Abstract
This systematic review and meta-analysis evaluated the effectiveness of dry needling combined with exercise compared with exercise alone for pain and functional outcomes in tendinopathies. A systematic search of PubMed, Cochrane Library, ClinicalTrials.gov, and Google Scholar was conducted from inception to August 13, 2025, for randomized controlled trials involving adults with clinically confirmed tendinopathy. Eligible studies compared dry needling plus exercise with exercise alone and reported pain or functional outcomes. Four trials with 255 patients were included, covering lateral epicondylitis (two trials), patellar tendinopathy (one trial), and rotator cuff tendinopathy (one trial). Pooled analysis showed that dry needling combined with exercise reduced pain more than exercise alone (mean difference (MD) = -2.14; 95% CI, -3.50 to -0.78), although heterogeneity was substantial (I² = 95%). Immediate-term pain reduction was modest (MD = -0.44; 95% CI, -0.87 to 0.00), with larger but variable effects at mid- and long-term follow-ups. Functional outcomes favored the combined intervention, particularly for Patient-Rated Tennis Elbow Evaluation scores at 3-4 weeks (MD = -5.24; 95% CI, -6.89 to -3.60; I² = 21%). Risk of bias was low in one trial and raised some concerns in three, mainly due to blinding and outcome assessment limitations. Overall, dry needling combined with exercise appears to provide greater pain relief and functional improvement than exercise alone, especially in the short to long term. However, substantial heterogeneity and methodological concerns highlight the need for further high-quality randomized controlled trials to confirm these findings and establish optimal treatment protocols.