🥇 The Athlete Development Journal
Developing speed, strength, power, health, and character, so athletes get the most out of their athletic career.
Listen to this episode in the car with your athlete. ⬇️
You can also listen on Spotify or Apple Podcasts.
“Is dry needling a safe and useful treatment?”
Honestly, I don’t have a clear answer going into this.
Over the last 10 years, dry needling has gone viral in physical therapy clinics. It’s purported to be safe, yet one of the best players in the NFL was just sent to the hospital because of it.
Some people say it’s their magic elixir, while others say it does nothing at all.
With so many conflicting stances, I’m excited to get to the truth.
The story.
To tell the story of dry needling, we have to start with acupuncture.
Early versions of acupuncture started in China as early as 6000 BC.
It was revised and workshopped for a few thousand years, until around 100 BC when the foundational text, The Yellow Emperor’s Classic of Internal Medicine, was compiled. In it, Huangdi Neijing outlined meridians, points for healing, and how to poke people with needles to alter their Qi and make them feel better.
If we fast forward a couple millennia and travel across the globe, we find Dr. Janet Travell, who was JFK’s White House physician, experimenting with “wet needling.”
Wet needling involved injecting some sort of solution, usually a corticosteroid or saline, into a trigger point. After more experimenting and iterating, by the 1970s people started to forego the injections and just poke the needle into the trigger points.
Since then, it’s gone mainstream. It seems everyone and their mother is getting needled nowadays.
In the 2025 season, it became an incredibly hot topic when TJ Watt, who is one of the best players in the NFL, announced he was missing games because he suffered a collapsed lung after a dry needling session.
Players and fans from around the league weighed in with their thoughts, but what does the science say?
The science.
Our 3 main questions today are:
- Is dry needling safe?
- Is dry needling effective at reducing pain?
- Is dry needling more effective at reducing pain than other treatment choices?
Before we get into that, we need to establish some background knowledge.
The background: What’s the physiology?
Dry needling is centered around inserting a needle into a trigger point.
A trigger point is defined as “a hyperirritable spot within a taut band of skeletal muscle that is painful when you press on it and can cause characteristic familiar pain.”
Trigger points in and of themselves are a hotly debated issue, but we’ll table that discussion for today.
One proposed mechanism of action for dry needling is mechanical disruption of dysfunctional motor endplates to normalize muscle chemistry, while the resulting local twitch response improves blood flow and flushes out pro-inflammatory substances. These are responses that are purported to happen at the local level.
It’s also suggested to modulate the nervous system by activating descending pain-inhibitory pathways and stimulating the release of natural painkillers like endorphins. These are responses that are proposed to happen at the system level.
But, in all likelihood, it probably works like any other modality in the manual-therapy genre: it provides a neurophysiological stimulus that resets or desensitizes the pain response and subsequently decreases tissue tone.
That’s cool and all, but does it work?
Remember, our 3 main questions today are:
- Is dry needling safe?
- Is dry needling effective at reducing pain?
- Is dry needling more effective at reducing pain than other treatment choices?
To answer these 3 questions, I have 5 studies for us to work through. Then, at the end, we’ll form a cohesive narrative and I’ll give my current stance.
Let’s dive into our first study:
1) Efficacy of Dry Needling for Chronic Low Back Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials (by Laro-Paloma and others in 2022).
“Can I trust the results?”
Yes.
It’s a high quality systematic review with only RCTs. The authors have no conflict of interest.
“What did the study find?”
In regard to pain, dry needling alone wasn’t any better than other treatments.
However, dry needling combined with other treatments was statistically more helpful both immediately after the session and in the short-term (which is about 3 weeks).
The effect size (SMD) for immediately after treatment was only -0.42, which is a small to medium effect. The effect size for the short-term relief was -0.99, which is a large effect and makes this interesting.
When we double click on that segment, we see that there were only two studies that looked at dry needling combined with other treatments and short-term outcomes.
The first study compared it to “standard physical therapy”, which consisted of TENS, ultrasound, heat, and McKenzie exercise.
Guys, that is trash physical therapy. If your PT consists solely of TENS, ultrasound, heat, and Mckenzie exercises… run out of there.
Of note, there was no manual therapy in there.
The second study, however, compared it to sham dry needling (both groups had exercise as well). For the sham dry needling, they use a specialized tool designed to blind participants so they cannot tell if the needle has actually entered their skin.
This is actually pretty interesting. The sham device is a “telescoping” needle housed in a guide tube. When the therapist “taps” the needle, the tip touches the skin to create a pricking sensation, but the needle shaft slides back into the handle (like a stage dagger) instead of piercing the tissue.
This study had a large effect size and low risk of bias. That’s promising!
In regard to disability, dry needling alone or combined wasn’t found to be any better than other treatments.
“Can I use these results in my context?”
Ehh.. the population was all adults with chronic, non-specific low back pain. So, not that much.
It still gives us insight into whether dry needling is effective at relieving pain at all, so it’s worth studying. It’s just not that reflective of our population of adolescent athletes, who normally have acute back pain with a very specific cause.
This study was a good starting point, but I don’t want to be too focused on one body part or type of injury. I want to know as a whole, does dry needling have high effectiveness and safety?
Cue the next study!
2) The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis (by Gattie and others in 2017).
“Can I trust the results?”
Yes.
It’s a high quality systematic review with only RCTs. There were 13 included RCTs, with a total of 723 participants.
The authors have no conflict of interest.
“What did the study find?”
The first thing they did was compare dry needling against doing nothing or having a sham treatment.
They found a moderate effect on pain in the short term (up to 12 weeks) (SMD of -0.7), but with high heterogeneity (I² = 78%).
As a refresher, high heterogeneity means that the results varied wildly from study to study. There was no consistency between the studies.
There was a small effect size on pain in the long-term (6 to 12 months) (SMD = -0.26), with low heterogeneity, (11%) and the 95% CI crosses the line of no difference.
The next outcome measure was “pressure pain threshold” or PPT for short.
PPT is the minimum amount of pressure required for a person to first perceive a physical sensation as painful, serving as a more objective measure of how sensitive an individual’s tissues or nervous system are to mechanical stimulus.
Essentially, what they do here is press on you with a device that measures how much pressure they’re pushing with. Once you feel the first hint of pain, you tell them to stop.
There was moderate effect on PPT (SMD of 0.8) in the short term, but with high heterogeneity (I² = 87%).
The last outcome measure they looked at was “functional outcomes.” Which is a host of different tests that kind of spell out whether they’re actually moving better and able to do more than they were previously.
They found a small effect on functional outcomes (-0.44) in the short term, but with high heterogeneity (I² = 79%).
Likewise, there was a small effect on functional outcomes in the long term (-0.32).
The next comparison was dry needling vs “other treatments.”
On pain, there was a small effect in the short term (up to 12 weeks) (SMD of -0.43) in favor of dry needling, with moderate heterogeneity (I² = 67%).
Importantly, only 1 of the 12 studies that measured this found a clinically meaningful difference on the pain scale.
On pain in the long-term (6 to 12 months), there was again a small effect size (SMD = -0.26), with low heterogeneity (11%), and the 95% CI crossed the line of no difference.
There was a moderate effect on PPT (SMD of 0.61) in the short term, but with high heterogeneity (I² = 85%).
There was no effect on functional outcomes in the short term (SMD -0.01).
However, I don’t love the grouping of “other treatments” into one lumped sum. All treatments are not created equally. So, let’s look at the specific “other treatments.”
- “Physical therapy” (Isn’t that helpful?)
- Manual therapy.
- Importantly, there were more studies that found manual therapy was significantly more effective than DN than the inverse.
- Ischemic compression technique
- Exercise
- Stretching
- Proprioception
- E-stim.
- Importantly, stim gets made fun of incessantly in the physical therapy community for being a low-value, passive treatment. In this study, there was no difference in any of the outcomes between stim and DN…
“Can I use these results in my context?”
Kind of! This review excluded studies with participants less than 18 years old, but it does cover a wide range of injury types.
So, it seems appropriate that we could sum this up by saying that dry needling is mildly better than doing nothing, mildly better than some treatments, and no better or even worse than other treatments.
Looking at this study, I’m highly intrigued by the manual therapy bit. I’d like to see how manual therapy and dry needling stack up head to head.
Cue the next study…
3) Comparison of dry needling and trigger point manual therapy in patients with neck and upper back myofascial pain syndrome: a systematic review and meta-analysis (by Lew and others in 2021).
“Can I trust the results?”
Yes.
It’s a high quality systematic review with only RCTs. There were 6 included RCTs, with a total of 241 participants.
The authors have no conflict of interest.
“What did the study find?”
They looked at trigger point manual therapy versus dry needling in four outcomes: pain on the visual analog scale, pressure pain threshold, neck disability index, and pain via the numeric rating scale.
They found no statistical significance between TPMT and DN in any outcome measure.
“Can I use these results in my context?”
Not particularly. We really chose this study to see how manual therapy and dry needling stack up head to head. This is specific to neck and upper back pain in patients at least 18 years old, but the average age was much higher than that.
Okay, so we’re getting a pretty good picture of how dry needling generally fits in as an intervention. But, do we have anything specific to athletes?
Cue up the next study!
4) Dry Needling in Sports and Sport Recovery: A Systematic Review with an Evidence Gap Map (by Kużdżał and others in 2025).
“Can I trust the results?”
Yes.
It’s a high quality systematic review with 24 included studies: 17 RCTs and 7 case reports, with a total of 580 participants.
The authors have no conflict of interest.
“What did the study find?”
This study was a hodge-podge that didn’t really leave us with specific numbers.
In general, their takeaway was that there was some benefit for pain reduction in athletes, but no benefit in performance. In fact, it might even decrease force production capabilities.
“Can I use these results in my context?”
Yep! This was all about athletes, including those under 18-years-old.
So, I’ve got a pretty clear picture about the efficacy of dry needling, but what about the safety?
5) Adverse Events Associated with Therapeutic Dry Needling (by Boyce and others in 2020).
“Can I trust the results?”
In my opinion, not really. But, it’s the best that’s out there.
The methods are ripe for bias. The authors sent out 7,000 emails to therapists who have taken a dry needling certification, to which 420 responded.
Then, each week those therapists filled out an online survey about how many minor adverse effects (like bleeding, soreness, pain, etc.) and major adverse effects (like pneumothorax, nerve injury, forgotten needles, etc.) they experienced.
That leads to bias in several ways:
- Self-selection bias: Therapists who respond to an email asking for participants are going to be unrepresentative of all therapists.
- Nonresponse bias: If I needle someone and puncture their lung, I’m probably going to stop responding to those surveys.
- Reporting bias: Therapists might simply be unaware that someone went to the hospital with a punctured lung later that day, because they never saw them again.
“What did the study find?”
Over the 6 weeks of collecting data, 223 therapists completed all weekly surveys. There were a total of 20,494 treatments with 7,531 minor adverse events (36.7%) and 20 major adverse events (0.1%).
Again, the methods are ripe for bias. It’s all based on clinician self-reporting surveys, with very low response rates and adherence rates over a 6 week period.
So, I’d venture to say the number is probably a bit higher than the studies show, but the risk of a major adverse event is likely still small.
“Can I use these results in my context?”
I’m not overly sure, because they don’t give any patient data in this study.
A note on black swans
Before we go into the summary and key takeaways, I want to take a moment to introduce the relevant concept of “black swan events.”
Nassim Taleb coined the term to describe rare, unpredictable events with massive, far-reaching impacts. He uses it to describe events like the 2008 financial crisis.
In 2007, nobody was forecasting a financial crisis, because the likelihood of it happening was small. The housing market was deemed to be stable and “low-risk.”
While the odds of the housing market collapsing might have been low, the implications if it did happen were catastrophic.
After it collapsed, hindsight bias kicked in and everyone talked about how the subprime mortgages made this inevitable, despite no one acting on those risks before it happened.
That sounds a lot like the TJ Watt story. Dry needling has become ubiquitous and almost all papers I read mention its low-risk safety profile (despite the evidence seeming shoddy).
Then, once that low-risk event resulted in a collapsed lung and one of the most valuable players in the NFL missing important games, everyone started talking about how obvious it was that something like this would happen if you’re getting poked with needles.
A punctured lung from dry needling is a classic “Black Swan” in a clinical setting. It is rare, often unexpected, and carries a high impact that can lead to hospitalization.
Taleb argues that if an intervention has a “fat-tailed” risk (a small chance of a total catastrophe), the statistical “average safety” is a dangerous metric to rely on.
The takeaways.
What’s actually important here?
- We have some reason to believe that dry needling is more effective at reducing pain than doing nothing or sham treatment.
- We have little to no reason to believe that dry needling is more effective at reducing pain than manual therapy.
- We have some reason to believe that the odds of having a major adverse event occur from dry needling are small.
- We have strong reason to believe that the implications from a major adverse event from dry needling can be catastrophic.
My stance: “Is dry needling a safe and useful treatment?”
If someone:
- has rigorously modified their workload with a skilled PT,
- has gone through a prolonged exercise rehab program with a skilled PT,
- has gone through manual therapy with a skilled PT,
- is not dealing with an injury in the thoracic region,
- and still has not had relief from their pain,
then dry needling can be worth a shot.
Dry needling should NOT be used as a primary intervention and should be saved for when other methods fail.
The black swan nature and risk to reward profile of dry needling is just dwarfed by other treatments. Manual therapy is at worst just as effective, with absolutely none of the catastrophic risk associated with dry needling.
The Attia categories
You’ve probably noticed that the answer to “Does it work?” is rarely a simple yes or no. It’s usually a messy mix of “statistically significant” yet “clinically confusing.”
I’ve adopted a framework developed by Dr. Peter Attia. It emphasizes that in science, “proven” isn’t binary; it is a spectrum of confidence.
I use these five categories to grade the interventions we discuss:
- Proven: Interventions supported by robust, reproducible human data where the probability of them being ineffective is near zero (creatine, whey protein, strength training, etc.).
- Promising: Treatments backed by strong mechanistic logic, animal data, or early human data that look effective but lack definitive long-term human trials.
- Fuzzy: Topics where the data is inconsistent, contradictory, or confusing, making it currently impossible to determine clear benefit or harm.
- Noise: Hyped interventions where the signal is too weak to form a conclusion because the “evidence” relies mostly on anecdotes, theory, or low-quality studies.
- Nonsense: Approaches that have been rigorously tested and proven not to work, despite continued popularity and marketing.
I’d place dry needling in the noise category.
A note on legality
- State to state, the laws vary drastically around who is allowed to dry needle.
- Dry needling is a gray area legally for physical therapists and athletic trainers in Pennsylvania. It’s not addressed in our practice act. If a PT gets sued for a needling issue, their malpractice insurance likely won’t cover them. There’s legislation that’s trying to push it through, but I’d imagine that took a big hit with the notoriety of the TJ Watt injury.
- Dry needling in the thoracic region has been taken out of the UK physio practice act, specifically due to the black swan risks we talked about above.
Let’s wrap it up with a couple important things…
- This newsletter and podcast is completely free. I spend many hours each week researching, writing, illustrating, recording, editing, and uploading. The best way you can support it and allow it to continue is to share it with people you know. You can just send them to gtperformance.co/newsletter and they can subscribe there!
- Everything in these newsletters, podcasts, social media, and on our website is for educational purposes only and should not be taken as medical advice for you or your athlete. Consult directly with a healthcare professional.
Thanks so much for your help in spreading the word about athlete development!
Be >,
Zach
Dr. Zach Guiser, PT, DPT, CSCS