Dry needling for plantar heel pain

INTRODUCTION

Plantar heel pain, most commonly labelled plantar fasciitis, is the leading cause of inferior heel pain in adults and accounts for a substantial share of foot-related consultations in primary care and musculoskeletal practice.(1,2) The condition affects roughly one in ten people across the lifespan, produces pain that is typically worst with the first steps in the morning, and reduces health-related quality of life below that of the general population.(3,4) The clinical label is itself imprecise, because the plantar fascia shows degenerative rather than inflammatory changes on histology, yet the term plantar fasciitis remains entrenched in both the clinical and the research literature.(1,5) Obesity, prolonged standing, limited ankle dorsiflexion, high training loads and a tight gastrocnemius-soleus complex are the risk factors most consistently associated with the disorder, which explains its concentration in workers who stand for long periods and in runners.(3,6) The diagnosis is clinical and rests on the history of pain with the first steps after rest, on tenderness at the medial calcaneal tubercle and on the exclusion of competing causes of heel pain, so imaging is reserved for atypical or refractory presentations.(1,2) Although the natural course is favourable in many patients, a meaningful proportion develop persistent symptoms that interfere with walking, standing and occupational activity, and this chronicity is what drives the search for effective interventions.(4,7)

Conservative treatment is the mainstay, and it spans stretching, orthoses, taping, manual therapy, electrotherapy and injection, with stretching and load modification forming the core of most guideline recommendations.(2,7) The evidence base for these options is uneven: stretching and orthoses are supported by trials of moderate quality, whereas the effect of many electrotherapy modalities is smaller and less certain, which leaves room for disagreement about the best sequence of care.(7,8) Systematic reviews have repeatedly concluded that no single conservative intervention is clearly superior, and that most comparisons rest on small trials with short follow-up, which is precisely the gap that the present review addresses for dry needling.(7-9) Corticosteroid injection produces rapid but frequently short-lived relief, whereas other options such as extracorporeal shock wave therapy, platelet-rich plasma and autologous blood injection are reserved for symptoms that do not respond to first-line care.(10,11) The choice among second-line treatments therefore depends as much on availability, cost and patient preference as on demonstrated superiority, because direct comparisons have rarely shown one option to be clearly better than the alternatives.(8) Within this range of available treatments, dry needling has grown rapidly in physiotherapy practice because it is inexpensive, requires minimal equipment and targets the myofascial trigger points in the calf and intrinsic foot muscles that are thought to maintain heel pain.(12) The procedure inserts a fine filament needle into a trigger point without injecting any substance, with the aim of mechanically disrupting the taut band and producing a local twitch response, and the same needle can be used with electrical stimulation to prolong the stimulus.(9,13)

The rationale for dry needling is attractive in a condition in which the fascia itself is degenerative and in which adjacent muscles such as the gastrocnemius, soleus, quadratus plantae and abductor hallucis frequently harbour trigger points whose referral pattern reproduces the heel complaint.(14) The proposed mechanisms include mechanical disruption of the taut band, a local twitch response that normalizes muscle activity, and segmental and descending modulation of pain processing, effects that are plausible but that have been demonstrated more convincingly in the laboratory than in the clinic.(9,12) Because the needle also produces a strong sensory stimulus, the distinction between specific trigger point effects and nonspecific needle effects remains a central problem in the field, and it is exactly this distinction that sham-controlled and head-to-head trials are designed to address.(13) Previous syntheses have examined dry needling for plantar heel pain, yet they relied on searches that closed several years ago, mixed needle-based techniques such as acupuncture and percutaneous electrolysis with dry needling, and predated a wave of randomized trials published between 2023 and 2026.(15-17) The comparative question that matters to clinicians, whether dry needling is better than sham needling or than another conservative treatment, has therefore not been answered with the most recent trial evidence. The wave of trials published after 2023 is timely, because it permits the first synthesis in which dry needling is compared against a broad set of conservative and invasive options within a single framework. The objective of this review was to synthesize randomized trials published between 2018 and 2026 that compared dry needling with sham needling, placebo or another conservative treatment, and to estimate its effects on pain and foot function in adults with plantar heel pain.

METHODS

This review was reported in accordance with the PRISMA 2020 statement.( 18)

Eligible studies were randomized controlled trials that enrolled adults with a clinical diagnosis of plantar heel pain, plantar fasciitis or plantar fasciopathy and that allocated at least one group to trigger point dry needling, with or without electrical stimulation. Comparators were sham needling, placebo, no dry needling or another conservative treatment such as stretching, exercise, taping, ultrasound, extracorporeal shock wave therapy, injection therapy, cupping or percutaneous needle electrolysis. Outcomes of interest were pain intensity, foot-related function or disability, quality of life and plantar fascia thickness measured by ultrasonography. Sham needling was defined as any procedure intended to mimic the needle stimulus without penetrating a trigger point, and sham-controlled trials were sought explicitly because they are the design best able to isolate the specific effect of the intervention. Studies were restricted to the publication window from 2018 to 2026, in line with the bibliographic scope of the review, and to English-language reports. Conference abstracts, case reports, protocols, secondary or economic analyses and non-randomized designs were excluded.

RESULTS

Selection of studies

The searches identified 242 records, of which 115 were duplicates and 127 were screened by title and abstract (Figure 1). After 104 records were excluded, 23 reports were sought for retrieval; 10 could not be retrieved from open access, and 13 were assessed in full text. One report was excluded at full text because the allocation method was not randomized, leaving 12 randomized trials with 680 participants in the synthesis (Table 1). The direction and magnitude of the effects within each thematic axis are summarized in (Table 2).

Study (year)	Country	n	Dry needling arm	Comparator	Main finding
Dunning 2018	United States	111	Electrical DN plus manual therapy, exercise and ultrasound	Manual therapy, exercise and ultrasound	Greater first-step pain and function at 3 months
Al-Boloushi 2020	Kuwait	102	DN plus stretching, four sessions	PNE plus stretching	Equivalent foot pain; DN better for pain at 4 weeks
Singh 2023	India	50	DN of gastrocnemius and soleus plus conventional care	Conventional care	Greater pain and function gains at 4 weeks
Jain 2024	India	50	DN plus ankle exercises	Ultrasound plus ankle exercises	Greater pain and range of motion
Mahakul 2024	India	30	DN plus ultrasound and stretching	Ultrasound and stretching	Better pain and disability
Karabulut 2025	Turkey	75	DN	Corticosteroid or PRP injection	Comparable to corticosteroid at 6 months
Mahmoodi 2025	Iran	40	DN of quadratus plantae plus massage and stretching	Massage and stretching	Similar pain; greater thickness reduction
Ashraf 2025	Pakistan	60	DN plus conventional physiotherapy	Kinesiology taping plus conventional physiotherapy	Lower VAS and higher FAOS at 6 weeks
Basu 2025	India	30	DN of calf muscles plus conventional therapy	Dry cupping plus conventional therapy	Greater pain relief and function
Rahim 2026	Pakistan	46	DN plus conventional treatment	Conventional treatment	Greater pain and function at 4 weeks
Sumanth 2026	India	20	Electrical DN	DN plus laser acupuncture	Equivalent pain and function
Iqbal 2026	India	66	DN three times weekly	Dynamic cupping plus IASTM	Cupping superior on VAS and FFI

Note: DN = dry needling; PNE = percutaneous needle electrolysis; PRP = platelet-rich plasma; VAS = visual analogue scale; FFI = Foot Function Index; FAOS = Foot and Ankle Outcome Score; IASTM = instrument-assisted soft tissue mobilisation.

Axis	Studies	Comparators	Direction of effect	Representative estimate
Dry needling as an adjunct to conventional care	6	Conventional care alone	Pain and function favour dry needling	First-step pain F = 22.021, P < 0.001; between-group pain difference 2.4 points at 4 weeks
Dry needling versus needle-based or injectable interventions	3	PNE, corticosteroid, PRP, laser	Equivalent to superior	Foot pain change 29.7 points; comparable to corticosteroid at 6 months
Dry needling versus taping and soft-tissue comparators	3	Kinesiology taping, cupping	Mixed; cupping superior in one trial	VAS 1.83 versus 1.97 at 6 weeks; cupping VAS 3.26 versus 4.82

Note: Direction reflects the dry needling arm relative to the comparator arm.

DISCUSSION

The main implication of this synthesis is that dry needling is a reasonable adjunct rather than a standalone cure for plantar heel pain, and that its advantage over other active treatments is small and frequently inconsistent. Across the twelve trials the most reproducible finding was the added benefit of needling when it was combined with stretching, exercise or electrotherapy, whereas comparisons against shock wave, injection or electrolysis showed equivalence more often than superiority. The practical reading of this pattern is that clinicians may add dry needling to a structured conservative programme when trigger points are identifiable, but should not expect it to outperform other invasive or physical options on its own.( 20,21,27)

The findings agree with earlier meta-analyses that reported short-term reductions in pain after dry needling for plantar heel pain, and they extend those estimates with trials published after the earlier searches closed.(9,15,17) The most recent of those meta-analyses pooled twelve randomized trials with 781 participants and concluded that dry needling reduced pain relative to several control conditions, a conclusion the present review confirms while noting that its authors also judged the underlying evidence to be limited, which mirrors the risk of bias profile observed here.(17) The landmark trial by Cotchett and colleagues, which lies outside the review window, likewise found that dry needling reduced pain more than sham needling at two weeks, an effect direction consistent with the studies added here.(13) Convergent evidence from trials that compared dry needling with corticosteroid injection is also relevant, because those studies reported that corticosteroid relieved pain faster while dry needling provided comparable or better outcomes in the longer term, a pattern reproduced by the three-arm trial included in this review.(27,32,33) The comparison with extracorporeal shock wave therapy is less settled: two trials published within the window reported that combined shock wave and dry needling was superior to shock wave alone, while later trials found dry needling comparable or superior to shock wave on pain and function, which suggests the two techniques overlap substantially rather than compete.(34-36) In the direct comparison of the two treatments, dry needling produced a significantly greater improvement in activity pain and in the disability subscale of the Foot Function Index than shock wave therapy, with the remaining domains showing no difference, and a further trial that measured balance, proprioception and quality of life found dry needling more effective than shock wave on those outcomes.(35,36) The pattern is therefore one of approximate equivalence on pain with sporadic advantages for dry needling on function, rather than a consistent hierarchy favouring either technique. In parallel, trials that compared dry needling with autologous blood injection, with stretching alone or with cross friction massage reported similar or greater benefit in the needling arms, although the differences were small and inconsistently significant.(37-39) A recent trial that compared dry needling, kinesiology taping and a control group likewise reported that all interventions reduced pain, with a greater improvement in the dry needling group relative to control rather than to taping, which reinforces the view that dry needling adds to, but does not clearly exceed, other active modalities.(40)

Several sources of heterogeneity can explain the inconsistencies between trials. The dry needling protocols differed in the muscles treated, the number and frequency of sessions, and the use of electrical stimulation, and the dose of needling was rarely standardized, a problem documented across the dry needling literature.( 12) The comparator programmes also varied from passive stretching to fully supervised multimodal rehabilitation, which changes the room left for an added effect. Participants ranged from athletes to patients with refractory chronic symptoms, and the outcome instruments mixed the Foot Function Index, the Foot and Ankle Outcome Score and the Lower Extremity Functional Scale, so the estimates are not directly interchangeable. The setting also varied from secondary and tertiary hospitals in Kuwait and Turkey to private physiotherapy clinics and university departments in South Asia, and the baseline severity, symptom duration and access to alternative treatments differed accordingly, which limits the transportability of any single estimate. Irrespective of these differences, the direction of effect was consistent for pain, which argues that the signal is real even if its magnitude is imprecise.

The plausibility of the mechanism also deserves attention when interpreting the estimates. Dry needling is proposed to act through mechanical disruption of the trigger point, a local twitch response, and segmental and descending modulation of pain, yet these mechanisms do not depend on the condition being fasciitis rather than fasciopathy, and they overlap with the effects attributed to acupuncture and to other needle-based techniques.(9,12) This mechanistic overlap helps to explain why dry needling, percutaneous electrolysis and sham needling produce similar symptomatic trajectories in several trials, and why the specific effect of the needle beyond its nonspecific sensory stimulus is difficult to isolate.(13,20) The structural change in plantar fascia thickness observed in two included trials is consistent with a local mechanical action, and an earlier trial that measured the same outcome likewise reported that dry needling reduced pain and plantar fascia thickness without changing ankle range of motion, which suggests the effect is tissue-specific rather than a general improvement in mobility.(14,26,41) The correlation between thickness and symptoms was not established, so the imaging finding should be interpreted as a marker of tissue response rather than as proof of a causal pathway.

For clinical decision-making, the practical questions are when to needle, which muscles to target and how many sessions to provide, and the included trials offer only partial answers. The most consistent protocols needled the gastrocnemius and soleus together with the intrinsic foot muscles, delivered three to six sessions over two to six weeks, and reported that the additional benefit appeared within the first month and was maintained to three months in the trials that measured that point.(21,22) The trials that found equivalence with electrolysis or injection used fewer sessions and still observed improvement, which suggests that the dose-response relationship is flat across the range tested rather than absent.(20,27) Clinicians should therefore select the muscles by palpation for trigger points rather than by a fixed recipe, and should set expectations that one or two sessions are unlikely to be sufficient.

Eight of the twelve trials were at high risk of bias and none was at low risk, allocation concealment was frequently unreported, and the inability to blind therapists and participants in a needling trial inflates the apparent effect of the active intervention.(19) Attrition reached one third in the longest trial, and the majority of trials reported post-intervention outcomes only, which leaves the durability of the effect uncertain beyond three to six months.(20) Publication bias is also plausible in a field dominated by small trials from physiotherapy groups with an interest in the technique, and the absence of pre-registration in most included trials raises the possibility that unfavourable outcomes went unreported.(13,15)

For practice, the results support offering dry needling as an adjunct to exercise and stretching in patients with palpable trigger points who have not responded to first-line care, while counselling that sham-controlled advantages are small and that injection or shock wave alternatives are not clearly inferior.(5,8) In podiatry practice, where the scope of intervention overlaps with physiotherapy but often emphasizes mechanical offloading and footwear, dry needling occupies a niche for patients whose heel pain persists after orthoses, taping and load modification have been optimized. The evidence reviewed here does not position needling as a replacement for those measures, because every trial delivered it alongside a structured programme and none isolated the needle against a true no-treatment control. Podiatrists who add dry needling to their scope should therefore present it as an adjunct with a modest expected effect, should confine it to patients with identifiable trigger points in the calf and foot, and should document the muscles treated and the response in the same way the trials did, so that outcomes can be audited. Corticosteroid injection remains the fastest option when rapid relief is the priority, and dry needling is a reasonable needle-based alternative when corticosteroid is contraindicated or when longer-term relief is sought.(10,11) The safety profile observed in the trials was benign, with transient soreness and small haematomas the only events reported, which supports dry needling as a low-risk option once contraindications such as anticoagulation and needle phobia have been excluded.(20,22) Whether specific subgroups benefit more is unresolved, because the trials did not stratify by symptom duration, trigger point count or fascial thickness, so the selection of patients remains based on clinical judgement rather than on predictive markers.(9) For research, the agenda should prioritize sham-controlled trials with standardized needling dosage, blinded outcome assessment and follow-up beyond six months, and trials should report the number of needles, the muscles treated and adverse events so that dosing can be compared across studies.(9) Plantar fascia thickness measured with ultrasound deserves further study as a candidate surrogate, because two included trials reported structural change that paralleled symptom relief.(14) The inconsistency of the head-to-head comparisons also argues for network meta-analysis once a sufficient number of trials with comparable outcomes has accumulated, so that the relative ranking of dry needling, injection and shock wave therapies can be estimated with precision rather than by narrative juxtaposition.(8)

Against these limitations, the review has strengths that support the credibility of its conclusions. The search combined four sources with Scopus as the primary index, the screening was fully documented in a PRISMA flow, and the eligibility criteria were narrow enough to exclude acupuncture and other needle-based techniques that are often confused with dry needling. The inclusion of trials from six countries across the Middle East, South Asia, Europe and North America provides a wider geographic base than earlier syntheses, which drew mainly on European and Australian studies. The extraction recorded the location of every datum and did not impute missing values, and the risk of bias judgements were deliberately conservative, so the low certainty assigned to the evidence reflects the state of the literature rather than the strictness of this review.

The research agenda that follows from these gaps is concrete. Sham-controlled trials should use a needle inserted away from the trigger point or a sham device, because only that design can separate the specific trigger point effect from the nonspecific sensory effect of the needle, and none of the included trials approached that comparison. Dose-finding is overdue, because the number of needles, the number of sessions and the use of electrical stimulation were confounded with one another, and a factorial or dose-response design would resolve whether more needling is better. Trials should adopt a core outcome set that includes pain, the Foot Function Index and a quality of life measure, report means and standard deviations at each time point rather than P values alone, and follow participants to at least twelve months. Adverse events should be collected systematically and reported by group, because the present review found that ten of twelve trials were silent on safety. Progress on each of these fronts would move the field from repeated small trials toward the sham-controlled, dose-defined evidence that clinical guidance requires.

CONCLUSIONS

Dry needling reduces pain and improves foot function in adults with plantar heel pain, principally when it is added to conventional care, and it reaches outcomes comparable to those of corticosteroid injection, extracorporeal shock wave therapy and percutaneous needle electrolysis. The certainty of this conclusion is low because most included trials were at high risk of bias, the effect against sham or no needling was small, and the advantage over other active comparators was inconsistent. The recommendation to add dry needling to conventional care is therefore conditional rather than strong, and shared decision-making should reflect the small expected benefit, the benign safety profile and the availability of alternatives.

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