Fascia guide
Dry needling is a treatment in which a clinician, usually a physiotherapist, pushes thin, solid needles into tight or tender spots in muscle. It uses the same kind of needle as acupuncture. Against a convincing fake needle, any benefit is small and short-lived, and in trials that added it to exercise, the real needle made little or no difference.
This guide explains what happens in a session, how dry needling differs from acupuncture, and what trials found for neck, back, shoulder, heel and elbow pain. It covers who is trained to do it in the UK and US, the common side effects, the rare but serious risk to the lungs and who should avoid it, with the exercise that matters most shown in 3D. For the knots themselves, see the trigger points guide.
A clinician pushes thin, solid needles through the skin into a tight or tender spot in a muscle, often called a trigger point. "Dry" means nothing is injected: the needle itself is the treatment, and it's the same kind of needle acupuncture uses.
Reviews find it eases pain a little more than a fake needle or no treatment in the short term, and no more than other treatments. Long-term benefit hasn't been established.
In sham-controlled trials in neck pain, whiplash and shoulder pain, adding real rather than fake needling to exercise and hands-on treatment made no clear difference to pain or disability at 1 year. Added to physiotherapy for neck pain, it eased pain a little at 1 month only.
US physiotherapy guidelines give it a Grade B (moderate evidence) for heel pain and tennis elbow. A UK elbow care pathway found no trial against a placebo and doesn't recommend it. The National Institute for Health and Care Excellence (NICE) allows a single short course for long-term pain with no clear cause, but advises against acupuncture for low back pain and against acupuncture or dry needling for osteoarthritis.
Bruising, bleeding or soreness followed about 1 in 5 to 1 in 3 sessions in two large surveys, and serious events followed fewer than 1 in 1,000. The most serious risk is a collapsed lung after needling near the chest, upper back, shoulders or neck. The Chartered Society of Physiotherapy (CSP), the UK physiotherapy professional body, says a collapsed lung is the injury most often reported to it.
In the UK, look for a physiotherapist registered with the Health and Care Professions Council (HCPC), or a practitioner on a register accredited by the Professional Standards Authority. In the US, whether a physical therapist may dry needle depends on the state, so check with your state's board.
The US federation of physical therapy licensing boards defines dry needling as a skilled technique that uses thin, solid (filiform) needles to pierce the skin and the tissue beneath it, to help manage pain, movement problems and disability. US heel and Achilles guidelines describe inserting a thin, solid needle to stimulate or release a muscle trigger point or a tender spot in muscle.
In 1979 the doctor Karel Lewit reported that when he injected painful spots with local anaesthetic, the needle seemed to matter more than the drug. He needled 312 painful sites in 241 people and reported immediate relief in 86.8% when the needle hit the most tender point, which he called "the needle effect". There was no comparison group.
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The clinician examines you, explains the risks, checks for reasons not to needle and asks for your consent. A sterile, single-use needle goes through the skin into the chosen muscle. It may be left in place, or moved in and out to provoke a twitch, a brief jump of the muscle. In one trial, most people felt a deep ache or a twitch as the needle went in. Some clinicians also pass a small electric current through the needles.
There's no established course. Trials used weekly sessions for 6 weeks for heel pain, 7 sessions over 4 weeks for neck pain and 6 weeks of treatment for whiplash, often alongside exercise.
Acupuncture needles are thin, solid, sterile and for single use, and in the US they're regulated as medical devices. Dry needling uses the same kind of needle.
Traditional acupuncture is based on meridians and traditional Chinese diagnosis. Western medical acupuncture, as UK acupuncture physiotherapists describe it, starts from anatomy, physiology and pain science instead of ideas such as Qi. Dry needling aims at tender spots in muscle. The British Acupuncture Council (BAcC) describes it as used by doctors, physiotherapists and nurses after a short course, to manage symptoms.
A US acupuncture safety group's white paper calls dry needling "a form of simplified acupuncture using biomedical language". The American Physical Therapy Association (APTA) supports dry needling by physical therapists with appropriate training. Much of the argument is about which professions may do it.
The World Health Organization (WHO) assessed traditional acupuncture and dry needling together for its 2023 back pain guideline, and found no consistent difference in their benefits or harms. NICE names "acupuncture or dry needling" together, both when it suggests them and when it advises against them.
An umbrella review of 36 reviews found dry needling eased short-term pain more than a sham or no treatment in every body region, but no more than other treatments, with little data beyond the short term.
A review of 13 trials of needling by physical therapists found less pain than with comparison treatments for up to 12 weeks, but no clear benefit at 6 to 12 months. A meta-analysis of 42 trials found less pain for up to 24 weeks, but mostly on low-quality evidence because results varied so much. The first pooling of sham-controlled trials (4 trials, 134 people) found no clear difference from placebo.
There's no accepted sham needle, and no trial has tried to blind the therapist: of 27 sham-controlled trials, 22 had a high or unclear risk of bias.
When 24 trials were grouped by how well patients were blinded, poorly blinded trials favoured real needling. Trials with good blinding showed no clear difference from sham, though the authors said the evidence was too thin to be sure.
Pooling 28 trials, needling eased neck pain by about 1.5 points out of 10 straight afterwards and 2.3 points in the short term compared with sham, a waiting list or other needling, on low to moderate quality evidence. Against manual therapy it was half a point better in the short term, and against other physiotherapy no better. It didn't change neck movement and showed nothing at mid-term.
In a sham-controlled trial of 77 adults followed for a year, adding needling to 7 sessions of manual therapy and exercise made no difference at 4 weeks, 6 months or 1 year. The authors said it shouldn't be part of a first-line approach. Added to guideline-based physiotherapy in 116 adults, it eased pain by 1.2 to 1.6 points out of 10 at 1 month only. In 80 people with chronic whiplash, real needling with exercise beat sham needling with exercise by amounts the authors called "not clinically worthwhile".
Reviews report short-term relief, but from trials mostly at high or unclear risk of bias. One review of 16 trials called the evidence "not robust", and another of 11 trials (802 people) found larger effects than other treatments straight after treatment, with unclear effects later. A sham-controlled pilot of 22 people favoured real needling, but it was too small to rely on.
NICE says don't offer acupuncture for low back pain. WHO conditionally supports needling for chronic low back pain as part of wider care, not on its own, but against a sham it found only a trivial benefit straight after treatment, on low-certainty evidence.
Pooling 6 trials, needling eased shoulder pain by about half a point out of 10 in the short term (moderate quality) and helped disability more (low quality). Another review of 11 trials rated the evidence of short-term benefit "very low". A third (8 trials, 538 people) found needling added to other care did better than that care alone, though half its trials were at unclear or high risk of bias.
In the largest sham-controlled trial, 121 people with subacromial pain (pain from the tendons under the bony tip of the shoulder) had physiotherapy alone, with sham needling or with real needling. At 1 year, shoulder pain and disability scores didn't differ significantly. More of the needled group rated their symptoms as acceptable, and they were less likely to seek more care for the shoulder.
In a well-blinded trial of 84 people, 6 weekly sessions eased first-step pain by 14 points out of 100 more than sham at 6 weeks, less than the smallest change patients count as important. Minor, short-lived side effects followed 32% of real sessions and under 1% of sham sessions.
Pooling 6 trials (395 people), pain was about 1.7 points out of 10 lower in the short term and 1.8 points lower at up to 6 months than in comparison groups. Another review found needling added to routine care helped more than routine care alone, but needling on its own did no better than other treatments for pain. The 2023 US heel pain guideline gives it a Grade B, up from "cannot be recommended" in 2014, and gives stretching and hands-on treatment its top grade, A.
Pooling 7 trials (320 people), needling had large short-term effects on pain and disability, on low to moderate quality evidence. The 2022 US guideline says clinicians should use tendon or trigger point dry needling (Grade B), the same grade it gives wrist strengthening exercises.
The British Elbow and Shoulder Society (BESS) 2023 care pathway screened 764 studies and found no trial comparing dry needling with a placebo. It says patients should be told there is no evidence of benefit over placebo, and that it isn't currently possible to recommend dry needling.
The 2024 US Achilles guideline found one small trial in which needling, with or without electrical stimulation, added nothing to loading exercise. It allows needling for calf pain and stiffness only on expert opinion (Grade F, its lowest), mainly for people who can't yet tolerate loading. Heavy, progressive tendon loading is its first-line treatment, graded A.
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NICE says don't offer acupuncture or dry needling for osteoarthritis. For chronic primary pain (long-term pain with no clear underlying cause), it says to consider a single course of acupuncture or dry needling, given in the community by a suitably trained professional, using no more than 5 hours of their time.
Not what the "release" story says. Against sham needling, it didn't change the electrical activity of the trapezius in 43 office workers with neck and shoulder pain. The twitch isn't needed for pain relief: in 66 people with back pain, a twitch made no difference to pain or disability. In 128 people with neck pain, its effect on disability ran mainly through less pain and tenderness.
The best reading is a short-lived change in pain, not a structural release. Whether trigger points exist as described is disputed; the trigger points guide covers that debate.
Physiotherapists, doctors and nurses offer it after extra training, and acupuncturists offer the closely related acupuncture. Physiotherapists must be registered with the HCPC and work within what they're trained and competent to do. The Acupuncture Association of Chartered Physiotherapists (AACP) gives full membership only after at least 300 hours of acupuncture training. Physiotherapists who practise acupuncture in England or Wales outside the London boroughs also need a licence from their local council, unless it has granted an exemption.
The BAcC's register has been accredited by the Professional Standards Authority since 2013. Most complementary therapists don't have to be registered by law, so the NHS advises choosing one on a register the Authority has accredited.
The CSP says a collapsed lung is the injury most often reported to it. From 1 July 2024, its group insurance stopped covering acupuncture or needling around the thoracic region (the chest, front and back), so physiotherapists who rely on it need separate cover for that work.
Whether a physical therapist may dry needle depends on the state: APTA says it's within physical therapists' scope of practice in some states and not others. Check with your state's physical therapy licensing board, and ask about the practitioner's needling training.
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Our checklist, built from the sources:
Most trials added needling to exercise or other physiotherapy, and in the sham-controlled neck trial the real needle added nothing. The US guidelines rate stretching for heel pain (Grade A), heavy loading for Achilles pain (Grade A) and wrist strengthening for tennis elbow (Grade B) at least as highly as needling.
Soreness is common: about half of 123 patients reported it within 24 hours, and some felt tired or had a headache. Gentle movement the same day is usually fine (our editorial advice); follow your clinician's plan for heavier exercise. Chest pain or breathlessness isn't normal soreness: see when to get help, below.
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Steps and dose from the move's page; the hold lengths are the range used in heel pain trials. Heel pain is where dry needling has its strongest guideline grade (B), and the same 2023 guideline gives plantar fascia and calf stretching its top grade, A (Koc 2023).
Loading the 3D figure…
The movement on the figure: Plantar fascia stretch (seated)
Pick the moves for the area being needled (heel, elbow, or neck and shoulders) and use each move page's dose where it gives one, or your clinician's plan.
3D demoPlantar fascia stretch (seated)Beginner · A bench or box
3D demoHeel raise with a towel under the toesIntermediate · A step + Other / check instructions
3D demoTyler twist (flexible bar, for tennis elbow)Beginner · Other / check instructions
3D demoWrist-extensor eccentricsBeginner · A dumbbell
3D demoDumbbell shrugBeginner · A dumbbell
3D demoSupported single-arm dumbbell rowIntermediate · A dumbbell + A bench or box
3D demoBand lateral raiseBeginner · A band
3D demoChin tuckBeginner · No equipmentFollow the routine for the area being treated, between sessions and after the course ends.
Plantar fascia and calf stretches, a gentle foot roll and the towel heel raise: the exercises the 2023 heel pain guideline supports.
8 minBeginner7 movesA bench or box, A massage ballWrist mobility and forearm strength for desk work, climbing, push-ups and handstands.
10 minBeginner7 movesA wall, A dumbbellDeep neck holds and shoulder-blade strength in under 20 minutes: one of the best-supported kinds of exercise for a stiff, sore neck.
18 minBeginner11 movesA band, An anchor pointKnotted neck and shoulders: a minute of self-pressure, two gentle stretches, then the shoulder-blade strength work that eased neck pain in trials.
15 minBeginner8 movesA foam roller, A bandIn 7,629 treatments by Irish physiotherapists, 19% were followed by minor effects, mostly bruising (7.6%) and bleeding (4.7%). In more than 20,000 treatments by US physical therapists, 37% were, mostly bleeding (16%) and bruising (7.7%). In a heel pain trial, minor, short-lived effects followed 32% of real sessions and under 1% of sham sessions. A 2026 review of 59 studies found minor effects after 0% to 48% of treatments.
There were no serious events in the 7,629 Irish treatments. In the US survey, 20 serious events followed more than 20,000 treatments, fewer than 1 in 1,000: prolonged flare-ups, faints, forgotten needles, flu-like reactions, 2 infections, a heavy bleed, and one episode each of leg weakness and numbness. Across studies, serious events followed 0% to 0.43% of treatments.
Case reports show what can happen, not how often. One Belgian hospital saw 4 women with a collapsed lung (pneumothorax) in 15 months, after needling of the shoulder, the top of the shoulder or the neck. All came in with chest pain and breathlessness the same day or the next, and one needed a chest drain for 6 days. A 24-year-old needled between the shoulder blades felt an unusually sharp pain, then over 2 days became breathless, with chest pain and a dry cough. The CSP says a collapsed lung is the injury most often reported to it.
Other reports describe bleeding around the spinal cord, with weakness in the arms and legs, after needling in or near the spine; a nerve injury that left a wrist drop; and a deep thigh infection in a 16-year-old.
The NHS says acupuncture may not be safe if you take blood-thinning medicine, are at increased risk of bleeding, or have a skin condition or skin infection. WHO advises caution with blood thinners, especially in older people. One NHS trust's needling guideline also rules it out with, among other things:
The same guideline lists pregnancy as a reason not to needle, but also says needling is safe in an uncomplicated pregnancy with a physiotherapist who has extra training in pregnancy care. Tell your practitioner, and see only someone with that training.
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Against sham needling, it didn't change the muscle's electrical activity in 43 office workers, and in 128 people with neck pain its effect on disability ran mainly through less pain. What it does is change pain for a while, and whether trigger points exist as described is disputed.
A review found the twitch isn't needed for pain relief, and in 66 people with back pain a twitch made no difference to pain or disability. More insertions mean more soreness afterwards.
It uses the same needles, and WHO and NICE judge the two together. The differences are the reasoning and who is trained, which is why the professions argue about it.
In neck pain it did no better than sham needling at 6 months or 1 year, in whiplash its effect wasn't clinically worthwhile, long-term benefit hasn't been established, and NICE advises against acupuncture for low back pain.
Soreness is a side effect, reported by about half of patients within 24 hours, and it rises with the number of needle insertions. We found no evidence linking it to better results.
Minor effects follow about 1 in 5 to 1 in 3 sessions, collapsed lungs do happen, and the CSP says a collapsed lung is the injury most often reported to it.
A clinician, usually a physiotherapist, pushes thin, solid needles through the skin into a tight or tender spot in a muscle. "Dry" means nothing is injected: the needle itself is the treatment. It uses the same kind of needle as acupuncture.
It uses the same needles, but the reasoning differs: dry needling targets tender spots in muscle using anatomy, while traditional acupuncture uses meridians and points. Acupuncturists argue dry needling is a simplified form of acupuncture, and WHO and NICE judge the two together. In practice, ask about the practitioner's training rather than the label.
It eases pain a little more than a fake needle or no treatment in the short term, but no more than other treatments, and long-term benefit hasn't been established. In trials that added it to exercise, the real needle changed little. US guidelines support it for heel pain and tennis elbow, while UK guidance is more sceptical.
Most people feel a deep ache or a brief twitch as the needle goes in, and soreness afterwards is common: about half of 123 patients in one survey reported it within 24 hours. Tell your practitioner straight away if a needle feels unusually sharp.
Bruising, bleeding and pain during or after treatment are common, following about 1 in 5 to 1 in 3 sessions in two large surveys. Tiredness and headache can follow too. Serious problems are rare, fewer than 1 in 1,000 sessions in the largest survey.
Yes, rarely. Needling near the chest, upper back, base of the neck or shoulders can cause a collapsed lung (pneumothorax). One Belgian hospital saw 4 cases in 15 months, and the Chartered Society of Physiotherapy says it's the injury most often reported to it. If you get chest pain or breathlessness after needling in those areas, even the next day, call 999 or go to A&E.
Skip it, or ask first, if you take blood thinners or have a bleeding disorder, a fear of needles, an infection or broken skin at the site, an arm or leg at risk of lymphoedema, unstable epilepsy or a stainless steel allergy. If you're pregnant, see only a practitioner with extra training in pregnancy care.
Sometimes. The NHS may offer acupuncture for long-term pain, and NICE allows a single short course of acupuncture or dry needling for long-term pain with no clear cause. But NICE advises against acupuncture for low back pain, and against both for osteoarthritis.
There's no established number. Trials used courses of 4 to 6 weeks, often alongside exercise. If nothing has changed after a few sessions, ask what else is in the plan.
In the UK, physiotherapists, doctors and nurses offer it after extra training; full members of the Acupuncture Association of Chartered Physiotherapists have done at least 300 hours of acupuncture training. Check your practitioner is on the HCPC register or a register accredited by the Professional Standards Authority. In the US it depends on the state, so check with your state's physical therapy board.
For heel pain, a well-blinded trial found real needling beat sham at 6 weeks, but by less than patients count as important, and the US guideline grades it B against an A for stretching. For tennis elbow the US guideline also grades it B, but a UK elbow care pathway found no trial against a placebo and doesn't recommend it. The heel and tennis elbow guides cover the exercise at the core of care.
Yes. Most trials added needling to exercise or physiotherapy, and in the sham-controlled neck trial the real needle added nothing to them. Gentle movement the same day is usually fine (our editorial advice); follow your clinician's plan for heavier loading.
Movement education, not medical advice. Stop for sharp or increasing pain, numbness or tingling, and get individual advice if you are pregnant, after an injury or surgery, or managing a health condition. Health disclaimer.
