Foundation | Movement & Injury Science

—

Dry needling has become one of the most talked-about treatments in sports physical therapy. If you’ve been to a PT in the last few years, there’s a good chance someone has either recommended it to you, poked you with thin needles, or at least brought it up as an option. The marketing around it ranges from measured (“it can help with certain types of muscle pain”) to breathless (“it’s a breakthrough technique that eliminates trigger points and restores function”). The truth, as usual, is less exciting than the marketing and more nuanced than the critics suggest. Like always, it’s somewhere in the middle.

I believe dry needling is useful and helpful. I also think the field has a clarity problem. The proposed mechanism is more complicated than most practitioners explain, the scientific basis is decent but not overwhelming, and the conditions for which it helps are narrower than the hype suggests. Here’s what I think you should know.

What it is

Dry needling involves inserting thin, solid filament needles (the same needles used in acupuncture, but applied with a different rationale) into muscle tissue, usually targeting what we call myofascial trigger points. Trigger points are irritable spots within a taut band of skeletal muscle. They’re tender when compressed, they can refer pain to other areas, and they’re associated with muscle dysfunction. We often call these “knots” colloquially. If you feel around your traps, I’ll bet you could find some.

The “dry” in dry needling means nothing is injected into the body. No medication, no saline, no anesthetic. The stabbing from the needle itself is the intervention. The method descends from a “wet needling” technique where lidocaine was injected into the muscle knots. The dry technique typically produces a “local twitch response,” which is a brief, involuntary contraction of the muscle fibers near the needle. This twitch is often considered a positive sign that the needle has hit the trigger point, though the clinical significance of the twitch response is debated and it can hurt sometimes. In a larger muscle, like a glute or calf, these twitches can even bend the needle!

How it might work

The traditional “trigger point model”, developed primarily by Drs. Travell and Simons in the 1980s and 1990s, proposes that trigger points represent localized areas of sustained muscle contraction caused by dysfunctional motor endplates. Basically, muscles are stuck contracted in certain spots because a small part of them isn’t working correctly. The theory goes like this: an area of muscle is stuck in a contracted state due to excessive acetylcholine release at the neuromuscular junction (acetylcholine is the main neurotransmitter that causes muscles to contract and the neuromuscular junction is the area where the neurons connect to the muscle fibers). The sustained muscle contraction creates a local energy crisis (the contracted fibers are consuming ATP faster than they can produce it), which leads to the release of inflammatory and pain-sensitizing chemicals, which leads to pain and referred patterns.

Put simply, the muscle gets stuck contracting, there isn’t enough energy there to uncontract it (it takes ATP to release a muscle contraction), and the whole area gets inflamed and uncomfortable.

According to this theory, dry needling mechanically disrupts the dysfunctional motor endplate by stabbing into it, causing a local twitch response that resets the contracted fibers, and allowing normal blood flow and metabolism to resume. Essentially, you poke the spot and shock it into changing.

This is a plausible mechanism, but the evidence supporting it is weaker than the confidence with which it’s often presented. The existence of trigger points at all has been questioned by several researchers. Drs. Quintner, Bove, and Cohen published a critique in 2015 in the journal Rheumatology that argues that the trigger point model is unfalsifiable and that the clinical findings attributed to trigger points (taut bands, referred pain patterns, etc.) can be explained by peripheral nerve sensitization without invoking a muscle-specific mechanism. That is, trigger point pain could be many things, it doesn’t have to be a muscle, and there isn’t great evidence that we know what it is. People are still arguing about this (there have been at least three more papers sent back and forth between these authors and their critics) and I’d predict that we’re a long way from the end of that debate.

What we can say for sure is that dry needling produces measurable effects: reduced pain, improved range of motion, and changes in muscle activation patterns. Whether these effects are mediated by the trigger point mechanism specifically, by a more general neurophysiological response (similar to manual therapy), or by a combination of both is still being sorted out and will be for quite a while. Fortunately, it doesn’t matter that much! You can do it or receive it without worrying about all this.

What the science says about dry needling

The evidence for dry needling is positive but limited. It consistently beats sham (placebo) needling for short-term pain relief in several conditions. The effects on long-term outcomes are less clear. But it does indeed do something.

A 2013 systematic review by Cagnie and colleagues in the Journal of Bodywork and Movement Therapies found that dry needling produced significant immediate and short-term improvements in pain and disability for myofascial pain (muscle/fascia pain). A 2017 Cochrane-style review (one of best ways to do a review) by Gattie and colleagues confirmed moderate evidence for short-term pain reduction in musculoskeletal conditions (kinda everything).

For specific conditions relevant to endurance athletes, the evidence is mixed. There’s reasonable evidence for dry needling as a treatment for plantar fasciitis, lateral epicondylalgia (tennis elbow), and neck/shoulder myofascial pain. The evidence for lower extremity tendinopathies (Achilles, patellar) is weaker, and loading programs remain the primary treatment regardless of whether needling is added. Adding needling can help, but you still need to load heavily.

Here’s a crucial point: most positive studies compare dry needling plus exercise to exercise alone. The added benefit of needling on top of a good exercise program tends to be small. The exercise is doing the heavy lifting (literally). The needling may speed up pain reduction in the early phase to make the exercise more tolerable, which connects to the same logic described in the manual therapy article. It’s a facilitator, not a treatment.

tl;dr on that portion: needling reduces pain and can make exercise more tolerable to do. Exercise actually heals you. Needling should be used alongside exercise, not instead of it.

What it’s good for (in my opinion)

Acute myofascial pain with identifiable trigger points. This is an athlete with a painful, palpable knot in their calf, glute, or upper trapezius that’s limiting their movement. Needling can produce rapid pain relief that allows rehab to proceed.

Muscle-related referred pain patterns. An athlete presenting with lateral hip pain that turns out to be referred from a glute min. trigger point rather than a true bursitis or tendinopathy. Needling the referring muscle can resolve the pain pattern quickly.

Facilitating range of motion. An athlete with acutely restricted dorsiflexion that’s limiting their calf raise progression during Achilles rehab. Needling the soleus or gastroc can produce a temporary range improvement that makes the loading exercises more effective.

What it’s not good for

Chronic pain without an identifiable muscular component. If the pain is driven by central sensitization (described in the pain science articles in the knowledge library), needling a muscle isn’t addressing the problem. It might provide temporary relief through a novel sensory stimulus, but it’s not targeting the mechanism. Pain neuroscience education and graded exposure are more appropriate.

Tendinopathy as a primary treatment. The evidence doesn’t support dry needling as a primary treatment for Achilles, patellar, or any other tendinopathy. Loading programs are the foundation. Needling might be useful for managing associated muscle pain or facilitating the loading work, but it’s not replacing the loading.

As a maintenance intervention. “I need my needling every two weeks” is a sign that the underlying problem hasn’t been addressed. Like manual therapy, dry needling should be a bridge to active rehab, not an ongoing dependency.

The risks

Dry needling is generally safe when performed by a trained clinician. The most common side effects are post-needling soreness (similar to the soreness after a deep massage, lasting 24 to 48 hours) and mild bruising. Serious complications are rare but include pneumothorax (lung puncture, primarily a risk with needling of the upper trapezius and thoracic paraspinals by poorly trained practitioners), nerve injury, and infection. These are uncommon, but possible.

The competency question matters. Dry needling training requirements vary by state and profession. Some states require extensive post-graduate training. Others allow practitioners to needle after a weekend course. The quality of the clinician performing the technique matters enormously. Ask about their training, their experience, and how many hours of dry needling-specific education they’ve completed.

The bottom line

Dry needling produces real, measurable pain relief for some conditions, particularly when associated with myofascial trigger points. The mechanism is probably a combination of local tissue effects and broader neurophysiological pain modulation. It works best as an adjunct to active rehabilitation, not as a standalone treatment. It’s not a replacement for loading programs in tendinopathy, not a cure for chronic pain, and not something you should need on an ongoing basis. Used well and at the right time, it’s a useful tool. Used as the entire toolbox, it’s a problem.

---

Wondering if dry needling might help your situation? Book a consultation with RVA Endurance PT.