We get this question a lot. Because there is not a lot of good information regarding dry needling In today’s post we will cover all aspects of dry needling from the theories behind it and different philosophies to how dry needling is performed and all the aches and pains that dry needling can help with.

For Starters, what is dry needling?

I know, I know. The word “needle” sounds really scary but in reality it’s not all that bad! Simply put, dry needling is an invasive technique that utilizes small micro-filament needles (just like acupuncture needles) that are inserted into painful/dysfunctional areas in the body to relieve pain, improve mobility, and stimulate the healing process.

Sounds simple right? Well, sort of. The theories and principals behind how and why dry needling works are a little more complex. Because of this we will go through all of the different models and philosophies behind dry needling.

1. Mechanical Model – Trigger Point

   In order to understand the underlying mechanisms of the mechanical model of DN, knowledge of the physiology and patholophysiology of myofascial trigger points (MTrP) is necessary. A MTrP is defined as “a hyperirritable point in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band.” They can be classified into 2 forms:

    

   ·       Active/Central MTrP: this type of MTrP is symptom producing, tender to palpation, and may elicit local and/or referred pain, and parasthesia. Commonly exist in the center of the muscle belly, where the motor endplate enters the muscle. The pain produced is typically the patient’s complaint. 

    

   ·       Attachment MTrP: this type of MTrP is symptomatic and can be exquisitely tender. They are typically located at the tendo-osseous junction. Known to be the result of an associated chronic active/central MTrP due to symptom reduction at the attachment MTrP once the primary central MTrP has been treated. 

    

   ·       Latent MTrP: this type of MTrP is typically asymptomatic, unless stimulated through palpation. The pain produced is typically not the patient’s complaint. Most active MTrP will turn into latent MTrP.

    

   MTrPs are the defining characteristics in myofascial pain syndrome. All MTrPs create clinical signs of disturbed motor function, muscle weakness, muscle stiffness, and potential loss of range of motion due to their inhibitory function on the muscle tissue.  In addition to motor deficits, MTrPs can induce pain sensory modulations at the peripheral and central level.  As result of the persistent tenderness of the MTrP, the patient’s pain threshold can be significantly altered over time. This commonly results in a reduction in pain threshold and an increase in excitability of the nocioceptors under lower than normal stimulus.  MTrPs are a common finding in those suffering from unexplained persistent pain and in the centrally sensitized state.  As a result, MTrPs can negatively affect autonomic function, including vasodilation, vasoconstriction, sympathetic and parasympathetic systems. Active MTrPs display significant sensory changes in the muscle, cutaneous, and subcutaneous tissue. Latent MTrPs have been shown to only show sensory changes at the muscle level. 

    

   The presence of MTrPs have been identified in numerous forms of musculoskeletal pathologies, including spinal dysfunction, temporomandibular dysfunction, tendinopathies, joint dysfunction, radiculopathies, headaches, carpal tunnel syndrome, hypermobilities, inflammatory conditions, and degenerative joint and disc diseases. 

   Etiology of MTrPs

    

   Having a good understanding of what the proposed underlying causes of MTrPs are is important to prevent the development of and successfully treat them once developed. Although the research is minimal, MTrPs are understood to be extremely common in all muscle pathologies, and there are a variety of proposed causes. 

    

   ·       Prolonged Muscular Tension / Intramuscular Pressure 

   The pressure inside a muscle unit is typically maintained at a normal level in healthy muscle, and is regulated during rhythmic muscle contraction. This regulation is negatively affected during sustained muscle contraction due to the lack of “pumping” action, leading to a significant increase in intramuscular pressure during low-level muscle contraction. Adenosine triphosphate (ATP) synthesis is required to produce a muscle contraction (on-off), and oxygen and glucose are the required molecules for ATP synthesis. During a low level sustained muscle contraction a local energy crisis is created due to the poor regulation of oxygen as result of the increase in intramuscular pressure.  The lack of oxygen will lead to a significant increase in lactic acid pooling and an accumulation of Ca2+, which are unable to be cleared due to the insufficient circulation caused by the increased pressure. As result of the increase in lactic acid and Ca2+ build up, the intramuscular pH levels will decrease. The decrease in pH levels will lead to an up-regulation of acetylcholine (ACh), which is the neurotransmitter responsible in the activation of a sarcomere and thus a muscle contraction. With an increase in ACh activity, the muscle contraction will be maintained and thus developing into an MTrP. The MTrP leads to more local hypoxia and ischemia, which triggers a cascade of nociceptive substances including bradykinins, cytokines, histamine, and prostaglandins. These substances sensitize the afferent nerve fibers of the muscle involved, which results in the specific and significant tenderness to palpation commonly seen in MTrPs. 

   This proposed theory can be expounded upon and applied to dynamic concentric muscle contractions (Cinderella Hypothesis), eccentric muscle contractions, and/or direct trauma to the muscle. The underlying pathophysiology regarding the energy crisis between the lack of oxygen to synthesize sufficient ATP, excessive lactic acid and Ca2+ accumulation, increase in ACh activity, and sustained muscle contraction and MTrP formation is the same. The initial threat, however, is not primarily the poorly regulated intramuscular pressure, but rather microtrauma to the sarcoplasmic reticulum, that can occur during heavy resistance training. The sarcoplasmic reticulum is responsible for the regulation of Ca2+. Damage to the reticulum will cause an excessive release of Ca2+ which results in muscle contraction and the energy crisis is initiated. Several mechanisms that lead to further damage of the cell membrane and cytoskeletal disruption are also initiated.  

   ·       Integrated Trigger Point / Motor End Plate Theory

   This model originally evolved from the previous model discussed. It was initially proposed that MTrPs discharged a distinct low amplitude frequency when measured by EMG. This was suggested as being related to damaged muscle spindles and was termed as spontaneous electrical activity (SEA). More recent evidence confirms that the SEA is not being produced by the MTrP and muscle spindle, but rather coming from a dysfunctional motor endplate releasing an excessive amount of ACh. The upregulation of ACh will lead to persistent muscle contraction and eventually the development of an MTrP, which will produce the same cascade of events due to the resulting tissue hypoxia and ischemia. The specific causes of motor end plate dysfunction include systemic pathologies, degeneration, and trauma (internal or external).

   MTrP Assessment

   There are several research articles including Sikdar 2009 and Chen 2016 that have reported objectively being able to quantify the presence of MTrP through diagnostic imaging including Magnetice Resonance Elastography and Ultrasound. Traditionally, however, identification has theoretically been confirmed through manual palpation.  Two techniques are commonly used; pincer palpation and flat palpation. Since MTrPs are found within a taut band of muscle fiber, the first step is to locate the taut band by palpating perpendicular to the muscle fiber direction. Once the taut band is located, the clinician will locate the area of most tenderness and rigidness. This will be the MTrP and location for intervention.

   The majority of data shows good agreement between clinicians on their ability to determine that a muscle or group of muscles have the signs of a trigger point. However, it is also important to acknowledge a large number of studies have shown poor inter-examiner reliability of identifying the exact location of an active MTrPs through manual palpation. This is definitely concerning especially if experts dictate that precise insertion of the needle is required to deactivate the MTrP. There currently exists significant inconsistency between experts and treatment models in the necessity of identifying a MTrP for the use of DN intervention.

2. Radiculopathy / Neurophysiologic Model

 

This DN model was established by Canadian physician, Dr. Chan Gunn, who states that myofascial pain syndromes are the result of radiculopathy. Gunn defines radiculopathy as “a condition that causes disordered function in the peripheral nerve.” It is important to note that this model does not specifically focus on the abolishment of MTrP, but rather the resolution of myofascial pain from a neurological perspective.

This model is based on the laws of denervation that states normal function and integrity of innervated structures is solely dependent on the normal function of the nerve root, nerve track, and nerve impulses of that particular structure. Conditions such as spinal DJD, DDD, spondylosis, bone spuring, and HNP are the most likely causes of radiculopathy and typically occur at the nerve root level. In addition, issues with the spinal multifidi can lead to foraminal compression, nerve root irritation, and peripheral neuropathy. 

Gunn states that if the normal flow of nerve impulses is altered, then all innervated structures, including muscle are negatively affected, which leads to the development of tender points, trigger points, myofascial pain, and/or dysfunctional soft tissue. Due to this position, Gunn feels the most effective treatment is to needle the musculotendinous junction where the muscle motor points are located. In addition, the respective spinal level and multifidi responsible for innervation of the specific region must also be treated. Gunn believes the consistent presence of spinal dysfunction can influence the tone of the multifidus causing shortening of the muscle, which leads to intersegmental compression of the nerve root. Gunn strongly feels unless the proximal spinal level is treated, full resolution of the myofascial pain at the distal segment will be not accomplished. 

It is also interesting to note that this model maintains that minor peripheral musculoskeletal injuries will not persist unless the associated nerve root is involved.  This model is particularly popular in the chiropractic arena since it supports that the neurological system affects all functions of the body, and a more proximal approach should be primary. Gunn believes myofascial pain is caused by a proximal component that typically manifests itself in the periphery, and are not mutually exclusive.

3. Biomedical Model / Systemic Theory

 

This DN model originates from the empirical and clinical experiences of Dr. Yun-tao Ma. In order to effectively understand this model, it will be important to discuss the concept of homeostasis and factors that effect homeostasis in the athlete and non-athlete. 

Optimal homeostasis of the musculoskeletal system is achieved when there is a sufficient balance and functioning of the cardiovascular, respiratory, nervous, endocrine, and immune systems, which ultimately supports normal mechanical movement, and thus high level performance in sports and in daily functional activities. 

According to this model, the major threats to an athlete’s optimal homeostasis and movement are physical, emotional, and mental stress. All forms of stress will negatively affect one or multiple systems of the body, with the nervous and musculoskeletal system consistently being one of the victims. If these forms of stress are not addressed appropriately, the individual will typically take steps toward symptom relief that are pharmaceutical and with negative long-term results. As clinicians who manage the athletic population, finding non-pharmaceutical approaches to treatment should be a top priority and consistently part of the clinical decision making process. 

The aim of this DN approach is to restore and maintain homeostasis by reducing all forms of stress, particularly chronic and acute physical stress of the musculoskeletal system. The underlying theory maintains that the insertion of a needle beyond the skin barrier creates a lesion in all the soft tissue levels encountered. This lesion(s) will immediately activate the body’s normal immune response to initiate the mechanisms of “self healing”. This process involves not only the immune system, but also activates the nervous, endocrine, and cardiovascular systems at both a central and peripheral level. By activating all systems that can mediate stress and induce tissue healing, homeostatic balance may be restored. 

A critical component in this theoretical model is the self-healing ability of the patient. There are many factors that can influence their ability to self-heal, including stress, training and recovery regimen, diet and nutrition, systemic conditions, illness, psychology, and intelligence. All these factors will play a role in the decision to implement DN, especially in the athletic population.  

This model, unlike the previous models, is a non-specific approach to DN. It does support the theories of MTrP, but does not highlight the assessment or direct intervention techniques specific to MTrP needling. It has been considered a slightly more comprehensive model that combines some principles of the mechanical model with those of the radiculopathy model. 

Sounds pretty crazy right? Good news for you is that you don’t need to understand all the scientific jargon for dry needling to be helpful for you!

I’m sure you’re wondering is dry needling right for you and can dry needling help with your pain? Well stay tuned because we are going to go through all the conditions that dry needling can help with from head to toe. Hold on tight, because it’s A LOT.

1. Headaches

   Yes, headaches. Dry needling is super effective at targeting specific muscles of the neck And face that are responsible for the creation of tension headaches/migraines.

2. Neck pain and/or Neck stiffness

   Dry needling can be great at specifically targeting the muscles that create neck pain as well as perceived stiffness in the neck. This technique mixed with a mobility routine can do wonders for improving your neck pain and stiffness.

3. Pinched nerves in the neck

   Really? Yes, really. How can it help with nerve compression though? Well the precise dry needling technique used targets very small muscles of the spine called the multifidi muscles. These muscles go into spasm and tighten up in the area of the pinched nerve. Dry needling can target these muscles and when done correctly can make these muscles release from spasm and thus take pressure off of the nerves coming out of the neck (cervical spine).

4. Upper trapezius muscles tightness

   This muscle group is super coming to have pain in because of poor posture or dysfunctional lifting of the shoulder joint. Dry needling is very effective at getting rid of pain in the area. If you can mix that with some posture changes and ergonomic corrections at work you have yourself a delicious recipe for neck pain relief.

5. Shoulder pain or rotator cuff pain

   One thing that creates a lot of shoulder pain (glenohumeral joint pain) if over use of specific muscles in the rotator cuff. When muscles get overused, they get sent into spasms (which creates trigger points or areas of tenderness). Because of the superficial nature of most of the rotator cuff tendons they are perfect for dry needling to release that spasm and stimulate healing of the rotator cuff muscles and rotator cuff tendons.

6. Lateral epicondylitis

   This is a fancy name for tennis elbow, which I’m sure you’ve heard of by now. Contrary to popular belief, minimal tennis players actually get tennis elbow, which I find oddly humerus (see what I did there?). Nonetheless, dry needling can be an awesome adjunct the treating lateral elbow pain because of the nature of this disorder. This mixed with some ergonomic changes and progressive loading of the tissue can really make a big difference.

7. Medial Epicondylitis

   What’s the opposite of tennis elbow? You guessed it, golfers elbow. This is characterized by pain on the inside of the elbow (aka medial epicondylitis). Similar to lateral epicondylitis, the nature of this condition makes it perfect for dry needling to help along with the same strategies noted above for is not so distant counterpart.

8. LOW BACK PAIN (sometimes classified as sciatica)

   Yep, you read that right. Low back pain. Similar to the way the dry needling helps with cervical pain (neck pain) it has the same capabilities in the lumbar spine (low back). Dry needling can get muscles spasms to relax which can reduce pressure on nerves and allow them to heal (this is how you fix sciatica).

9. Hip Pain

   Seems hard to believe right? Well it’s true. Underneath all that skin are a BUNCH of muscles that sit around the hip socket joint (femoroacetabular joint) and the pelvis that all can contribute to hip pain, hip tightness, and overall dysfunction. Similar to the way dry needling helps the rotator cuff is how it helps the hip joint. The shoulder and hip are more alike than you’d imagine.

10. Thigh Pain

    Whether it’s your quadriceps or your hamstrings dry needling can help reduce pain,soreness, and trigger points in these areas which can loosen tissue and actually help alleviate knee pain.

11. Knee Pain

    There are many causes for knee pain so having a expert check it out and diagnose you properly is important to making dry needling work for you. Not only can w dry needling the surrounding muscles of the knee, we can also needle the tendons that surround the knee which can often times be a large source of pain in the knee. Dry needling the patellar tendon or quad tendon can be very helpfully to stimulate new blood flow to that region.

12. Calf Pain or Calf Tightness

    Are you a runner? Or a dancer.? Or just like to walk a lot for exercise? Calf pain is super common for conditions of the calf. The large muscle bellies are very easy to target. Although the calf muscle has a high propensity for soreness, but boy does it feel good a few days later.

13. Achilles Tendinitis

    Attached to the gastrocnemius and soleus complex is the Achilles’ tendon. This tendon can present with pain in people who do a lot of repetitive activities (running, jumping, ballet class, burn boot camp, pure barre, even orange theory class. Dry needling can not only loosen the calf to take pressure off of the Achilles’ tendon, it can also stimulate healing of the tendon itself.

14. Planter fasciitis

    Yep that too. I bet you know someone right now that has or has had plantar fasciitis in their lifetime. It is an extremely painful disorder of the foot where you have a lot of heel pain and pain in the arch of the foot. Dry needling can be very helpful for targeting this area if pain and kick starting the bodies healing process to reduce their pain. This missed with a program that targets why you got plantar fasciitis but the first place is a great recipe for long term foot happiness.

To be honest, this is even this isn’t even close to the whole list but definitely some of the most common things dry needling can help improve.

I’ve stated it a few times before that dry needling is an ADJUNCT to traditional physical therapy interventions. Dry needling should not be used alone as a treatment style. This is a technique to reduce pain, muscle tightness, joint stiffness, which all allow you to move better and more pain free so that we can improve the underlying causes of your condition which are often related to muscle weakness/imbalance or lack of mobility/flexibility in specific muscles/joint around the area of pain. The other super helpful part of dry needling is that when we insert a needle we are creating tissue damage and what this does is help stimulate the bodies own natural healing response. 

If your provider creates a plan  for you that incorporates dry needling and mobility/strength exercises that specifically target the root cause of the problem you’re going to have a hard time not seeing improvements in your condition.

I’m sure you’re wondering what the drawbacks to dry needling are?

First off, it’s a needle. Some people don’t like needles. If that’s you, maybe dry needling isn’t for you. If you’ve exhausted all other treatment options I would still suggest giving it one try. 

One thing you should know if you’re interested in try dry needling is that it can definitely be an unpleasant experience during the process depending on the area that you’re having dry needled. My thought process around this is that going through a very short term amount of pain would totally be worth pain relief from something you’ve been dealing with. But that’s just me. Certainly you can always give it a try and if it’s too uncomfortable then you quit and never have to do it again. The choice is always yours.

Secondly, dry needling is an invasive technique. Which means we will be inserting a foreign object inside your body. That being said, no matter how much we try to reduce any negative side effects no clinician can be 100% certain that no side effects such as infection can occur. Rest assured at movement is medicine physical therapy and sports performance we take a precautions necessary to give our patients the best chance of a positive outcome possible. Lastly, the other drawback (which may not be so bad for some people) is that for certain muscle groups such as the calf and the forearm and should can become very sore for 24-48 hours post dry needling. This should be nothing more than soreness that you’d experience from your general exercise routine. Again, in my opinion i will take a small amount of short term discomfort for some long term pain relief, who else is with me?

In closing. Dry needling can be an extremely effective way to supplement and enhance your rehabilitation and improve your performance. That being said, from a patient perspective you HAVE to make sure that you’re finding a provider that takes the time to listen and diagnose you before starting dry needling. This technique doesn’t work when you’re just sticking needles in random places of the body. That’s not how it works. Guessing isn’t good enough. You also need to find a provider is is CERTIFIED in dry needling which seems obvious, but take it from me, there are clinicians out there doing things that they have never formally been trained to do. Do your research on your providers!

If you’re interested in trying dry needling or you know of someone who might be a good fit for it then click the button below to chat with our dry needling specialist today to see if we can help get you out of pain and back to the activities you love!