Can a Tennessee-licensed athletic trainer perform dry needling, also called intramuscular manual therapy or trigger-point dry needling?

Subject

Whether dry needling, also known as intramuscular manual therapy and trigger-point dry needling, is within the scope of practice for athletic trainers under Tennessee's Athletic Trainers Practice Act, Tenn. Code Ann. §§ 63-24-101 et seq.

Plain-English summary

Representative Tim Hicks asked whether a Tennessee-licensed athletic trainer can perform dry needling. The AG said likely not. Dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying tissues; the technique is defined for Tennessee physical therapists in Tenn. Code Ann. § 63-13-103(6). Whether athletic trainers can do it is a state-by-state question. Some states explicitly permit it (Arizona); others explicitly prohibit it (Delaware). The AG concluded Tennessee falls on the no-authorization side as the Act is currently drafted.

The Act lets athletic trainers use "physical modalities, such as heat, light, sound, cold, electricity, or mechanical devices." On a literal reading, "physical modalities" could be broad enough to cover dry needling. But Tennessee follows the canon of statutory interpretation that when general words are followed by a list of specific examples, the specific examples limit the scope of the general words. The specific examples (heat, light, sound, cold, electricity, mechanical devices) all share characteristics dry needling does not: they are externally applied, while dry needling penetrates the skin. So dry needling is not the same kind of thing the legislature was naming.

The AG noted three other contextual clues. First, the Office's prior 2014 opinion (Op. 14-62) had already concluded that dry needling does not constitute a mechanical device. Second, dry needling typically requires substantial additional training (other states require 50 to 200 hours of instruction and supervised practicum), but the Tennessee Athletic Trainers Practice Act has no provision for any additional training in dry needling. Third, when Tennessee has explicitly permitted dry needling in other professions (specifically, physical therapists under § 63-13-103(10)(B)(vi)), the legislature did so with explicit training and certification requirements. The contrast suggests that the silence in the Athletic Trainers Practice Act is intentional.

The AG also pointed to the Tennessee Board of Athletic Trainers, which in November 2023 noted in board minutes that dry needling "has not been approved for Athletic Trainers in Tennessee due to the rules and statutes." That is consistent with the AG's analysis. The opinion also mentions that the only other state AG to have opined on this question (Nebraska) reached the same conclusion in 2016, prompting the Nebraska legislature to amend its Athletic Training Practice Act to authorize dry needling explicitly. That kind of legislative correction has not happened in Tennessee.

What this means for you

Tennessee-licensed athletic trainers

The opinion concludes that dry needling likely falls outside an athletic trainer's scope of practice under the Act as currently written, because it is not a "physical modality" of the same class as the externally applied examples the statute lists, and the Act provides no dry-needling training requirement.

Athletic training program directors

The opinion's analysis is that dry needling is not authorized for athletic trainers under the Act. It distinguishes technique training from statutory authority to perform the technique: other states require 50 to 200 hours of additional training, and the Tennessee Act contains no such provision.

High school and college athletic departments and sports medicine clinics

The opinion holds that an athletic trainer's license likely does not authorize dry needling. It notes that Tennessee physical therapists are separately authorized to perform it under § 63-13-103(10)(B)(vi).

Tennessee Board of Athletic Trainers

The opinion is consistent with the Board's November 2023 minutes stating that dry needling "has not been approved for Athletic Trainers in Tennessee due to the rules and statutes."

Physical therapists

The opinion contrasts the silence in the Athletic Trainers Practice Act with the explicit dry-needling authorization for physical therapists in § 63-13-103(10)(B)(vi), which requires proper training and certification. It does not change the physical-therapist scope.

Acupuncturists

The opinion does not address whether dry needling is a form of acupuncture. It analyzes only the athletic-trainer scope question.

State legislators on health committees

The opinion notes that other states authorize athletic trainers to perform dry needling by statute, with required additional training (Arizona's S.B. 1398; Illinois, Nevada, and Maryland statutes), and that Nebraska's legislature amended its Athletic Training Practice Act in 2022 after its AG reached the same conclusion. Tennessee has not made that change.

Athletes and parents seeking dry needling care

The opinion's conclusion is that, under current law, dry needling is likely outside an athletic trainer's scope, while Tennessee physical therapists are authorized to perform it.

Common questions

What is dry needling?

The Tennessee statutory definition for physical therapists, at Tenn. Code Ann. § 63-13-103(6), describes dry needling as "a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying neural, muscular, and connective tissues for the management of neuromusculoskeletal conditions, pain, and movement impairments."

Is dry needling the same as acupuncture?

The opinion does not say. They share the use of thin filiform needles inserted into the body but differ in theoretical framework and clinical application. Some jurisdictions treat dry needling as a form of acupuncture for licensure purposes; Tennessee's physical-therapist statute treats them separately.

Is dry needling a "mechanical device"?

No, per the AG's 2014 Op. 14-62 and reaffirmed here. Dry needling is a skilled intervention performed with a needle; it is not a mechanical device used in the same sense as ultrasound or TENS units.

Can I get dry needling certified outside Tennessee and then practice in Tennessee?

Out-of-state certification does not change Tennessee licensure law. To perform dry needling lawfully in Tennessee you need authority under a Tennessee license that includes the technique within its scope. For physical therapists that is Tenn. Code Ann. § 63-13-103(10)(B)(vi). For athletic trainers under current law, no such authority exists.

What about hands-on or instrument-assisted soft tissue manipulation?

Those techniques (Graston, Active Release Technique, manual therapy) are different from dry needling because they do not penetrate the skin. The AG's analysis specifically turned on the externally-applied versus skin-penetrating distinction. The opinion does not analyze each non-needle technique, but the externally-applied techniques typically fit comfortably within the "physical modalities" framework.

Did the AG say dry needling is unsafe?

No. The opinion is about scope of practice, not safety. It does not rule on whether dry needling is safe or effective. The conclusion is statutory: the Athletic Trainers Practice Act does not authorize the technique, and the legislative silence is meaningful.

Has any other state's AG addressed this?

The AG cited Nebraska's 2016 opinion (Neb. Att'y Gen. Op. 16-009), which reached the same conclusion. The Nebraska legislature responded by amending its Athletic Training Practice Act in 2022 to explicitly authorize dry needling. Tennessee has not.

Background and statutory framework

Tennessee's Athletic Trainers Practice Act, Tenn. Code Ann. §§ 63-24-101 et seq., regulates the practice of athletic training. Section 63-24-101(2) defines the practice as "the prevention, recognition, evaluation, management, disposition, treatment, or rehabilitation of athletic injuries" and authorizes the use of "physical modalities, such as heat, light, sound, cold, electricity, or mechanical devices related to prevention, recognition, evaluation, management, disposition, rehabilitation, and treatment."

The opinion turned on whether dry needling is a "physical modality" under that authorization. Tennessee statutory interpretation begins with plain language (Funk v. Scripps Media, Inc., 570 S.W.3d 205, 219 (Tenn. 2019)) and looks at dictionaries published around the time of enactment for undefined terms (State v. Deberry, 651 S.W.3d 918, 925 (Tenn. 2022)). Decomposing "physical modalities" into its parts: "physical" means "of or relating to the body" and "modality" means "a usually physical therapeutic agency" (Merriam-Webster's Collegiate Dictionary, 9th ed. 1984). Read literally, the phrase could cover dry needling.

But meaning depends on context (FDA v. Brown & Williamson Tobacco Corp., 529 U.S. 120, 132 (2000); Yates v. United States, 574 U.S. 528, 537 (2015)). The Tennessee Supreme Court has long held that when specific words follow general ones, the specific words "limit the scope of" the statute (State v. Wheeler, 152 S.W. 1037, 1038 (Tenn. 1913)) and that a "term must be confined to include only entities of the same type or class as the examples listed" (State ex rel. Metro. Gov't of Nashville and Davidson Cnty. v. Spicewood Creek Watershed Dist., 848 S.W.2d 60, 63 (Tenn. 1993)). Here, the listed examples (heat, light, sound, cold, electricity, mechanical devices) are all externally applied. Dry needling penetrates the skin (Tenn. Code Ann. § 63-13-103(6)). It is not the same kind of thing.

The AG also pointed to the prior office opinion, Tenn. Att'y Gen. Op. 14-62 (June 19, 2014), which had concluded that dry needling does not constitute a mechanical device. And to the broader statutory context: dry needling typically requires substantial additional training, and other states have set the bar at 50 hours (Illinois), 80 hours (Maryland), 150 hours (Nevada), or even higher with supervised practicum. The Athletic Trainers Practice Act has no provision for additional dry-needling training. By contrast, Tennessee's physical-therapist statute, Tenn. Code Ann. § 63-13-103(10)(B)(vi), explicitly authorizes dry needling with "proper training and certification." The contrast supports a reading that the legislature deliberately chose to authorize dry needling for one profession and not the other.

The Tennessee Board of Athletic Trainers, in November 2, 2023 minutes, took the same position: dry needling "has not been approved for Athletic Trainers in Tennessee due to the rules and statutes." The AG opinion notes that the Nebraska Attorney General reached the same conclusion in 2016, after which the Nebraska legislature affirmatively amended its Athletic Training Practice Act in 2022 to include dry needling within the scope of practice. Tennessee has not made that change.

Citations

• Tenn. Code Ann. §§ 63-24-101 et seq. (Athletic Trainers Practice Act)
• Tenn. Code Ann. § 63-24-101(2) (definition of practice; "physical modalities" authorization)
• Tenn. Code Ann. § 63-13-103(6) (dry needling definition for physical therapists)
• Tenn. Code Ann. § 63-13-103(10)(B)(vi) (explicit dry-needling authorization for physical therapists with training and certification)
• Ariz. Rev. Stat. Ann. § 32-4101(g)(9) (Arizona authorizes athletic trainers to perform dry needling)
• 24 Del. Admin. Code § 2600-15.4.1 (Delaware: dry needling not in athletic trainer scope)
• 225 Ill. Comp. Stat. 5/4.5(b) (Illinois training requirements: 50+ hours instruction, 30 hours didactic, 54 practicum, 200 supervised treatment sessions)
• Nev. Rev. Stat. § 640B.260(5) (Nevada training requirement: 150 hours)
• Md. Code Ann., Health Occ. § 14-5D-11.4(b)(1) (Maryland training requirement: 80 hours)
• 2022 Ariz. Legis. Serv. Ch. 46 § 3 (S.B. 1398) (Arizona's authorization)
• 2022 Neb. Laws L.B. 436 (Nebraska legislature's response to its AG opinion)
• Funk v. Scripps Media, Inc., 570 S.W.3d 205 (Tenn. 2019) (plain-language starting point)
• State v. Deberry, 651 S.W.3d 918 (Tenn. 2022) (period-specific dictionaries)
• State v. Wheeler, 152 S.W. 1037 (Tenn. 1913) (specific words limit general words)
• State ex rel. Metro. Gov't of Nashville and Davidson Cnty. v. Spicewood Creek Watershed Dist., 848 S.W.2d 60 (Tenn. 1993) (same)
• FDA v. Brown & Williamson Tobacco Corp., 529 U.S. 120 (2000) (context shapes meaning)
• Yates v. United States, 574 U.S. 528 (2015) (same)
• Jaeger v. Palladium Holdings, LLC, 884 N.W.2d 601 (Minn. 2016) (component-term decomposition)
• Tenn. Att'y Gen. Op. 14-62 (June 19, 2014) (dry needling is not a mechanical device)
• Neb. Att'y Gen. Op. 16-009 (July 8, 2016) (dry needling outside athletic trainer scope of practice)

Source

• Landing page: https://www.tn.gov/attorneygeneral/opinions.html
• Original PDF: https://www.tn.gov/content/dam/tn/attorneygeneral/documents/ops/2024/op24-017.pdf

Original opinion text

STATE OF TENNESSEE
OFFICE OF THE ATTORNEY GENERAL
November 12, 2024
Opinion No. 24-017
Dry Needling and Athletic Trainers' Scope of Practice

Question

Is Dry Needling, also known as Intramuscular Manual Therapy and Trigger-Point Dry Needling, within the scope of the practice of athletic trainers under the Athletic Trainers Practice Act, Tenn. Code Ann. §§ 63-24-101, et seq.?

Opinion

Likely not.

ANALYSIS

Dry needling is "a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying neural, muscular, and connective tissues for the management of neuromusculoskeletal conditions, pain, and movement impairments." Tenn. Code Ann. § 63-13-103(6). Some States allow athletic trainers to perform dry needling; others don't. Compare, e.g., Ariz. Rev. Stat. Ann. § 32-4101(g)(9) (dry needling is a skilled intervention athletic trainers may perform) with 24 Del. Admin. Code § 2600-15.4.1 (dry needling "is not in the scope of practice for Athletic Trainers"). An analysis of Tennessee's Athletic Trainers Practice Act indicates that Tennessee likely falls on the no-authorization side of that divide.

The Act provides that an athletic trainer "carries out the practice of prevention, recognition, evaluation, management, disposition, treatment, or rehabilitation of athletic injuries." Tenn. Code Ann. § 63-24-101(2). "[I]n carrying out these functions," an "athletic trainer is authorized to use physical modalities, such as heat, light, sound, cold, electricity, or mechanical devices related to prevention, recognition, evaluation, management, disposition, rehabilitation, and treatment." Id. The pertinent question here, then, is whether dry needling qualifies as a "physical modalit[y]" under the Act.

Statutory interpretation always begins "with the plain language of the statute." Funk v. Scripps Media, Inc., 570 S.W.3d 205, 219 (Tenn. 2019). When a statutory term is undefined, courts start with "authoritative dictionaries published around the time of a statute's enactment." State v. Deberry, 651 S.W.3d 918, 925 (Tenn. 2022). And they often "separate a phrase into its 'component terms' and then reconstruct it to determine its meaning if the phrase is not a term of art, lacks a technical meaning, and is not otherwise defined in the statute." Jaeger v. Palladium Holdings, LLC, 884 N.W.2d 601, 605 (Minn. 2016); see also Deberry, 651 S.W.3d at 927. Splitting the phrase into its component parts here, "physical" means "of or relating to the body," Physical, Merriam-Webster's Collegiate Dictionary (9th ed. 1984), and "modality" means "a usu[ally] physical therapeutic agency," Modality, Merriam-Webster's Collegiate Dictionary (9th ed. 1984); see also Modality, Random House Dictionary of the English Language (2d ed. 1987) ("the application of a therapeutic agent, usually a physical therapeutic agent"). Thus, "physical modalities" are physical methods for treating ailments. This broad definition would appear to include dry needling, as it could conceivably encompass an almost limitless panoply of treatment methods for athletic injuries (including, for example, injections and other medical interventions).

But the "meaning" of a word or phrase "may only become evident when placed in context." FDA v. Brown & Williamson Tobacco Corp., 529 U.S. 120, 132 (2000). That is, the meaning of statutory phrases "is determined . . . by reference to the language itself" and "by the specific context in which that language is used, and the broader context of the statute as a whole." Yates v. United States, 574 U.S. 528, 537 (2015) (plurality opinion).

The statutory context suggests that "physical modalities" does not include dry needling. The Tennessee Supreme Court has long held that where specific words follow general words in a statute, the specific words "limit the scope of" the statute. State v. Wheeler, 152 S.W. 1037, 1038 (Tenn. 1913); cf. State ex rel. Metro. Gov't of Nashville and Davidson Cnty. v. Spicewood Creek Watershed Dist., 848 S.W.2d 60, 63 (Tenn. 1993) (holding that a "term must be confined to include only entities of the same type or class as the examples listed"). Here, "physical modalities" is immediately followed by "heat, light, sound, cold, electricity, or mechanical devices." Tenn. Code Ann. § 63-24-101(2). Dry needling is not on that list and differs entirely in form. For example, whereas heat, light, sound, cold, and electricity are all applied externally, dry needling "penetrate[s] the skin." Tenn. Code Ann. § 63-13-103(6). And as this Office opined in 2014, dry needling also does not constitute a mechanical device. See Tenn. Att'y Gen. Op. 14-62 (June 19, 2014). This suggests that dry needling may not be a "physical modalit[y]" within the scope of the Act.

Looking at the broader statutory context confirms as much. Dry needling is a skilled intervention that requires at least some training beyond that provided in athletic trainer curricula. See Board of Certification for the Athletic Trainer, Athletic Trainers' Use of Dry Needling in Practice (Oct. 19, 2022). Generally, States that allow athletic trainers to perform dry needling require additional education and training. See, e.g., 225 Ill. Comp. Stat. 5/4.5(b) (certification in dry needling requires completion of at least "50 hours of instructional courses," "30 hours of didactic course work," "54 practicum hours," and "200 supervised patient treatment sessions"); Nev. Rev. Stat. § 640B.260(5) (at least "150 hours of didactic education and training in dry needling approved by the Board"); Md. Code Ann., Health Occ. § 14-5D-11.4(b)(1) ("at least 80 hours of instruction"); see also 2022 Ariz. Legis. Serv. Ch. 46 § 3 (S.B. 1398). And when Tennessee has previously authorized the performance of dry needling, it has statutorily required "proper training and certification." See Tenn. Code Ann. § 63-13-103(10)(B)(vi) (physical therapists). But the Act currently makes no provision for additional dry needling training, yet another clue that dry needling falls outside the authorized practice of athletic trainers. This conclusion accords with the only other Attorney General's Office to opine on whether dry needling fits within an athletic trainers' scope of practice and the prior opinion of this office. See Tenn. Att'y Gen. Op. 14-62 (June 19, 2014).

In short, reading the statutory language in context suggests that dry needling likely does not fit within the scope of practice of athletic trainers under the Act.

JONATHAN SKRMETTI
Attorney General and Reporter

J. MATTHEW RICE
Solicitor General

JOSHUA D. MINCHIN
OSG Honors Fellow

Requested by:
The Honorable Tim Hicks
State Representative
425 Rep. John Lewis Way N.
Suite 518 Cordell Hull Building
Nashville, Tennessee 37243