Dry needling, the insertion of solid filiform needles into specific targets to increase blood flow to tissue and reduce trigger points, has become a common intervention in the treatment of musculoskeletal pain and soft tissue dysfunction. Dry needling has been used in the United States since the mid-1980s, initially by physical therapists and more recently by athletic trainers and occupational therapists. As a result, many continuing education courses have been developed to educate practitioners in safe and effective performance of dry needling techniques. State practice acts vary in terms of allowing and limiting these various health care professionals from performing dry needling with patients, and many practice acts mandate appropriate training and education prior to performing dry needling. Therefore, clinicians should consult their specific state practice acts to be sure they are not prohibited from performing dry needling as part of the plan of care. To date, although some evidence supports the short-term benefits of dry needling in the treatment of musculoskeletal pain, the long-term effectiveness of dry needling for pain reduction and improved functional outcomes is lacking.
Scifers: How are you using dry needling in your practice? How do you incorporate dry needling into the overall treatment plan for your patients?
Stewart: Gaining the ability to incorporate dry needling into my clinical practice has been instrumental in the treatment and recovery of our student-athletes at Georgia Tech. Currently, eight of our nine full-time athletic training staff members are dry needling practitioners and it has become one of the most popular and used modalities in our Sports Medicine department. When I initially began “needling,” my approach was to save it as the last tool in my toolbox because I wanted to exhaust other treatment options before implementing an invasive technique. More recently, however, I find myself using needling much earlier to rectify various conditions from chronic inflammation to acute swelling due to the positive outcomes and rapid improvement of injuries I have seen.
Adams: I am primarily using dry needling for the treatment of musculoskeletal injuries. Rarely, I also use dry needling in the treatment of general medical conditions. I typically incorporate dry needling as an accessory to long-term corrective exercise techniques. I also integrate it in certain acute settings, such as headaches and sinus infections.
Taylor: I tend to use dry needling as a preventative and maintenance treatment for muscular tightness and musculoskeletal injuries. When looking at each patient's treatment plan, I take into account their practice and lifting schedules, as well as the timing of any other soft tissue modalities. I also consider the patient's ability to tolerate a “needling” treatment and, for those who do not tolerate it well, we will consider other modalities.
Scifers: For which conditions do you find dry needling to be most useful? Have you experienced conditions that do not respond well to dry needling?
Adams: I have had the most success with dry needling with application related to tendon and musculotendinous junction pathologies, such as biceps tendinitis, medial and lateral epicondylitis, patella tendinitis, and rotator cuff tendinitis. I have also found it useful in the treatment of tension-related or cervicogenic headaches. I have not had success with the “periosteal pecking” technique for the treatment of chronic joint surface pathologies.
Stewart: Dry needling has been beneficial in treating a wide variety of conditions for me, but I would say it has been most effective with trigger points and soft tissue adhesions. Prior to becoming a dry needling practitioner, I have had cases where patients with moderate muscle strains would take approximately 2 weeks before returning to full activity with traditional modalities and techniques. By incorporating dry needling into my treatment regimen, I have not only seen recovery times drastically shorten, but have also had student-athletes state improvement with functional ability. Additional positive responses have been noted in the reduction of acute joint swelling associated with sprains and muscular contusions. Overall, there have been few instances where patients have responded with no or minimal improvement from dry needling.
Taylor: I have seen the most success when dry needling the lower leg for conditions such as shin splints and calf injuries. I have also had success treating proximal hamstring and upper trapezius pathologies. Carpal tunnel syndrome is a condition that I have seen not respond well to dry needling.
Scifers: How have you seen dry needling benefit your patients in terms of clinically measurable outcomes, such as decreasing pain and improving range of motion, strength, and function?
Adams: I have seen the technique lead to decreased pain and decreased tightness, which has led to an increase in the other three measures. I communicate with my patients that the technique will lead to a “one-step back, two-steps forward” approach with their pathology. The residual post-treatment soreness and tightness typically exacerbate the symptoms for a brief 12- to 18-hour period, before the positive results are seen.
Stewart: When working with a collegiate athletic population, I am dealing with patients who typically have sustained and recovered from numerous injuries throughout their careers. Although a fair amount of my evidence in regard to dry needling is anecdotal, I will say the majority of patients who undergo a session for the first time will state significant improvement in symptoms within 24 hours after treatment. Some of the most common responses are a feeling of decreased muscular restriction and decreased soreness. Other patients have noted relief in the overall recovery of muscles that have been subject to increased activity loads.
Taylor: Typically, my patients report decreased pain, increased range of motion, and increased function 24 to 48 hours after a dry needling treatment. We tend to especially see this when we are dry needling the lower leg, and these results typically last several days to weeks.
Scifers: Have you identified any negative effects from the use of dry needling that you would want other clinicians to be aware of?
Adams: I have noticed a localized histamine reaction at the location of the needle application that is a short-term effect of the treatment.
Stewart: At this point, I have not had any negative responses other than occasional soreness after a session.
Taylor: I have also noticed that some of my patients experience soreness lasting 2 to 3 days after dry needling. Therefore, clinicians must be cognizant of a patient's training and practice schedules when applying dry needling.
Scifers: There is a limited amount of peer-reviewed, clinical research regarding dry needling. How would you like to see this technique investigated in the future?
Adams: I would like to see the technique investigated, but I understand the limitations due to the individualized reactions to needles and predetermined notions surrounding treatment. I do not put much stock in cadaver-related research using this technique due to the removal of the human interaction variable mentioned previously. I believe roundtable discussions or similar question-and-answer publications will be the method of choice for dispersing knowledge about dry needling.
Stewart: What I would really like to see is research on high-level athletes and if there is a correlation between the use of dry needling and recovery time. At the collegiate level, training has become year-round for just about every sport and the expectation for these athletes is to become bigger, faster, and stronger. For clinicians, coming up with methods to improve and achieve this is the name of the game. I believe that dry needling can play a significant role in athletic recovery.
Taylor: I would like to see more evidenced-based research for dry needling, such as incorporating the use of musculoskeletal ultrasound to confirm that we are needling the structures we believe we are treating.
Scifers: Based on your personal experiences using dry needling in clinical practice, do you envision the procedure becoming part of entry-level athletic training education?
Adams: I do not believe dry needling will become part of entry-level athletic training education any time soon. This is primarily due to current limitations involving state practice acts that may restrict athletic trainers' ability to perform dry needling. I believe dry needling proponents would be better served lobbying state licensing boards for increased use of the technique.
Stewart: My initial reaction was to say no because it is an invasive treatment that can cause serious harm and complications if administered incorrectly, but that can be said about all modalities found in a clinical setting. I can definitely envision dry needling being taught in entry-level athletic training programs because of its high success rate as a treatment intervention. In general, I would like to see more uniformity in the educational standards surrounding dry needling. As I previously stated, I have many colleagues who are dry needling practitioners. Although we are all credentialed to perform dry needling and are attempting to accomplish the same treatment outcomes, our intervention techniques may be slightly different.
Taylor: At this point, I do not believe dry needling should become part of entry-level athletic training education. I believe that as a clinician, dry needling is beyond an entry-level skill and should require additional training and education. Clinicians need to have a thorough understanding of functional anatomy and biomechanics before adding dry needling as a treatment.
Scifers: For a clinician who has not used dry needling previously, what advice would you offer for getting started with this treatment intervention?
Taylor: For those clinicians thinking about using dry needling in their practice, my advice would be to know your anatomy. The better you can visualize the anatomy you are treating, the better your outcomes will be.
Stewart: I would highly recommend that any clinician who meets the necessary requirements to become a dry needling practitioner should become certified in this technique. Not only is it beneficial to you as clinician to obtain another credential and another set of clinical skills, but your patients will also see significant improvement when treating a wide variety of musculoskeletal conditions.
This clinical roundtable was conducted in January 2020.
- Dunning, J, Butts, R, Mourad, F, Young, I, Flannagan, S & Perreault, T. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014;19(4):252–265. doi:10.1179/108331913X13844245102034 [CrossRef]25143704
- Gattie, E, Cleland, JA & Snodgrass, S. The effectiveness of trigger point dry needling for musculoskeletal conditions by physical therapists: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2017;47(3):133–149. doi:10.2519/jospt.2017.7096 [CrossRef]28158962