Integrating Traditional Chinese Medicine into Endurance Sports: A Narrative Review of Evidence and Applications

Journal of Complementary Therapies in Health ISSN 2975-9323 |eISSN 2975-9552 Journal of Complementary Therapies in Health 2026:4(1). doi:10.5281/zenodo.17960420 institutoptc.com/journal-complementary-therapies Review Integrating Traditional Chinese Medicine into Endurance Sports: A Narrative Review of Evidence and Applications. Helena Pereira Alonso1*, Rossana Maneira Manso1, Micael Silva Ribeiro1, Ana Dias de Freitas1, Isabel de Sousa Nascimento1, and Joana Ferreira Faria1. 1 IPN – Portuguese Institute of Naturology, Porto, Portugal. * Correspondence: [email protected] Abstract Background: Traditional Chinese Medicine (TCM) is a holistic medical system with millennia-old theoretical foundations, including the Huangdi Neijing and other classical texts. TCM emphasises the balance of Qi, blood, and organ systems, offering potential complementary strategies for athlete recovery, performance optimisation, and injury prevention. Objective: This review evaluates the application of TCM modalities, including acupuncture, moxibustion, cupping therapy, Tuina, and Qigong, in endurance sports, focusing on physiological, neuromuscular, and psychophysiological outcomes. Methods: Evidence was synthesised from randomised controlled trials, pilot studies, systematic reviews, and mechanistic investigations addressing the effects of TCM interventions on endurance capacity, recovery, musculoskeletal rehabilitation, immune function, hormonal modulation, and psychological resilience. Results: TCM modalities offer complementary benefits for athletes. Acupuncture may enhance endurance, recovery, and neuromuscular function. Cupping primarily improves tissue flexibility and reduces fatigue markers. Moxibustion supports muscle recovery, immune modulation, and hormonal balance. Auricular acupuncture and vagal nerve stimulation aid cardiovascular recovery and coordination. Qigong promotes psychological well-being, body composition, and immune regulation. Tuina enhances musculoskeletal rehabilitation, particularly when combined with exercise. Conclusion: TCM offers a multifaceted, complementary framework for supporting endurance athletes by addressing recovery, physiological stress, and holistic performance optimisation. While preliminary evidence indicates potential benefits across multiple domains, robust, high-quality randomised trials are required to standardise protocols, validate efficacy, and clarify underlying mechanisms. Keywords: Traditional Chinese Medicine; Endurance Athletes; Acupuncture; Moxibustion; Cupping Therapy; Tuina; Qigong; Athlete Recovery; Performance Optimisation. 1. Introduction TCM is one of the oldest and most comprehensive medical systems in the world, deeply rooted in the philosophical and cultural traditions of China. Its foundations are described in classical medical texts such as the Huangdi Neijing (Yellow Emperor’s Classic of Internal Medicine), dating from between the 3rd and 5th centuries BCE, which outlines early understandings of physiology, including blood circulation regulated by the heart. This knowledge predate Western anatomical discoveries by over a millennium 1,2. Other seminal works, including Shang Han Lun (Treatise on Cold Damage) by Zhang Zhong Jing (2nd century CE), introduced the principle of disease classification based on patterns of Citation: Alonso H.P., Manso R.M., Ribeiro M.S., de Freitas A.D. Nascimento I.S., Faria J.F. Integrating Traditional Chinese Medicine into Endurance Sports: A Narrative Review of Evidence and Applications. Journal of Complementary Therapies in Health. 2026;4(1) 10.5281/zenodo.17960420 Academic Editor: Jorge Rodrigues Received: 7 November 2025 Reviewed: 5 December 2025 Revised: 15 December 2025 Accepted: 16 December 2025 Published: 17 December 2025 Publisher’s Note: IPTC stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: ©2026 by the authors. Submitted for open access publication under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/). Journal of Complementary Therapies in Health 2026: 4(1). 2 of 10 Alonso H.P., Manso R.M., Ribeiro M.S., de Freitas A.D. Nascimento I.S., Faria J.F. Integrating Traditional Chinese Medicine into Endurance Sports: A Narrative Review of Evidence and Applications. doi:10.5281/zenodo.17960420 symptoms, and the Shen Nong Ben Cao Jing, an early pharmacopoeia describing 365 medicinal substances and the Eight Principles of diagnosis 3,4. These texts established the theoretical basis of an integrative and systematic medical model encompassing diagnostic and therapeutic frameworks that continue to guide clinical practice today 5. In TCM theory, health is understood as the dynamic balance of vital energy (Qi), blood (Xue), and organ systems (Zang-Fu), influenced by environmental, emotional, and lifestyle factors 6. This holistic understanding has increasingly drawn attention in Western sports medicine for its potential to complement biomedical approaches, especially in the context of high-performance athletics 7-9. Elite athletes are routinely exposed to physiological and psychological stressors (intense training loads, competitive pressure, travel, and environmental variation) that may lead to homeostatic imbalance, overtraining, fatigue, immune suppression, sleep disturbances, and recurrent injuries 10. Conventional biomedical interventions often provide limited relief for these multifactorial syndromes, creating space for integrative approaches such as TCM to contribute to performance optimisation and recovery 11,12. TCM modalities including acupuncture, cupping therapy, moxibustion, Tuina (therapeutic massage), Qigong, and dietotherapy are increasingly employed in sports rehabilitation and prehabilitation to restore balance, improve circulation, support weakened systems, and prevent injury 13-15. For instance, acupuncture has demonstrated measurable effects on endurance, muscle recovery, and hormonal regulation, while Qigong and Tai Chi practices promote psychophysiological balance through controlled breathing, movement, and meditation 16-18. According to TCM theory, physical activities such as running mobilise Qi and blood circulation but may also deplete the Spleen, Liver, and Kidney systems when performed excessively, leading to fatigue, muscle weakness, or tendon vulnerability 3. Therefore, TCM emphasises balancing active training with restorative practices, appropriate footwear, and attention to meridians originating in the feet, such as the Kidney Meridian (Shaoyin) beginning at point KI1 (Yongquan) and the Liver Meridian (Jueyin) starting at LV1 (Dadun), which are believed to play a key role in grounding energy and maintaining musculoskeletal integrity 19-24. Therefore, this article aims to explore the integration of TCM concepts into high-performance sports and understand if TCM techniques can enhance recovery, modulate physiological stress, and maintain energetic balance. 2. Results and Discussion 2.1. Acupuncture Acupuncture has been investigated for potential effects on multiple aspects of athletic performance and recovery, but the existing evidence base is preliminary, heterogeneous, and in many cases inconclusive. In endurance performance, one randomised study demonstrated that acupuncture training (8 sessions over 4 weeks) improved 3 km running performance and increased speed at the ventilatory threshold compared with baseline values in healthy recreational runners, suggesting a possible enhancement in endurance capacity after repeated acupuncture application 18. A controlled field trial also reported that runners receiving acupuncture showed greater improvements in running time and a composite “complexity factor” (running time × heart rate measures) than placebo or control groups, although interpretation is limited by study design and reporting quality 25. Overall, these studies suggest potential benefits of acupuncture on running performance, but results should be viewed with caution due to small sample sizes and methodological limitations 26. Regarding recovery outcomes, preliminary research indicates that acupuncture at acupoints such as PC6 and ST36 may be associated with faster post-exercise heart rate and lactate recovery compared with sham or no acupuncture, particularly in trained athletes after exhaustive exercise 27. A pilot case study with a small sample also reported that acupuncture applied after a cycling sprint test might enhance lactate removal at 30 and Journal of Complementary Therapies in Health 2026: 4(1). 3 of 10 Alonso H.P., Manso R.M., Ribeiro M.S., de Freitas A.D. Nascimento I.S., Faria J.F. Integrating Traditional Chinese Medicine into Endurance Sports: A Narrative Review of Evidence and Applications. doi:10.5281/zenodo.17960420 60 minutes post-exercise, although larger controlled studies are needed 28. These outcomes align with systematic review findings that some trials using PC6 and ST36 have shown reductions in lactate and heart rate versus control at later recovery time points, but the overall evidence is inconsistent 26. Evidence on strength, power, and anaerobic performance is sparse and mixed. Some small studies and observational work have reported immediate increases in measures such as explosive strength or vertical jump height following stimulation of acupuncture or acupressure points (e.g., ST36), but these findings have typically lacked appropriate control conditions or rigorous blinding, and have not been widely reproduced 29,30. Systematic reviews note the limitations of the literature and the need for adequately powered randomised controlled trials before definitive conclusions can be drawn about effects on muscle performance, sprinting, or power output 26. Some research has explored neurophysiological effects of acupuncture at points such as ST36, indicating changes in motor cortical excitability, but the implications of these findings for functional athletic performance remain uncertain 31. In summary, while individual trials and case studies have reported outcomes such as improved endurance times, enhanced lactate clearance, and modulations of cardiovascular recovery, the current evidence does not consistently support robust performance enhancements across diverse athletic domains. Most studies are limited by small sample sizes, inconsistent methodologies, and heterogeneous intervention protocols. Accordingly, acupuncture may hold promise as an adjunct for certain recovery or physiological responses, but further high-quality, blinded, and adequately powered trials are required to determine its true efficacy as an ergogenic aid in both endurance and resistance training contexts 26. 2.2. Cupping Therapy Recent quantitative and mechanistic information from multiple studies provides evidence for some physiological effects of cupping therapy in athletic populations. The application of cupping therapy to the dorsal Shu points resulted in a greater decrease in serum creatine kinase (CK) levels as compared to the control group, indicating a marked decrease in muscular fatigue and enhanced recovery following exertion 32,33. Hematologic profile information from Abdelfattah et al. 34 reported significant increases in total white blood cell (WBC) count and increased numbers of neutrophils and lymphocytes during four weeks of wet cupping therapy in athletes. Additionally, a significant increase in red blood cell (RBC) count and haemoglobin concentration and an increase in packed cell volume (PCV) were also evident, reflecting enhanced oxygen-carrying capacity and tissue perfusion. There were no statistically significant differences in mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH) or mean corpuscular haemoglobin concentration (MCHC), indicating there was no change in erythrocyte shape or function. The platelet count and mean platelet volume (MPV) count also remain stable. For inflammatory analysis, cupping therapy decreased monocyte-to-lymphocyte (MLR) and platelet-to-lymphocyte (PLR) ratios, both of which are recognised prognostic information for systemic inflammation. There were no changes to the neutrophil-to-lymphocyte ratio (NLR) after cupping therapy intervention. In addition to systemic and haematological effects, cupping therapy has demonstrated meaningful impacts on flexibility and joint mobility in athletic populations. The study by Corrêa et al. 35 evaluated lower limb chain dry cupping in male football athletes and reported significant improvements in knee extension and ankle dorsiflexion after four sessions, although no changes were observed in hip flexion or pressure pain threshold. These results suggest that cupping therapy can enhance joint range of motion even in well-trained athletes, potentially facilitating dynamic movements, reducing muscular stiffness, and supporting injury prevention. Journal of Complementary Therapies in Health 2026: 4(1). 4 of 10 Alonso H.P., Manso R.M., Ribeiro M.S., de Freitas A.D. Nascimento I.S., Faria J.F. Integrating Traditional Chinese Medicine into Endurance Sports: A Narrative Review of Evidence and Applications. doi:10.5281/zenodo.17960420 When considered alongside other interventions, such as moving cupping therapy applied to the posterior lower limb 36, which also improved hip and knee range of motion without immediate increases in muscle power, these findings support the notion that cupping therapy primarily influences tissue extensibility and joint mobility rather than immediate contractile performance. Collectively, evidence from these studies highlights the utility of cupping therapy as an adjunct for enhancing functional flexibility and recovery in athletes, while suggesting that additional modalities may be needed to directly affect strength or pain modulation. 2.3. Moxibustion Moxibustion, a therapeutic technique used in TCM, shows some promise in the prevention and treatment of sports fatigue. Kimura et al. 15 reported full symptom resolution in water polo athletes following treatment with acupuncture and moxibustion on dorsal Shu points, as well as site-specific pain points. Gao et al. 37 examined molecular immune modulation provided by moxibustion stimulation on Guanyuan (CV4), Zusanli (ST36), and Sanyinjiao (SP6). In trained male runners, moxibustion was shown to modulate the balancing expression of the mRNA transcription factors T-bet (Th1) and GATA-3 (Th2), which indicated that moxibustion enhanced immune modulation compared to controls by favouring a contained Th1 immune response, while avoiding harmful Th2 rebound effects observed in controls. Li et al. 38 assessed the effects of moxibustion on table tennis athletes at acupoints Shenshu (BL23) and Guanyuan (CV4), reporting improved erythrocyte immune function, as indicated by enhanced RBC-C3b binding and diminished immune complex binding RBC-ICR, and evidenced a significant increase in T lymphocyte subsets (CD3, CD4) respect to control in the same group; hence, it was concluded moxibustion has an enhancing effect on both innate and adaptive immune responses in athletes undergoing a regime of intensified exercise training. Studies indicate that moxibustion on specific acupoints significantly increases serum testosterone levels in male athletes after intensive training, compared to control groups who do not receive moxibustion. High-load exercise can cause a decline in blood testosterone, and moxibustion appears to counteract this effect.39-41. Lastly, the effects of moxibustion on recovery from muscle fatigue showed that indirect moxibustion at the LR9 (Yinpo) led to a significant enhancement in the median frequency recovery of electromyographic wave patterns, and also normalised peak torque in the isokinetic knee fatigue study, showing improved recovery of muscle performance after forced exercise interruptions 42. Finally, Tang et al. 43 compared an acupuncture–moxibustion intervention with conventional physiotherapy in athletes with lateral collateral ligament injury of the ankle. After eight weeks of treatment, the acupuncture–moxibustion group demonstrated significantly greater improvements in ankle proprioceptive function, as evidenced by reduced joint repositioning error, compared with the physiotherapy group, indicating a beneficial effect on sensorimotor recovery following ligamentous injury. In summary, these studies confirm that moxibustion provides multi-faceted benefits to athletes in the context of performance and recovery by modulating the immune system, hormonal system, muscle fatigue recovery, and proprioception indicating the potential of moxibustion as a valuable adjunct therapy for athlete care and rehabilitation. 2.4. Auricular Acupuncture and AVNS Auricular acupuncture (AA) takes advantage of the somatotopic mapping of the ear to different body regions and has experimentally been studied as a treatment to enhance recovery and performance in athletes. Lin et al. 44 conducted a randomised controlled study with 24 male basketball athletes assigned to either an auricular acupuncture group (AAG) or a normal control group (NCG). The AAG received magnetic pellets applied to auricular points including Shenmen (vertical), heart, lung, liver, triple warmer, subcortex, Journal of Complementary Therapies in Health 2026: 4(1). 5 of 10 Alonso H.P., Manso R.M., Ribeiro M.S., de Freitas A.D. Nascimento I.S., Faria J.F. Integrating Traditional Chinese Medicine into Endurance Sports: A Narrative Review of Evidence and Applications. doi:10.5281/zenodo.17960420 and pituitary. Following exhaustive cycling exercise, the AAG exhibited significantly lower maximal heart rate (HRmax) and blood lactate levels at 30 and 60 minutes postexercise compared with the NCG, indicating accelerated cardiovascular and metabolic recovery. Peak oxygen consumption (VO₂max) was also significantly lower in the AAG at 30 minutes post-exercise, suggesting improved efficiency of oxygen utilisation during recovery. No significant differences were observed at 5 minutes post-exercise, indicating that the effects of auricular acupuncture became evident during later stages of post-exercise recovery. Auricular vagal nerve stimulation (AVNS) alters the balance of the autonomic nervous system by stimulating the auricular branch of the vagus nerve. Caliota et al. 45 conducted an open‑label randomised controlled trial to assess the acute effects of a single session of noninvasive auricular vagus nerve stimulation (AVNS) compared with sham stimulation in elite athletes. After AVNS, within‑group measures showed significant reductions in heart rate and improved lower limb balance as assessed by the modified Star Excursion Balance Test, but between‑group comparisons for quadriceps isometric strength and grip strength did not achieve statistical significance. These findings suggest that while a single AVNS session may acutely influence autonomic and balance parameters, it does not produce significant acute effects on key muscular performance metrics relative to sham stimulation. Overall, AA and AVNS have the potential to improve autonomic recovery, reduce indices of fatigue, and improve neuromuscular coordination to emphasise the advantages of non-invasive neural enhancement therapies when combined into sports recovery strategies. 2.5. Qigong TCM adopts a comprehensive method towards enhancing the performance of endurance athletes and their recovery from strenuous exercise with a focus on moving vital energy in a balanced system. One of the treatment approaches TCM provides is Qigong, which incorporates mind-body practice combining slow movement patterns, attentive breathing, meditation-focused thought, and relaxation for the purpose of optimum physical and emotional health 46-48. Research by Johansson et al. 49 has demonstrated that a single session of Qigong exercise can produce immediate psychological benefits, including enhanced positive mood and reduced state anxiety, with similar effects observed for both 30‑minute and 60‑minute practice durations. These findings suggest that even brief Qigong sessions may confer emotional benefits, which is particularly relevant for endurance athletes who experience prolonged physical stress and may derive support in developing psychological resilience. In addition to psychological health, Qigong has been shown to provide a clinical value in many areas which are particularly relevant to endurance athletes, such as blood pressure, glycaemic regulation, chronic musculoskeletal pain and cardiac benefits 47,50. A systematic review by Oh et al. 51 evaluated the effects of Tai Chi and Qigong on immune function and inflammatory biomarkers, reporting that these practices were associated with modest increases in overall immune cell levels compared with control conditions. Although pooled analyses did not demonstrate statistically significant changes in systemic pro‑inflammatory cytokines or natural killer cell activity, trends in several markers suggest potential immunoregulatory effects. Such immunomodulatory responses may be relevant to endurance athletes, for whom training‑related inflammatory processes are linked to prolonged physiological stress. A systematic review and meta‑analysis by Larkey et al. 52 evaluated randomised controlled trials of Tai Chi and Qigong and reported that, compared with inactive control conditions, regular practice of these meditative movement modalities was associated with a small‑to‑medium reduction in body mass index, reflecting potential benefits for body composition. Such effects may have relevance for endurance athletes, as reduced BMI and Journal of Complementary Therapies in Health 2026: 4(1). 6 of 10 Alonso H.P., Manso R.M., Ribeiro M.S., de Freitas A.D. Nascimento I.S., Faria J.F. Integrating Traditional Chinese Medicine into Endurance Sports: A Narrative Review of Evidence and Applications. doi:10.5281/zenodo.17960420 improved body composition are associated with enhanced endurance capacity and lower injury risk. Together, these aspects highlight the importance of utilising Qigong as an approach in TCM-based practice to enhance endurance sports performance, with respect to both physiological and psychological strategies, in one model of performance. The holistic benefits of Qigong are also in accordance with beliefs espoused in TCM theory, which suggest the movement, practice, and incorporation of Qigong expands the scopes of balance and energy work, allowing for greater safety, accessibility, and multiple options, to effectively help an individual's performance in endurance sports while promoting health in any model. 2.6. Tuina Tuina, a traditional Chinese manual therapy, has been investigated for its effects on sports‑related musculoskeletal conditions and rehabilitation outcomes. A randomised controlled clinical study by Su et al. 53 involving 93 patients with grade I–II meniscal injury found that Tuina, functional training, and their combination all produced significant improvements in clinical symptoms and balance measures after an 8‑week intervention period. The combination of Tuina plus functional training demonstrated greater improvement in overall Knee Injury and Osteoarthritis Outcome Score (KOOS), as well as enhanced daily living and sports/recreation subscale scores versus functional training alone. However, no statistically significant between‑group differences in balance performance (Y‑Balance Test) were observed at study conclusion. Preliminary evidence suggests that Tuina may enhance tissue microcirculation and support neuromuscular function, which has been proposed to mitigate muscle atrophy following peripheral nerve injury and to contribute to recovery processes in various soft‑tissue conditions; however, high‑quality mechanistic studies in sports populations are limited. In the context of lumbar disc herniation, multicentre randomised evidence has recently begun to emerge. A large clinical trial reported that Tuina combined with traditional Chinese exercises (TCEs) produced superior improvements in disability, pain, quality of life, and gait parameters compared with TCEs alone through 24 weeks of follow‑up, indicating potential utility as an adjunctive rehabilitation modality for symptomatic LDH 54. Several other LDH–related trials and protocols are currently underway, including assessor‑blinded multicentre RCTs designed to further evaluate Tuina plus exercise versus exercise alone for functional disability and pain, which will add rigorous evidence once published 55. For knee osteoarthritis, a recent randomised trial comparing Tuina therapy with manual physical therapy found that Tuina produced similar benefits in joint pain and function, with some outcomes favouring Tuina at intermediate follow‑up time points, though the overall pattern was of comparable clinical effectiveness between treatments 56. Overall, existing clinical evidence indicates that Tuina, whether used alone or in combination with exercise or adjunct modalities, can improve symptoms and functional outcomes in musculoskeletal conditions relevant to sports rehabilitation. However, further high‑quality randomised controlled trials are needed to standardise intervention protocols, determine dose–response relationships, and elucidate underlying physiological mechanisms. 3. Conclusion TCM provides a valuable complementary toolkit that addresses the complex demands faced by endurance athletes, to support a balanced, resilient, and optimised performance and health state. This integration into the field of sports medicine affords opportunity to decrease dependence on pharmaceutical support within the therapeutic practices, while also enhancing the whole health and performance of the athlete at a sustained Journal of Complementary Therapies in Health 2026: 4(1). 7 of 10 Alonso H.P., Manso R.M., Ribeiro M.S., de Freitas A.D. Nascimento I.S., Faria J.F. Integrating Traditional Chinese Medicine into Endurance Sports: A Narrative Review of Evidence and Applications. doi:10.5281/zenodo.17960420 high level of functioning. 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