Dry needling inserts a solid, fine needle of the kind used in acupuncture into a myofascial trigger point, a tender spot in a muscle, and injects nothing. “Dry” separates it from trigger point injection, which puts a local anaesthetic or saline into the same spot. Physiotherapists, physicians and acupuncturists practise it, and the technique overlaps with needling at ashi points, the tender spots that classical practice needles wherever they are found, without a fixed location or name. The overlap is at the centre of a dispute in the United States over who may perform it. This page reports where the method came from, how its theory is contested, what the professions and courts have decided, and what reviews and safety surveys found.
Where the method came from
The trigger point model comes from the American physician Janet Travell and her colleague David Simons, whose Trigger Point Manual mapped the referred pain of each muscle; its fourth edition, edited by Donnelly, Freeman and Fernández-de-las-Peñas, was published by Wolters Kluwer in December 2025. A 2015 historical review by Shah and colleagues defines trigger points as hard, discrete nodules in a taut band of skeletal muscle that hurt on their own (active) or only when pressed (latent).
The idea that the needle alone does the work comes from the Czech physician Karel Lewit. In a 1979 paper in Pain, he reported needling 312 painful sites in 241 patients without injecting anything. Pain eased at once in 86.8% of cases when the needle reached the most tender spot, and of 288 sites followed up, relief was permanent at 92. Lewit concluded that the puncture, not the anaesthetic, was what injection therapy had in common. The series had no control group.
A contested model
The trigger point itself is disputed. In a 2015 critique in Rheumatology, Quintner, Bove and Cohen argued that the theory of myofascial pain caused by trigger points has been refuted and that trigger points have no scientific basis, while accepting that the pain patients report is real. Examiners also disagree on where trigger points are. A 2009 systematic review of 9 reliability studies by Lucas and colleagues found agreement between examiners ranging from poor to perfect for tenderness and lower for the objective signs: the kappa statistic, where 0 is chance agreement and 1 is perfect, ranged from −0.08 to 0.75 for a taut band and from −0.05 to 0.57 for a local twitch. The authors concluded that physical examination could not be recommended as a reliable test. A 2018 Delphi consensus of 60 experts from 12 countries agreed on three essential criteria for diagnosis: a taut band, a hypersensitive spot and referred pain.
Dry needling and acupuncture
How far trigger points coincide with acupuncture points has been argued since the 1970s. In 2003, Stephen Birch re-examined Ronald Melzack’s 1977 claim of a 71% correspondence, found that 61% of the acupuncture points in that comparison are not indicated for pain, put the likely correspondence nearer 18 to 19%, and proposed that trigger points match a different class of points, the ashi points. Peter Dorsher replied in 2008 that the clinical correspondence of trigger points and classical points in treating pain is likely 95% or higher. A 2015 review by Zhou, Ma and Brogan found that the two overlap in needle technique and in parts of their theory, treated dry needling as one subcategory of Western medical acupuncture, and called for an accrediting body for dry needling courses. Needling and de qi describes the filiform needle and the sensations both traditions use.
Who may do it
In the United States the question is decided state by state, by physical therapy boards, attorneys general, legislatures and courts. The two sides set out their positions in 2016 and 2017:
- The American Medical Association’s House of Delegates adopted policy in June 2016 recognising dry needling as an invasive procedure, noting that physical therapists were performing it with as little as 12 hours of training against a 300-hour minimum for physicians who practise acupuncture.
- The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) states in its position statement that dry needling is acupuncture, and contrasts physical therapists’ continuing-education workshops with the 1,905 hours, 660 of them clinical, that its certification requires.
A 2019 report by West Virginia’s legislative auditors counted 21 state physical therapy boards and the District of Columbia that had said dry needling is within physical therapy, and seven that had said it is not: California, Florida, Hawaii, New Jersey, New York, Oregon and Washington. Florida’s and Hawaii’s physical therapy statutes forbid physical therapists to puncture the skin. The response of West Virginia’s physical therapy board, printed with the report, records that the North Carolina Supreme Court in December 2018 affirmed the North Carolina physical therapy board’s ruling that dry needling falls within physical therapy, after the state’s acupuncture licensing board challenged it.
The lists move. Washington’s attorney general advised in April 2016 that the best reading of the statute excluded dry needling from physical therapy. The legislature then passed a law in 2023 letting physical therapists perform “intramuscular needling” with an endorsement that requires 325 hours of training, including 100 hours of classroom teaching and 75 hours of in-person needling, and a year of postgraduate patient care. In New York, the state education department says there is no official definition of dry needling, that acupuncturists may perform it and that chiropractors may not.
In the UK, the Chartered Society of Physiotherapy states that acupuncture and dry needling are both within the scope of the profession, and the indemnity insurance it arranges for members excludes acupuncture over the thorax. Choosing a practitioner covers how acupuncture itself is regulated in each country.
What the reviews report
Most trials compare dry needling with sham needling, with no treatment, or with another physical therapy. The comparison decides what a result can mean: a difference from no treatment includes everything that comes with being treated, while a difference from sham needling isolates more of the needle itself. Sham acupuncture explains why no sham is inert.
| Review | Scope | Trials | What it found |
|---|---|---|---|
| Chys and colleagues, 2023 | Umbrella review, musculoskeletal pain | 36 systematic reviews | Ahead of sham or no intervention for pain in the short term in every body region, and level with other treatments; little evidence beyond the short term, and contradictory results for function. |
| Navarro-Santana and colleagues, 2020 | Neck pain | 28 | Less pain than sham, placebo or waiting list, immediately (mean difference 1.53) and in the short term (2.31), both low-certainty evidence (GRADE); slightly ahead of manual therapy in the short term (0.53, moderate certainty); level with other physical therapy; no difference at mid-term. |
| Gattie and colleagues, 2017 | Dry needling by physical therapists, any musculoskeletal pain | 13 | Very low- to moderate-quality evidence of less pain than no treatment, sham or other treatments up to 12 weeks; better function than no treatment or sham, not than other physical therapy; no significant benefit at 6 to 12 months. |
| Liu and colleagues, 2015 | Neck and shoulder pain | 20 (839 patients) | Less pain than control or sham in the short and medium term; trigger point injection did better than dry needling in the medium term, and other therapies did better at 9 to 28 days. |
| Navarro-Santana and colleagues, 2022 | Dry needling against trigger point injection, neck pain | 6 | Low-certainty evidence that injection reduced pain more than dry needling. |
| Tough and colleagues, 2009 | Myofascial trigger point pain | 7 | Four placebo-controlled trials pooled (134 patients): needling was not significantly ahead of placebo, with marked differences between trials. |
| Furlan and colleagues, 2005 (Cochrane) | Low back pain, acupuncture and dry needling | 35 | Dry needling appeared a useful addition to other therapies for chronic low back pain. Cochrane split the review in 2020; its successor covers acupuncture for chronic low back pain. |
AcuiQ’s myofascial pain page lists the protocols individual studies prescribed, each with its citation, and Neck pain and Low back pain report the reviews of acupuncture for those conditions.
Adverse events
Two prospective surveys asked physical therapists to record every event as it happened. In Ireland in 2014, Brady and colleagues followed 39 chartered physiotherapists through 7,629 treatments and recorded 1,463 mild adverse events, 19.2% of treatments: bruising after 7.6% of treatments, bleeding after 4.7% and pain during treatment in 3.0%. No significant event occurred, which put the upper estimate of risk at 0.04% or less. In the United States in 2020, Boyce and colleagues surveyed 420 physical therapists over six weeks and more than 20,000 sessions. They recorded a minor event in 36.7% of sessions, mainly bleeding, bruising and pain during needling, and 20 major events, about 1 in every 1,000 treatments.
The most serious reported harm is pneumothorax, a collapsed lung, when a needle passes through the chest wall. Patel and colleagues reported a 44-year-old man whose left lung partly collapsed after needling of muscles over the shoulder blade and upper back, and who recovered with oxygen. Cummings and colleagues reported a pneumothorax during a teaching demonstration of deep dry needling. Needling over the chest covers where the pleura lies and what case series report, and After a treatment lists the symptoms that call for a doctor.
How AcuiQ records it
Each protocol on AcuiQ records how the points were treated, from a fixed list of modalities; Reading a protocol explains each field. The list has no separate entry for dry needling, so a trial of it is recorded as needling. AcuiQ’s catalogue gives codes to named points, not to trigger points or ashi points, and a protocol reaches the index only when its paper names points the catalogue can code; a trial that needled trigger points by muscle alone is not in it.
What the sources cannot settle
The reviews agree on short-term pain and say little beyond three months. They cannot say whether the trigger point is the right target, because examiners disagree on where trigger points are and the model is itself disputed. Tough’s review called the placebo-controlled trials small and of poor quality, and the shams they used are not inert. The scope-of-practice disputes turn on training and regulation rather than on any trial, and the state lists change; the West Virginia count above predates Washington’s 2023 law.