In recent years, the popularity and prevalence of acupuncture as an alternative treatment option have steadily increased. This review elucidates acupuncture based on the traditional understanding of its application, which involves the placement and manipulation of thin needles on particular locations on the skin called acupoints to manipulate the flow of qi, or energy, through meridians, or pathways. This practice is grounded in various Taoist principles, such as yin and yang and de-qi, the latter of which describes a spectrum of sensations experienced during acupuncture, ranging from warmth to numbness and aching [1]. Meridians constitute 14 lines that link specific points on the body, as named by the meridian theory, which was proposed based on empirical experience accrued over centuries [2]. Ancient physicians observed, for example, that for alleviating stomach pain, needling certain pulsing locations on the inside part of the lower leg was more effective than needling other regions of the body. Consequently, lines were delineated to connect these empirically determined points on the body, resulting in a comprehensive map of 14 meridians, each corresponding to distinct systems in the body [2].

Although the origins of acupuncture remain unknown, its role in traditional medicine in China has evolved alongside several other treatments involving herbs and moxibustion [3]. While historical documentation of the benefits of acupuncture is largely anecdotal, recent clinical applications have shown its efficacy in addressing several conditions, including chronic musculoskeletal pain, menstrual cramps, mood disorders, and even the adverse effects of chemotherapy [4]. Furthermore, acupuncture has garnered attention in Western medicine, particularly for patients’ immunological and neurological health. Acupuncture has been shown to exert anticancer, antistress, and anti-inflammatory effects, as well as positive modulatory and stimulating effects on the nervous system [5-8]. As its popularity continues to surge, the role and scope of acupuncture as a therapeutic intervention have been actively investigated in various contexts, including sports and athletics.

An experienced medical reference librarian conducted an exhaustive literature search to identify relevant articles for this study. The search encompassed the following databases: PubMed, Scopus, Medline (1946-present, Ovid interface), and Embase (1974-present, Ovid interface). The search methodology was designed to comprehensively retrieve pertinent literature pertaining to acupuncture and sports medicine.

1. Search strategy

The search methodology employed a combination of MeSH terms and keywords to ensure the retrieval of relevant articles. MeSH terms were applied whenever applicable, while keywords encompassed various terms associated with acupuncture modalities and sports medicine. Specifically, the search terms included MeSH terms for acupuncture, related modalities (acupuncture, moxibustion, pharmacopuncture, acupoints, electroacupuncture, and auriculotherapy), and sports medicine (athletic medicine, sports medicine, sports physicians, sports injuries, and athletic injuries). These terms were employed as needed to enhance search precision.

2. Inclusion and exclusion criteria

No exclusion criteria were applied throughout the search and selection process. The search encompassed all available languages and imposed no restrictions on publication dates, thereby ensuring comprehensive retrieval of relevant literature.

3. Search date

The search was completed on August 23, 2021, and aimed to create a snapshot of the extant literature as of that date.

Acupuncture encompasses various treatments that involve the insertion of needles into the body to treat or prevent a medical condition, rather than relying on a specific type of needle or a single type of insertion technique [9]. Even in ancient Chinese medicine, several needle types found application in acupuncture. In modern acupuncture practice, needles are available in various sizes and lengths, with diverse insertion techniques. The selection of needle types and techniques can be influenced by the specific condition being addressed, the culture or region, and practitioner or patient preferences. Acupuncture needles can be left in place without stimulation, or stimulation may be applied through needle rotation, heat application (moxibustion), or electricity application. Furthermore, acupuncture has evolved to incorporate technological advancements, with the utilization of low-level laser beams for stimulating acupuncture points emerging as a promising, noninvasive, and minimally adverse alternative to traditional acupuncture treatment [10]. Additionally, modern acupuncture has expanded to include techniques that focus exclusively on the scalp, ear, and hand.

From a traditional Chinese standpoint, acupuncture serves as a medicinal modality for addressing qi dysfunction in medical conditions. Conversely, in Western cultures, such as in the United States, acupuncture is employed for the treatment of conditions based on scientific evidence. Noteworthy conditions demonstrating substantial empirical backing for acupuncture’s efficacy include nausea and vomiting, migraines and tension headaches, neck pain, knee pain, back pain, and fibromyalgia [6,9,11-15]. Other common applications of acupuncture include neuropathies, musculoskeletal pain, asthma, allergies, and psychiatric disorders, as well as a broad range of GYN and GI conditions [16].

Modern acupuncture applications are associated with minimal risk, with rates of severe adverse events estimated to be as low as 5 per 1 million treatments and 55 per 1 million patients [17]. In China, 182 cases of adverse events were reported between 1980 and 2013, while a study of acupuncture encompassing 25 countries identified 308 adverse events between 2000 and 2011 [18,19]. Most adverse events have occurred during periods characterized by limited standardization of acupuncture practice, with the highest concentration of cases in China between 1985 and 1989 [18]. These adverse events primarily included pneumothorax and injuries to the central and peripheral nervous systems [17,18].

Although adverse event rates have been investigated in the context of general acupuncture usage, the potential contraindications and health risks associated with acupuncture have not been extensively studied for athletes or individuals engaged in regular strenuous physical activity [20]. Recent studies indicate that the lower incidence of adverse events observed in general acupuncture usage is similarly reflected in the treatment of sports-related injuries. The aforementioned systematic review by Lee et al. [21] reported only minor adverse effects in three cases (13.6%); however, the incidence of adverse effects was assessed in only five of the cases included in their review.

Although uncommon today due to the widespread use of disposable needles among clinicians, it is noteworthy that infection due to a lack of sterile technique remains the most prevalent adverse outcome associated with acupuncture. The primary infection encountered in this context is hepatitis, stemming from the reuse of needles [17,19]. This may further extend to issues faced by athletes, as acupuncture treatment in proximity to joints carries an elevated risk of infection. For example, the Xiyang acupoints predominantly target the right knee joint, and in isolated cases, infections have arisen through bleeding or direct needle exposure [22]. However, modern acupuncture practices advocate for modifications, such as targeting periarticular spaces and inserting needles at a specific angle [22]. The potential for infection remains but is rare; therefore, clinicians should ensure that athletes are well-informed about potential adverse effects when seeking their informed consent for treatment.

Rates of injury among various types of practitioners have not been systematically documented; thus, the interplay between training, knowledge, efficacy, and safety in practice is yet to be elucidated. However, given the notably low occurrence of adverse events, it is reasonable to infer that concerns associated with acupuncture’s application for general conditions and sports are rare and possibly stigmatized.

1. Pain management through acupuncture in athletes

Wu et al. [23] highlighted the distinct advantages of a synergistic approach involving acupuncture and Western medicine in managing acute and chronic waist injuries among a cohort of 45 sports dance athletes. This combined approach demonstrated an enhanced clinical efficacy rate of 95% compared to the groups solely receiving acupuncture (84%), or Western medical treatments (90%). Similarly, evaluation of the Owen Disability Index and Visual Analog Scores (VAS) across these groups indicated that individuals in the combined-treatment group exhibited superior outcomes during follow-up visits, experiencing less pain than those in the single-treatment groups [23]. These findings were corroborated by a study involving 38 recreational athletes with plantar fasciitis. The study elucidated statistically significant reductions in pain and disability scale scores after three months of measurements, particularly when comparing Western medical management alone (i.e., ice, rest, nonsteroidal anti-inflammatory medication, and a stretching program) with a regimen that combined Western medical management and acupuncture [24].

Measurements of pain index scores comparing simulated acupuncture to actual acupuncture have yielded varied results in patients experiencing exercise-induced delayed-onset muscle soreness (DOMS) over 72 hours. Hubscher et al. [25] observed a distinct difference in VAS among seven patients with DOMS; after 72 hours, scores were significantly lower (p < 0.05) in individuals receiving acupuncture compared to those undergoing simulated acupuncture. However, an evaluation of VAS and pressure pain thresholds in patients receiving acupuncture, simulated acupuncture, laser acupuncture, or simulated laser acupuncture for DOMS revealed no differences after 72 hours compared to baseline [26]. These findings indicate the need for further investigation to evaluate the efficacy of acupuncture in alleviating pain in patients with DOMS. However, it appears that pain index scores and symptoms exhibit improvement when a combination of Western medicine and acupuncture is employed for recreational and sports athletes.

2. Acute injury management through acupuncture in athletes

Wu et al. [23] observed a reduction in swelling at the injury site, measured in centimeters, between days 7 and 14 post-intervention in patients who underwent combined therapy as opposed to those who received either Western therapy or acupuncture alone (p < 0.01). Yang and Wang [27] compared elbow joint effusion and swelling reduction using magnetic resonance imaging. They examined 30 injured elbow joints of athletes in sports such as gymnastics, tennis, weightlifting, table tennis, judo, basketball, and badminton treated with acupuncture and compared them to 30 elbow joints exhibiting similar symptoms that were treated with rest alone. The acupuncture group demonstrated marked improvements in joint mobility, swelling, and VAS, achieving a striking 100% rate of improvement, in contrast to the 40% rate observed in the control group [27].

3. Effects of acupuncture on strength in athletes

Wang et al. [28], in their study on explosive force production in 10 right knee joints treated with acupuncture, observed statistically significant improvements in higher peak power, total work, average maximum torque, average work, and average peak power compared to those of 10 right knees treated with simulated acupuncture (p > 0.05). In contrast, Banzer et al. [29] found no statistically significant differences in kinetic parameters such as maximum jumping height and duration of ground contact among 12 athletes receiving acupuncture, simulated acupuncture, or no acupuncture in cases of normalized muscular innervation. Indeed, measurements of drop jump height and mean-power frequency by Hübscher et al. [30] also indicated that values were not statistically different among 33 athletes receiving acupuncture, simulated laser acupuncture, or simulated acupuncture. Furthermore, studies have reported that maximum isometric voluntary forces do not differ between groups receiving acupuncture or simulated acupuncture [25,26]. These findings indicate that the efficacy of acupuncture for enhancing strength is not well established. While there may be enhancements in explosive force production, improvements in kinematic and static measures of muscle force cannot be conclusively attributed to acupuncture.

4. Cardiovascular benefits of acupuncture for athletes

The current literature provides support for the improvement in physiological parameters following acupuncture. As previously mentioned, male athletes who undergo acupuncture demonstrate decreased values of heart rate, oxygen consumption volume, and blood lactate levels compared to those who receive simulated acupuncture or no acupuncture at all [31]. This finding is bolstered by observations of reduced heart rate and blood lactic acid levels 30 and 60 minutes after exercise on a cycle ergometer among elite male basketball players who received auricular acupuncture in a separate study [31]. Another study revealed that athletes who receive acupuncture exhibit improved regulation of blood pressure and heart rate compared to those who undergo simulated acupuncture, correlating with improvements in maximal physical performance [32]. In addition, a combination of heat and acupuncture therapy has been reported to markedly increase blood volume and oxygen saturation within the Achilles tendon 30 minutes post-treatment [33].

While heart rate measurements have been observed to be lower at 20, 50, and 60 minutes post-exercise in recreationally active adults who receive acupuncture compared to their counterparts who do not receive acupuncture, no differences have been observed in blood lactate, blood pressure, oxygen consumption, or respiratory rate [34]. Additionally, single acupuncture treatments have failed to demonstrate improvements in resting heart rate, oxygen consumption, and heart rate during submaximal loads of dynamic exercises [35]. Therefore, while acupuncture may offer certain advantages in aspects of post-exercise recovery, physiological rehabilitation should not rely solely on acupuncture therapy.

5. Psychosomatic benefits of acupuncture for athletes

It is noteworthy that the restorative effects of acupuncture also encompass psychological aspects. Competition anxiety, and particularly cognitive anxiety, have been observed to be reduced among adolescent athletes who receive acupuncture compared to those who receive simulated acupuncture; however, the assessment of the effectiveness of acupuncture in relation to skin conductance tests and posttest somatic anxiety scores has yielded conflicting results [36,37]. These findings indicate the promising advantages of acupuncture in alleviating competition-related stress in adolescent athletes. This is further supported by ongoing trials investigating the use of wrist-ankle acupuncture to mitigate precompetition nervous syndrome in youth track and field athletes while enhancing emotional regulation, attention, and concentration among archers [38,39].

6. Sex, age, and sports

It is reasonable to consider that biological differences between the sexes may play a role in the efficacy of acupuncture as a treatment modality. Neurological investigations have identified differences in the activation and deactivation patterns of specific structures and networks within the limbic and paralimbic systems between men and women due to acupuncture [40]. Additionally, improvements in sex-specific conditions and disorders, such as polycystic ovarian syndrome in women and erectile dysfunction in men, have been attributed to various forms of acupuncture [41,42]. In contrast, we observed substantial enhancements in overall athletic performance in both sexes. Several sports medicine studies investigating the utilization of acupuncture on the shoulder joint have shown significant improvements in shoulder abduction/adduction and flexion/extension measures for both men and women, encompassing metrics such as average power, average work, and total work generated [43,44]. Notably, when comparing men and women, neither group exhibits an enhanced average maximum abduction torque; however, both demonstrate improvement [43,44]. These findings indicate that treatments involving acupuncture may affect the underlying mechanisms of musculoskeletal physiology in male and female athletes similarly, irrespective of differences in the benefits observed between the sexes following acupuncture application for other conditions.

Acupuncture’s effectiveness does not appear to favor any specific age group. Although most medical studies have reported positive health outcomes in adults, acupuncture and related alternatives, such as laser acupuncture, have shown promise in alleviating postoperative nausea and emesis as well as addressing nocturnal enuresis in pediatric populations [45]. Moreover, research conducted by Meng et al. [46] revealed that patients over the age of 60 with chronic lower back pain experience a greater reduction in pain after receiving combined standard therapy and acupuncture compared to those receiving standard therapy alone. In the realm of physical activity and athletics, acupuncture and needling techniques have demonstrated their efficacy across various age groups. In a sports study, dry needling combined with eccentric loading exercises led to marked improvements in proximal hamstring injuries for two patients aged 69 and 70, enabling both to return to long-distance running activities within 8 to 10 weeks [47]. Low-level laser therapy applied to various acupoints has demonstrated effectiveness in alleviating pain in 65.9% of patients aged 17 to 77, improving several prominent athletic conditions, including jumper’s knee and Achilles tendinitis [48]. Additionally, sports studies have demonstrated a significant reduction in average somatic and cognitive anxiety scores following acupuncture therapy among young athletes. Specifically, these scores decreased by 26% and 34%, respectively, as assessed by the Competitive State Anxiety Inventory-2, a 27-item questionnaire encompassing three subscales pertaining to cognitive anxiety, somatic anxiety, and self-confidence [37]. The reported benefits of acupuncture in treating various conditions across diverse age groups suggest its potential as an effective therapeutic option, irrespective of age.

Acupuncture therapy has demonstrated its efficacy in benefiting athletes across various sports. A study conducted at the Korean National Sports University revealed that out of the nearly 15% of elite college athletes who opted for Korean medicine alternatives, over 44% selected acupuncture as their primary treatment modality [21]. These athletes participated in several sports of varying intensities, including kayaking, golf, wrestling, and taekwondo [21]. Furthermore, a systematic review of case studies conducted by Lee et al. [20] indicated that athletes participating in various sports, including soccer, track and field, hockey, football, and skiing, also benefit from acupuncture.

Acupuncture has demonstrated benefits in various sports, making it worthwhile to consider its impact on several physiological parameters crucial for athletic performance. A seminal review by Pelham et al. [49] indicated that acupuncture significantly improves athletic flexibility, aerobic conditioning, and hemodynamics. Additionally, a sports medicine study demonstrated that a single session of acupuncture combined with static stretching results in a significant increase in hip joint abduction range, indicating improved flexibility [50]. Furthermore, elite basketball players who undergo acupuncture treatments exhibit lower maximum heart rates and higher peak oxygen uptake levels following exercise compared to players who receive simulated acupuncture or no acupuncture at all [31]. Although Pelham et al. [49] acknowledged the scarcity of evidence regarding the role of acupuncture in enhancing muscle strength and endurance, a study showed that individuals who undergo a session of acupuncture exhibit an increase in maximum involuntary contraction force, surpassing that of individuals who undergo simulated laser acupuncture by 27 Newtons, signifying enhanced muscle strength [30]. Another sports study elucidated an enhancement in the average maximum torque exerted by women’s forearm muscles during flexion and extension following an acupuncture session, suggesting an increase in the force generated by these muscles [51]. These benefits will be further elaborated upon in subsequent sections; nonetheless, these findings collectively underscore acupuncture’s potential utility for athletes across various sports by enhancing physiological parameters necessary for achieving excellence in athletic performance.

7. Cultural considerations

Culture exerts a significant impact on the reception and utilization of acupuncture [52,53]. Traditional East Asian cultures, where acupuncture has served as a medical therapy for thousands of years, demonstrate a greater propensity for adopting this therapeutic modality compared to Western cultures [53].

While acupuncture has gained popularity in Western cultures, there remain perceived obstacles to its utilization in the United States, including a lack of comprehension, familiarity, and reimbursement [54,55]. Given these factors, athletes hailing from Asian backgrounds may be more receptive to acupuncture as a treatment option compared to athletes raised in Western cultures [56].

Western and Eastern cultures may perceive the underlying rationale and mechanism of action of acupuncture differently. Eastern cultures typically regard acupuncture as a means of restoring energy flow by harmonizing qi within the body’s meridians. In contrast, Western cultures tend to interpret acupuncture’s mechanism of action in terms of its measurable impact on neurotransmitters, blood flow, and inflammatory markers [57]. This cultural difference has led to a greater tendency in American sports medicine to integrate acupuncture with medications and treatments grounded in Western evidence-based medicine, as compared to Asia, where acupuncture is more readily employed as a standalone therapeutic approach by many practitioners.

Traditional East Asian cultures may incorporate acupuncture along with evaluation techniques not employed in Western cultures. For example, in Chinese medicine, the assessment of one’s health involves the examination of the tongue, as alterations in tongue characteristics are believed to correspond to shifts in qi balance [58]. Conversely, Western cultures often employ acupuncture in conjunction with contemporary diagnostic techniques such as imaging and laboratory blood testing [59]. The physical examination conducted alongside acupuncture in Western cultures primarily targets patient concerns and aids clinicians in formulating a differential diagnosis [60].

As acupuncturists in Eastern cultures typically adhere to traditional Chinese medicine theories of the qi and meridians, they may not be trained to consider or recognize anatomical vessels and organs at the treatment site. In traditional Eastern medicine, an acupuncturist may insert needles directly over the chest at specific acupoints, while in Western medicine, an acupuncturist might consider the possibility of causing a collapsed lung and may avoid needling in that area. Therefore, although acupuncture is widely considered a safe therapeutic modality, the risk of adverse effects may be higher in Eastern cultures where acupuncturists are not mandated to undergo training in human anatomy. For example, a study found that adverse effects stemming from acupuncture in China, including accidental organ or central nervous system injuries and pneumothorax, were primarily attributed to the grassroots nature of acupuncture practice and the lack of robust knowledge of human anatomy [18].

Given that culture significantly influences the reception and utilization of acupuncture, we summarized cultural considerations of acupuncture in Table 1.

Table 1

Cultural considerations of acupuncture.

Cultural considerations	Eastern (Asian) cultures	Western cultures
Perceived barriers to use	No requirement for acupuncturists to train in human anatomy	Understanding, familiarity, and reimbursement [54,55]
Perceived mechanism of action	Restoring energy flow by balancing qi in body meridians	Measured effect on neurotransmitters, blood flow, and inflammatory markers [57]
Mode of treatment	Individual treatment	Adjunctive treatment
Human anatomy training required	Yes/no [18]	Yes
Receptiveness to acupuncture treatment	More [56]	Less
Supplemental assessment in acupuncture	Qi balance assessment (ie, tongue will be examined to assess health as changes in the tongue are believed to represent alterations in qi balance) [58]	Diagnostic methods (ie, imaging or laboratory blood testing) [59]
Physical examination focus with acupuncture	Areas related to qi balance (ie, tongue) [58]	Areas related to patient’s concern and clinician’s physical diagnosis [60]

The clinical efficacy of acupuncture in sports and athletics has become an increasingly prominent research area, with most primary literature pertaining to the advancements of the technique being published over the past 20 years [35]. However, preliminary analyses indicate that acupuncture offers several therapeutic advantages applicable to a diverse range of sports. This suggests that acupuncture holds promise as a valid therapeutic approach for improving health metrics and aiding in injury rehabilitation among athletes and other physically active individuals.

No discernible differences in the benefits of acupuncture have been reported with respect to age or sex. Thus, it is no surprise that athletes across various disciplines and competition levels have benefited from acupuncture therapy. These benefits encompass enhanced joint mobility and explosive force production, reduced competition anxiety and pain scores, and, in some instances, improvements in physiologic and kinetic parameters [24-39]. However, conflicting evidence in the literature has yielded mixed results regarding the improvement of muscle strength, muscle recovery, and other physiologic parameters through acupuncture intervention; thus, relying solely on acupuncture for improving performance and facilitating recovery is not recommended [25,29,30,34,35].

With the growing adoption of alternative complementary medicine treatments, there is a concurrent decline in adverse event rates. While instances of needle infection and pneumothorax have been documented, a discernible trend toward decreased incidence of these adverse effects is observed when acupuncture is employed alongside more formal technologies and protocols. Given this trend and acupuncture’s inherently low rate of associated adverse events, incorporating acupuncture into sports medicine in conjunction with Western therapies can be recommended.

Acupuncture is gaining popularity in the field of sports medicine. Musculoskeletal pain and neuropathies appear to benefit from acupuncture. Acupuncture affects the underlying mechanisms of musculoskeletal physiology in male and female athletes similarly and appears to be an effective treatment for athletes across different age groups. Western culture tends to perceive acupuncture’s mechanism of action in terms of its measurable effects on neurotransmitters, blood flow, and inflammatory markers, while traditional East Asian culture interprets its actions in the context of qi. Studies on flexibility, range of motion, pain level, and swelling indicate that acupuncture yields positive outcomes with implications for sports performance. Furthermore, acupuncture has shown promise as an effective treatment modality for sports-related injuries, with supporting evidence for racket sports, martial arts, and weightlifting, among others. Notably, injuries appear to benefit most from a combined approach of acupuncture and physical therapy. Additionally, acupuncture appears to improve emotional regulation and the ability to withstand psychology.

Conceptualization, G.P., A.M., and N.P.S.; data curation, G.P. and A.M.; investigation, G.P., A.M., and N.P.S.; methodology, G.P.; project administration, G.P.; resources, G.P. and N.P.S.; software, G.P.; supervision, G.P. and A.I.P.; validation, G.P.; visualization, G.P.; writing – original draft, G.P., M.M., A.M., N.P.S., and A.I.P.; writing – review & editing, G.P., A.M., D.D.P., N.P.S., and A.I.P.

The authors declare no conflict of interest.