What Is Best for Chronic Pain: Dry Needling versus Corticosteroid Injections for Pain Management

By Cody De La Mater, PT, DPT, FAAOMPT, Dip. Osteopractic, Cert. DN/SMT/VCS

As a physical therapist I encounter patients with some kind of chronic pain every single day. Treatments vary from patient to patient due to diagnoses and comorbidities that may complicate the entire prognosis or outcome expected. Since being dry needling certified and applying it to practice, I have seen its great benefits to people who suffer from chronic pain almost anywhere in the body. I have found that most people have not heard of dry needling as well as many physicians do not offer it for alternative treatment for pain management. The reasoning may be because they themselves do not know much about it as well as understand it as a more holistic method to Western medicine approaches. The trend I have seen most predominantly is that people suffering from chronic pain tend to go to their primary care physicians first. Although they may get a physical therapy referral, due to their symptoms they may be given the option for pain medications or even a cortisone or corticosteroid injection at the site of pain for treatment. Cortisone shots or injections usually contain corticosteroids that can help to relieve pain, swelling and irritation in a specific area of your body most often being injected into joints.¹ In my opinion, this seems to offer more of a quick fix that does not have lasting effects. So what is this dry needling I am referring to? Dry needling is the application of inserting thin monofilament needles through the skin without injectate to help treat muscles, ligaments, tendons, subcutaneous fascia, scar tissue, peripheral nerves, and neurovascular bundles for pain management with various etiologies.^2-6 

These treatments tend to lean towards chronic pain issues as acute pain may naturally heal on its own. Corticosteroid injections help to reduce chronic inflammation through cytokine suppression.^7-8 Cytokine migration is a part of the inflammatory process and can have negative effects to an injured area that can cause an exacerbation of symptoms as well as lead to further damage of the joint (i.e. intervertebral disc degeneration).^7-8 Dry needling takes a different course of action. It has been found that with the insertion of a dry needle that it helps to release the body’s endogenous opioid peptides, inducing an inflammatory response favoring tissue regeneration, and resetting neuromuscular junctions allowing for a decrease in pain (nociceptive) and uptake in chemical substances within the area of pain.^9-11  

Corticosteroids have two main paths for treatment: oral medications or transcutaneous injection. These injections can have side effects associated with them and have to be deemed appropriate for treatment. Some local side effects may include: post-injection flare, soft-tissue calcification, infection, tendon, ligament, or fascial insufficiency or rupture, accelerated progression of osteoarthritis, and osseous injury.¹² Systemic side effects may result in facial flushing, insomnia, headache, altered mental status, and/or transient hypertension.¹² Of course these do not all occur with corticosteroid injection but they are all possible. The main concern with the use of corticosteroids is that with multiple injections to the same body area/region it can cause a breakdown of both soft and hard tissues. Due to this, corticosteroid injections are usually held within four injections per year to the same body part/region/area to reduce the risk of damaged tissues.^13-14 

Dry needling, however, has a variety of treatment approaches and dosing applications. Dry needling may be applied to myofascial trigger points or in regions of suspected cause that may not be tender to palpation or have any hypertonicity of the muscle. In addition, needle length, needle diameter, insertion depth, quantity of needles inserted, techniques such as tenting, pistoning, periosteal pecking, uni- or bi-directional winding, as well as use of adding electrical stimulation may all be used for treatment.¹ Dry needling may cause people to have certain side effects. These may include needling soreness around area of insertion, bruising at needle site, and syncopal responses (i.e. dizziness, nausea, sweating, fainting, etc.).^15-17 The most prolific of adverse responses from dry needling is the possibility of puncturing a lung during treatment and causing a pneumothorax.^16,18 This phenomenon is very unlikely and mortality is rare at best.¹⁶ 

So which of these choices should be best for my pain management you may ask? Corticosteroid use is limited to areas of inflammation whereas dry needling has applications that stem to a variety of etiologies as well as regions of pain. Dry needling is a cost effective, minimally invasive (compared to using hypodermic needles), with better long term outcomes compared to corticosteroid applications.^19-20 Dry needling offers the more holistic approach to medicine compared to corticosteroid injections as the manipulation of the needle allows your own tissue(s) to help heal itself as opposed to relying on an injectate that is foreign to your body to relieve pain. The risks are a lot lower as well as treatment can be utilized more often compared to corticosteroid injections.

References:

1.      Cortisone Shots. Mayo Clinic. Published September 21, 2023. Accessed April 17, 2024. https://www.mayoclinic.org/tests-procedures/cortisone-shots/about/pac-20384794#:~:text=Overview,might%20benefit%20from%20cortisone%20shots.

2.      Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T. Dry needling: a literature review with implications for clinical practice guidelines. Physical Therapy Reviews. 2014;19(4):252-265. doi:10.1179/108331913x13844245102034.

3.      Tough EA, White AR, Cummings TM, Richards SH, Campbell JL. Acupuncture and dry needling in the management of myofascial trigger point pain: a systemic review and meta-analysis of randomized controlled trials. Eur J Pain. 2009;13(1):3-10.

4.      Tough EA, White A. Effectiveness of acupuncture/dry needling for myofascial trigger point pain-a systemic review. Phys Ther Rev. 2011;16(2):147-154.

5.      Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual, Vol. 1. Baltimore, MD, USA: Williams and Wilkins; 1983.

6.      Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual, Vol. 2. Baltimore, MD, USA: Williams and Wilkins; 1992.

7.      Knezevic NN, Jovanovic F, Voronov, D, Candido KD. Do corticosteroids still have a place in the treatment of chronic pain?. Frontiers in pharmacology. 2018;9:1229. doi:10.3389.fphar.2018.01229.

8.      Risbud MV, Shapiro IM. Role of cytokines in intervertebral disc degeneration: pain and disc content. Nat. Rev. Rheumatol. 2014;10:44-46. doi:10.1038/nrrheum.2013.160.

9.      Woerhrle J, Roman G, Russell B. Dry Needling and its Use in Health Care - A Treatment Modality and Adjunct for Pain Management. Journal of Pain & Relief. 2015;4(5). doi:https://doi.org/10.4172/2167-0846.1000194

10.   Núñez-Cortés R, Cruz-Montecinos C, Vásquez-Rosel Á, Paredes-Molina O, Cuesta-Vargas A. Dry Needling Combined with Physical Therapy in Patients With Chronic Postsurgical Pain Following Total Knee Arthroplasty: A Case Series. Journal of Orthopaedic & Sports Physical Therapy. 2017;47(3):209-216.

11.   Lavelle ED, Lavelle W, Smith HS. Myofascial trigger points. Anesthesiol Clin. 2007;25: 841-851. doi:10.1016/j.anclin.2007.07.003.

12.   Kamel SI, Rosas HG, Grobachova T. Local and Systemic Side Effects on Corticosteroid Injections for Musculoskeletal Indications. American Journal of Roentgenology. 2023;222:1-12. doi:10.2214/AJR.23.30458.

13.   American College of Rheumatology Subcommittee on Rheumatoid Arthitis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 update. Arthritis Rheum 2002; 46:328-346.

14.   Blankenstein M, Lentine B, Nelms NJ. Common practices in intra-articular corticosteroid injection for the treatment of knee osteoarthritis: a survey of the American Association of Hip and Knee Surgeons membership. J Arthroplasty. 2021; 36:845-850.

15.   Ga H, Choi JH, Park CH, Yoon HJ. Dry needling of trigger points with and without paraspinal needling in myofascial pain syndromes in elderly patients. J Altern Complement Med. 2007;13:627-624.

16.   Valdes VR. Dry Needling in Physical Therapy Practice: Adverse Events. Int J Phys Ther Rehab. 2019;5:157. doi:10.15344/2455-7498/2019/157.

17.   Boyce D, Wempe H, Campbell C, et al. Adverse Events Associated with Therapeutic Dry Needling. Int J Sports Phys Ther. 202;15(1):103-113.

18.   Cummings M, Ross-Marrs R, Gerwin R. Pneumothorax Complication of Deep Dry Needling Demonstration. Acupuncture in Medicine. 2014;32(6):517-519. doi:10.1136/acupmed-2014-010659.

19.   Nagarajan V, Ethiraj P, Prasad A, Shanthappa A. Local Corticosteroid Injection Versus Dry Needling in the Treatment of Lateral Epicondylitis. Cureus. 2022;14(11):1-6. doi:10.7759/cureus.31286.

20.   Nankar A, Nankar Y. A Promising Treatment Modality for Greater Trochanteric Pain Syndrome. Journal on Recent Advances in Pain. 2020;6(2):19-22. doi:10.4103/jrap.jrap_6_20.