Dry needling research can sometimes be surprisingly frustrating. For both seasoned dry needlers and dry needling students who recently have completed—or are currently progressing through—the Myopain Seminars dry needling curriculum, the findings are especially interesting because they force us to ask a fundamental question: When researchers use the term “dry needling,” are they studying the same clinical procedure we think they are studying?
A paper may state that participants received “dry needling,” but that description alone tells us remarkably little about what was actually done. Where was the needle inserted? How many needles were inserted? How was the target selected? Was a myofascial trigger point identified through palpation? Was familiar pain reproduced? Was the clinician following a fixed anatomical protocol? Was the needle manipulated? Was a local twitch response sought? How many sites were treated, and how many sessions were provided? These details are more than minor technical details, since they define the intervention.
Over the past decades, much of the regulatory debate surrounding dry needling has focused on the seemingly straightforward question of whether dry needling falls within a physical therapist’s scope of practice. Increasingly, occupational therapy boards and state legislatures are confronting the same question for occupational therapists. Colorado, for example, enacted legislation in 2026 authorizing qualified occupational therapists to perform dry needling beginning September 1, 2027, with implementing rules still to be developed. State boards and legislators are challenged by the dilemma how to characterize and define dry needling.
The Regulatory Problem: Defining Dry Needling Too Narrowly or Too Broadly
State legislatures and licensing boards must translate clinical practice into statutory and regulatory language. A statute must be specific enough to identify the practice being regulated but broad enough to remain applicable as clinical practice and scientific knowledge evolve. A regulator unfamiliar with contemporary dry needling practice may approach the subject with a relatively simple mindset and assume that dry needling means inserting a thin needle into a myofascial trigger point. While the trigger point model has historically been the most prominent form of dry needling, and remains so, it does not encompass the full range of procedures described in the clinical and research literature. That question becomes even more important when considering dry needling of tendons and tendon-related disorders.
A new paper by Dr. Andrew M. Ball in the Journal of Bodywork & Movement Therapies implies that state boards and legislators should consider the question, “what exactly constitutes dry needling?” Ball’s paper shows that even within focused neck-pain research, interventions labeled “dry needling” differ depending on how they select targets. Recent tendinopathy research adds another layer: the intended target may not even be muscle or a trigger point. It may be tendon or another connective-tissue structure, such as an enthesis, scar tissue, or fascial adhesions. The problem is that dry needling is not a single standardized procedure.
State boards and legislators face a difficult task, because this is not simply an academic distinction; it is also a definition problem. If the definition is incomplete or wrong, the regulations built on it may be deficient as well. The question is what is included under the umbrella term of dry needling. A definition such as:
Dry needling is the insertion of a filiform needle into a myofascial trigger point.
sounds precise, but Ball’s analysis demonstrates why such a definition may be too narrow. If a statute defines dry needling exclusively as the insertion of a needle into a myofascial trigger point, what happens when a licensed clinician uses a solid filiform needle to treat a tendon? Has the clinician suddenly stopped performing dry needling? Has the clinician entered an entirely different regulated or unregulated procedure? Or was the original statutory definition simply too narrow?
A few states, such as Washington State, have adopted the term intramuscular needling, which may also be too restrictive, similar to defining dry needling as:
Dry needling is insertion of a needle into muscle.
Both exclude fascial dry needling, and dry needling of tendons and entheses, among others. The challenge is identifying the essential characteristics of the intervention without accidentally freezing one particular technique into law. Any legal dry needling definition will determine the competency standard in that jurisdiction. If regulators define the procedure too narrowly, they may inadvertently establish educational requirements that are too narrow as well. Statutory terminology chosen decades ago can become problematic as clinical applications evolve. A regulatory definition built around the word intramuscular may unintentionally create ambiguity regarding procedures directed toward other tissue targets, which is why legislatures should be cautious about embedding a particular historical conception of a clinical technique permanently into statutory language.
What about intra-articular needling and perineural dry needling? Following the publication of a study by Dunning and colleagues that included intra-articular and perineural needling, multiple state boards of physical therapy indicated that their statutes, rules, or regulations do not explicitly prohibit intra-articular dry needling, but in other states the definition of dry needling may preclude these forms of dry needling. Of interest is that in 2024, the North Carolina Physical Therapy Board excluded perineural dry needling from the scope of physical therapy in North Carolina, which illustrates some of the challenges of dry needling regulations.
By contrast, a definition recently adopted by the International Dry Needling Education and Training Advisory Group (IDNETAG),
Dry needling is the therapeutic insertion of a solid filiform needle into somatic tissue.
may be too broad for legislators, because it says almost nothing about target selection, clinical reasoning, purpose, patient examination, depth, anatomical considerations, or how the intervention is integrated into the management of a neuromusculoskeletal condition. The challenge for regulators, therefore, is not merely choosing the correct words.
Dry Needling Is a Category of Intervention, Not One Standardized Technique
Ball begins with a critical observation: the term dry needling is applied to interventions that may differ in the tissue or point selected, the clinical rule used to select that target, needle dimensions and depth, manipulation or retention, treatment frequency, and accompanying interventions, which together may have substantial regulatory implications. A statute may use only two words—dry needling—while the clinical procedures represented by those two words can vary along multiple dimensions.
Ball identified three operational categories.
1. Trigger Point Dry Needling — TrP-DN
This category defined an intervention as TrP-DN when needle placement depended upon patient-specific identification of a myofascial trigger point or taut band. Descriptions supporting this category include findings, such as a palpable taut band, a hypersensitive spot or nodule, reproduction of familiar or referred sensations, and identification of an active or latent trigger point.
The defining concept is contingency. The clinician examines the patient. A patient-specific finding is identified. That finding determines where the clinician inserts the needle.
2. Semi-Standard Protocol Dry Needling — SSP-DN
Ball classified a second group as SSP-DN when the intervention involved a predefined anatomical site, landmark-based trajectory, standardized map, or protocolized needling algorithm that does not depend on identifying an individual trigger point.
Both procedures involve a solid filiform needle. Both may be described as dry needling. But the clinical reasoning behind needle placement differs substantially. Ball appropriately emphasizes that SSP-DN is an operational research label created for his analysis, not a universally accepted clinical taxonomy.
3. Under-Specified Dry Needling
The third category contained studies reporting dry needling without providing enough information to determine whether target selection was trigger-point contingent or anatomically/protocolically predefined. This category should be of particular interest to regulatory boards. If the words “dry needling” do not provide researchers with enough information to determine what procedure was performed, regulators should be cautious about assuming that the term by itself describes one uniform intervention.
Following citation verification, eligibility review, and de-duplication, Ball identified 28 unique randomized trials involving 1,551 participants. Of those:
- 24 trials (85.7%) used trigger-point-contingent dry needling;
- 1 trial (3.6%) used a fixed anatomical or landmark-based protocol;
- 3 trials (10.7%) were insufficiently described to determine how they selected the target.
Within the body of neck-pain dry needling research, TrP-DN clearly represented the predominant form of needling studied. But Ball specifically warns against interpreting these numbers as either prevalence estimates for the entire dry-needling literature or evidence that one approach is clinically superior. The categories describe how targets were selected, not which procedure works better.
The Missing Dimension: What Tissue Is Being Needled?
Ball’s classification primarily addresses one axis:
Target-selection method
- patient-specific trigger point;
- predetermined anatomical target;
- under-specified.
But regulation may require another axis:
Target tissue
A needle may be directed toward a skeletal muscle, a myofascial trigger point, a musculotendinous tissue, a tendon, the tendon-bone interface or enthesis, other connective tissues, or perineural and intra-articular tissues. Ball actually anticipated this broader issue in his introduction by noting that interventions labeled dry needling may differ in the “tissue or point selected.” That phrase becomes increasingly important as tendon needling receives more scientific attention.
Tendinopathy Makes the Regulatory Problem Much More Obvious
Two recent 2026 systematic reviews illustrate why regulatory definitions centered exclusively on myofascial trigger points may be increasingly difficult to defend as comprehensive definitions of dry needling. Song and colleagues conducted a network meta-analysis of physical interventions for lateral epicondylitis, which they described as a chronic tendinopathy involving degenerative changes of the extensor tendons.
Their treatment taxonomy is particularly revealing. Within their dry needling category, the investigators grouped standard dry needling, ultrasound-guided dry needling, percutaneous micro-puncture, and Fu’s subcutaneous needling. In a separate category, they classified percutaneous electrolysis, which involves ultrasound-guided insertion of a cathode needle into damaged soft tissue such as the common extensor tendon, combined with the application of a galvanic current. Whatever one thinks of the authors’ decision to aggregate these procedures statistically, their taxonomy shows the problem facing regulators: contemporary needling literature is no longer confined to inserting needles into palpated muscular trigger points. Should regulators define dry needling to include ultrasound-guided percutaneous electrolysis? At this point, the FDA has not yet approved any electrotherapy devices designed for percutaneous electrolysis, but the technique is used worldwide and likely will soon be approved in the US. Should legislators and state boards define dry needling broadly enough to be prepared for future expansions of dry needling concepts?
Perhaps the most important passage for regulators appears in the study’s limitations. The authors acknowledged that their broad dry-needling category combined deep, target-specific trigger-point needling with more superficial or generalized structural needling. They specifically caution that this macro-level grouping obscures technical differences in needle gauge, retention time, and manipulation and may contribute to clinical heterogeneity, which is remarkably consistent with Ball’s central message.
Do not assume everything grouped within a dry-needling node is technically the same intervention.
Together, Ball and Song and colleagues exposed an important weakness in regulatory definitions that reduce dry needling to a single procedure.
Rotator Cuff Tendinopathy Provides Another Example
The 2026 systematic review and network meta-analysis by Lazzarini and colleagues examined 89 randomized trials involving 5,532 participants with rotator cuff tendinopathy. The authors identified a remarkably heterogeneous treatment landscape: 101 different single-component or multicomponent interventions containing 63 individual treatment components. Among those interventions were both trigger-point dry needling and percutaneous electrolysis. Importantly, the authors treated them as separate therapeutic components.
Exercises targeting shoulder and scapular muscles combined with trigger-point dry needling appeared among the highest-ranked interventions for function, while exercise combined with percutaneous electrolysis appeared among the higher-ranked interventions for pain. The authors repeatedly stressed however, that the evidence is very uncertain and based on limited data.
That distinction is valuable for regulatory purposes as it demonstrates that not every intervention involving a percutaneously inserted solid needle should automatically be treated as identical. The Lazzarini review accordingly analyzes TrP-DN and percutaneous electrolysis separately as distinct interventions. The family of percutaneous needling procedures used by rehabilitation professionals is broader than trigger-point needling, and regulatory definitions need enough precision to distinguish related but operationally different interventions.
Ultrasound Guidance Adds Another Regulatory Dimension
The Song review specifically included ultrasound-guided dry needling within its dry-needling category, which is another development regulators should notice. Traditional descriptions of dry needling often assume that target localization occurs entirely through physical examination, palpation, and anatomical knowledge. The increased use of musculoskeletal ultrasound changes the picture as is may potentially influence:
- target identification;
- needle trajectory;
- depth estimation;
- avoidance of vulnerable structures;
- confirmation of needle placement;
- and selection of tendon or other connective-tissue regions.
This month, the American Physical Therapy Association organized a musculoskeletal ultrasound joint conference to advance the responsible and meaningful integration of musculoskeletal ultrasound into physical therapy clinical practice. Therefore, regulations drafted around a clinician palpating a trigger point and inserting a needle into muscle may increasingly describe only one subset of the clinical procedures being performed. While ultrasound is not required for all forms of dry needling, statutory definitions should not inadvertently make contemporary ultrasound-guided applications conceptually impossible. As a side note, Myopain Seminars offers two musculoskeletal ultrasound courses in association with SonoSkills.
What Might a More Contemporary Definition Look Like?
A modern regulatory definition could conceptually describe dry needling as:
a skilled intervention in which a qualified licensed practitioner inserts a solid filiform needle through the skin into or toward neuromusculoskeletal or connective tissues, with targets selected through examination, anatomical knowledge, clinical reasoning, patient-specific findings, defined anatomical procedures, or appropriate imaging guidance, for the evaluation or management of pain, movement impairment, functional dysfunction, or other conditions within the practitioner’s professional scope.
This conceptual regulatory definition should not be mistaken for model statutory language, but it illustrates a regulatory principle. It is important to note that the definition does not
- make identification of a myofascial trigger point the sole criterion for dry needling
- require the target to be muscle
- make ultrasound guidance mandatory.
But it also does not define every procedure involving a needle as dry needling. Professional purpose, the nature of the target, clinical decision-making, and the practitioner’s scope and competency remain relevant.
A Framework for State Physical Therapy and Occupational Therapy Boards
When PT or OT boards develop or revise dry-needling regulations, these papers suggest at least six questions that deserve consideration:
- Does the definition unnecessarily restrict dry needling to myofascial trigger points?
Trigger-point dry needling is an important form of dry needling, but Ball demonstrates that even within neck-pain research it is not the only operational target-selection method.
- Does the definition unnecessarily restrict dry needling to muscle?
Contemporary tendinopathy literature increasingly includes percutaneous needling procedures directed toward tendon-related disorders and structural targets.
- Does the definition distinguish target tissue from target-selection method?
“What are we needling?” and “How did we decide where to needle?” are different regulatory questions.
- Do competency requirements correspond to the range of tissues clinicians are authorized to treat?
Trigger-point examination alone does not constitute comprehensive preparation for tendon-directed or other advanced needling procedures.
- Can the regulatory framework accommodate image-guided procedures?
Ultrasound-guided dry needling is already represented in the contemporary research literature and should at least be conceptually anticipated.
- Is enough flexibility retained for clinical practice to evolve?
Detailed safety and competency requirements can be updated by boards. An excessively narrow statutory definition may be much harder to change.
Because clinical practice evolves more rapidly than statutes, a definition written around the clinical practice of 1984, when Maryland first approved dry needling for physical therapists, may not adequately describe practice in 2026, much less 2036.
A good regulatory definition should be broad enough to accommodate legitimate evolution in professional practice while remaining precise enough to support meaningful competency and safety standards.
Jan Dommerholt, President/CEO, Myopain Seminars
References
Ball AM. Operational classification of dry needling interventions in an audited neck-pain corpus: A reporting and taxonomy analysis. J Bodywork & Movement Ther. 2026;48:1058–1062. doi:10.1016/j.jbmt.2026.08.019
Dunning, J., Young, I., Taylor, N., et al. Effect of dose interval of periosteal and intraarticular electrical dry needling boosters on pain and disability in patients with knee osteoarthritis: a multi-center randomized clinical trial. Physiother Theory Pract, 2025;1–14. https://doi.org/10.1080/09593985.2025.2575837
Song Y-H, Lan J-Y, Fu H-H, Tang L-X. Short-term efficacy of physical interventions for lateral epicondylitis: a network meta-analysis based on multidimensional evaluation of pain and function. Frontiers in Pain Research. 2026;7:1855508. 10.3389/fpain.2026.1855508
Lazzarini SG, Bettariga F, Mosconi B, et al. Comparative effectiveness of physical therapy interventions in adults with rotator cuff tendinopathy: a systematic review and network meta-analysis. British J Sports Med. 2026;60:970–982. 10.1136/bjsports-2025-110024