A 19-year-old female athlete came to clinic for her health supervision visit during the summer. She was a discus thrower completing at the NCAA Division I level. Overall her freshman year had gone well and she had no general medical concerns. She said that she had no specific injuries or problems with her training, but she said in retrospect she probably didn’t listen to her coach as well as she should have and overtrained early. She relayed that early in the preseason winter/spring she had had some upper back/lower cervical pain in her right side (throwing side). She had worked with the university physicians and trainers with a program of stretching, heat, and massage. “I had this one place that we couldn’t quite fix. They tried pressure on that too but it didn’t work. They then stuck some needles into the muscle a few times. That along with the other stuff, plus listening to my coach more, eventually stopped the pain in that spot.”
The pertinent physical exam showed a healthy muscular female with normal vital signs.
She had a normal examination including both shoulders and arms with no specific tight muscles or pain elicited on exam.
The diagnosis of a healthy female was made. The physician discussed how important it was to listen to her coaches regarding her training and to really do the physical therapy when it was recommended. “The pain in my shoulder and back was really bad for a while. It was hard and irritating to do my classes and regular activities. I don’t want to do that again. My coach has us doing a summer program and is checking in on us a few times a week. Believe me, I’m doing what they say including the physical therapy,” she said.
Myofascial pain is pain from muscle or fascia, and usually associated with myofascial trigger points which are “…a highly localized, hyperirritable spot in a palpable, taut band of skeletal muscle fibers.” Trigger points are common reasons people, especially adults, seek relief in primary care or pain clinic settings. Athletes may also complain of pain caused by them. They are treated in a variety of ways, none of which used as a single method is successful for all individuals. Muscle “…stretching, massage, ischemic compression, laser therapy, transcutaneous electrical nerve stimulation, biofeedback, and pharmacological treatment…” are some options.
“With dry needling, a solid needle is passed through the skin into muscles, ligaments, tendons, subcutaneous fascia, and scar tissue to relieve or stimulate myofascial trigger points. The practitioner palpates the trigger point, places the need into the position over the target area on the skin, and taps or flicks the top of the needle to penetrate the skin. The needle may be inserted into a muscle to elicit a local twitch response, or into other connective tissue to elicit tissue relaxation. The needle is removed and placed into neighboring areas or allowed to remain in place for two minutes until the trigger-point sensitivity decreases.” It is called “dry” needling as the needles are solid and do not inject any fluid. Dry needling is also called Western acupuncture, medical acupuncture and intramuscular stimulation.
Dry needling is different than acupuncture. Dry needling is based on Western anatomy and physiological principles. Its mechanism is not understood, but may disrupt the trigger points, modulate nerves or some other effect. This appears to be the treatment the patient above had. Acupuncture is meant to stimulate acupoints and meridians in the body to help with the body’s energy flow. The underlying mechanism of its effect is not understood but may be due to changes in chemical and electrical activity within the body or other mechanisms. Acupuncture is also used for pain management and may be helpful in back, neck and osteoarthritis/knee pain. It is also used for some other problems such as nausea due to chemotherapy.
For acupuncture, the Federal Drug Administration “…requires that needles be sterile, non-toxic, and labeled for single use by qualified practitioners only.” Dry needling has similar requirements. Both are safe when performed by experienced practitioners using appropriate methods. Potential dry needling complications include bleeding or bruising in the site and pain are relatively common. Syncope can also occur. Less common complications include infection (local or deep usually with common skin organisms), injury to nerve, pneumothorax or cardiac tamponade.
Dry needling is offered by physicians (including pain and rehabilitation specialists), physical therapists and other similar health care practitioners. Efficacy data is difficult as randomized controlled trials do not represent real life situations and in most cases multiple interventions are being offered or have been tried by individuals. Dry needling may be used as part of a comprehensive strategy which could include exercise, soft tissue mobilization, postural interventions, ergonomic interventions and education about pain. A systemic review and meta-analysis concluded that while the data was low- to moderate- quality, dry needling was more effective than no treatment and sham dry needling for both shorter and intermediate term end points for pain relief and other functional outcomes.
Questions for Further Discussion
1. Where can you find good, scientific resources about complimentary and alternative medicine?
2. What complimentary and alternative medicine methods do you employ in your clinical practice and why?
2. How is acupuncture different than acupressure?
3. Where are your local resources for dry needling and acupuncture?
4. What complimentary and alternative medicine methods do you employ in your clinical practice and why?
- Symptom/Presentation: Pain
- Specialty: Orthopaedic Surgery and Sports Medicine | Physical Medicine and Rehabilitation / Physical Therapy
- Age: Young Adult
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
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Acupuncture: In Depth. NCCIH. https://nccih.nih.gov/health/acupuncture/introduction. Published January 1, 2008. Accessed March 6, 2020.
Kalichman L, Vulfsons S. Dry needling in the management of musculoskeletal pain. J Am Board Fam Med JABFM. 2010;23(5):640-646. doi:10.3122/jabfm.2010.05.090296
Zhuang Y, Xing J, Li J, Zeng B-Y, Liang F. Chapter One – History of Acupuncture Research. In: Zeng B-Y, Zhao K, Liang F-R, eds. International Review of Neurobiology. Vol 111. Neurobiology of Acupuncture. Academic Press; 2013:1-23. doi:10.1016/B978-0-12-411545-3.00001-8
Gonzalez-Lopez-Arza MV, Sautreuil P, Varela-Donoso E, Rodriguez-Mansilla J, Garrido-Ardila E. Epidemiological data on acupuncture and physical and rehabilitation medicine in the European Union. J Tradit Chin Med. 2015;35(4):478-482. doi:10.1016/S0254-6272(15)30128-X
Gattie E, Cleland JA, Snodgrass S. The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther. 2017;47(3):133-149. doi:10.2519/jospt.2017.7096
Kim DC, Glenzer S, Johnson A, Nimityongskul P. Deep Infection Following Dry Needling in a Young Athlete: An Underreported Complication of an Increasingly Prevalent Modality: A Case Report. JBJS Case Connect. 2018;8(3):e73. doi:10.2106/JBJS.CC.18.00097
Dommerholt J. How have the views on myofascial pain and its treatment evolved in the past 20 years? From spray and stretch and injections to pain science, dry needling and fascial treatments. Pain Manag. March 2020. doi:10.2217/pmt-2019-0055
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa