The injury occurred when a needle, likely targeting the upper back or shoulder region, was inserted at a depth or angle that inadvertently pierced the pleura, the protective lining surrounding the lung. This breach allowed air to leak into the pleural space, the narrow gap between the lung and the chest wall, creating external pressure on the lung that caused the lung to partially collapse, i.e. pneumothorax. While minor cases may cause only mild pain and can often be managed with observation and supplemental oxygen, the condition can quickly become life-threatening in worst-case scenarios. The most dangerous manifestation is a tension pneumothorax, in which air continues to enter the pleural space but cannot escape, causing a buildup of pressure that can shift or compress vital structures like the heart and major blood vessels in addition to the lungs. This can lead to respiratory failure or cardiovascular collapse, requiring immediate emergency intervention such as needle aspiration or the placement of a chest tube to re-expand the lung. Symptoms include sharp chest pain and significant shortness of breath.
The wound in the pleura caused by the needle can quickly heal itself, and if only a small amount of air is trapped in the pleural space, then this air can be absorbed into the circulating blood. A larger amount may require the removal of the air by a syringe i.e. needle aspiration.
The mishap occurred during a dry needling session for Mr. Watt. Dry needling is a technique used in modern rehabilitation and sports medicine in which a trained clinician inserts a thin "filiform" needle through the skin to stimulate myofascial trigger points (tender, tight muscle bands) and related muscular or connective tissues, with the goal of reducing neuromusculoskeletal pain and improving movement impairments. It is called "dry" because nothing is injected -- the needle itself is the stimulus; a filiform needle is a very thin, solid (non-hollow) needle that doesn’t have a central canal to inject or withdraw fluid. The approach is typically framed in Western anatomy and pain physiology with targets chosen by palpating painful or tight areas.
Dry needling is most effective as a pain-modulation tool, particularly when used in conjunction with exercise and active rehabilitation. Meta-analyses of randomized controlled trials indicate that the procedure provides meaningful short-term relief for chronic neck and low back pain by improving pressure pain thresholds and reducing disability scores. Some of the most robust support for the practice is found in the treatment of plantar fasciitis. However, while many studies show statistically significant results, the scientific community often rates the overall certainty of these benefits as "low to moderate." This is due to the high level of heterogeneity in treatment techniques and the inherent difficulty of designing "sham" controls that can effectively blind patients to the treatment in randomized controlled trials.
In many respects dry needling resembles acupuncture, which also inserts filiform needles into the body, but at specific "acupoints" to stimulate the body's natural healing processes. Acupuncture is a cornerstone of Traditional Chinese Medicine that purports to balance the flow of qi (vital energy) through meridians (channels) in the body. Modern Western medicine views the practice as a form of neuromodulation that affects nerve signaling and brain pathways to trigger the release of natural pain-relieving chemicals like endogenous opioids and adenosine. Scientific evidence for the medical benefits of acupuncture is strongest in the realm of chronic pain management. However, many clinical reviews note that the treatment’s benefits are often modest when compared to "sham" acupuncture, suggesting that patient expectation and the therapeutic context play a significant role in its overall effectiveness.
Despite using physically identical filiform needles, dry needling and acupuncture are distinct practices rooted in different clinical frameworks and philosophies. Dry needling is a targeted intervention based on Western anatomical principles, focusing specifically on relieving neuromusculoskeletal pain by deactivating myofascial trigger points and dysfunctional muscle bands. In contrast, acupuncture is a comprehensive medical system originating from Traditional Chinese Medicine that involves stimulating specific "acupoints" to balance the flow of energy throughout the body. The practical difference often lies in the practitioner's training and intent: dry needling is typically performed by physical or occupational therapists who palpate muscles to find painful loci, whereas acupuncture is performed by licensed acupuncturists who select points based on a holistic diagnostic framework.
Despite these different intents, the two modalities share significant physiological overlap by activating local sensory nerves and nociceptors that engage a complex hierarchy of biological responses involving local tissue, the spinal cord, and the brain to "turn down" pain signaling. Acupuncture is thought to primarily operate through the release of endogenous opioids and adenosine (a local anti-nociceptive chemical). Dry needling focuses more specifically on the physiology of myofascial trigger points, where it seeks to elicit a "local twitch response." Myofascial refers to the combined system of muscle (“myo-”) and the connective tissue fascia (“-fascial”) that surrounds and supports muscle. A trigger point is thought to be a locally overactive segment of muscle fibers resulting in increased resting tension and sensitivity compounded by stiffer fascia. Stimulating this region may help to relax the muscle and surrounding fascia.
While both dry needling and acupuncture are generally considered safe when performed by trained professionals, they carry a spectrum of risks ranging from minor side effects to rare but life-threatening complications. Most commonly, patients experience localized soreness, bruising, minor bleeding, or a temporary vasovagal (sudden drop in heart rate and blood pressure caused by vagus nerve stimulation) response such as lightheadedness. However, the use of filiform needles introduces the possibility of serious injury if improper technique or non-sterile practices are employed, including systemic infections, nerve damage, or vascular injury. The most significant danger -- and the one that brought national attention to the practice via T.J. Watt’s injury -- is a pneumothorax (punctured lung) which can occur when needles are inserted too deeply or at unsafe angles near the chest, neck, or upper back. To mitigate these dangers, it is essential for patients to ensure their clinician adheres to strict sterile protocols and to disclose underlying health factors, such as the use of blood thinners or immune suppression, before treatment begins.
Additional precautions include verifying the clinician’s credentials and specific training in dry needling, as regulations for practitioners like physical therapists vary by state. Finally, the patient should be fully informed of the "red flag" symptoms such as sudden chest pain or shortness of breath that require immediate medical evaluation following the session.
It should be noted that dry needling accidents as described above are quite rare. Research suggests the risk is incredibly low, with estimates ranging from roughly 1 in 200,000 to 1 in over 1 million treatments. Some large-scale studies reviewing tens of thousands of treatments have found zero instances of pneumothorax in their specific sample groups. On the other hand, as dry needling becomes more popular the total number of pneumothorax incidents will most likely increase.
Figure 1. The Pittsburgh Steeler football player T.J. Watt rushing the passer.
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