2-minute #DryNeedling tip from @DPTwithneedles


I hope it would be obvious to say, “knowing the anatomy” of a region or muscle you intend to dry needle is paramount – but that’s exactly what I’m saying. Not necessarily point A to point B origin-insertion anatomy, but the thorough geography and topography of the muscle.  Beyond that, what are the physical characteristics, histological properties and patient-specific qualities of that muscle.

Let’s think next level anatomy.

Before you even begin palpating a muscle to needle, here are a few things to consider –

  • Myotendinous junction – based on your knowledge, where are you expecting this muscle to begin its transition from contractile muscle tissue in to more fibrous tendinous attachment. Depending on your goal, this would guide where you treat along this specific muscle.
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  • Fiber orientation – appreciating which angle or direction the specific fibers within a muscle will traverse should guide your palpation as well as your needle insertion/penetration angle. Some good muscles to practice this on would be VMO, Vastus Lateralis, deltoid or infraspinatus.B9780323039895000043_f003-002-9780323039895
  • Neural supply – beyond using landmarks to identify where neurovascular tissue physically resides, think what affect you may have on treating a specific tissue both in peripheral nerve supply and myotomal central innvervation. Why?  Because we have an influence on the entire supply when we elicit a response from local tissue. With that natural twitch response signifying an H-like spinal cord reflex, we have an afferent signal returning with his efferent buddies.neurons1348928024654


As a dry needling clinician employing a more invasive intramuscular technique, being an anatomical expert is a must.  Try re-acquainting yourself with some of the didactic info from this list and see if it improves your technique.

Thanks for reading – feel free to comment, share, or write sarcastic remarks below!

Otherwise follow me on IG or Twitter @dptwithneedles…do it.


Paul Killoren PT, DPT is a physical therapist who instructs Level 1 and Level 2 coursework with Kinetacore Education, and is a member of US Dry Needling and Physio Products (iDryNeedle).  Editorials expressed on this blog are his own and do not represent a specific organization.


DISCLAIMER – Dry needling is an advanced technique to be performed by properly licensed and training clinicians.  Do not attempt if not trained.  Tips provided are for currently practicing clinicians to consider.

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Sarcastic Anatomy – Quadriceps

Name – Quadriceps Femoris

Scrabble score – “Quadriceps” = 24 points.  “Femoris” I assume is too nerdy to qualify and spaces between words aren’t allowed anyways.

Latin for – “four-headed muscle of the femur”.  Try sleeping at night knowing you have a four-headed monster in your thigh.

Fun fact – flamingos don’t have quads.


Bruce Lee, Chuck Norris, Arnold Schwarzenegger – they all have quads.  And before you get on your smug high horse like “pff, everyone has quads”…what about Gumby?  The tin man, T-rexs, Charlie Brown? None of them have discernable quads. Don’t feel bad, that took my 15 minutes to research, but I digress.

Quadriceps femoris, not to be confused with Quadratus Femoris (the deep hip rotator primarily employed during the “stanky leg” dance move) are the four musketeers of knee extension.  The open-chain function of ninja kicks and the swing phase of gait are important, but the closed-chain eccentric control of squatting and dropping it (like it’s hot) also define the quad squad.  For the sake of this post, I’ll stick with Netter anatomy and proclude articularis genu and the other mythical fifth “quad” Tensor Vastus Intermedius, because the main four sound Harry Potter-named enough. Lets just keep it to Vastus Lateralis, Vastus Medialis, Rectus Femoris, and Vastus Intermedius.

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Patellofemoral pain accounts for roughly 125% of knee pain and although the quads masquerade as a unified group, they don’t necessarily always play well together.  Patellar tendonitis, subluxation, ligament or meniscus injury, bursitis, or IT band syndrome.  They all suck.  And although we won’t incriminate the quads alone for this all, they are largely appreciated to stabilize the free-floating party barge that is our patella…like a bunch of drunken sailors.

Let’s meet the crew.

Vastus Medialis – If you were privy to any knee pain or surgery between 1980 and 2000, then you most likely know medialis is the pint-sized atrophied and/or inhibited muscle belly on the inside of your knee.  And the rehab plan likely stimmed, quad setted, leg raised, lunged, squatted, balanced, wished, hoped, and prayed it’d come back to life.  Medialis seems to run and hide – atrophying like a scared turtle into his shell with almost any knee injury, but if you are thinking medialis and it’s VMO fibers are designed solely to neutralize the patella against the massive force of Vastus Lateralis…you’re wrong.  Glute medius and minimus do more to “mechanically advantage” medialis and the entire lower extremity than straight up tug-o-war between medial and lateral.  Shakira once said “the hips don’t lie” and in the case of patellofemoral tracking, it’s true.  VM is kind of like the smaller kid on the playground that is technically on your team, but really just gets pushed around by the bigger kids on the other teams.  It’s not fair.

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Vastus Lateralis – He just overheard what we said about his size and got a little defensive, but lateralis is a power mama for sure.  In succinct words of The Trump, “It’s huge”.  And if anyone is doing the bullying in the anterior thigh, it’s VL.  Don’t worry, he often gets punishment via foam rolling.  Suffice it to say over 90% of patellar subluxation and tracking issues are lateral and again this is largely due to biomechanics so take your Z-snaps elsewhere.  However being the gaudy beast it is and having the most expansive attachment to the IT band doesn’t help the argument if we are looking to blame the quads for knee pain.  If lateralis were a person, he’d most likely be the 6’2” man-child in 6th grade growing a mustache and accounting for the most dodgeball injuries.

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Rectus Femoris – The multi-tasker of the group, as RF is a knee extensor with the rest of the quads, assists with hip flexion, and even has a reflected tendinous head attaching closer to the hip capsule to reduce impingement with flexion.  Having more length than girth compared to the other quads, you could surmise this 2-joint muscle does more accessory work versus power production and adds the most proprioceptive value with the other 2-joint divas Sartorius and Gracilis.  Rectus as a person has varsity letters in choir, academics and sports, and may not be the star of any of them, but still seems to be the most popular kid in school well-liked by all cliques and likely dictating fashion trends.

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Vastus Intermedius – Living in the shadow of older sibling Rectus Femoris, Intermedius is literally buried by the other quads anatomically.  My cadaver in PT school made VI seem more like a shallow, fleshy covering of the anterior femur, but other cross-sectional data shows VI contributing heavily to the mass of the thigh.  Assisting primarily with short-range shin kicks underneath tables and fairly pure elevation of the patella, VI seems not to favor either lateralis or medialis in the side-to-side tug-of-war.  Largely overshadowed and underappreciated in it’s efforts, VI is the younger sibling tagging alone with matching sneakers but knowing all the handshakes and dance moves as the rest of the group.

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So far you know – 1) quads primarily contributeto knee extension and karate, 2) they contribute to knee pain, and 3) they act like pubescent high schoolers in their interrelations.

But knowing this, what are some things you can do to improve knee?  Here’s a good place to start.


#1 – Strengthen you glutes, specifically medius and minimus.  The biomechanical sequelae of poor hip stability will directly contribute to knee pain.


#2 – Learn how to squat.  Not necessarily focusing on perfect “ass-to-grass” depth, but training your body how to initiate and utilize hip-dominance versus knee-dominance again biomechanically reduces amount of strain through the knee.


#3 – Foam rolling.  Self-myofascial release can be effective if done consistently.  It’ll be exquisitely uncomfortable, but do these for 2 minutes twice a day for 5 days and things will improve.

#4 – Dry needling.  Really soft tissue work of any kind, but if myofascial restrictions have gotten to the point of actively producing pain in your knee – dry needling will likely have the most benefit.


#5 – Walk more.  Not saying you need to do a 2 mile walk everyday, but if you walk more and limit sitting for long periods – knee joint and muscle health will improve.


If these basic strategies do little to mitigate the situation or if you’ve had a more traumatic injury to cause your knee pain, it may be time to see a physical therapist. A good PT can assess the situation and may use manual techniques like instrument-assisted soft tissue work, joint mobilization, taping, dry needling, or more structured stability training to more quickly improve your condition.

Thanks for reading this cynical overview of the quads…feel free to ask questions, comment or follow me on Instagram, Facebook and Twitter (@dptwithneedles)!

Paul Killoren PT, DPT


Sarcastic Anatomy – Infraspinatus

Name – Infraspinatus (in·fra·spi·na·tus)

Scrabble score – 18 points

Fun Fact – Leading actor in those boring theraband external rotation exercises, but also plays supporting role in more vigorous shake weight use.


Infraspinatus and his fancy-pants name really just means “below the spine” (of the scapula), but this little hater contributes to all sorts of shoulder pain. Although this triangular-shaped peacock admittedly does most of the forceful external rotation of the shoulder joint, he seriously won’t shut up about it. We get it, technically you are the main stabilizing antagonist to subscapularis, but you get some help from supraspinatus and teres minor. Not to mention in most cases infraspinatus is posturally-strained and weak. Meaning if infra was a person, he’d likely be taking mirror selfies in front of the mirror in between curls sets and negative bench pressing way more than he should.


When “hangry” (or overworked), infraspinatus can make sleeping, lifting, pushing, pulling and pretty much just sitting in a chair uncomfortable.  Throwing shade from its anatomical region all the way in to the elbow, forearm and hand in severe cases.


And for being an almost impossible muscle to stretch, he offers little solution to the drama incurred. Kind of like that friend who spends the entire happy hour complaining about how exhausted they are after a long day of work.  But you can’t unfriend infra.


And honestly it’s not all his fault, especially when you are sitting at your computer like that…essentially the position of your thoracic spine and scapula positions both your glenohumeral shoulder joint and affects the length-tension of all rotator cuff muscles.


So what can you do? If this shoulder prima donna is truly the star quarterback for our “rotator cuff” squad, then improving his utility and health will likely change the locker room atmosphere of your entire shoulder… if you know what I mean *towel slap*. Needless to say, more needs to be done than those boring theraband ER reps; like fixing thoracic mobility, scapular position and stability, and posture overall. Here’s a quick list of things to try if your shoulder is bothering you.

  • Postural mobility foam roller series
  • Scapular strengthening/stability work


  • Myofascial release


If these basic strategies do little to mitigate the situation, it may be time to see a physical therapist. A good PT can assess if a more severe tendonitis developed or if a tear has occurred and may use manual techniques like instrument-assisted soft tissue work, joint mobilization, taping, dry needling, or more structured stability training to more quickly improve your condition.

No infraspinati were harmed during the writing of this blog.

Thanks for reading this cynical overview of infraspinatus…feel free to ask questions, comment or follow me on Instagram, Facebook and Twitter (@dptwithneedles)!

Paul Killoren PT, DPT


What’s next for dry needling? 5 crazy guesses from @DPTwithNeedles


Weren’t we supposed to have hoverboards in 2015?  If we can learn anything from the 1985 versus the 2015 Marty McFly, it’s that the future is tough to predict.  At least without 1.21 giggawatts.  But that’s exactly what I intend to do with regards to the future of dry needling in the US.

Dry needling has come a long way in the past few years, but where is it headed?  Understandably a premature question as some states have yet to formally ratify dry needling practice by physical therapists; but with over 35 states allowing it, FSBPT (Federation of State Boards of Physical Therapy) and APTA (American Physical Therapy Association) endorsement, and exponential growth in terms of clinician and patient recognition – what’s next?  I first assert there are far more qualified individuals to postulate (or prophesy) the course of dry needling, but here are 5 trajectories I see dry needling taking in future years.

  1. Dry needling will be an entry level DPT skill. {gasps from the crowd} I am not even necessarily saying this is good, bad, or otherwise; but with growing interest from DPT students (and even prospective students), it will most certainly be a topic of consideration for DPT programs.  Honestly, it will only take one establishment to incorporate dry needling into their doctorate program for others to quickly follow suit.  A valid point would be that anatomical knowledge-base is debatably best immediately following graduation.  Counterpoint – new grads potentially lack the clinical reasoning on when, where, and why to implement dry needling, which comes with experience for any treatment technique.
  2. More physicians will implement dry needling. Sounds like an obvious statement as some specialized pain and ortho physicians already use dry needling, but I’m imaging a world where physicians will widely use dry needling as a precursor or alternative to pharmaceuticals and injections.  A more naturopathic versus pharmaceutical model, if you will.  I see this coming as a product of an upward trend in consumers requesting care alternatives and also the hopeful downward trend of over-prescribed medication for musculoskeletal pain in the US.
  3. Dry needling will be used with neuro and oncology patient populations. Dry needling is appreciated as one of the more effective myofascial modalities for orthopedic conditions, but currently contraindicated for many other diagnoses primarily due to lacking clinical research.  I see this changing.  As we learn more about the biochemical, vasomotor, lymphatic and neuromuscular effects of dry needling, we know we can affect the CNS, somatosensory cortex, muscle patterns, and the peripheral constructs of other systems directly with a needle and electrical stimulation.  To be sure – this is not an endorsement to go “maverick” on our traditional precautions and contraindications, but I see clinical research delving deeper into these subpopulations.  Think CP, Parkinson’s, SCI, TBI, lymphedema and oncology.
  4. Medicare will reimburse for dry needling.  “When you wish upon a star, it makes no difference who you are; anything your heart desires, will come true”.  I know, I know.  But sincerely, the recognition of Medicare for PTs implementing dry needling will likely be the domino needed to cascade third-party reimbursement.  They’d be silly not to with a likely decrease in visits per episode of care resulting.  And guess what?  When insurance covers it, patients will utilize it.  Then we can complain about the poor reimbursement we get for it.
  5. Dry needling-specific products will boom.  This isn’t even an advertisement for Myotech Dry Needles {insert chime}, but with an exponentially growing market and the need to differentiate dry needling from acupuncture; industry-specific products will result.  Especially considering the archaic electrical stim units and some of the cringe-worthy needle brands available today.  Physical therapists are concerned too much with quality and patient experience for this evolution not to occur.

Before we bring the focus back to the future (see what I did there) of dry needling, I think it’s worth applauding the efforts of the many who have elevated dry needling to what it is today.  Groups and individuals like the APTA, the FSBPT task force, the state associations who have worked to approve dry needling, the passionate clinicians in each city and state promoting its use, the visionary educators of the dry needling cirricula in the US, and the patients who have advocated for their own care. It takes a village. And it is because of this hard work we can look forward to decades and generations of better serving our patients using dry needling.

Your turn, folks. Here is your call to action. You have 3 choices –

#1 – There are still some states working to formally allow dry needling in PT practice. Please support specific causes like the North Carolina PT Association, PTWA (Washington State) or become more active in your own state association.  

#2 – If you are a patient or clinician utilizing dry needling, share this post or create your own. This could be a “how dry needling helped me” post or a simple “thanks” to someone who has helped you in regards to needling.

#3 – Watch Back to the Future. Probably the least productive option, but I don’t think you’ll be disappointed.

Thanks for reading and feel free to ask questions, comment or follow us on Instagram, Facebook and Twitter (@DoctorsofPT or @DPTwithneedles)!

Paul Killoren PT, DPT

Acupuncture is great too!


Recently I’ve had two acupuncturists on my caseload. They are both amazing individuals and I can’t say enough about them and their passion for helping people feel better. As humans, we are all broken and in need of some serious help. I’ve referred numerous people to acupuncture for relief of their symptoms. Different things work for different people. I could go in depth about intrinsic motivational factors and chronic pain sciences, but for this post, who the heck cares?

If acupuncture works for you, awesome! If dry needling helps you, awesome! I’ve had so many conversations with acupuncturists about dry needling. The acupuncturists I see at my practice get it. Our methods and goals are so different. Is one better than the other? Does it really matter?

No one profession can own a tool. I just used a hammer to secure some twine to hang Christmas cards, yet I am not a carpenter. The hammer can do many things for many people. Just like the hammer, thin monofilament needles can help people in different ways. I use a thin monofilament needle to help reset neuromuscular activity with the goal of improving overall function. If you use a similar needle as an acupuncturist to do what you do, that’s cool too!

Dry needling by physical therapists is not this huge health safety crisis some acupuncturists make it out to be. Seriously, stop the unnecessary fear mongering. We all know this is not the case. The acupuncturists I know agree as well. If you have an issue with this, I would love to see your research of physical therapists vs. acupuncturists with needles.

If we could spend even half the energy that’s gone into this acupuncture vs. dry needling debate into helping people, we’d all be better off as human beings.

As always, comments are welcome.

Austin Woods, PT, DPT (@awoodsdpt)


Not all Dry Needles are Created Equal

Cost vs QualityMany months ago I came across a paper published in Acupuncture in Medicine by Xie et al discussing the quality and consistency of commonly used stainless steel acupuncture needles. After reading it, two things became apparent to me. First, the amount of variance and quality between current acupuncture needles is crazy, and second, there has to be a better product out there that utilizes superior materials and implements stricter quality control measures.

More than thirty years have passed since the first disposable acupuncture needle was introduced. After all this time, acupuncture needles, even from the most highly regarded companies, continue to show significant irregularities and inconsistencies. A decade ago Hayoe et al found faults in most of the acupuncture needles being manufactured at that time. Since then, there has been nothing more reported on the subject until the release of this more current paper by Xie et al.

Xie et al set out to examine surface conditions and various other properties of currently used single-use stainless steel acupuncture needles. They chose two of the most common acupuncture brands to do so, one from China and the other from Japan. Ten needles from each brand were randomly selected from different batches of the commercial product for testing. Various inconsistencies were found.

Not only were the inconsistencies notable, but also the “after effect” of the needle after insertion. More specifically, many of the metallic lumps found on these needles “smoothed out” after the first or second needle insertions. What happened to these metallic lumps? Could we be depositing them into human tissue?

acupuncture needle quality

The small metallic lumps found on the needles were mainly comprised of iron, chromium, and nickel. Nickel allergies are one of the most common causes of allergic contact dermatitis. The percentages of nickel found between the two metals evaluated in this paper were between 10-12%.

Aside from the makeup of these metals, other practical implications of poor quality and metal deposits include decreased patient comfort and inconsistency of application between needles. As a practicing clinician that utilizes dry needling on a daily basis, nothing is more frustrating than opening up a pack of needles and having completely different experiences between each one.

Is there such a thing as a 100% perfect needle? No, that’s impossible. But there is a better needle out there using higher quality materials with less irregularities and inconsistencies; Myotech Dry Needles by Red Coral.

Here’s the deal on Myotech Dry Needles. First and foremost the company’s commitment to quality is top notch. The material used for their needle shaft is the highest quality surgical German steel (from Germany) available in the world today. It contains less than 4% nickel, which is far better than other materials on the market (also far less likely to trigger a nickel allergy). This steel also has improved tensile strength, which allows the practitioner to use longer needles with smaller gauges ultimately improving patient comfort. This means I can use 100mm or 135mm needles without compromising on practitioner or patient experience. In addition, the needle shaft features a micro-channeled body and is fully coated with parylene to help decrease insertion discomfort. Parylene is the most bio-accepted coating and is used on many medical implants including stents and pace makers. The handle used on Myotech Dry Needles is larger than acupuncture needles, which helps with improved dexterity and control. The other nice thing about the handles is conductivity, making it far easier for your electrical stimulation application. If you are using alligator clips, they hold much better on these than thinner handles or the needle shaft.

In addition to never wavering from using the highest quality materials, Red Coral has also implemented the most comprehensive quality control process to ensure the production of the most pure dry needle on the market.

The four-part process for Myotech Dry Needles includes twelve more quality control steps than other needle companies. The handle is fabricated differently to an acupuncture needle and is designed for dry needling. The raw materials process has an extra step involved as does the accessories control process. And the finished products control process has an extra 10 times inspection of the products. These extra steps are around the quality control of the German steel and fittings to the needle and ensuring that the accepted needles have an error rate of <1%.

Does all of this truly matter? To me the answer is an easy yes. My clients and patients deserve the highest quality in all aspects of their care, from customer service to the types of needles I put in their bodies. The minimal extra cost per treatment session to provide the most comfortable dry needling experience is worth it to me. Most, if not all of my clients that have experienced Myotech Dry Needles never want me to go back to the other types of needles I’ve used in the past. The intent of this post isn’t necessarily to tell you what to use, but to shed some light on the fact that the quality of currently made needles seems to be deteriorating.

How about you? What are your thoughts? Please comment below about your experience with various types of needles.

– Austin Woods, PT, DPT


If you are interested in trying Myotech Dry Needles, go to idryneedle.com and enter ‘MDN10’ at checkout for 10% OFF your first order.

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What does the FSBPT Dry Needling Competencies Report tell us?


Dry needling remains one of the hottest topics in Physical Therapy over the past decade and consequently has fostered both ardent support and opposition.  Almost the exclusive focus of my blog, strong state advocacy efforts, current best evidence momentum and unfortunately the dismay of many acupuncturist substantiates this.  And with this trend comes the need for education and safety standards (as alluded to in this post).  This maturation process of dry needling from obscure modality to mainstream technique added a significant endorsement when the FSBPT recently released its Analysis of Competencies for Dry Needling by Physical Therapists.

And if my nerdhood has not yet been fully exposed to you all, buckle up – here it comes…

My unabashed appreciation for the FSBPT report rivals the ice cream fervor of a 12-year old and when the report was released, I read it cover to cover…twice.  Like a teenage girl reading a Nicholas Sparks novel, minus most of the tears.  The hard work of the FSBPT, the APTA and a group of industry leaders didn’t necessarily drop a ground-breaking revelation on a physical therapist’s ability to dry needle; what they did was quantify what we have all been trying to qualify in garnering nationwide approval of dry needling.

‘Competencies’ per the FSBPT “are defined as measurable or observable knowledge, skills, or abilities an individual must possess to perform a job effectively. They possess both descriptive and evaluative information (i.e., what characteristics an individual must possess and to what extent or level of quality)”

But what does this 47-page report on dry needling competency actually tell us?  Well, it’s likely more obvious than you think.

1) More than 4/5 (86%) of the competencies required by a physical therapist are achieved in school. 

Aside from the obvious comprehensive knowledge of human anatomy (which is perhaps THE most important competency to have when penetrating tissue), the Doctorate of Physical Therapy involves relevant curriculum matter like differential diagnosis, physiology, neuromusculoskeletal evaluation, manual therapy interventions, environmental safety, infection control and professional responsibility – to name a few.  Basically this substantiates that once PTs are trained in dry needling, they know how to use it safely, why it is being used, what mechanisms are occurring on the tissue and neuromuscular level, and where to treat for functional and therapeutic benefit.

2) The other 14% of the competencies for dry needling must be gained through specialized training. 

Carry the 1 and that leaves only a 14% gap in competency from entry-level skill to dry needling proficiency.  But this also means dry needling is not an entry-level skill.  No one is claiming a therapist untrained in dry needling is capable of implementing the technique based on our anatomical knowledge alone and nor should they.  The psychomotor skills of manipulating a needle along with sub-specialized considerations in terms of environmental safety and patient communication are required, and reinforcement of soft tissue palpation and 3-dimensional anatomy are both noted advantages.

3) Background review distinguishes dry needling as different than acupuncture. 

From a deductive evaluation of sources encompassing websites, resource papers, text publications, peer-reviewed research journals, instructional curricula, and testing materials; the FSBPT extracted 937 relevant fragments from 30 sources as a foundational definition for dry needling, it’s mechanisms, and it’s required knowledge base.

Here are just a few –

“Dry needling is a neurophysiological evidence-based treatment technique that requires effective manual assessment of the neuromuscular system”

“Anatomical knowledge of the vascular system is important as there is a potential to puncture blood vessels during needling”

“The clinician should be cognizant of anatomical structures within the treatment area that are vulnerable to [dry needling], e.g. neurovascular structures and the lung, and ensure that the needling technique avoids penetration of vulnerable anatomical structures.”

“Sustained contractures of taut bands cause local ischemia and hypoxia in the core of trigger points.”

4) Dry needling is definitively within the scope of physical therapist practice. 

The purpose of this report was not necessarily to prove or disprove this point, but rather to qualify and quantify the skills required to safely and effectively implement the technique.  Even with dry needling inclusion in the most recent APTA Guide to Physical Therapy Practice and endorsement by the growing majority of state legislatures, 9 states have yet to definitively endorse it as within PT practice.  The hope is continued systematic definition and validation of dry needling will be more than sufficient to encourage these undefined states to ratify its use by physical therapists.

With an admitted abbreviation to an incredibly thorough process and report, these four points say a lot. A process involving background review, practitioner survey and task force meeting of industry leader essentially equates to what we as physical therapists already know, but others may not.  I see this report as the springboard first for nationwide acceptance of dry needling by physical therapists, but secondarily to establish education standards for dry needling coursework in the US.  All of which with the ultimate focus on patient betterment and safety, and the continued progression of physical therapy.

Paul Killoren PT, DPT

As always, I encourage feedback, commentary and professional discussion…and witty rhetoric or jokes.

Thanks for reading, feel free to ask questions, comment or follow us on Instagram, Facebook and Twitter (@DoctorsofPT or @DPTwithneedles)!


4 Reasons Dry Needling Is About To Explode


It’s interesting to think that dry needling, a technique developed in the 1980’s, remains in its infancy.  Even with top hierarchical research on safety and effectiveness, widespread acceptance worldwide and (almost) entirely in the US, use by every major sports league and our military, and recognition by DPT programs – dry needling is in diapers.  Estimations have been made that <3% of physical therapists in the US are currently practicing dry needling and the number of emails, calls and conversations I get centering on “so, what exactly is dry needling?” speaks to the budding youth of this innovative technique.

Don’t get me wrong, I understand the natural progression of healthcare and as physical therapists we are only several decades removed from this…


But dry needling is a little different.  For those of you familiar with my outspoken biases, I strongly feel dry needling will almost singularly elevate our profession in terms of the ability to execute an invasive technique safely and judiciously.  It won’t always be the shiny new toy in our toolbox, but as the acceptance and natural maturation of dry needling increases I only see us moving on to bigger and better things.  True direct access (both public and third party payer recognition), diagnostic imaging prescription, and autonomy as musculoskeletal experts, you ponder?

Before we lay back and stare at the clouds of what could someday be, back to my initial point.  Dry needling.  Diapers.  As gradual and resistive as the infancy of dry needling has been in the United States, I optimistically see future growth, acceptance and clinical practice of dry needling exploding in the next 5 years.  I would not be entirely surprised if the number of physical therapists practicing dry needling goes from <3% to over 15% within that time frame.

And those projections are based on nothing aside from these 4 indications as I see them that dry needling is about to explode in the United States.

1) State rulings approving dry needling are trending upwards. 


True, the main headlines you’ve seen over the past couple years regarding dry needling have possibly been about the heated battle some states have dealt with.  But plainly stated, in 2005 ~5 states specifically allowed dry needling and in 2015 ~35 states have now specifically endorsed physical therapist practice of dry needling in either formal law, attorney general rulings or PT board endorsements.  I believe as the numbers of dissenting states dwindles the debate with heighten, but I also have faith the remaining states will ultimately rule appropriately in favor of our ability to perform dry needling.

2) Dry Needling introduction in DPT curricula. 

At this point it is perhaps little more than just an overview of innovative new techniques, but the fact students are being introduced to dry needling creates awareness.  I agree with many much wiser than I who believe dry needling will someday be an entry-level skill taught in our DPT programs.  This will increase both practitioner and public acceptance of dry needling as a mainstream modality in physical therapy practice.

3) Dry Needling-specific products being introduced. 


Suffice it to say, the majority of resistance to PTs dry needling comes from acupuncturists and being able to definitively differentiate our practice from acupuncture in both training and products will be imperative.  Products like Myotech Dry Needles are the highest quality needles I’ve ever used personally and the fact spending a little more per needle allows me to say I not only use the best, but unarguably do not practice acupuncture or even use acupuncture needles is priceless.

4) Mainstream practices always starts with pro athletes and our military.


We’d obviously all love if public sector PT was granted the same autonomy as military PTs, but the fact dry needling has been used by America’s finest and highest level athletes for over a decade only speaks to its established efficacy.  The trickle down to mainstream PT will occur and I have a feeling it could occur rapidly.  We just need one Lebron, Derek Jeter, Jordan Spieth, or Russell Wilson tweet and dry needling will be #viral.

Take these thoughts for whatever you think they are worth and I agree that it will not necessarily be a seamless integration of dry needling to mainstream PT practice. As I stated earlier, my enthusiasm over dry needling is not necessarily just because I love dry needling.  I do and for good reason as I have seen it help countless people who experienced minimal relief elsewhere.  But I also foresee this as perhaps the most significant and opportunistic stepping stone our profession has to demonstrate our proficiency and expertise in management of the neuromusculoskeletal system – be it with a more invasive technique.  Our ability to mitigate potential risk as well as capably “do no harm” to our patients is paramount if we expect to ever achieve the true potential of our profession.

But these are my thoughts, what are yours?  As always, I encourage feedback, comments, questions and sarcastic rhetoric.

Thanks for reading and be sure to follow and share on Instagram, Facebook and Twitter (@DPTwithneedles).

Paul Killoren PT, DPT

Dry Needling Digest: Journal Club for Dry Needling Clinicians Part I


The therapeutic mechanisms of dry needling are still relatively unknown, and this bothers some people.  You’ll hear proposed benefits ranging from lengthening mechanically shortened sarcomeres, to decreasing ascending nocioception, to eliciting local tissue changes at an ischemic triggerpoint, to a complete neuromuscular reset at the cortical and CNS level.  You’ll also find similar variance in the explained benefits of joint manipulation – is it gapping a compressed joint articulation, is it a gaseous release, is there an endogenous opioid release following a cavitation?  All we know is that pain is less and function is better – the goal of any clinician.

But for some of my textbook-thumping EBP brethren, we need to know why.  And that ‘why’ sure as heck better be in the form of a well-organized double-blind randomized-control trial or we will be throwing the BS flag of placebo-wrought indignation. Sarcasm aside though, the volume of evidence surrounding dry needling is building and as a responsible clinician looking to understand the science behind the art of dry needling, I welcome you to Part 1 of what I hope to be a continued collaborative platform for clinicians interested in dry needling research.  I’ve titled this “Dry Needling Digest: Journal Club for Dry Needling Clinicians”.  So grab a pint, a coffee or glass of choice and join me.

Take a few minutes to read our first selection –

Skorupska E, Rychlik M, Samborski W. Intensive vasodilatation in the sciatic pain area after dry needling.  BMC Complementary and Alternative Medicine. 2015;5:72 DOI 10.1186/s12906-015-0587-6.

If you’re like me, the immediate mental image conjured by the title was the Travell and Simons referral chart for glute minimus.  Highly regarded as innovators of myofascial and triggerpoint referral-patterned pain, Travell and Simons’ literature and pain charts have become an adjunct to my previous joint- and Maitland-focused methodologies.  Through the mentorship of many much wiser than myself, I have begun to recognize myofascial pain as an often under-treated origin (or at least contributor) of my patient’s pain.  If not familiar, here is a look at the glute minimus referral pattern as identified by Travell And Simons – the ‘x’ is where Travell penetrated an identified triggerpoint with a hypodermic needle and the red pattern represents concentrated patient-reported referral pain.


Based on this image, it is clear to see why glute minimus is regarded as one of the main sciatic mimickers in the body and likely why it was the chosen muscle in this study.

Journal club in session – let’s dive in.

What they did well. 

This study is cool.  Infrared thermovision cameras add more objectivity to the study in comparison to patient-report originally offered by Travell and Simons, but eery how similar the images are.


What’s also interesting is that the objective of this study was not pain reduction or functional gain, but straight up vasomotor response in TrP versus non-TrP dry needling treatments. As the authors mention, what the results inadvertently (or completely intentionally) demonstrate is an autonomic response (vasodilation and tissue temperature change) from a localized myofascial tissue, suggesting sympathetic nerve sequelae and involvement in myofascial pain pathomechanism.  Meaning, a very localized triggerpoint is not-so indirectly associated with CNS changes. Furthermore treatment of a triggerpoint can elicit a CNS response.

The patient selection and exclusion seem logical and I like that the inclusive diagnosis was simply “sciatica” versus necessarily first identifying a neural versus myofascial origin.  They take that next step to identify glute minimus triggerpoint presence afterwards, but in terms of clinical application the study found 16 people with a ‘sciatica’ diagnosis which was reproducible with soft tissue compression.

Taking a look at the findings, we essentially see a tissue temperature increase in the TrP-positive group at the thigh, calf, and foot; what we also see is that the temperature continues to increase in the thigh and foot of TrP-positive subjects for 6 minutes after treatment.  More needs to be done to assess beyond 6-minutes, but what we can initially extrapolate is that the benefits extend beyond the time of actual treatment.


What they could have done better.

This is where most people turn into Statler and Waldorf (the grumpy old muppets in the balcony) and micro-criticize the minutia to invalidate any findings from a study.  Let’s keep it classy, Journal Club.

I don’t think it’s a perfect study, but I feel this study was very well done. When it comes to dry needling research I think the main contention will come in the form of treatment application.  Some will even debate the inter-rater reliability of TrP identification, and if that is the debate then glute minimus is potentially one of the most difficult muscles to identify in terms of tissue depth, body type variability, and the fact we are palpating through glute medius.  Dry needling is also heavily dependent on “treating the dysfunction”, which means we don’t necessarily have a standardized roadmap of where to treat but rather treating the tissue found to be dysfunctional.

Aside from those limitations, it wasn’t completely clear how the DN treatment was applied aside from the fact it lasted 5 minutes per location and with the intent of diagnosis versus therapeutic effect.  Thinking clinically, limiting the use of needle to a 60mm length may have added some skepticism to the treatment aspect appreciating the depth of tissue and body type differences among the groups, but it does detail “strong subcutaneous tissue compression”.

Overall, I feel the strengths of the study far outperformed any critiques or inherent limitations.

Where do we go from here.

The authors mention a cross-over study including a healthy population and IRT sans dry needling, which I agree would add depth to the findings in the study.  And perhaps selfishly, I find myself wandering down the Radiculopathic Model path in terms of wanting to know if treating multifidus segmentally would have similar findings in a myotomal or dermatomal pattern.  Expanding the subject matter and findings to other diagnoses and anatomical regions would also likely intrigue certain specialities – ala pelvic floor, TMD, or neurologic diagnoses populations.

Otherwise, this study excites me and what I think we can take from it is that the effects we impart on the musculoskeletal system with dry needling are comprehensively neuromuscular, vascular, cortical, and likely biochemical.

Now it’s your turn.

The objective of this journal club is to foster an interactive environment of professional communication regarding research, dry needling, and clinical practice.  Whether you a student, a clinician currently using dry needling, a curios skeptic, or a patient…I want to hear your thoughts.  There is no such thing as a dumb question unless it go unasked, and all opinions are welcome.  Feel free to share this on social media or comment below.  Based on response we will keep this going on a monthly basis and dissect literature past and present.

Thanks for reading!

Paul Killoren PT, DPT

Feel free to ask questions, comment or follow on Instagram, Facebook and Twitter (@DPTwithneedles).

Skorupska E, Rychlik M, Samborski W. Intensive vasodilatation in the sciatic pain area after dry needling.  BMC Complementary and Alternative Medicine. 2015;5:72 DOI 10.1186/s12906-015-0587-6.

I am a physical therapist using dry needling.


The dry needling debate comes in many forms – Is it acupuncture? Is it within the scope of physical therapy practice? Is current training sufficient for clinicians who dry needle?

Answers – No. Yes. Not always.

I feel the first question/answer requires its own post, and 30 state legislatures have already answered the second (that it is within PT scope of practice), but the last comes with the completely honest admission that not all dry needling courses are created equal. This was highlighted with a recent well-written piece authored by an acupuncturist.  Although the commentary was certainly biased, I found myself agreeing with many of her thoughts on how poorly the dry needling course was organized in terms of safety and practical training.  Not cool.

Instead of debating the good, bad and ugly of this previous piece, I thought it may be more informative to detail my training as a physical therapist who utilizes dry needling.  Hopefully to illustrate the standard of dry needling education is higher than the original piece suggested. So the purpose of this post will be to describe what some dry needling education organizations have already embraced in terms of clinical education safety standards, and maybe how the rest of them ought to. Whether you are a clinician considering training in dry needling or a patient seeking a proficient clinician, I feel there are some necessities to consider in terms of dry needling education.

First though, it’s difficult to qualify these standards without recognizing that the clinicians taking these courses all have post-graduate education and at least 1-2 years of clinical experience.  My education includes a Bachelors in Biology/Pre-Physical Therapy, a Doctorate of Physical Therapy, and 2 years of clinical experience prior to my first dry needling course.  Dry needling is not an entry level skill and most organizations realize that the clinical reasoning and practical skills fostered in this requisite period prior to dry needling coursework is crucial.  The majority of clinicians taking dry needling courses have either their MD, DPT, or DC. Acupuncturists seem very quick to criticize a weekend dry needling curriculum, but deny this doctoral education of physical therapists, chiropractors and physicians.

Unfortunately, it has been my experience that many acupuncturists lack substantial background education in basic human anatomy, musculoskeletal differential diagnosis, soft tissue palpation (or “hands on anatomy”), and clinical reasoning. And this observation was made both during conversation with acupuncturists as well as observing them during the same weekend workshops they condemn. My intent is not to be harsh, but simply to illustrate the expertise these acupuncturists criticize under the guise of safety is specious, and paradoxically is typically much more than their own in terms of human anatomy.  But this is truly an apples v. oranges comparison considering the focus of coursework for a Master’s in Eastern or Oriental Medicine versus the Doctorate of Physical Therapy.  That’s soapbox #2 on why acupuncture and dry needling are very different.

However, if the safety of needle penetration into human tissue is the concern, I suggest a simple field test. If you are considering dry needling as a patient with knee pain, ask your dry needling physical therapist, chiropractor or physician what the path of the femoral nerve is as it traverses the upper medial thigh and where it branches into anterior and posterior components.  Now ask an acupuncturist.  Do the same for the cervical plexus, sciatic nerve and where it branches into tibal and peroneal divisions, the adductor hiatus, femoral triangle, dorsal root ganglia, tibial artery, ulnar nerve, median nerve, and lung field.  Point being, if we are looking to arbitrate a clinician intending to penetrate dermal and subcutaneous layers of tissue, they ought to be fully cognizant of every layer and potential structure that needle could influence.  Safety of any medical procedure is predicated primarily on this appreciation of anatomy, not necessarily more hours handling needles.  In fairness, I’m not implying that every single physical therapist will readily know these answers, and if they don’t I would be wary of undergoing dry needling with them. Just as I would be wary of an acupuncturist with debatable anatomical knowledge inserting a needle deeper into tissue.

So with an emphasis on clinical application, here is a list of 6 things specific to my dry needling education which I feel were of utmost importance in regards to safely and effectively implementing the technique.  Specifically I intend to compare my experience to the unfortunately poor experience referenced in the post. Supporting literature, history, clinical dosage, and didactic lecture on mechanism, physiology and pathology are all very important; but let’s talk in terms of dry needling safety and technique first.

#1 – Education on clean needle technique.

It is unrealistic to maintain a sterile field in a PT clinic or gym, but using gloves, sanitizer, alcohol swab on the skin, sterile needles and basic training in clean needle technique is a necessity. Yes, the risk of infection is nearly zero, but why would you even slightly increase the risk of this?

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#2 – Education on bloodborne pathogens and transmittable disease. 

Again, the risk of this is nearly zero when practicing clean needle technique, but appreciating the needle as a potential vehicle for such disease is a necessary component of dry needling education. Protect your patients, protect yourself.

#3 – Instructor ratio of at least 1 instructor : 6 students. 

My opinion – If you do not have small group lab instruction and supervision for a dry needling course, you are not being sufficiently trained. I see this as the main contributor to safety, practitioner understanding, and clinical efficacy. All coursework I completed was within this ratio and to be completely frank, I’m not sure I would have felt comfortable needling if I hadn’t had such tutelage.

#4 – Regional anatomy education including lecture, lab, and multimedia resources.

Before you even think about needling a region, you must know the 3-dimensional, cross-sectional, and palpable anatomy of ALL structures that needle may encounter.  Not just muscles and tendons, but complete neurovascular, visceral and musculoskeletal anatomical integration.  This is where physical therapists should excel.  We are no longer just looking at Netter’s textbook pages or even a static cadaver; we are positioning a muscular system, manipulating tissue in our grip and directly influencing layers we were previously unable to.

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#5 – Written and practical testing.

More specifically, practical testing that will fail you if you are unsafe, ineffective, or simply uneducated on clinical application.  My practical testing included both oral and technical portions and not everyone in our class passed.  Dry needling shouldn’t be a continuing education course where you pay registration and automatically expect a certificate afterwards. It is an advanced technique and I feel advanced manipulative courses should embrace this philosophy as well.

#6 – 200 documented patient contact hours required prior to Level 2 coursework.

With completion of Level 1 coursework, a required 200 patient treatment hours documenting muscles treated, outcomes, and response was needed to enroll for Level 2.  In hindsight, I found this to be incredibly helpful in more objective assessment of my skills and the obvious repetition required to refine basic skills prior to advanced training.

Fast forward over 3 years and I personally have now used dry needling in over 3500 treatments since taking my first dry needling course.  Dry needling has become a cornerstone of my manual skill set as a physical therapist and many patients come to us having minimal relief from other treatments, procedures, and modalities.  I’m happy to say that in that time, no significant adverse event has occurred and we have been able to help a lot of people.  Not necessarily because I am an extraordinary clinician (although I hope to be some day), but because of my background education, training, and respect of dry needling as a powerful modality.

As the popularity of dry needling increases, we will see federal and state standardization of the requirements and coursework associated with it. This is a good thing. In 2015, the Federation of State Boards of Physical Therapy commissioned a task force of industry leaders to create such standards for both certification coursework and hours required on a state level. In the meantime, as a healthcare consumer or practitioner, do your homework on the training your health professional has undergone. First comes safety, then comes expertise.

My hope is that the tone of this article did not come off as combative, but moreseo an expression of my personal experience which I felt upheld the high standards of safety and excellence in dry needling education. Although there are obvious foundational discrepancies between clinicians who dry needle and acupuncturists, I hope there can be agreement on the common goal to improve our patient’s lives.

As always, I encourage commentary of any opinion if it can be done so professionally.

Paul Killoren PT, DPT

Thanks for reading, feel free to ask questions, comment or follow us on Instagram, Facebook and Twitter (@DoctorsofPT or @DPTwithneedles)!