What is dry needling?

Trigger point dry needling, or dry needling for short, is a manual therapy technique used to increase motion, decrease overall muscle tension, and break up the painful “knots” that often form within muscles. It is known as dry needling because there is nothing injected.

I discussed how muscles often generate pain in this previous post. This type of pain is frequently overlooked. 

Dry needling the low back. Image courtesy of Corridor Magazine, 2014

Dry needling the low back. Image courtesy of Corridor Magazine, 2014

Why use dry needling?

Those knotted areas are known as “myofascial trigger points.” They are often irritable and chemically different than a normal section of muscle. One type of trigger point, the active trigger point, is often the root cause of pain. Not only will the knotted area often be painful, there can be pain very far away from the actual trigger point. This is known as “referred pain” and it might be the only pain a person even feels with their injury. Referred pain can be present just a couple inches from the source but as much as multiple feet away. For instance, the gluteus minimus muscle that is deep at the side of each hip is approximately 3-4 inches in length. It can cause pain all the way down the outside of the leg to the ankle and will trick some people into thinking they have a sciatic nerve problem. Trigger points in the rotator cuff muscles of the shoulder frequently cause pain in the arm, forearm and even the hand. They can mimic a pinched nerve in the neck.

What does dry needling feel like?

There are multiple techniques that can be used when performing dry needling. A simple technique would involve placing the needle within the tightened muscle area and letting it rest there briefly. This is very easily tolerated and feels like a pressure, but it can cause a mild aching sensation in the most irritable trigger points. Another technique involves using the needle to get the muscle to contract. Again, there’s usually a sense of pressure but the aching can be stronger. The contractions themselves are more uncomfortable but are well worth the result. This is because it is common for someone to have their pain stop or nearly stop after a single session of correctly applied dry needling. Their motion is very often improved too.

What types of injuries benefit from dry needling?

Several things tend to form troublesome active trigger points. Overuse of a muscle - simply doing too much, too soon -  is a common factor. This could occur with an athlete that increases their training to quickly. A muscle that has decreased strength but is placed under a high demand will also often have trigger points. This often occurs with our shoulder’s rotator cuff muscles. They usually aren’t as strong as they should be and when we suddenly decide to clean out the garage the trigger point pain starts afterward. Trauma that suddenly strains a muscle can also be a cause of active trigger points. The low back muscles have this issue frequently, especially as repeated injuries have occurred the years. Tendon injuries commonly benefit from dry needling the muscle that attaches to the injured tendon. One of the best times to use dry needling is for a neck or low back injury that is causing nerve irritation. Relaxing the deepest muscles around the spine can decrease the nerve pain.

Are there other ways to fix trigger points?

Yes and no. Some trigger points are near to the surface and can be treated with techniques like myofascial trigger point release or massage. However, some trigger points are very deep and do not respond well to these techniques because there is so much muscle and fatty tissue to get through. I tend to favor trigger point dry needling because it achieves a great result with much less time per trigger point site. I can often have a more positive impact with dry needling three sites in 90 seconds than myofascial release to a single site that takes 4-12 minutes.

Don't forget about the muscles

To some this may seem like a silly concept, but I’ve noticed that many patients and clinicians aren’t giving muscles their due attention. Pain can be generated from a variety of structures in the body, and I often see that one structure is blamed while an entirely separate structure actually generates the pain. This is particularly true with muscles.

Take the low back, for instance. The public has a tendency to blame the intervertebral disks between the bones for their low back pain. Yes, the disks tend to degrade with age, but that is no guarantee of pain. Many times, we are trying to find a single structure to blame for what is really a long-term problem that stems from a lack of activity and poor postural habits that weaken and stress the spine’s stabilizing muscles.

Another issue to consider is that structures can interact to cause pain. At the low back again, consider that increased muscle tension will change how the spine’s joints move and will change the stress on the nerves that exit out of the spine. In this instance it may be necessary to treat multiple structures. Both the muscle and the nerves could be causing pain. Also, weak spine and hip muscles may have led to premature wear and tear on the spinal joints and disks. There can be a lack of overall stability in the hip and low back region. Treating one area is insufficient.

Trigger point Pain referral pattern from a single hip muscle, image courtesy of Triggerpoints.net

Trigger point Pain referral pattern from a single hip muscle, image courtesy of Triggerpoints.net

I expect we partly have an educational bias to blame for this issue. If instructors didn’t spend time describing muscle pain and appropriate treatments, then it must not happen that much, right? Unfortunately that's not true. Prior to the work of Drs. Travell and Simons in the 1940s, few practitioners cared about “myofascial trigger points” or muscle pain referral. And perhaps it’s difficult for the medical profession and the public to accept that a muscle generated or trigger point pain isn’t going to produce an extraordinary finding on an MRI, CT or X-ray image. And no matter what tissue it is, imaging does not guarantee pain in the presence of a damaged structure. Sometimes people have pain with little to no visible tissue damage.

Often there are patients who do have a good understanding of the underlying problem because they are able to touch the affected tissue and have figured out that massaging or placing pressure on the correct muscles makes them feel better for a while. That’s a good sign that soft tissue treatment techniques would be effective. A good exam and assessment all of the appropriate structures is the key here. Physical Therapy and certain types of massage therapy would be excellent methods to treat this type of muscle pain. Following up the hands-on soft tissue work with strengthening exercises is a great option to prevent recurrence.

Please let me know if you have any questions about muscle pain identification and treatment at mountainridgept@gmail.com.