Summary
Paul Klorin, dry needling division lead at the Institute of Clinical Excellence, tackles the question of whether clinicians should use real-time ultrasound imaging to guide their dry needling techniques. He reviews multiple validation studies showing that surface palpation and bony landmarking consistently achieve near-100% accuracy for needle placement in muscles like infraspinatus, supraspinatus, cervical multifidus, popliteus, and the pterygoid muscles. While acknowledging that ultrasound does provide marginally better accuracy, Paul argues that the current cost ($4,000+ for quality units), additional procedure time, and minimal safety improvement do not justify routine clinical use. He draws the line at higher-risk techniques like rib-blocking, where research shows only 72-75% accuracy with surface palpation, and abdominal needling, where direct anterior-to-posterior approaches risk entering the peritoneum. He concludes that ultrasound is not necessary now, but as devices become smaller and cheaper, this may change.
Key Points
- Surface palpation and bony landmarking achieve near-100% accuracy for most dry needling targets based on validation research
- A 2024 study (Witt) confirmed 19/20 needle placements in infraspinatus and supraspinatus were accurate using palpation alone
- Validation studies for cervical multifidus, inferior obliquus capitis, lumbar multifidus, popliteus, and medial pterygoid all confirm palpation-based accuracy
- Ultrasound is slightly more accurate but the time and cost ($4,000+ for quality units) do not justify routine clinical use
- Rib-blocking techniques have only 72-75% accuracy with surface palpation (Cushman 2021), making them higher risk without imaging
- Direct anterior-to-posterior abdominal needling carries peritoneum entry risk and should be avoided without ultrasound guidance
- As ultrasound devices become smaller and cheaper (potentially phone-based apps), the equation may change in 2-5 years
- Many dry needling techniques were originally validated using ultrasound in research settings before being translated to palpation-based clinical use
Key Moments
Palpation-based dry needling is nearly 100% accurate
A 2024 validation study showed 19 out of 20 needle placements in infraspinatus and supraspinatus were accurate using surface palpation alone, confirmed by post-insertion ultrasound imaging.
"Each subject had an infraspinatus needle, a supraspinatus needle. Once that needle was placed, they came in with ultrasound and said, "Did we get it?" And the conclusion was yes. 19 out of the 20 needles could be visualized."
Rib-blocking techniques are only 72-75% accurate
Research by Cushman (2021) found that experienced physical therapists could only accurately block a rib 72-75% of the time, which is essentially a C- grade and too risky for clinical use without imaging.
"The reason we are not using ribs or rib blocking techniques, ribs is a bony backdrop, is Cushman in 2021 said, you know, some fairly experienced physical therapists were about 72% and 75% accurate at truly blocking a rib. So if you're asking yourself or if you're asking our profession, how comfortable would we feel using the rib as a backdrop"
Ultrasound is not worth the cost for routine dry needling
While ultrasound provides marginally better accuracy, the combination of $4,000+ equipment costs, additional procedure time, and minimal safety improvement means it's not justified for routine clinical dry needling.
"They also concluded that the palpation-based dry needling was thoroughly safe and really it was not that much less accurate. So their conclusion from the author was based on the time it took to do the technique using ultrasound and based on the cost of a dry needling unit,"
