Dry Needling

Original Editor - Ajay Upadhyay

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Introduction

TrP-DN used to target and relieve myofascial trigger points in muscle tissue.

Over the past two decades, dry needling has gained considerable popularity in the management of musculoskeletal pain and associated disability, used either independently or alongside other therapeutic approaches.

The most widely used and evidence-supported dry needling approach is Trigger Point Dry Needling (TrP-DN). It is a minimally invasive procedure where a fine needle or acupuncture needle is inserted into the skin and muscle, with no substances being injected or withdrawn during the process. It targets myofascial trigger points (MTrPs), hyperirritable spots palpable as nodules in the taut bands of skeletal muscles.

Pathophysiology of MTrPs

The pathophysiology of MTrPs is most widely explained by the energy crisis model:

• Muscle overload or repetitive strain reduces local blood flow, depriving tissue of oxygen and nutrients.
• This triggers excessive acetylcholine release at the neuromuscular junction, sustaining muscle contraction.
• Sustained contraction further compresses blood vessels, worsening ischemia and causing metabolic waste accumulation.
• These sensitise peripheral nerve endings, activate nociceptors, and amplify pain signals, leading to peripheral sensitisation.
• The result is localised pain and stiffness, characteristic of a myofascial trigger point.

MTrPs also play a role in central sensitisation. While the mechanism is not fully understood, MTrPs could, over time, sustain nociceptive input into the dorsal horn, thereby contributing to central sensitisation.

MTrPs can be categorised into active and latent MTrPs.

• Active MTrPs can spontaneously trigger local or referred pain. They cause muscle weakness, restricted range of motion (ROM), coordination deficits, pain and autonomic phenomena.
• Latent MTrPs do not cause pain unless they are stimulated. They may alter muscle activation patterns and restrict ROM.
• Both active and latent MTrPs cause allodynia at the trigger point site and referred pain in response to applied pressure.

Causes of MTrPs are likely multifactorial, including eccentric muscle overload, sustained postures, and repetitive low-load stress, all of which can contribute to the vulnerability of muscle to develop MTrPs.

Trigger Point Dry Needling Approaches

Superficial TrP-DN

Superficial TrP-DN involves inserting the needle up to 10 mm into the subcutaneous tissue, without reaching the MTrPs. Its benefits include ease of administration, decreased risk of significant tissue trauma, reduced risk of nerve and visceral injury and patient comfort.

Mechanisms of action:

Superficial TrP-DN appears to work by stimulating Aδ nerve fibres just beneath the skin, triggering the release of natural pain-relieving chemicals in the spinal cord that block pain signals. It may also reduce sympathetic nervous system activity and improve local blood flow, further easing pain and muscle tension. However, its overall effectiveness remains debated.

Deep TrP-DN

Deep TrP-DN involves the insertion of the needle beyond the subcutaneous tissue into the muscle to reach MTrPs.

Mechanisms of action:

Evidence suggest that TrP-DN immediately increase pressure pain threshold and ROM, decrease muscle tone, and decrease pain in patients with musculoskeletal conditions. The suggested mechanisms of action include:

• Local Twitch Response: TrP-DN can elicit a ‘local twitch response’, an involuntary spinal reflex resulting in a localised contraction of the affected muscles that are being dry-needled. Local twitch response can lead to alteration in the length and tension of muscle fibres and stimulate mechanoreceptors like Aβ fibres.
• Effects on Blood Flow: Sustained contraction of taut muscle bands in trigger points might cause local ischemia and hypoxia. TrP-DN causes vasodilation in the small blood vessels leading to increased muscle blood flow and oxygenation.
• Neurophysiological effects: TrP-DN can elicit local and central nervous responses, promoting homeostasis at the trigger point site and leading to a decrease in both central and peripheral sensitisation to pain.
• Remote Effects: Some studies have shown that TrP-DN of distal MTrP has been found to have an analgesic effect on proximal MTrP. Interestingly, other studies used electromyography to show that needling of active MTrPs can elicit twitch responses on both the treated and contralateral side. This supports the theory of a centrally-maintained state rather than a purely peripheral phenomenon. This contrasts with latent MTrPs, which appear to produce twitch responses on the treated side only. Overall, the literature remains conflicting regarding contralateral effects.
• Patient Expectation: Studies have demonstrated that expectation, referred to as the placebo effect, can activate similar brain regions to those modulated by TrP-DN. This could in turn influence pain perception.

Electrical Trigger Point Dry Needling

Demonstration of EDN applied to the right hamstring muscles.

Electrical Trigger Point Dry Needling (EDN) is a technique in which two needles are inserted as electrodes for passing an electric current to the MTrPs.

Mechanisms of action:

Studies suggest that EDN shares the same therapeutic benefits as conventional TrP-DN. It may additionally enhance endogenous opioid inhibitory pathways, stimulate spinal serotonin receptors, and promote GABA response.

Indications

The following conditions have clinical rationale supporting the use of TrP-DN:

• Myofascial pain with the presence of trigger points
• Chronic pain
• Spine-related conditions, including low back pain
• Strains
• Tendinopathies
• Tension-type headaches
• Osteoarthritis
• Fibromyalgia

Contraindications

Contraindications to TrP-DN vary across jurisdictions and clinical guidelines. Practitioners are advised to refer to their local regulatory body and clinical guidelines for specific contraindications (see Safety Considerations section). The following list is not exhaustive and provides general guidance only:

• Needle phobia or unwillingness to undergo TrP-DN
• Significant cognitive impairment limiting the patient's understanding of the procedure
• Active local or systemic infection at/near the treatment site
• Oedema in the area to be treated
• Vascular conditions in the treatment area, such as varicose veins
• Compromised immune system, which may increase the risk of infection
• First trimester of pregnancy
• Children under the age of 12

Clinical Evidence

Musculoskeletal Pain

An 2023 Umbrella Review (i.e. a review of systematic reviews and meta-analyses) reported that:

• TrP-DN is effective for short-term pain relief, outperforming sham or no treatment across all body regions
• TrP-DN is not superior to other treatments such as manual therapy or exercise, but may offer additional benefit when combined with conventional physiotherapy
• Evidence on ROM improvements remains inconclusive, varying considerably across body regions and treatment protocols
• TrP-DN appears most effective in the early stages of acute musculoskeletal pain; as rehabilitation progresses, exercise therapy becomes increasingly important
• Evidence on strength improvements is limited and conflicting
• Mid- and long-term effects remain insufficiently studied, with high heterogeneity between trials

Concerning superficial vs deep dry needling:

A 2025 systematic review comparing deep and superficial dry needling for neck pain, which included eight RCTs with varying risk of bias, found that:

• Both approaches may be effective in reducing MTrP-related pain in the short term
• The majority of included studies reported no significant difference in pain outcomes between the two techniques, consistent with findings from similar reviews on other body regions
• Two RCTs demonstrated a statistically significant advantage of deep over superficial dry needling, with pain reductions exceeding the minimal clinically important difference for neck pain, suggesting potential clinical relevance

Concerning EDN:

Findings from a 2023 systematic review and meta-analysis on the impact of EDN on pain and disability in patients with musculoskeletal shoulder pain suggest that:

• EDN, used alone or in combination with conventional physiotherapy, may yield clinically meaningful improvements in pain and disability
• However, these improvements did not reach statistical significance when compared to conventional physiotherapy alone
• Those results are based on a meta-analysis of five fair-to-good quality RCTs, warranting caution in results interpretation

TrP-DN and neurological conditions

Stroke

According to a 2020 systematic review, which included studies of varying methodological quality, the use of DN alone or with other interventions generally resulted in improvement in spasticity level, pain intensity, and ROM  in stroke survivors.

Fibromyalgia

A 2022 systematic review and meta-analysis showed that TrP-DN may produce short-term improvements in pain, quality of life, vitality, social functioning, psychological wellbeing, and symptom severity in patients with fibromyalgia. It appeared to outperform techniques such as manual myofascial release and cross taping. However, the authors note that the overall quality of evidence remains low-to-moderate.

Practical Applications

Dosage and Treatment Parameters

While no consensus exists on optimal DN parameters, weekly sessions over a one-to-three week period may be sufficient to achieve short-term pain relief. The number of needles and needle retention time should be adapted to the individual patient, as the literature currently lacks clear guidance on these parameters.

Integration into treatment

TrP-DN is best used as part of a broader physiotherapy programme rather than as a standalone intervention. Where wet needling is also considered, DN may be a practical first-line option given its simplicity and lower cost.

Safety Considerations

Since TrP-DN is an invasive needle technique, clinicians must understand the associated risks and adhere to their country's specific regulations.

TrP-DN Associated Adverse Events

An adverse event (AE) refers to any unintended, non-therapeutic harmful effect, regardless of its severity.

Patient-related AEs:

Patient-related AE range from minor issues to serious incidents.

Minor AE describes a temporary, non-serious reaction that leaves the patient's function unchanged and resolves within hours or a few days. Minor AE effects include:

• Post-needling soreness
• Hematoma in the needle area
• Pain during or after treatment
• Autonomic symptoms like nausea, vertigo, and sweating

Major adverse events are defined as moderate-to-severe incidents lasting days to weeks, potentially requiring further treatment and causing significant distress. Serious AE include:

• Pneumothorax (the most frequently reported severe AE, particularly with deep insertion into the iliocostalis, upper trapezius, and levator scapulae)
• Spinal cord injury
• Infection
• Iatrogenic injury to vessels, nerves, internal organs, or implanted devices

While temporary discomforts like soreness and bruising affect approximately 19–36% of individuals, serious complications occur in fewer than 0.1% of cases. However, the likelihood of severe harm increases significantly if the practitioner lacks adequate training in invasive techniques. Clinicians should ensure patients are fully aware of the potential risks and side effects before undergoing TrP-DN.

Therapist-related AEs:

Clinicians risk accidental needle sticks during handling or disposal. The American Centers for Disease Control and Prevention (CDC) reports approximately 385,000 annual sharps injuries among healthcare workers, 65% of which are needle sticks.

Practice Regulation

This page is for educational purposes only. TrP-DN should only be performed by trained and licensed healthcare professionals within their permitted scope of practice. Physiopedia strongly discourages readers from attempting to use TrP-DN on themselves or others without appropriate training. Regulation of TrP-DN varies considerably between countries and professional bodies. Practitioners are advised to consult their own jurisdiction's legislation and professional guidelines before practising.

Summary

TrP-DN is an increasingly popular technique among rehabilitation professionals. It is primarily used for short-term pain relief in patients with musculoskeletal conditions. While recent evidence suggests it is superior to sham or no treatment, it is best used as an adjunct to a broader physiotherapy programme rather than as a standalone intervention. Given its invasive nature, practitioners must adhere to contraindications and consult their local regulatory guidelines, as scope of practice varies internationally.