripheral
Percutaneous nerve 350 µA for 72 s,
Jorge 3 sets of characteristics of Nerve
Electrolysis, stimulation 0.30 × 40 mm
Góngora- M: 36; Supraspinatus 10 repetitions of up to the tendon Stimulation, and
Percutaneous RCT Human YES (n = 25) and 44.24 ± 11.80 PT / / acupuncture N.A.
Rodríguez, F: 14 tendinopathy each of the 24 weeks (echogenicity, EE is an effective
Peripheral Nerve conventional needles; PNS is
2024 [57] 3 exercises, thickness, and option, with
Stimulation and electrother- carried out after the
twice a day, hypervascular- positive results in
Eccentric Exercise apy treatment application of PE,
during the ization) and the short and
Combined Therapy: (TENS + with the same
4 weeks functionality long terms
A Single-Blinded therapeutic treatment frequency
(DASH and
Randomized US)
SPADI)
Clinical Trial

Pulsed negative
pressure
myofascial
vacuum therapy
and ultrasound-
guided
percutaneous
electrolysis, as an
adjunct to an
Pulsed negative
Pain, Range of eccentric exercise
pressure myofascial
Motion (ROM), program, is more
vacuum therapy and One weekly session
pressure pain effective for pain,
Manuel percutaneous of PNE, for 4 weeks,
threshold (PPT), range of No
Rodríguez- electrolysis in the M: 25, Lateral Epi- 1 and with a needle
RCT Human YES 40 40.1 PT NOT YES NOT Patient-Rated movement, adverse
Huguet, treatment of lateral F: 15 condylalgia 3 months 0.3 mm in diameter.
Tennis Elbow pressure pain events
2024 [50] epicondylalgia: A Intensity of 3.5 mA
Evaluation threshold, and
single-blind for 80 s
Questionnaire functionality
randomized
(PRTEE) than manual
controlled trial
therapy and
ultrasound
treatment as an
adjunct to the
same exercise
program in
patients with
lateral
epicondylalgia
Healthcare 2025, 13, 1793 20 of 35

Table 2. Cont.
Human/Not US Age: Mean, Type of Rehabilitation Rehabilitation Rehabilitation Follow- Adverse
Authors, Year Title Study Type Sample Size Sex Operator Setting Outcomes Results
Human Imaging (Range) Disease Pre During Post Up Events

Eccentric exercise
could be effective
in improving
functionality in
patellar
tendinopathy
and DN could
48 random- improve
ized into Eccentric eccentric power
Functionality and One treatment
groups: DN, exercises Spanish version in jumps
jump performance session
percutaneous (three sets of of VISA-P and a performance.
in patellar every 2 weeks.
López-Royo electrolysis Lateral Epi- fifteen single-leg Up to jump protocol Moreover, the
tendinopathy with RCT Human YES M: 42, F: 6 32.46 ± 7.14 PT NOT NOT Needles N.A.
MP, 2024 [59] (PNE), and condylalgia squat repetitions 3 months to assess DN group
the application of (0.25 × 25 mm), for
sham on a decline participants’ experienced an
three different 2 s at 3 mA
needling as board twice performance increase in
treatments galvanic current
the control a day) functionality that
group (CG) correlated
with the
improvements
found in jump
performance in
eccentric power
and concentric
strength

48 divided
Placebo and nocebo
into 3 parallel
effects of
groups: Needling
percutaneous needle
“no-sham unilateral Clinical pain therapies for
electrolysis and
group” (PNE eccentric exercise reduction after individuals with
dry-needling: an
intervention), program of the Every group needle patellar
intra and
“single-sham quadriceps received intervention tendinopathy are
Doménech- inter-treatment Secondary No
group” (sham 35.16 Patellar muscle on the four sessions of the (placebo) and prone to elicit
García V, sessions analysis of analysis Human YES M: 42, F: 6 PT NOT NOT / adverse
PNE by using (28–43.5) Tendinopathy affected side needling therapies needle-related placebo effects
2024 [60] a three-arm of RCT events
dry needling), (3 sets of targeting the patellar pain intensity regarding clinical
randomized
and 15 repetitions tendon over 8 weeks after needle pain and nocebo
double-blinded
“double-sham daily on a intervention effects regarding
controlled trial in
group” (sham decline board) (nocebo) needling-
patients with
PNE by using related pain
patellar
sham
tendinopathy
needles).

VAS decreased
Biochemical Pain (VAS), from 8/10 to
Mustafa
reactions and function 2/10;
Turgut 4 weeks US-guided PNE, No
ultrasound insights Lateral (QuickDASH), QuickDASH
Yildizgoren Case Report Human YES 1 F 45 / / / / post- three sessions, adverse
in percutaneous epicondylitis ultrasound improved from
et al., 2025 treatment 350 µA, 80 sec each events
needle visualization of 56 to 18;
[46]
electrolysis therapy gas formation hyperechoic foci
(gas) seen on US

N.A.: Not available.

Healthcare 2025, 13, 1793 21 of 35

3.2. Animal Studies

Only two papers were retrieved about animal studies. Sanchez-Sanchez et al. (2020) [5]
investigated the effects of PE on Achilles tendon tendinopathy in a mouse model. They
divided fifteen mice into three groups: PE, DN, and a control group with no treatment.
All groups received a single intra-tendinous collagenase injection to induce tendinopathy.
The PE group received three weekly sessions of PE (3 mA, 4 s). Gene analysis revealed
increased activity of genes involved in rebuilding collagen and the surrounding tissue in
the PE group, suggesting that PE may promote healing. Margalef et al. investigated a
mouse model of sciatic nerve entrapment to assess the potential therapeutic effects of PE.
The researchers applied PE (1.5 mA for 3 s, repeated three times) near the site of nerve
entrapment caused by induced fibrosis. After three weeks, they observed a near-complete
recovery of the compound muscle action potential amplitude, suggesting that PE may have
facilitated the release of the entrapped sciatic nerve [61]. Papers on PE applied on animal
models are reported in Table 3.

3.3. Cadaveric Studies

Five papers were retrieved about PE application on cadavers (Table 4). Belón-
Pérez et al. [62] conducted a study to investigate the accuracy and safety of PE targeting
the supinator muscle. The study involved two parts: a human volunteer experiment and
a cadaveric dissection analysis. In the human volunteer experiment, PE was applied to
five healthy participants using US imaging to guide needle placement. The researchers
assessed two different needle insertion approaches with the forearm in supination and
pronation, both with the elbow extended. The cadaveric dissection analysis involved
three Thiel-embalmed cadaver forearms. A needle was inserted into the supinator muscle
with the surrounding tissues intact. The researchers then left the needle in place during
dissection to confirm if the tip had reached the targeted muscle. The study findings demon-
strated that PE achieved accurate needle placement within the supinator muscle in 100%
of the trials, based on both US imaging in the human volunteers and visual confirmation
during cadaveric dissection. Additionally, no punctures of the deep branch of the radial
nerve bundle were observed in any of the needle insertions. Calderón-Díez et al. [63]
investigated the safety and accuracy of PE targeting the interface between the Achilles
tendon and Kager’s fat. The study employed a two-part design as well: a human volunteer
experiment with US guidance and a cadaveric dissection analysis. In the human volunteer
experiment, 10 healthy individuals (4 males; mean age, 45 years) participated. US imaging
was used to guide needle placement during PE application at the targeted interphase. A
25 × 0.3 mm filiform solid needle was inserted from the medial to the lateral side, under the
body of the Achilles tendon, approximately 5 cm from its insertion point on the calcaneus.
The cadaveric dissection analysis involved 10 fresh cadaver legs. However, unlike the
human experiment, US guidance was not employed for needle placement in the cadavers.
The study concluded that PE can be safely performed at the Achilles tendon–Kager’s fat
interphase if US imaging is used to guide needle placement. The same group investigated
the safety of US-guided PE targeting the interface between the patellar tendon and Hoffa’s
fat pad. The study utilized a two-part design: a human volunteer experiment with US
guidance and a cadaveric dissection analysis. In the human experiment, 10 healthy vol-
unteers (7 males, mean age 42 ± 10 years; 3 females, mean age 33 ± 8 years) participated.
US imaging was used to guide needle placement during PE application at the targeted
interphase. A 25 × 0.3 mm filiform solid needle was inserted from the lateral to the medial
side, traversing the patellar tendon to reach the deep interface with Hoffa’s fat pad. The
procedure was performed by an experienced PT. The cadaveric analysis involved 10 knees
from 5 fresh cadavers (2 males, mean age 69 ± 4 years; 3 females, mean age 75 ± 6 years).
Healthcare 2025, 13, 1793 22 of 35

Unlike the human experiment, US guidance was not employed for needle placement in
the cadavers. Dissection was performed to identify the anatomical relationship between
the patellar tendon, saphenous nerve, and infrapatellar nerve branches. The study found
that in all cadaveric specimens, infrapatellar nerve branches ran predominantly through
the medial aspect of the knee and crossed in front of the patellar tendon. None of the
nerve branches were pierced when the needle was inserted from the lateral side. In the
human experiment, US imaging allowed for safe needle placement, though visualization
of the infrapatellar nerve was challenging. The authors concluded that PE can be safely
performed at the patellar tendon–Hoffa’s fat pad interface if a lateral approach is used
and US imaging guides needle placement. The medial approach poses a higher risk to the
infrapatellar nerve branches due to their variable anatomy and proximity to the tendon [64].
Borrella-Andrés et al. [65] conducted a cadaveric study to investigate whether PE ap-
plications generate temperature changes in musculoskeletal tissues. This research aimed to
clarify a proposed mechanism of action for PE, which is its potential thermal effect. Ten cry-
opreserved knees (five from male donors and five from female donors) were used in the
study. US guidance ensured accurate needle placement within the targeted tissues: patellar
tendon, infra-patellar fat pad, and vastus medialis muscle. A thermometer was positioned
near the needle tip to measure temperature changes during PE application. Two different
PE protocols were employed depending on the targeted tissue: tendon: three applications
of 3 s each with a current intensity of 3 mA; fat or muscle: three applications of 3 s each
with a current intensity of 1.5 mA; all tissues: a single application of 24 s with a current
intensity of 1 mA. The study found no significant temperature increases within the tendon,
fat, or muscle tissues following PE application using either protocol.
Malo-Urriés et al. [66] conducted a cadaveric study to evaluate the dose-dependent
structural effects of PE on muscle tissue using quantitative US imaging. The primary
aim was to determine whether varying intensities of galvanic current induce measurable
changes in muscle architecture and to identify objective ultrasound-based biomarkers for
optimizing PE dosage. Twenty-nine samples of medial gastrocnemius muscle, obtained
from cryopreserved cadavers (50% male, mean age 73.7 years), were used. Each sample
received a single, randomly assigned dose of galvanic current ranging from 0 to 10 mA
for one second under ultrasound guidance by an experienced operator. Quantitative
US analysis was performed immediately after each application to assess geometric and
textural changes in the tissue. The study found clear dose–response relationships in several
ultrasound parameters, particularly the number, area, and perimeter of affected regions,
as well as measures of homogeneity and contrast. Notably, significant structural changes
became apparent at intensities above 1 mA, with a plateau effect observed beyond 4 mA,
suggesting a physiological threshold for muscle tissue response.
Healthcare 2025, 13, 1793 23 of 35

Table 3. Papers on the use of PE in animal models.

Human/Not US Age: Mean, Type of Rehabilitation Rehabilitation Rehabilitation Follow- Adverse
Authors, Year Title Study Type Sample Size Sex Operator Setting Outcomes Results
Human Imaging (Range) Disease Pre During Post Up Events

Percutaneous
Needle Electrolysis amplitude
sciatic nerve was
Reverses Mouse model 1.5 mA for 3 s and (peak-to-peak) of
definitively
R Margalef, Neurographic Signs of sciatic 3 repetitions in the the compound
/ Animal / 46 / / / / / / released from its N.A.
2020 [61] of Nerve nerve immediacy of muscle action
fibrous
Entrapment by entrapment perineural fibrosis potential
entrapment
Induced Fibrosis (CMAPs)
in Mice

3 sessions (one per

week) Each
Changes in Gene percutaneous
Expression electrolysis session
Associated with consisted of percutaneous
Collagen three punctures electrolysis
15 divided
Regeneration and targeting the increases the
into
Remodeling of Achilles genes involved expression of
José Luis three different
Extracellular Matrix Achilles intra-tendon 2 mm in tendon repair some genes
Sánchez- groups (no
after Percutaneous / Animal / / 8 weeks / tendon / / / / away from the and remodeling associated with N.A.
Sánchez, treatment vs.
Electrolysis on tendinopathy osteotendinous and histological collagen
2020 [5] percutaneous
Collagenase- junction. The tissue changes regeneration and
electrolysis vs.
Induced Achilles intensity of the remodeling of
needling)
Tendinopathy in an continuous extracellular
Experimental (galvanic) electrical matrix
Animal Model: A current was set at
Pilot Study 3 mA and applied
for 4 s on
each puncture

N.A.: Not available.

Healthcare 2025, 13, 1793 24 of 35

3.4. Ultrasound Imaging and Percutaneous Electrolysis

The use of US guidance in PE was evident in all the papers and was motivated by
several factors that enhance the safety, precision, and overall effectiveness of the treatment.
US allows for the real-time visualization of the treatment area, enabling precise needle
placement within pathological tissue. This precision is critical for the effectiveness of
percutaneous electrolysis, as it ensures that the galvanic current is delivered exactly where
it is needed to stimulate the desired healing response. Moreover, the ability to accurately
target the damaged tissue minimizes the risk of affecting surrounding healthy structures,
which can reduce the likelihood of unnecessary damage and improve patient outcomes.
Additionally, US guidance was particularly useful in complex cases [31,32,45,48,52], where
the anatomical structures are difficult to navigate without visual assistance. It allows
practitioners to adapt the treatment to the specific needs of the patient, ensuring that the
therapy is both effective and safe.

3.5. Risk of Bias Assessment and Applicability Concerns

The complete set of randomized controlled trials (RCTs) (k = 100%) was evaluated,
and the scores are shown in Figure 2.
The 80% were assessed with a low risk of bias for random sequence (selection bias),
and the 55% were assessed with low risk of bias for allocation concealment (selection bias).
About the blinding of participants and personnel (performance bias), 40% were assessed
with low risk, while 30% had a high risk and the other 30% had an unclear risk. Regarding
the blinding of outcome assessment (detection bias), 80% were assessed with a low risk of
bias and 20% with an unclear risk. Concerning incomplete outcome data (attrition bias),
70% were assessed with a low risk, 10% with a high risk, and 20% with an unclear risk. In
relation to selective reporting (reporting bias), 25% were assessed with a low risk and 75%
with an unclear risk. Finally, for other bias, 25% were assessed with a low risk, and 75%
were assessed with unclear risk. NOS scores of the included studies’ articles are shown in
Table 5. After evaluation by two researchers, the studies received an average NOS score of
9.0, indicative of high-quality studies.
The JBI Critical Appraisal Checklist for Case Reports Studies was used to assess the
quality of case reports (Table 6).
The RoB for the included animal studies was evaluated using the SYRCLE Risk of
Bias tool (Table 7). Sequence generation and allocation concealment were frequently
not adequately addressed. Sánchez-Sánchez did not report random sequence generation
or allocation concealment, indicating a high or unclear risk of selection bias. Margalef
reported appropriate sequence generation but not allocation concealment [61]. Both studies
lacked random housing and blinding of caregivers or investigators, suggesting a high risk
of performance bias. Neither study reported random outcome assessment or blinding
of outcome assessors, indicating a high risk of detection bias. Both studies adequately
addressed incomplete outcome data, minimizing the risk of attrition bias. Both studies
were free from selective outcome reporting, suggesting low risk in this domain.
The QUACS scale’s results are reported in Table 8. The main sources of potential
bias across all studies were the lack of control for intra- and inter-observer variability and
the absence of sample size justification. These limitations should be considered when
interpreting the findings. However, the studies were otherwise methodologically sound,
with clear aims, well-described procedures, and appropriate statistical analyses.
Healthcare 2025, 13, 1793 25 of 35

Figure 2. Risk of bias summary: review authors’ judgements about each risk of bias item for
each included study. Green dots with “+”: low risk of bias; red dots with “−”: high risk of bias;
white square: unclear risk. Al-Boloushi [40], Arias-Buría [55], Benito-de-Pedro [51], De la Cruz
Torres (2016) [34], De la Cruz Torres (2020) [47], De Miguel Valtierra [54], Doménech-García [60],
Fernández [41], Fernández-Rodriguez [39], Fernández-Sanchis [36], García Naranjo [42], Góngora-
Rodríguez [57], Lopez-Martos [58], López-Royo (2021) [33], López-Royo (2024) [59], Moreno [43],
Rodríguez–Huguet (2020-1) [49], Rodríguez-Huguet (2020-2) [56], Rodríguez-Huguet (2024) [50],
Sánchez–González [44], Valera–Calero [37], Varela–Rodríguez [1].
Healthcare 2025, 13, 1793 26 of 35

Table 4. Cadaver studies.

Human/Not Type of
Authors, Year Title US Imaging Sample Size Sex Age: Mean, (Range) Operator Follow-Up Setting Outcomes Results
Human Disease

Three applications for 3 s of 3 mA

Application of of intensity (3:3:3) when the
The application of two different PE
Sergio Percutaneous Needle tendon was the targeted tissue,
protocols did not produce
Borrella- Electrolysis Does Not 10 cryopre- three applications for 3 s of 1.5 mA Temperature changes in target tissues
Cadaver YES M: 5; F: 5 67–85 / / / appreciable thermal changes in the
Andrés, Elicit Temperature served knees of intensity (1.5:3:3) when the fat or after PE application
tendon, fat, and muscle tissues of
2022 [65] Changes: An In Vitro muscle was the targeted tissue,
human cadavers
Cadaveric Study and 24 s of 1 mA of intensity
(1:24:1) in all tissues

Human: Two approaches were

taken, the first one with the
forearm in supination and the
Five healthy
Cadaveric and second one with the forearm in Accurate needle penetration of the
volunteers
Ultrasound Validation of pronation, both with the supinator muscle was observed in
(ultrasound
Pedro Percutaneous elbow straight 100% in both US-imaging and
study) and 5 humans + Radial tunnel
Belón-Pérez, Electrolysis Approaches YES (Human) / / PT / Ability to reach the target tissue cadaveric studies. No
three Thiel- 3 cadavers syndrome
2022 [62] at the Arcade of Frohse: Cadaver: The needle was inserted neurovascular bundle of the
embalmed
A Potential Treatment for into the cadaver with all the tissues radial-nerve deep branch was
cadaver
Radial Tunnel Syndrome overlaid and left in situ during the pierced in any insertion
forearms
anatomical dissection to determine
if the tip of the needle properly
reached the supinator muscle

A needle was inserted from the

Cadaveric and medial to the lateral side under the
Ultrasound Validation of body of the Achilles tendon, just
10 healthy
Percutaneous between the tendon and the Percutaneous electrolysis can be
Laura volunteers Achilles
Electrolysis Approach at human + Kager’s triangle, about 5 cm from safely performed at the Kager’s
Calderón- YES + M: 4; F: 6 45 ± 14 years PT tendon / Ability to reach the target tissue
the Achilles Tendon as a cadaver the insertion of tendon in fat-Achilles tendon interphase if it
Díez, 2022 [63] 10 fresh tendinopathy
Potential Treatment for the calcaneus is US-guided.
cadaver legs
Achilles Tendinopathy:
A Pilot Study Humans: 25 × 0.3 mm filiform
solid needle

The Safety of Humans: mean No neurovascular bundle of

Ultrasound-Guided 10 healthy 42 (males), Cadaveric dissection infrapatellar nerve branches was
Laura Anatomical safety of needle approach,
Needle Approaches for human + humans, Humans: M: 7; F: 3 33 (females); Patellar (non-US-guided) pierced in any insertion from the
Calderón- YES (Human) PT / visualization of infrapatellar nerve
Patellar Tendinopathy: A cadaver 10 knees from Cadavers: M: 2; F: 3 Cadavers: mean tendinopathy Ultrasound-guided needling in lateral side; lateral approach
Díez, 2025 [64] branches, safety of lateral approach
Theoretical 5 cadavers 69 (males), healthy volunteers considered safe; medial approach
Cadaveric Model 75 (females) vulnerable to nerve injury

0.00–10.00 mA.
Dose-dependent changes in
Quantitative Ultrasound
ultrasound parameters;
Characterization of None Initial intensity increments were set at
Yes Muscle_Electrolysis_Dose variable
Miguel Intensity-Dependent (cadaveric 0.10 mA, followed by 0.50 mA increments
(quantitative Not explained 66.7% of dose variance;
Malo-Urriés, Changes in Muscle Cadaver 29 M: 50% 73.7 ± 9.94 None medial / up to the
ultrasound specified significant differences between low,
2025 [66] Tissue During gastrocnemius maximum intensity (10.00 mA).
imaging) medium, and high doses;
Percutaneous muscle)
identified a 1–4 mA therapeutic
Electrolysis Each application lasted exactly
window for muscle response
one second

Table 5. Study of quality assessment using Newcastle–Ottawa scale for case–control studies. Each asterisk represents whether individual criterion within the
subsection was fulfilled.
References Selection Comparability of Cohorts Ascertainment of Exposure Outcomes Non Response Rate NOS Score

Adequate Case Definition Representativeness of Cases Selection of Controls Definition of Controls Same Method of Ascertainment

Iborra-Marcos [38] ** * * ** * * ** - 10

De-la-Cruz-Torres [53] ** * * ** * * * - 9

García Bermejo [35] * * * * * ** ** - 9

Healthcare 2025, 13, 1793 27 of 35

Table 6. Study of quality assessment using JBI Critical Appraisal Checklist for Case Reports Studies.
Were Patient’s Demographic Was the Patient’s History Clearly Was the Current Clinical Were Diagnostic Tests or Was the Intervention(s) or Was the Post-Intervention Were Adverse Events (Harms) or
Does the Case Report Provide
References Characteristics Described and Presented as Condition of the Patient on Assessment Methods and the Treatment Procedure(s) Clinical Condition Unanticipated Events Identified
Takeaway Lessons?
Clearly Described? a Timeline? Presentation Clearly Described? Results Clearly Described? Clearly Described? Clearly Described? and Described?

Abat [31] Y - Y - Y Y Y Y

Valera-Garrido [45] Y - Y - Y Y Y Y

Abat [32] Y Y Y - Y Y Y Y

Moreno [52] Y Y Y Y Y - Y -

Jiménez-Rubio [48] Y - - - Y - - -

Yildizgoren [46] Y Y Y Y Y Y Y Y

Table 7. SYRCLE Risk of Bias table for animal studies: 0 = no; 1 = yes.
Blinding of Random Outcome
References Sequence Generation Baseline Characteristics Allocation Concealment Random Housing Blinding of Outcome Assessor Incomplete Outcome Data Selective Outcome Reporting Other Sources of Bias
Caregivers/Investigators Assessment

Sánchez-Sánchez [5] 0 1 0 0 0 0 0 1 1 1

Margalef [61] 1 1 0 0 0 0 0 1 1 0

Table 8. QUACS Risk of Bias scale: 0 = no; 1 = yes.

Detailed Anatomical Intra-Observer Inter-Observer Outcome
Clear Aim of Adequate Sample Inclusion/Exclusion Appropriate Procedural Statistical Analysis Sample Size Conflict of Interest
References Dissection Landmarks Variability Variability Measurement
the Study Description Criteria Instrumentation Reproducibility Performed Justification Disclosed
Procedure Described Controlled Controlled Described

Borrella-Andrés [65] 1 1 0 1 1 1 0 0 1 1 1 0 1

Belón-Pérez [62] 1 1 1 1 1 1 0 0 1 1 1 0 1

Calderón-Díez [63] 1 1 1 1 1 1 0 0 1 1 1 0 1

Calderón-Díez [64] 1 1 0 1 1 1 0 0 1 1 0 0 1

Malo-Urriés [66] 1 1 0 0 1 1 0 0 1 1 1 0 1
Healthcare 2025, 13, 1793 28 of 35

4. Discussion
PE is gaining traction as a novel therapeutic strategy for MSK disorders, particularly
tendinopathies. Notably, the reviewed studies did not consistently report the inclusion of a
motor re-education program alongside PE interventions. When present, motor re-education
was typically implemented either concurrently with PE or immediately following the PE
protocol, often continuing a previously established exercise regimen. Interestingly, we did
not identify any data on the potential benefits of applying physiotherapy interventions
specifically before PE treatment. The studies that incorporated motor re-educational
programs primarily focused on eccentric exercises or stretching techniques. The association
of PE and physiotherapy seems to improve the results of both techniques carried out
alone. Standardized re-educational programs are crucial to ensure patient safety and
proper technique.
In the course of our research, we found other possible delivery methods or diseases
where PE is applied in different fields, either as protocols/suggestions or as completed
clinical trials (i.e., for endogenous pain modulation [67], mammary fistulas [8,68], bi-
ceps brachii tendinopathy [69], debridement of the plantaris tendon [70], proximal ham-
string tendinopathy-related sciatic nerve entrapment [71], patellar tendinopathy [72,73],
plantar heel pain [74], chronic masticatory myalgia [75], infectious diseases [76,77], lung
tumors [78–80], liver tumors [81], orbital venous malformation [82], to dissolve metallic
stents leaving the luminal tissues intact [83], and recanalization of urinary collecting system
obstructions [84]).
While PE application is gaining traction in clinical practice, several key points warrant
further discussion based on the findings presented in this review. The studies included in
this review suggest that PE may be effective in treating various MSK conditions, including
patellar tendinopathy, plantar fasciitis, chronic low back pain, lateral epicondylitis, and
others. However, it is important to note that a major limitation across the studies reviewed
is the lack of standardized protocols for PE application. This inconsistency includes varia-
tions in participant characteristics (e.g., anthropometrics), evaluation methods, use of US
guidance, and the incorporation of motor re-education. The absence of standardization
makes it challenging to directly compare the findings and weakens the overall quality
of evidence for PE. Another limitation identified in the reviewed studies is the lack of
reporting on the healthcare professional administering PE. While the studies included
here primarily involved PTs performing the procedure, not all studies disclosed this infor-
mation. It is well-established that PTs play a vital role in rehabilitation of patients with
MSK disorders through physiotherapy techniques like motor re-education and physical
agent application [23,85]. However, concerns arise regarding the safety of PTs adminis-
tering invasive or minimally invasive procedures like PE. Research suggests that PE can
induce significant autonomic imbalance and potentially trigger vasovagal reactions [34,35].
While the clinical relevance of this finding requires further investigation, it highlights the
importance of minimizing the risk of vasovagal episodes, including syncope. Therefore,
to ensure patient safety, it is crucial for either a medical doctor to perform PE directly
or for PTs to be adequately supervised by a physician during the procedure. Moreover,
from a legislative standpoint, the practice of US-guided percutaneous needle electrolysis by
physical therapists varies significantly depending on the country and its specific regulations
governing physical therapy and invasive procedures.
The precise mechanisms underlying the therapeutic effects of PE remain elusive.
Proposed theories suggest that PE may induce a localized inflammatory response, promot-
ing tissue healing and regeneration [86]. Additional mechanisms might involve thermal
changes, alterations in blood flow patterns, modulation of pain perception, or direct me-
chanical effects from needle insertion, similar to DN. However, in-depth analysis of PE’s
Healthcare 2025, 13, 1793 29 of 35

effects on biological tissues is still lacking. Notably, one cadaveric study included in this
review found that two different PE protocols did not generate significant temperature
changes in tendon, fat, or muscle tissues. This suggests that a thermal effect is unlikely
to be a primary mechanism of action for PE in clinical practice [65]. These findings are in
agreement with an in vitro study by Margalef et al. [87] aimed at the evaluation of safety of
PE procedures by analyzing potential alterations in the needles used. Authors examined
the effects of three different PE protocols on commonly used PE needles. Temperature
changes were measured by immersing the needles in test tubes containing Ringer’s so-
lution. A multimeter assessed changes in electrical resistance, and a scanning electron
microscope was used to compare the pre- and post-treatment needle morphology. Ad-
ditionally, radiographic diffusion analysis evaluated the needle composition. The study
found no significant temperature changes in Ringer’s solution during PE application. No-
tably, the in vitro analysis did not detect any loss of metal particles or alterations in the
needle morphology following PE protocols, which is reassuring for the application of PE in
clinical practice.
This review also identified a wide heterogeneity in treatment protocols across studies,
including variations in needle type, intensity of electrical current, and treatment duration.
Standardization of treatment protocols is necessary to optimize PE’s effectiveness and
facilitate comparisons between studies. PE administration under US guidance seems to
be a valid option to raise its effectiveness and safety. US-guided invasive procedures
are usually more precise, as also confirmed by cadaver studies [4,62,73]. US provides
real-time visualization, allowing for precise needle placement within pathological tissue,
which is crucial for delivering the galvanic current effectively and minimizing harm to
surrounding healthy structures. This approach is effective in reducing pain and enhancing
the combination with other rehabilitation techniques.
As previously mentioned, these studies were conducted using varying protocols.
Additionally, discrepancies in terminology and the explanation of methodologies pose a
significant limitation, making it difficult to translate and compare results. This extreme
heterogeneity hampers to the performance of quantitative analyses and undermines the
overall level of evidence. Moving forward, it is crucial to develop more high-quality clinical
trials to validate the use of PE in the different musculoskeletal disorders and facilitate the
application in daily practice, ensuring that these key technical aspects are standardized.
Lastly, cost-effectiveness analyses suggest PE might be a cost-effective option for some
MSK conditions compared to other interventions. However, further research is needed to
confirm these findings.
Importantly, PE aligns with the principles of personalized medicine (PM), which em-
phasizes tailoring treatments to individual patient profiles [88]. The variability in patient
responses to PE underscores the potential for precision approaches, such as customizing
galvanic current intensity, needle placement, and treatment frequency based on specific
conditions and individual characteristics. Gender differences should also be systematically
considered to evaluate potential variations in outcomes and responses [89]. By integrating
PM into PE protocols, clinicians can deliver targeted interventions that maximize therapeu-
tic benefits while minimizing risks. This personalized approach could significantly enhance
the clinical utility of PE in rehabilitation settings.

Limitations and Future Perspectives

Our findings showed that PE emerged as a clinically meaningful tool to improve
pain and functional outcomes for tendinopathies and other musculoskeletal disorders,
particularly when combined with eccentric exercise or stretching protocols. However, het-
erogeneity in treatment parameters (e.g., current intensity: 0.3–660 mA, session frequency:
Healthcare 2025, 13, 1793 30 of 35

1–10 sessions), operator expertise, and patient selection criteria limit its standardization.
While most of the assessed studies used US guidance to enhance precision, significant gaps
persist in understanding its biological mechanisms and long-term cost-effectiveness. Over-
all, the included studies showed low bias levels, but sample size was generally fairly small.
Thus, current evidence supports the use of PE as a supportive intervention, but it
should not yet be recommended as a first-line standard treatment. The reason for this
is the lack of comparative effectiveness data, protocol variability, and uncertainty about
PE’s mechanistic effects. PE may play a role in multimodal Individual Rehabilitation
Projects [90–92] for the treatment of patients with chronic tendinopathies unresponsive to
physical therapy and athletes needing an accelerated return to play. Patient selection criteria,
protocol standardization, and practitioner training requirements are central for clinical
integration. Contraindications to be considered should involve acute inflammation, cardiac
pacemakers, autonomic dysfunction, and local skin infections. Based on current evidence,
a current intensity of 1.5–3 mA, with sessions occurring once a week for 3–5 weeks, not
exceeding ten sessions, appears as the best clinical framework. Adjunctive measures
include eccentric exercises and US guidance. Practitioner training requires physicians
(physiatrists or orthopedic surgeons), along with safety protocols for autonomic instability
screening and post-treatment monitoring. Future research priorities should include studies
on electrolysis-induced cellular changes, dose–response RCTs comparing low- and high-
intensity protocols, and health economic analyses to assess cost-effectiveness against other
established therapies.

5. Conclusions
PE is emerging as a novel and promising treatment for MSK disorders, especially
those affecting tendons. Studies show PE effectively reduces pain and improves function
in several conditions. US guidance is often used for accurate needle placement and better
results. Interestingly, most studies combined PE with physiotherapy exercises, typically
eccentric exercises or stretching, and this combination seems to be more effective than PE
alone. However, these physiotherapy programs were inconsistently applied, either along-
side PE or following PE, highlighting the need for standardized re-educational programs to
ensure patient safety and proper technique. By integrating PM principles into PE protocols,
more targeted and effective interventions could be delivered while minimizing risks. This
personalized approach could significantly enhance PE’s clinical utility in rehabilitation
settings. Some points still raise concerns: variations in patient characteristics, treatment
methods, and even who administers PE make it difficult to compare results and assess the
overall effectiveness of PE; secondly, the exact mechanisms by which PE works are still
unclear; thirdly, cost-effectiveness analyses suggest PE might be a cost-effective option, but
more studies are needed to confirm this. In conclusion, PE is a promising new approach
for treating MSK disorders, but further research is necessary to standardize protocols,
understand its mechanisms of action, and confirm its cost-effectiveness.

Author Contributions: Conceptualization, C.P.; methodology, C.P. and N.M.; software, C.P. and N.P.;
validation, C.P., N.M., A.S., N.P. and C.F.; formal analysis, C.P., N.M., A.S., N.P. and C.F.; investigation,
C.P., N.M., A.S. and N.P.; resources, C.P. and C.F.; data curation, C.P., N.M., A.S. and N.P.; writing—
original draft preparation, C.P. and N.M.; writing—review and editing, C.P., N.M., A.S., N.P. and C.F.;
visualization, C.P., N.M., A.S., N.P. and C.F.; supervision, C.P.; project administration, C.P. All authors
have read and agreed to the published version of the manuscript.

Funding: This research received no external funding.

Institutional Review Board Statement: Not applicable.

Informed Consent Statement: Not applicable.

Healthcare 2025, 13, 1793 31 of 35

Data Availability Statement: No new data were created or analyzed in this study. Data sharing is
not applicable to this article.

Conflicts of Interest: The authors declare no conflicts of interest.

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