Dry Needling for the Treatment of Musculoskeletal Ailments With Trigger Points

Abstract

Background:

Dry needling is an increasingly popular technique for relieving musculoskeletal pain, through targeting myofascial trigger points. Existing evidence indicates that dry needling is effective in short-term management of pain, with research showing efficacy in improving functional outcomes when compared to other treatments.

Indications:

Myofascial trigger points may result in range of motion limitations and muscle weakness. Noninvasive treatments for musculoskeletal pain associated with myofascial trigger points, such as stretching or warm compresses, may not provide significant benefit for patients. Dry needling is a minimally invasive technique that provides significant short-term functional improvement and analgesia for musculoskeletal pain associated with myofascial trigger points, seen with reductions in visual analog scale (VAS) pain scores and decreased need for pharmacologic therapies.

Technique Description:

This video demonstrates dry needling at the tensor fascia latae, extensor carpi radialis longus, and gastrocnemius muscles. Myofascial trigger points and important anatomical landmarks are identified and labeled. A needle is inserted into the region of the myofascial trigger point to a depth of 10 to 100 mm and remains in situ for about 10 to 20 seconds with the use of a piston technique, although this time varies dependent upon patient response.

Results:

Dry needling may significantly decrease pain and improve functional outcomes in patients with short-term musculoskeletal ailments. Randomized controlled trials have examined dry needling for fibromyalgia, mechanical neck pain, myofascial pain, and following total knee arthroplasty, with these finding significant reductions in pain scores in short-term follow-up. A randomized single-blind placebo-controlled trial found dry needling with exercise to be more effective than sham dry-needling and exercise. Dry needling may provide improved long-term analgesia but also results in increased pain during the procedure and increased soreness afterwards. Pain relief may not last beyond 6 months, although little research investigating long-term outcomes has been performed.

Discussion/Conclusion:

The usage of dry needling in clinical settings is increasing, as it has shown strong efficacy in providing short-term pain relief and ability to improve functional outcomes. Dry needling is a simple, minimally invasive technique that is easily and quickly learned by physical therapists and may provide great benefits to patients.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

In this video, we will be reviewing the dry needling technique used for pain management. We will walk through the current use of dry needling, discuss the rationale and indications for dry needling, and perform demonstrations of needling of the tensor fasciae latae, extensor carpi radialis longus, and the gastrocnemius muscles.

There are no relevant disclosures to this presentation.

Dry needling is an increasingly popular technique used by physical therapists and athletic trainers that relieves musculoskeletal pain through targeting myofascial trigger points. During this technique, needles are inserted into the myofascial trigger points to a depth of 10 to 100 millimeters. A piston technique is typically performed over 5 to 20 seconds, with attempts to elicit twitch responses in the muscle. Randomized controlled trials have shown significant reductions in pain scores in short-term follow-up, as well as improved functional outcomes.^4,7,10

Myofascial trigger points are areas of skeletal muscle characterized by local tenderness and twitch responses with stimulation. These trigger points may be asymptomatic, although they may result in a range of motion limitation and muscle weaknesses. ¹ Musculoskeletal pain associated with myofascial trigger points may be relieved through dry needling, although the mechanism of analgesia is unclear.^3,9 Insertion of needles into these trigger points may interrupt motor end-plate signals and help normalize muscle tone. ⁹ Dry needling is typically performed in patients with musculoskeletal pain as an alternate to conservative methods, such as warm compress and stretching. Patients should be advised to reduce or eliminate risk factors that may contribute to their myofascial pain, such as chronic overuse or stress injury. ¹ If these patients are identified to have latent myofascial trigger points, dry needling may provide a benefit. Dry needling has been shown to be effective in several patient populations, including those with fibromyalgia, mechanical neck pain, myofascial pain, and total knee arthroplasty postoperative patients. ⁵ Dry needling should be performed in conjunction with stretching, joint mobilizations, strengthening, neuromuscular re-education exercises, and any other interventions to improve pain and functional outcomes.

The following are steps taken before dry needling at any anatomic location. First, a clinician will identify the anatomic bony landmarks. They will then typically palpate for the myofascial trigger points. These trigger points are often identified by patient reports of tenderness. Clinicians may also be able to discern areas of muscles that feel tight, have tension, or seem to have a nodule. These methods are heavily debated in clinical practice and at the time of publication, there is not a widely accepted best practice for identifying trigger points.

Next, the clinicians will don gloves and then sanitize the patient’s skin as well as the outside of the gloves with alcohol. Due to this, dry needling is not performed under sterile technique, but rather clean technique. The needle is then inserted into the skin though the guidance of a plastic tube casing. The needle is then progressed through the muscle to the desired depth. This depth will vary based on muscles attempted to be needled, body type, development of muscles, and presence of adipose tissue. Anatomical knowledge is utilized to attempt to avoid blood vessels as well as nerves. Patient feedback is continuously requested throughout the technique to ensure repetitive trauma to nerves does not occur, as this often elicits a referral, shooting, and lightning sensation. The technique is continued by moving the needle up and down through the muscle for 5 to 10 piston strokes. This is often done in a star pattern to elicit a muscle twitch response. Once completed, the needle is removed and the area is rubbed to help alleviate postneedling soreness.

The first demonstration will be of the anterior hip, specifically at the tensor fasciae latae.

The patient is positioned supine. The practitioner first locates the anterior superior iliac spine (ASIS), marked with a blue dot in this video. The iliac tubercle can be palpated along the lateral edge of the iliac crest to denote the boundary between the tensor fasica latae (TFL) and the gluteus medius muscle. A finger is then just placed posterior and distal to the ASIS and iliac crest. The patient is then asked to internally rotate their hip, followed by relaxation. The practitioner will feel the muscle contract with active internal rotation of the hip to ensure that they are on contractile tissue that composes the TFL. ² Trigger point formation is then palpated. Trigger points are typically associated with more referred and diffuse pain, which distinguishes them from tender points that are only caused by local pain with palpation. ¹ However, a range of interrater reliabilities has been noted in literature in the identification of myofascial trigger points. ⁶

While trigger point alleviation is often the objective of dry needling, muscles can be needled without suspected trigger points to provide an increase in extensibility of the muscle and/or alter the peripheral and/or the central nervous system level of activation of muscles. Gloves are then donned by the clinician. To continue with the treatment, an alcohol prep pad is utilized to remove excessive oil and sanitize the skin as well as the therapist’s gloves.

The needle system is removed from its casing. The glue seal between the needle and the plastic tube is broken. The needle is placed against the skin, with the trigger point directly underneath it. Several taps are provided to break the skin barrier with the needle, and then the plastic tubing is removed. The 4 cm needle is then inserted into maximal depth. This is a threading technique across the TFL, and therefore it is a clinical decision of the clinician to determine length of needle from prior palpation of anatomic landmarks. Several piston strokes are provided to elicit all trigger points.

The therapist seeks feedback for any radicular sensations which may suggest nerve infraction with the needle. In this example, the patient reported several twitch responses, however they were not visible at the skin level. The needle is then removed with brief tissue mobilization provided after for comfort along with re-palpation to reassess the patient’s tenderness to palpation.

The second demonstration will be of the forearm muscles, specifically the extensor carpi radialis longus.

The brachioradialis is easily palpated with resisted elbow flexion. Moving the fingers laterally off of the brachioradialis will allow the therapist to palpate the muscle fibers of the extensor carpi radials longus (ECRL) muscle. The palpation of the ECRL can be confirmed by having the patient radially deviate the hand-against resistance. ² The muscle belly is then palpated for a trigger point; a skin marker can be utilized to reference a specific location.

After clean technique is utilized, the needle is inserted into the ECRL, with utilization of the index finger to move the brachioradialis muscle superiorly. This video demonstrates a clear twitch response of the ECRL, with noted carpal deviation. With a direct technique, the radius can be used a bony back drop for determining maximal depth. Feedback is sought from the patient verbally to ensure no repeated trauma to nerves throughout the forearm is performed.

The final demonstration will be of the calf muscles, specifically the gastrocnemius.

First a trigger point suspected location is found with palpation and patient report. The gastrocnemius can be differentiated from the soleus by plantar flexing the ankle with a bent knee. ² This will contract the soleus, while the gastrocnemius remains relatively relaxed. The practitioner can estimate the depth of the gastrocnemius muscle belly based on this brief examination. If the practitioner moves slightly too deep during needling, they will be needling the soleus, and while this may not be the precisely desired muscle, it is in no way contraindicated. It is not uncommon for a practitioner to needle both the soleus and gastrocnemius in the same bout.

After clean technique is utilized as previously demonstrated, the needle is then inserted into the gastrocnemius. Piston strokes in a star pattern are provided to elicit all twitch responses. Several twitch responses are visually seen, as pointed out by the physical therapist.

Dry needling is minimally invasive and serious adverse events are extremely rare. Most potential adverse events have been studied in acupuncture, rather than in dry needling specifically. The most common adverse event is soreness at the sites of needling which may be worsened with an increasing depth of needle placement. Needle-site hemorrhage and infection are rare complications. Pneumothoraxes may occur with needling in the thoracic region, so caution in depth of needle placement, as well as being mindful of bony backdrop, is warranted in this region. Rarely, damage to the central nervous system may occur.

Several potential contraindications have been noted in the literature for dry needling, including patients with a needle aversion or phobia, local skin lesions, local or systemic infection, abnormal bleeding or on anticoagulant therapy, or immunosuppression. ⁸ Additionally, caution in using dry needling after surgery where the joint capsule is opened is warranted, as there exists potential for septic arthritis. ⁸

Upon completion of dry needling, patients are able to return to sport or daily activities immediately. However, other exercises such as stretching and strengthening may be needed to continue to improve pain and functional outcomes.

Patients will often experience significant decreases in their pain.^5,7 Patients often report reductions in pain scores in addition to decreased usage of pharmacological therapies following dry needling. ⁵ Pain relief due to dry needling may not last beyond 6 months, although little research investigating long-term outcomes has been performed. ⁵

Dry needling is associated with range of motion improvements, as well as increased muscle strength. ⁵ In a randomized controlled trial, dry needling of the hip muscles, including the tensor fascia latae, was associated with increased hip strength and force. ⁴ When used for lateral epicondylitis, another study found significant decrease (P < .05) in pain and improvement in functionality scores, when compared to the control group. ¹⁰ Dry needling of the lower extremity was found to decrease muscle spasticity and improve gait in poststroke patients.

This concludes our video on the use of dry needling in the treatment of musculoskeletal pain associated with myofascial trigger points.

Thank you.