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Superficial vs. deep dry needling: What science tells us

Brian V. Hortz

dry needling

The use of dry needling, an emerging therapeutic intervention, is rising in the chiropractic profession.

Dry needling is a commonly used intervention for managing various painful conditions, which can manifest in many forms. The physiologic mechanisms at play, mechanisms of pain relief and the overall efficacy of dry needling have been discussed extensively in the literature over the last decade.,,, More recent studies have elicited additional insights on the dosing necessary for dry needling effectiveness. Much of this information is related to the study of the depth of needle penetration and its impact on pain.

What is the difference between superficial and deep lesions?

Dry needling can be performed at various depths. Superficial dry needling (SDN) involves inserting a needle at a depth into the subcutaneous tissue and may be combined with needle manipulation while in situ. Some of the benefits of needling this way include less risk of significant tissue trauma, reduced risk of nerve or visceral injury and increased patient comfort.

Deep dry needling (DDN) involves inserting a needle through the skin, beyond subcutaneous tissue and into muscular or other connective tissue structures. It can also be combined with needle manipulation. Many practitioners have questioned the use of deep needle penetration as it has not consistently demonstrated superior results in pain management compared to superficial needle insertion in some research.,, This has led to several studies comparing superficial vs. deep dry needling,5,8,,,, the results of which are starting to demonstrate a common trend regarding the depth of the lesion.

How effective are superficial and deep lesions?

A 2002 article by Peter Baldry brought to the forefront discussion of the difference between SDN and DDN.5 In 2017, Sedighi, et al., looked at both dry needling methods for addressing cervicogenic headaches. Both approaches reduced headache index and trigger point tenderness. However, DDN significantly improved cervical range of motion and functional rating index. Researchers concluded that dry needling suboccipital and upper trapezius muscles significantly improves headache index, decreases trigger point tenderness and increases functional rating index and range of motion in patients with cervicogenic headaches. DDN significantly affected functional rating index and range of motion.

Two related articles followed in 2018. Sarrafzadeh, et al., evaluated the effects of SDN and DDN on pain and muscle thickness in subjects with upper trapezius myofascial pain syndrome. They found both techniques induced significant short-term changes in pain as measured by VAS. Muscle thickness at rest, fair and regular contractions showed no substantial changes between groups.11 Ezzati, et al., performed a study to compare the effects of SDN and DDN on range of motion and functional ability in subjects with upper trapezius myofascial pain syndrome. The study’s authors observed changes over time when SDN and DDN techniques were used. Still, these changes were more significant in patients treated with DDN, especially in extended follow-up periods at 15 days post-treatment.10

Most recently, a systematic review with meta-analysis evaluated the literature regarding the effects of DDN versus SND on spine-related pain. What they concluded was quite enlightening. It appears the difference between SDN and DDN is time-dependent. Five of the 12 studies in their review reported the immediate effects of pain with mixed results. Two reported significant between-group differences in favor of DDN immediately following treatment. However, three studies reported no differences between deep and superficial needle insertion immediately following treatment.13

Several studies focused on dry needling’s effects on pain over time, looking at SDN vs. DDN one to 12 weeks post-treatment. Nine of the 12 studies reported the impact of pain from one to less than 12 weeks. Six studies demonstrated a statistically significant difference favoring DDN. At the same time, three studies reported insignificant differences. Seven of the 12 reported long-term effects on pain beyond the 12-week post-treatment window. Of these, three demonstrated a statistically significant difference favoring DDN. They concluded that deep needle insertion provides more substantial pain relief than superficial needling.13

Integrating dry needling into chiropractic practices

DCs’ use of dry needling is growing, so you should understand how to incorporate these methods into your comprehensive therapy regimens. As per the findings of recent systematic reviews, DDN has a time-dependent effectiveness and offers more significant pain relief than SDN, especially in the long run. This allows you to incorporate DDN into your treatment plans for musculoskeletal dysfunction and myofascial pain, where deeper lesions may result in more advantageous outcomes.

Carefully weigh the decision between SDN and DDN when safety is a concern. To identify the proper needle length and angle, you must thoroughly understand the area’s anatomy relative to the targeted tissues. SDN can be a helpful alternative to DDN that reduces inherent hazards and improves patient outcomes.

Final thoughts

These research results suggest DDN and SDN produce meaningful changes in pain and function in multiple pain-related conditions. Still, deep needle penetration seems to be more effective. Chiropractic treatment plans integrating dry needling with manipulation and therapeutic exercise approaches seem particularly effective in optimizing patient care.

As DCs, we must have a thorough knowledge of anatomy to determine the appropriate needle length to needle intended structures safely. If safe, create a more significant lesion by performing deep dry needling. Whenever safety is in question, superficial lesions are recommended, as they are less risky and still effective.

BRIAN V. HORTZ, PHD, AT, SFDN, is director of research and education at Structure and Function Education. For more information, email brian@structureandfunction.net or visit structureandfunction.net.

References

  1. Cagnie B, et al. Physiologic effects of dry needling. Curr Pain Headache Rep. 2013;17(8):348. PubMed. https://pubmed.ncbi.nlm.nih.gov/23801002/. Accessed April 7, 2025.
  2. Butts R, et al. Peripheral and spinal mechanisms of pain and dry needling mediated analgesia: A clinical resource guide for healthcare professionals. Int J Phys Med Rehabil. 2016;4(2). Researchgate.net. Accessed April 7, 2005.
  3. Perreault T, et al. Mechanisms and dose parameters of electric needle stimulation: clinical considerations – Part I. Acupuncture in Physiotherapy. 2018;30(2):17-26.
    Researchgate.net. Accessed April 7, 2025.
  4. Perreault T, et al. Mechanisms and dose parameters of manual needle stimulation: Clinical considerations – Part 2. Acupuncture in Physiotherapy. 2019:31(1):9-23.
    Researchgate.net. Accessed April 7, 2025.
  5. 5 Baldry P. Superficial versus deep dry needling. Acupunct Med. 2002;20(2-3):78-81. PubMed. https://pubmed.ncbi.nlm.nih.gov/12216605/. Accessed April 7, 2025.
  6. Tsai CT, et al. Remote effects of dry needling on the irritability of the myofascial trigger point in the upper trapezius muscle. Am J of Phys Med Rehabil. 2010;89(2):133 140. PubMed. https://pubmed.ncbi.nlm.nih.gov/19404189/. Accessed April 7, 2025.
  7. Sedighi A, et al. Comparison of acute effects of superficial and deep dry needling into trigger points of suboccipital and upper trapezius muscles in patients with cervicogenic headache. J Bodyw Mov Ther. 2017;21(4):810-814. PubMed. https://pubmed.ncbi.nlm.nih.gov/29037632/. Accessed April 7, 2025.
  8. Ceccheerelli F, et al. Comparison between superficial and deep acupuncture in the treatment of the shoulder’s myofascial pain: A randomized and controlled study. Acupunct Electrother Res. 2001;26(4):229-238. PubMed. https://pubmed.ncbi.nlm.nih.gov/11841108/. Accessed April 7, 2025.
  9. Ceccherelli F, et al. Comparison of superficial and deep acupuncture in the treatment of lumbar myofascial pain: A double-blind randomized controlled study. Clin J Pain.
    2002;18(3):149-153. PubMed. https://pubmed.ncbi.nlm.nih.gov/12048416/. Accessed April 7, 2025.
  10. Sarrafzadeh J, et al. Research paper: The efficacy of superficial and deep dry needling techniques on functional parameters in subjects with upper trapezius myofascial
    pain syndrome. Caspian J Neurol Sci. 2018;4(15):152-158. https://cjns.gums.ac.ir/article-1-191-en.pdf. Accessed April 7, 2025.
  11. Sarrafzadeh J, et al. Effects of superficial and deep dry needling on pain and muscle thickness in subject with upper trapezius muscle myofascial pain syndrome. J Pain
    Relief. 2018;7(3). EuroPub. https://europub.co.uk/articles/effects-of-superficial-and-deep-dry-needling-on-pain-and-muscle-thickness-in-subject-with-upper-trapeziusmuscle-myofascial-pain-syndrome-A-578089. Accessed April 7, 2025.
  12. Sedighi A, et al. Comparison of acute effects of superficial and deep dry needling into trigger points of suboccipital and upper trapezius muscles in patients with cervicogenic headache. J Bodyw Mov Ther. 2017;21(4):810-814. PubMed. https://pubmed.ncbi.nlm.nih.gov/29037632/. Accessed April 7, 2025.
  13. Griswold D, et al. The effectiveness of superficial versus deep dry needling or acupuncture for reducing pain and disability in individuals with spine-related painful conditions: A systematic review with meta-analysis. J Man Manip Ther. 2019:27(3):128-140. PubMed. https://pubmed.ncbi.nlm.nih.gov/30935320/. Accessed April 7, 2025.

 

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