Dry needling with stretching improves pain and function in patellofemoral pain syndrome: a randomised sham-controlled trial

Background Patellofemoral pain syndrome (PFPS) is a prevalent knee disorder involving quadriceps dysfunction, proximal hip control deficits, and myofascial trigger points (MTrPs). Although dry needling is increasingly used as an adjunct intervention, evidence on its efficacy for correcting neuromuscular deficits—particularly the hamstring-to-quadriceps (H/Q) peak torque ratio—remains limited. This study aimed to determine whether dry needling targeting MTrPs in the quadriceps, hip adductors, and tensor fasciae latae combined with home stretching is superior to sham needling plus stretching in improving pain, function, and the H/Q ratio. Methods This was a randomised, single-blind, sham-controlled superiority trial. Sixty-six participants with PFPS were randomly assigned 1:1 to active dry needling of MTrPs plus home stretching ( n = 33) or sham superficial needling at non-trigger point sites plus identical stretching ( n = 33). Interventions were delivered once weekly for six weeks. Primary outcomes were pain intensity (Visual Analogue Scale, VAS) and knee function (Lysholm Knee Scoring Scale, LKSS) assessed at baseline, week 8, and six-month follow-up. Secondary outcomes included active knee flexion range of motion, pressure pain threshold, isokinetic quadriceps and hamstring peak torque, and the H/Q ratio, assessed at baseline and week 8. Results At week 8, the dry needling group showed significantly greater improvements in pain (mean difference − 1.18, 95% CI − 1.60 to − 0.77, P < 0.001; Cohen’s d = 1.23) and function (mean difference 5.74, 95% CI 3.30 to 8.19, P < 0.001; Cohen’s d = 1.08) compared with controls, with benefits sustained at 6 months (VAS: mean difference − 1.16, 95% CI − 1.58 to − 0.75, P < 0.001, Cohen’s d = 1.21; LKSS: mean difference 5.75, 95% CI 3.31 to 8.20, P < 0.001, Cohen’s d = 1.08). For the H/Q ratio, the overall group×time interaction was not statistically significant ( P = 0.125); however, the secondary week-8 between-group comparison was statistically significant. The H/Q ratio decreased from 0.69 to 0.60 in the dry needling group (mean difference − 0.12, 95% CI − 0.20 to − 0.03, P = 0.009), moving it towards the normal reference range of 0.47–0.66; no significant change occurred in the control group. Secondary outcomes, including knee ROM, pressure pain threshold, and quadriceps and hamstring strength, also improved significantly more in the dry needling group than in the control group. Both groups showed comparable adherence, and no serious adverse events were reported. Conclusions Dry needling targeting quadriceps, hip adductor, and tensor fasciae latae MTrPs combined with home stretching is superior to sham needling plus stretching for reducing pain and improving function. It was also associated with a reduction in the elevated H/Q ratio in PFPS. The benefits on pain and function persist for at least 6 months. Trial registration Chinese Clinical Trial Registry ChiCTR2500099532. Prospectively registered on 25 March 2025.