Dry Needling, Pistoning versus twisting the needle

Which is more effective?

Twisting of course!

There are two types of methods,

  • Pistoning, which involves moving the needle in and out, in a fan shape motion.
  • Twisting,  which is placing the needle onto the site and gently twisting the fibres around the needle.

at Myotherapy and Massage we use  the twisting method which has been proven to be the better technique.

Myofascial trigger point (MTrP) injection and trigger point dry needling (TrPDN) are widely accepted therapies for myofascial pain syndrome (MPS). Empirical evidence suggests eliciting a local twitch response (LTR) during needling is essential.

According to a recent narrative review, there is a sizeable consensus that elicitation of a Local Twitch Response( LTR ), provides greater immediate and long-term pain relief with needling therapy than no Local Twitch Response (Shah et al., 2015).

However, this assumption is based on very limited research and relies predominantly on clinical observation.

Dry needling to elicit LTRs is a commonly used technique to treat Myofascial TrPoint Syndrome for the management of Myofacial Pain Syndrome; the benefits of needle manipulation via needle rotation or winding of connective tissue, rather than repeated pistoning directly into muscular trigger points, is well supported in the literature. In addition, the number of needle insertions during “pistoning” at one insertion site appears to positively correlate with levels of post-needling soreness, increased levels of inflammation within muscle fibers, and mechanical injury at or near the neuromuscular junction. In addition, TrPDN using needle rotation (i.e. unidirectional or bidirectional winding) and manual MTrP techniques have been shown to elicit neurophysiological responses that can positively alter the MTrP status and reduce pain without the need for a LTR. Therefore, the LTR during TrPDN appears unnecessary and may not be required for managing myofascial pain and may be unrelated to many of the positive effects of dry needling. However, further investigation is required.


TrPDN also helps elicit spinal segmental pain inhibitory effects (Mejuto-Vazquez et al., 2014Srbely et al., 2010) and descending pain control pathways (Niddam et al., 2007) that may not rely on eliciting LTRs. Strong needle stimulation via winding stimulates the release endogenous opioids, which is considered one of the most potent mechanisms for pain suppression in the periphery and at the spinal cord level secondary to needling treatment (Chou et al., 2012Zhang et al., 2014). Hsieh et al. (2016) demonstrated that needling distal but segmentally related MTrPs induced increases in enkephalin at the spinal dorsal horn and β-endorphin in the serum and dorsal root ganglion neurons. In addition, endogenous opioids were markedly increased in the proximal muscle in proportion to needle dosage (Hsieh et al., 2016). Most importantly, this study used slow and gentle needle insertion with rotation to MTrPs during a 30 s period and did not report eliciting a LTR (Hsieh et al., 2016). In clinical studies, deep needle stimulation to muscular afferents at acupuncture points and MTrPs with needle rotation, not multiple rapid insertions at the same entry point and with the same needle, demonstrated a superior treatment effect that persisted at 3 month follow up compared to superficial needling in subjects with chronic shoulder (Ceccheerelli et al., 2001) and lumbar myofascial pain (Ceccherelli et al., 2002),