DryNeedlinginOverheadAthleteswithMyofascialShoulderPain:ASystematicReview

Shoulder pain is a common and debilitating problem among overhead athletes such as volleyball players, baseball pitchers, tennis players, and handball athletes. These athletes perform explosive, repetitive overhead movements that can lead to overuse injuries, with shoulder injury prevalence ranging from 5% to 36% depending on the sport, age, gender, and training level. Among the various shoulder pathologies, myofascial trigger points (MTrPs) represent a significant source of pain and dysfunction. MTrPs are irritable points within tense muscle bands that cause pain during stretching, contraction, or palpation, and they can lead to postural changes, reduced movement, and muscle weakness.

In high-level athletes, myofascial pain can significantly reduce performance and potentially threaten careers. The upper trapezius, infraspinatus, and teres major are among the most commonly affected muscles in overhead athletes. Dry needling (DNY) has emerged as a minimally invasive treatment approach that uses thin monofilament needles without drugs, inserted directly into trigger points to reduce pain and improve function. While DNY has shown promising results in various musculoskeletal conditions, its specific role in managing myofascial shoulder pain in overhead athletes remained unclear, prompting this systematic review.

The researchers conducted a systematic review following PRISMA guidelines, searching PubMed, Scopus, and Web of Science databases from inception to March 2024. They used a PICO framework to guide their search: overhead athletes with shoulder pain (Population), dry needling (Intervention), various comparisons including no treatment, manual therapy, and other rehabilitation approaches (Comparison), and outcomes including pain, disability, range of motion, and pain pressure threshold (Outcomes). They included randomized controlled trials, case-control studies, and feasibility studies with full text available in English that focused on overhead athletes with shoulder pain treated with dry needling for myofascial trigger points. Studies were excluded if they did not include athletes, did not focus on MTrP treatment with DNY, were other reviews, lacked full-text availability, or were not in English.

From 399 initial articles, 165 duplicates were removed, leaving 234 articles for screening. Only seven articles met inclusion criteria, and after quality assessment using modified STROBE criteria, one article was excluded, resulting in six studies included in the final review. These six studies comprised a total of 145 patients (96 men and 49 women) aged 18 to 60 years. Four were RCTs, one was a case study with one patient, and one was a case study with four patients.

The quality assessment found that four studies (66%) were of excellent quality, one was of very good quality, and one was of good quality.

The review found that dry needling improved pain rapidly and in the short term across all included studies, though there was no consensus on the minimum number of treatments or optimal intervals between sessions. Pain was evaluated using VAS, NRS, and McGill Pain Questionnaire scales. Kheradmandi et al. (2021) found significant improvement in NRS (p<0.001) for both dry needling plus manual therapy and manual therapy alone groups, with scapular dyskinesia improving in 70% of the DNY+MT group versus 30% of the MT-only group.

Kamali et al. (2019) reported significant improvement in VAS (p<0.001) for both upper trapezius and infraspinatus dry needling groups, with DASH scores improving significantly (p<0.001) in both groups (20.76 ± 21.92 for UT vs. 25.00 ± 19.04 for ISP). Pain pressure threshold improved significantly (p=0.020) only in the infraspinatus group (0.36 ± 0.61). Ceballos et al.

(2021) found significant improvement in NRS (p<0.001) only in the DNY group (3.30, 95% CI 2.02-4.59) compared to no treatment, with significant improvements in internal rotation (23.6°, p<0.001 between-group) and extensibility (13.63°, p=0.025 between-group). Javed et al. (2020) reported improvement in ROM and VAS pain in a single case study using two DNY sessions combined with heating, progressive resistance exercises, and aerobic training. Osborne et al.

(2010) found improvement in ROM and functional pain scores in four female volleyball players after a single DNY session combined with post-training icing, exercises, and stretching. Jiménez-del-Barrio et al. (2023) found no between-group difference between DNY and diacutaneous fibrolysis for teres major muscle mechanical properties. Notably, no studies reported serious adverse effects, though pain during the procedure and post-injection soreness were noted.

Treatment protocols varied widely: one study used two sessions, two used three sessions, and three used only one session. Four studies combined DNY with other treatments (manual therapy, strengthening exercises, diacutaneous fibrolysis, stretching).

For clinicians working with overhead athletes, this systematic review suggests that dry needling can be a valuable tool for rapid, short-term pain reduction in myofascial shoulder pain, with potential benefits for disability, range of motion, and muscle strength. The treatment appears relatively safe with minimal adverse effects, making it particularly attractive in sports settings where minimizing time lost to competition is critical. However, several important caveats exist. First, there is no established optimal protocol—studies used anywhere from one to three sessions with varying intervals, and most combined DNY with other rehabilitation approaches, making it difficult to isolate the specific effect of needling alone.

Second, all outcomes were assessed only at short-term follow-up, with no evidence for medium- or long-term benefits. Third, the included studies were heterogeneous in terms of sport type, specific muscles treated, needle sizes, and outcome measures, limiting the ability to develop standardized treatment guidelines. For patients and athletes, this means that while dry needling may offer quick pain relief, it should likely be viewed as one component of a comprehensive rehabilitation program rather than a standalone solution. The review authors emphasize that multidisciplinary treatment including manual therapy and core evaluation is needed, as shoulder dysfunction involves complex biomechanical factors.

Athletes considering DNY should discuss with their healthcare provider whether it fits into their broader rehabilitation and performance goals, and should be aware that post-needling soreness is common though typically short-lived. Future research with larger samples, standardized protocols, long-term follow-up, and inclusion of diverse sports and both sexes is needed to strengthen the evidence base for this treatment approach.