Ankle sprain

An ankle sprain is a stretch or tear of one or more of the ligaments that hold the ankle joint together, most often on the outer side of the ankle when the foot rolls inward. Most people recover within weeks, but some are left with chronic ankle instability, a lasting sense that the ankle gives way, and repeated sprains. The research on needling divides along that line. Most trials, nearly all from China, test acupuncture or acupressure in the first days after an acute sprain, mostly against rest, ice, compression and elevation (RICE) or Chinese herbal patches. A smaller group, mostly from physical therapy, tests dry needling of the calf and fibularis muscles in people with chronic instability.

What did the Cochrane review find?

A 2014 Cochrane review by Kim, Lee, Kim, Kang, Choi and Ernst, searched to August 2013, found no reliable support for the effectiveness or safety of acupuncture for acute ankle sprain in adults, alone, added to other treatment or compared with other treatment. It included 20 randomised or quasi-randomised trials with 2,012 participants, 17 of them conducted in China, and counted needle acupuncture, electroacupuncture, laser acupuncture, acupressure and moxibustion as acupuncture. None of the trials used a sham control, so neither participants nor practitioners were blinded, and the reviewers rated the certainty of the evidence for cure rate very low in every comparison. The comparisons, kept apart in the review, were these:

• Against no treatment. One trial of 61 people found every person in the acupuncture group cured at five days, against 1 of 30 in the untreated group.
• Added to standard treatment. Eight trials gave acupuncture on top of a treatment both groups received. Most reported higher cure rates with acupuncture, but the pooled estimate was inconsistent and imprecise (risk ratio 1.32, 95% CI 0.95 to 1.84, heterogeneity 98%).
• Against other treatments. Fourteen trials compared acupuncture with Chinese herbal patches, ice packs, hot and cold water, oral herbal medicine or elastic bandages. The pooled cure rate leaned slightly towards acupuncture without reaching significance (risk ratio 1.07, 95% CI 0.94 to 1.22).

No trial reported function as patients rated it. One trial recorded adverse events: three people in a control group had skin reactions to over-the-counter Chinese herbal patches. The review has not been updated since its publication on 23 June 2014.

Later systematic reviews

A year before the Cochrane review, Park, Hahn, Park, Park and Lee reported that more people improved with acupuncture than without it (risk ratio of symptoms persisting 0.56, 95% CI 0.42 to 0.77), and that the result held in the two trials at low risk of bias. They judged the pooled figure probably an overestimate: only three trials described an adequate method of randomisation and one described allocation concealment. Given those shortcomings, they wrote, the evidence was not enough to recommend acupuncture as an evidence-based treatment.

In 2017 Doherty, Bleakley, Delahunt and Holden reviewed 46 systematic reviews of every treatment for acute ankle sprain and chronic instability, which scored a mean 6.5 of 11 on AMSTAR, a checklist of review quality. They found strong evidence for anti-inflammatory drugs and early mobilisation after an acute sprain, moderate evidence for exercise and manual therapy, and conflicting evidence for acupuncture and for surgery.

Searching Chinese and English databases to September 2020, Liu, Gong, Chen and Zhai included 17 Chinese trials with 1,528 patients, published from 1999 to 2018. On their primary outcome, the Kofoed ankle score of pain, function and mobility, acupuncture did not differ from RICE. Pain and cure rate favoured acupuncture over RICE, and favoured acupuncture added to RICE, massage or Chinese medicine over each of those alone. The authors list small samples, varied interventions and methodological flaws as limits, and call for larger trials.

For chronic instability, a 2024 review by Salemi and colleagues found seven studies of dry needling, with 169 people injured more than a year earlier. Most reported short-term gains in pain, function and balance after needling the fibularis longus, the muscle along the outer calf that turns the foot outward, and one found needling better than placebo needling for postural control. The authors judged the evidence premature, citing small, underpowered studies with inconsistent techniques and controls.

Trials

• Acupuncture against analgesic drugs in the emergency department, 2017. In four Melbourne emergency departments, Cohen and colleagues randomised 528 people with acute low back pain, migraine or ankle sprain, 166 of them with a sprain, to acupuncture, acupuncture with drugs, or drugs alone, with assessors blinded. For ankle sprain the three groups were equivalent in pain at one hour on the intention-to-treat analysis, though the per-protocol equivalence test did not hold. Across all three conditions, 15.6% of patients had their pain brought below 4 on a 10-point scale at one hour, and the authors concluded that none of the treatments gave optimal acute pain relief.
• Acupressure against mock acupressure, 2018. At two hospitals in Dali and Hangzhou, Zhao and colleagues randomised 62 people seen within 48 hours of a sprain to standard RICE treatment, RICE with acupressure, or RICE with mock acupressure. After three sessions, swelling measured by foot and lower-leg volume had fallen further with acupressure than in either other group, and range of movement, pain and ankle scores after the first session and quality of life at four and eight weeks also favoured it. It is one of the few trials in this field with an inactive control.
• Micro-needle-knife against acupuncture, 2024. Lu and colleagues randomised 80 people injured within 72 hours to six sessions of micro-needle-knife release of the superficial fascia or six sessions of acupuncture at GB39 (Xuanzhong), BL60 (Kunlun), BL40 (Weizhong), ST41 (Jiexi), KD09 (Zhubin) and KD06 (Zhaohai). Pain and Kofoed scores improved in both groups. The needle-knife group scored better at the end of treatment, and the groups did not differ a month later. The trial had no sham or untreated group.

What guidelines say

• Dutch guideline, 2018. The update of the Dutch evidence-based guideline on ankle sprains, published by Vuurberg and colleagues with searches to September 2016, added acupuncture for the first time. It found the evidence inconclusive because of large heterogeneity between studies, drew no conclusion because no study had used a sham acupuncture group, and does not advise acupuncture, ultrasound, laser, electrotherapy or shortwave therapy for acute lateral ankle sprain, since none has strong evidence of effect. It recommends tape or a brace with an exercise programme.
• US physical therapy guideline, 2021. The revised clinical practice guideline from the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association, by Martin and colleagues, states that the evidence on acupuncture to reduce symptoms after an acute lateral ankle sprain is conflicting, and that the few well-designed studies need replicating before it can make a recommendation. For chronic instability it says clinicians may use dry needling of the fibularis muscles together with a proprioceptive training programme, exercises that retrain the sense of joint position, resting on a few small trials.
• NICE Clinical Knowledge Summary, revised June 2025. The UK primary care summary on sprains and strains advises analgesia, protection, rest, ice, compression and elevation, review after five to seven days, and physiotherapy when symptoms are not improving. It does not mention acupuncture.

Clinical guidelines compares how guideline bodies treat acupuncture across conditions.

What the reviews could not settle

The acute-sprain trials compare acupuncture with RICE, herbal patches or nothing, and add it to treatments the control group also received; the Cochrane review found none that used a sham, so the trials cannot separate an effect of needling from the attention and expectation that come with it. Their main outcome is a cure rate graded by the investigators, and no trial in the Cochrane review measured function as patients reported it, one of the two outcomes Doherty and colleagues took as primary; the other was repeat injury. The one large trial outside China measured pain for an hour in an emergency department. For chronic instability, the dry needling studies are small and short. Sham acupuncture describes the controls these trials lacked, and the plantar heel pain page reports the needling trials for another painful condition of the foot.

AcuiQ’s ankle pain page lists the protocols individual studies prescribed, each with its citation.