Myofascial trigger points are a common type of pain. The word myofascial means muscle tissue (myo-) and the connective tissue in and around it (-fascial). These trigger points are usually the result of a muscle injury, such as common running injuries or repetitive strain. “From a pain science perspective, trigger points are constant sources of peripheral nociceptive input leading to peripheral and central sensitization,” according to a study in the Journal of Manual and Manipulative Therapy. (A2)

In other words, trigger points are painful when pressed on and can create pain in another area as well, which is called referred pain. It can even generate something called hyperalgesia, which is an increased sensitivity to pain and which is often the result of damage to nociceptors or the peripheral nerves.

For example, trigger points in the muscles of the shoulder, neck, and face are a common source of headaches because the trigger point refers pain to the head. According to research published in Current Pain and Headache Reports, muscle overtraining or direct trauma to the muscle can lead to the development of trigger points. Trigger points can develop during occupational, recreational, or sports activities when muscle use exceeds muscle capacity, and normal recovery is disturbed. Dry needling differs from other types of therapy because it focuses on stimulating these trigger points and releasing the tension in order to alleviate pain. (B)

The very small solid filament needle used allows the trained therapist to target tissues that are not manually palpable, such as the subscapularis, iliacus, and lateral pterygoid muscles.

When using dry needling techniques for the treatment of trigger points, the therapist will palpate the target muscle for a taut band (or area of tense muscles) and identify the hyperirritable spot, thereby confirming the trigger point that needs to be treated.

The needle is typically in a tube and it is fixed with the non-needling hand against the trigger point using a pincer grip or flat palpation depending on the location and orientation of the muscle. Palpation is when the therapist feels with her fingers or hands to pinpoint areas of tenderness. With the needling hand, the needle is gently loosened from the tube and the top of the needle is tapped gently by the therapist, allowing the needle to penetrate into the superficial layer of the skin.

With deep dry needling, the needle is guided toward the trigger point until the therapist feels resistance or notices that the patient has a local twitch response. A local twitch response is a spinal cord reflex that creates an involuntary contraction that can be triggered by a snapping palpitation or penetration with a needle. Research shows that the local twitch response is the result of alleviation or mitigation of some sort. This can be due to a release of immune system-related chemicals, inflammation, or even spontaneous electrical activity. When the patient has an involuntary twitch response, that suggests that the needle has hit the right spot.

When the needle has located the trigger point, as suggested by the local twitch response, the therapist will focus on this specific area or other neighboring areas by drawing the needle back toward the layer of tissue directly under the skin without taking it out of the skin.

The needle will then be redirected toward the remaining trigger points until local twitch responses have stopped. Needles placed in deep treatment zones can be left in for 15 minutes. The goal is to invite the parasympathetic branch of the autonomic nervous system to take over and start healing the associated tissues.

During superficial dry needling therapy, the needle is placed just slightly into a muscle in the vicinity of a trigger point, but the local twitch response is not induced. The needle will be kept in place for about 30 seconds and then withdrawn. If the trigger point still appears to be sensitive after the first round, the needle will be placed in the same area again for 2 minutes.

With superficial needling, the therapist will try to alleviate trigger point sensitivity with these shorter intervals of therapy, repeating this process until he/she notices a difference. This is the chosen technique for patients who cannot tolerate deep needling or who cramp or become stiff easily.

Dry needling involves using a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular and connective tissues in order to relieve pain and movement impairments.

According to the American Physical Therapy Association, trigger points have been identified in numerous diagnoses, including:

• migraines
• tension-type headaches
• carpal tunnel
• computer-related disorders
• whiplash-associated disorders
• spinal dysfunction
• pelvic pain and other urologic syndromes
• post-herpetic neuralgia
• complex regional pain syndrome
• nocturnal cramps
• phantom pain
• tendonitis
• disk pathology
• joint dysfunction

This alternative therapy is also used to treat dysfunctions in skeletal muscle, fascia, and connective tissue. It reduces and restores impairments of body structure and function, leading to improved activity and participation. (C)

1. Reduces Pain
Several studies have demonstrated immediate or short-term improvements in pain or disability by targeting trigger points with dry needling. A 2007 study published in the American Journal of Physical Medicine and Rehabilitation suggests that dry needling significantly reduced shoulder pain by targeting a trigger point. In the study, 14 patients with bilateral shoulder pain and active myofascial trigger points in the bilateral muscles underwent dry needling therapy on one side and no therapy on the other side, which served as the control.

Dry needling physical therapy increased both active and passive range of motion of shoulder internal rotation, and the pressure pain threshold of the trigger points. The pain intensity of the treated shoulder was significantly reduced as well. The study provides evidence that using this technique on a specific myofascial trigger point does reduce pain and sensitivity in that area. (D1)

In a 2016 Manual Therapy study, dry needling was used to treat the upper trapezius latent myofascial trigger point or MTrP — pain in the upper back region — experienced by 60 females. All the participants experienced a reduction in pain. (D2)

2. Improves Movement
Research shows that patients undergoing dry needling therapy, in conjunction with movement-based therapy, experience more fluid movement. In fact, this technique can help mechanically disrupt a dysfunctional motor endplate. (D3) A 2010 case report published in Acupuncture in Medicine treated four international female volleyball athletes during a month-long intense competitive phase with dry needling therapy. Range of motion, strength, and pain was assessed before and after treatment and all scores were improved post-treatment. The athletes were able to continue with overhead activities, which proves that this technique does not cause functional weakness and reduced range of motion immediately after treatment.

These cases support the use of dry needling in elite athletes during a competitive phase with short-term pain relief and improved function in shoulder injuries. (E)

Speeds Up the Recovery Process
Patients who undergo dry needling therapy experience less pain quickly; in fact, most patients feel the benefits immediately after their first treatment. According to reports published by the Journal of Orthopaedic & Sports Physical Therapy, the patient function is restored much more quickly when dry needling is incorporated as part of the total package such as spinal manipulation and dry needling.

A study conducted at the University of Queensland in Australia investigated the effectiveness of dry needling for chronic whiplash, which is associated with sensory hypersensitivity and has poor responsiveness to physical treatments such as exercise. In order to enhance the treatment outcomes of an exercise intervention, dry needling was used in conjunction with exercise to address the sensory hypersensitivity of whiplash. Because exercise programs alone did not fully eliminate the symptoms of whiplash after three months of treatment, the physical therapists added dry needling to the treatment plan in order to speed up the healing process, reduce the economic cost of treatment and minimize pain and disability. (F)

Dry needling is appropriate for nearly all patients who do not have a significant needle phobia or other anxiety about being treated with needles. Like any type of therapy, it may deliver unintended side effects, such as pain at the stop of needle insertion, muscle soreness, fatigue, and bruising. In the hands of a skilled dry needle therapist, it is a safe and effective treatment option and the patient will see benefits in the range of motion and joint use right away.

It’s normal that it may take several dry needling therapy sessions before the muscle is fully functional again. This is because trigger points are located under deep layers of muscles, so it typically takes several sessions for the changes to take full effect. But patients will notice the difference right after each treatment. (G)

Dry needling is also known to be relatively painless. Generally, the needle insertion is not felt and the local twitch response only provokes a very brief pain or discomfort response, feeling more like a mild zap or cramping sensation. A local twitch response is a therapeutic response that serves as a sign that the needle has hit the trigger point, so it’s actually a good and desirable reaction.

Caution is warranted with younger patients; based on empirical evidence, this type of needling is not recommended for children younger than 12 years of age. If a child is undergoing it, the parent and child’s consent is needed and the child should fully understand the procedure before treatment begins.