Dry Needling for Shoulder Pain: Does It Add Value to Standard Physical Therapy?

Dry needling has become one of the most popular adjunct treatments in physiotherapy practice. Walk into almost any musculoskeletal clinic and you'll find clinicians using thin filiform needles to target myofascial trigger points. But when it comes to shoulder pain—specifically subacromial pain syndrome—does adding dry needling to our standard treatment approach actually improve patient outcomes?

A new sham-controlled randomised clinical trial published in the Journal of Orthopaedic & Sports Physical Therapy provides the most rigorous evidence to date on this question.

The Study at a Glance

Researchers from the United States conducted a three-arm randomised controlled trial involving 121 participants with subacromial pain syndrome (commonly known as shoulder impingement). This multicentre trial represents one of the few studies to use a true sham control for dry needling.

The Three Treatment Groups

1. Standard Physical Therapy Only: Manual therapy and exercise
2. PT Plus Dry Needling: Standard PT with actual trigger point dry needling
3. PT Plus Sham Dry Needling: Standard PT with a convincing placebo procedure

The sham procedure used a validated technique: a guide-tube with a blunted toothpick that simulates the sensation of needling without actual tissue penetration. This is critical because it helps separate the specific effects of needle insertion from the general effects of the treatment ritual.

What Did They Find?

Primary Outcomes: No Significant Difference

The primary outcome was the Shoulder Pain and Disability Index (SPADI) at 1 year—a well-validated measure of shoulder pain and function.

The headline finding: Differences in SPADI scores between the PT plus dry needling group and the PT only group did not reach statistical significance. Similarly, no significant difference was found between actual dry needling and sham dry needling groups.

In plain terms: adding dry needling to a well-designed manual therapy and exercise program did not produce meaningfully better outcomes on the primary measure.

Secondary Outcomes: A More Nuanced Picture

While the primary analysis showed no benefit, secondary outcomes painted a more complex picture:

• Patient-perceived symptom acceptability improved at both 6 months and 1 year in the dry needling group
• Healthcare utilisation was lower—participants receiving dry needling were less likely to seek additional shoulder care during the 12-month follow-up

These secondary findings suggest dry needling may influence patient satisfaction and treatment-seeking behaviour, even if it doesn't produce measurable improvements in pain and disability scores.

Why This Study Matters

The Sham Control Problem

Most dry needling research suffers from a fundamental limitation: it's difficult to blind patients to whether they received a real needle or not. This study addressed that limitation directly with a validated sham procedure.

When patients don't know if they received real or sham treatment, we can better isolate the specific effects of the intervention from placebo effects and expectation.

Comparing to Common Practice

Previous systematic reviews on dry needling have shown mixed results, but many included studies compared dry needling to no treatment or waiting lists. This trial asked a more clinically relevant question: does dry needling add benefit on top of effective physical therapy?

The answer appears to be: not for the primary pain and disability outcomes.

What Does This Mean for Clinical Practice?

The Case for Caution

The findings suggest clinicians should be cautious about the incremental value of dry needling when:

• Already providing high-quality manual therapy and exercise
• The primary goal is reducing pain and improving function scores
• Justifying additional treatment costs or session time

The Case for Continued Use

However, several factors might support continued selective use:

1. Secondary outcomes showed benefits in patient perception and healthcare utilisation
2. Individual patient variation means some may respond better than others
3. Patient preference matters when evidence is equivocal
4. This is one study—the evidence base continues to evolve

A Balanced Approach

Perhaps the most pragmatic interpretation is this: dry needling for subacromial pain syndrome should not be considered essential, but it may still have a role for selected patients.

If you're achieving good results with manual therapy and exercise alone, this study suggests dry needling may not substantially improve those outcomes. If patients have specific myofascial components to their presentation, respond well to dry needling, or have strong preferences for the treatment, it remains a reasonable option.

Methodological Strengths

This trial gets several things right:

• True randomisation with three parallel arms
• Validated sham procedure to control for placebo effects
• Clinically relevant comparison to standard practice
• 12-month follow-up for long-term outcomes
• Multicentre design improving generalisability
• Intention-to-treat analysis preserving randomisation benefits

Limitations to Consider

No study is perfect, and several factors warrant consideration:

• Sample size: While adequate (n=121), larger trials might detect smaller effects
• Specific protocol: Results apply to the specific dry needling approach used
• Population: Findings may not generalise to all shoulder presentations
• Single trial: Replication is needed before drawing firm conclusions
• Standard PT quality: The comparison group received high-quality care

Integrating With the Broader Evidence

This study aligns with several recent findings in the dry needling literature:

A 2021 JOSPT study found that dry needling added no benefit to neck pain treatment compared to sham. Similar questions are being raised across various musculoskeletal conditions.

At the same time, systematic reviews continue to show dry needling can produce short-term improvements in pain and disability for various conditions when compared to no treatment or minimal intervention.

The emerging pattern suggests dry needling may have value as a standalone or early intervention, but adds less when combined with already-effective treatments.

Practical Takeaways for Clinicians

Based on this evidence, consider:

When Dry Needling Might Add Less Value

• When your manual therapy and exercise program is producing good results
• When primary goals are long-term function and pain reduction
• When treatment time or costs are limited

When It Might Still Be Appropriate

• Patients with prominent myofascial trigger point components
• Those who have responded well to dry needling previously
• When patient preference strongly favours the intervention
• As part of a multimodal approach when other treatments plateau

Communication Points for Patients

• "This is an optional add-on treatment"
• "The main evidence supports our manual therapy and exercise program"
• "Some patients report benefits beyond what we can measure on questionnaires"
• "We can try it and see how you respond"

The Bigger Picture

This study contributes to an important trend in physiotherapy: critically examining our adjunct treatments and asking whether they truly add value beyond our core interventions.

The foundation of treatment for subacromial pain syndrome remains:

• Therapeutic exercise targeting strength and motor control
• Manual therapy addressing joint and soft tissue restrictions
• Patient education about activity modification and prognosis
• Progressive loading to rebuild tissue tolerance

Dry needling can complement these approaches, but this evidence suggests it shouldn't replace them or be considered essential.

Looking Forward

Future research should examine:

• Patient subgroups who might respond better to dry needling
• Different needling protocols (depth, technique, frequency)
• Cost-effectiveness analyses
• Combination with other adjuncts like taping or shockwave therapy
• Earlier intervention points in the treatment pathway

Bottom Line

This well-designed sham-controlled RCT found that adding trigger point dry needling to standard physical therapy for subacromial pain syndrome did not significantly improve pain and disability outcomes at 1 year.

Secondary outcomes showed potential benefits in patient-perceived acceptability and reduced healthcare utilisation, suggesting the intervention may have value beyond what standardised outcome measures capture.

For clinical practice, this supports a pragmatic approach: dry needling is not essential for treating shoulder impingement, but it remains a reasonable option for selected patients when integrated with evidence-based manual therapy and exercise.

The strongest shoulder rehabilitation programs will continue to prioritise progressive exercise and skilled manual therapy, with dry needling available as an adjunct for patients who may benefit.

Key Takeaways

• No significant SPADI improvement at 1 year when adding dry needling to standard PT
• 121 participants in a three-arm sham-controlled RCT
• Secondary benefits observed in patient satisfaction and healthcare utilisation
• Sham control strength allows better isolation of specific needle effects
• Clinical implications: Dry needling is optional, not essential, for shoulder pain
• Exercise and manual therapy remain the treatment foundation
• Patient-centred decisions should guide adjunct treatment selection

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This article is part of our Clinical Evidence Series, designed to help Australian physiotherapists stay current with high-quality research relevant to daily practice.