Effects of Complementary and Integrated Therapies on Performance and Recovery in Mountain Ultra-Endurance Running: A Case Study.

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.17721261 institutoptc.com/journal-complementary-therapies Clinical case study Effects of Complementary and Integrated Therapies on Performance and Recovery in Mountain Ultra-Endurance Running: A Case Study. 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 Mountain ultra-endurance running represents one of the most physiologically demanding sports, combining biomechanical stress, cardiorespiratory demands, metabolic strain, and psychological resilience. This study provides a comprehensive case analysis of a 44-year-old male athlete specialising in races exceeding 100 km, with a competitive history including distances up to 308 km. The investigation integrates Western physiological insights with Traditional Chinese Medicine (TCM) diagnostic frameworks and therapeutic approaches. Biomechanical and physiological mechanisms underlying performance and injury risk are described, followed by a longitudinal clinical assessment of recurrent musculoskeletal complaints, systemic imbalances, and therapeutic interventions. Treatments included acupuncture, auriculotherapy, moxibustion, manual therapy, and Chinese herbal medicine, combined with modern supplementation strategies. Results suggest that integration of TCM-based interventions with conventional physiological understanding may support endurance athletes in injury prevention, recovery, and performance stability. Keywords: Biomechanics; Endurance Physiology; Trail Running; Traditional Chinese Medicine; Acupuncture; Moxibustion; Ultra-Marathon; Sports Injuries. 1. Introduction Trail running, as an organised sport, has its origins in informal competitions along natural routes, with historical references dating back to the late 19th century and gaining its modern form in the 20th century through emblematic races such as the Dipsea Race in the USA and similar initiatives in Europe and Asia. The field evolved rapidly from short trail and hill challenges to the ultra-endurance events seen today, marked by distances well beyond the marathon, significant elevation change, technical terrain, and exposure to variable environmental conditions 1-3. Ultra-endurance trail events differ fundamentally from road running and standard marathons due to the multidimensional physiological, mechanical, and psychological demands involved. Athletes must contend with uneven surfaces, steep ascents and descents, extreme weather, sleep deprivation, and prolonged periods of muscular and metabolic stress. This leads to multi-systemic responses, potentially affecting the cardiovascular, renal, musculoskeletal, immunological, and nervous systems in ways not observed in conventional endurance events 4-6. Despite the growing popularity of trail running, there remains uncertainty regarding the physiological responses elicited by different uphill locomotion strategies, particularly when contrasting running and walking on steep inclines. Key factors such as maximal oxygen uptake (VO2max), running economy (Cr, defined as the energy cost of running, Citation: Alonso H.P., Manso R.M., Ribeiro M.S., de Freitas A.D. Nascimento I.S., Faria J.F. Effects of Complementary and Integrated Therapies on Performance and Recovery in Mountain Ultra-Endurance Running: A Case Study. Journal of Complementary Therapies in Health. 2026;4(1) 10.5281/zenodo.17721261 Academic Editor: Jorge Rodrigues Received: 7 November 2025 Reviewed: 20 November 2025 Revised: 24 November 2025 Accepted: 25 November 2025 Published: 26 November 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 9 Alonso H.P., Manso R.M., Ribeiro M.S., de Freitas A.D. Nascimento I.S., Faria J.F. Effects of Complementary and Integrated Therapies on Performance and Recovery in Mountain Ultra-Endurance Running: A Case Study. doi:10.5281/zenodo.17721261 or the amount of energy required to transport the body a given distance), and the proportion of VO2 sustained throughout the race have demonstrated considerable variability across studies, often due to differences in testing protocols and athlete populations 7. Additionally, important biomechanical and metabolic determinants, including muscle strength, architecture, fibre recruitment patterns, and terrain characteristics, influence the energetic cost of running uphill. The interplay between individual athlete characteristics and the topographical profile of each race further complicates the prediction of performance and fatigue. Given these complexities, comparative studies conducted in realistic trail running conditions remain scarce. Despite the surging popularity and participation in ultra-trail events, the energetic demands and physiological responses experienced by athletes in these extreme contexts remain inadequately characterised, particularly in real-world racing conditions. The complexity of continuously measuring metabolic and cardiopulmonary parameters over several consecutive days has contributed to a paucity of field-based research. Consequently, much of current understanding is derived from laboratory studies or short-duration outdoor experiments, limiting ecological validity. Recently, case studies 6,7 conducted in actual events have begun to shed light on the metabolic cost, efficiency of locomotion, and adaptive strategies athletes employ during mountain ultra-marathons. Preliminary findings suggest that, contrary to expectations, welladapted athletes may sustain exercise intensities and mechanical efficiency even as fatigue accumulates, potentially through progressive locomotor adaptations over the course of the race. However, the interplay between environmental challenges, race strategies, and physiological adaptations deserves further investigation to inform training, preparation, and recovery protocols for trail endurance athletes. Therapeutic interventions for ultra-endurance trail runners have traditionally centred on conventional sports medicine, focusing on acute injury management (e.g., musculoskeletal injuries), hydration strategies, nutritional protocols, and physiotherapy. Therapies such as cryotherapy, non-steroidal anti-inflammatory drugs, and physical therapy remain predominant among these athletes, with studies indicating more than 90% of ultra-endurance runners use such conventional treatments regularly. However, despite the widespread adoption of these conventional methods, challenges remain in prevention, recovery, and management of chronic fatigue, overtraining, and subtle metabolic-immune imbalances 5,6,8. TCM is increasingly considered a complementary or alternative therapeutic modality for endurance athletes. Clinical and experimental evidence highlights TCM’s holistic framework, incorporating herbal therapy, acupuncture, tuina massage, and dietary modifications, as supporting energy balance (Qi), accelerating recovery, and addressing not only acute musculoskeletal complaints but also underlying systemic fatigue and immune modulation. However, surveys and recent systematic reviews suggest that, globally, less than 10% of ultra-endurance athletes consistently incorporate TCM interventions compared to conventional treatments 9-13. Within TCM, the meridians and organs most often affected by ultra-endurance trail running include the Spleen and Stomach (responsible for nourishment and energy transformation), Liver (governing tendons and smooth flow of Qi), Kidney (basis of endurance and bone strength), and Heart (regulating circulation and mental resilience). Excessive physical exertion, environmental exposure, and inadequate recovery are believed to deplete Spleen Qi, injure Kidney Jing, stagnate Liver Qi, and disturb Heart Shen, resulting in chronic fatigue, muscle/tendon injuries, oedema, suboptimal recovery, and psychological imbalance. TCM’s targeted interventions, especially when mapped to these meridians and organ systems, may offer distinct benefits: improving nutritional assimilation, promoting musculoskeletal resilience, enhancing immune recovery, and facilitating psychological adaptation to the rigors of ultra-endurance sports. These advantages justify further integration and rigorous comparative study of TCM within sports medicine for this unique population 11-13. Journal of Complementary Therapies in Health 2026: 4(1). 3 of 9 Alonso H.P., Manso R.M., Ribeiro M.S., de Freitas A.D. Nascimento I.S., Faria J.F. Effects of Complementary and Integrated Therapies on Performance and Recovery in Mountain Ultra-Endurance Running: A Case Study. doi:10.5281/zenodo.17721261 2. Case presentation This case study details the therapeutic management of an ultra-endurance athlete who sustained two significant musculoskeletal injuries during multi-stage ultra-distance events in 2023 and 2024. The case illustrates the integration of acupuncture, moxibustion, cupping therapy, manual therapies, and phytotherapy guided by the principles of TCM to facilitate recovery and performance maintenance. The subject is a male trail runner affiliated with EDV Viana Trail Club from Portugal, renowned for participation and success in national and international trail endurance competitions. His body weight is within the normative range for high-performance endurance athletes, and he regularly competes at distances requiring significant aerobic and musculoskeletal adaptation. Given the extreme demands and endurance-specific hazards of the scheduled ultratrail events, the clinical and sports intervention team opted for a comprehensive, longitudinal monitoring approach. The aim was early detection and management of potential musculoskeletal, metabolic, or systemic physiological deteriorations that may occur over high cumulative training and competitive loads. It should be noted that the athlete is an amateur who works in an environment with climate control set to cold temperatures. A notable factor in this case is the athlete's occupational exposure to a cold working environment. This chronic exposure to cold temperatures is recognised as a primary contributing factor to the development of Internal Cold and Yang Deficiency syndrome. Such environmental stress leads to impairment of Yang energy, resulting in symptoms including cold intolerance, reduced metabolic function, and compromised circulation. This syndrome heavily influenced the subsequent treatment protocols, with warming therapies such as moxibustion and the use of warming herbal formulas being central to the therapeutic strategy. Over the course of several weeks the athlete underwent regular clinical evaluations and performance monitoring. These included musculoskeletal examinations, nutritional assessments, physiological and biochemical testing, and continuous feedback during preparatory and competitive phases. The intervention team’s objective was to safeguard the athlete’s physical integrity, optimise performance, and scientifically document adaptive or pathological changes in the context of repeated high-load exposures. As a non-professional elite-level competitor, the athlete demonstrated meticulous preparation and commitment to peak performance, seeking to represent his club at the highest standard. The clinical oversight allowed prompt identification of fatigue, injury, or maladaptive responses, supporting targeted interventions and personalised therapeutic strategies throughout the period of observation. A dedicated follow-up team was established to provide monitoring and intervention throughout the observation period, particularly in anticipation of musculoskeletal injury or physiological decline. This multidisciplinary team was tasked with real-time assessment of the athlete’s physiological and musculoskeletal condition, enabling therapeutic interventions as required. The need for targeted therapeutic intervention arose on multiple occasions during the monitored races, as well as in the recovery phases between competitions. Acute and subacute therapies were employed in response to emerging symptoms, including musculoskeletal discomfort, functional decline, or general fatigue. Therapeutic strategies included a combination of acupuncture sessions, with the selection and combination of acupuncture points tailored according to the athlete’s clinical presentation at each intervention. The set of acupuncture points used varied case by case, depending on ongoing physical findings, energetic assessment, or specific complaints. Additional supplemental therapies were incorporated as indicated, most notably, vitamin D supplementation and other micronutrients were prescribed as needed, according to biochemical screening and fatigue status. Other therapeutic interventions, such as manual therapy, trigger point release, physiotherapy modalities, and nutritional adjustments, were utilised based on the prevailing Journal of Complementary Therapies in Health 2026: 4(1). 4 of 9 Alonso H.P., Manso R.M., Ribeiro M.S., de Freitas A.D. Nascimento I.S., Faria J.F. Effects of Complementary and Integrated Therapies on Performance and Recovery in Mountain Ultra-Endurance Running: A Case Study. doi:10.5281/zenodo.17721261 clinical scenario and individual response. This dynamic and adaptive approach aimed to optimise recovery, minimise injury risk, and promote overall functional resilience throughout the period of intense physical demand. Pain assessment was systematically performed using the Numerical Rating Scale (NRS) for pain, as recommended by the Portuguese Directorate-General of Health (DGS) 14. This validated tool allowed quantitative documentation of pain intensity at each assessment point, facilitating objective monitoring and individualised adjustments to the therapeutic strategy. The perception of fatigue was assessed using the Rating of Fatigue (ROF) scale, a validated tool for quantifying subjective fatigue intensity in athletic populations 15. The NRS and the ROF are validated patient-reported outcome measures that use an 11point numeric scale ranging from 0 to 10. For both scales, 0 represents the absence of NRS for pain or ROF, while 10 indicates the worst imaginable pain or fatigue. These scales provide a simple, reliable means to quantify symptom intensity, facilitating clinical assessment and monitoring of treatment efficacy. 2.1. First Injury and Initial Presentation In September 2023, following a 100 km race, the athlete reported pain localised on the anterior aspect of the left leg along the femoral nerve path, more specifically corresponding to the saphenous nerve. Palpation revealed altered muscle tone without incapacitating features, allowing continued training despite discomfort. At the conclusion of the race, pain corresponded anatomically to the liver meridian between points F5 and F6. Clinical pulse and tongue signs indicate liver Qi stagnation and damp heat. 2.2. Second Injury and Progression In December 2023, during a 308 km race (ALUTAlgarviana Ultra Trail), the athlete developed digestive complaints, oedema and pain in the right calf, secondary to a compensatory protective posture. Post 15-day rest, muscular pain in the right leg persisted with symptoms reflective with palpatory tenderness along the Kidney, Bladder, and Liver meridians. 2.3. Acute Heat Stroke The athlete experienced a heat stroke during the race, which occurred on a 281 km trail event called PT 281. During an intensely hot period, he went for approximately three hours without access to fluid replacement on a section of the trail where autonomous hydration was the athlete's responsibility. This prolonged lack of hydration under extreme heat conditions led to the onset of heat-related illness. Heat stroke, an imbalance characterised by excessive internal heat and Yin-Qi deficiency compromising thermoregulation. 3. Therapeutic Interventions and results 3.1. 1st injury - September 2023 Table 1. Acupuncture points and meridians used in the treatment sessions, as well as the treatment procedure Treatment Session Point/Meridian Selection Procedure Target Meridian-Based Rationale NRS Before NRS After 2 weekly sessions GB34, ST40, SP9, ST34, LR2, LR3, LR5 (unilateral) Tendon influence, oedema, Qi circulation, liver fire dispersion GB34 (“Master point of tendons”) targets pain/stiffness in lower limb tendons; LR2/LR3 disperse Liver Qi/fire and treat tension near the saphenous nerve; ST40 clears dampness/oedema; SP9 supports lower limb fluid/oedema; ST34 Xi-cleft) acts on acute pain and mobility; LR5 connects meridian influence at the level of the injury. 8 2 Journal of Complementary Therapies in Health 2026: 4(1). 5 of 9 Alonso H.P., Manso R.M., Ribeiro M.S., de Freitas A.D. Nascimento I.S., Faria J.F. Effects of Complementary and Integrated Therapies on Performance and Recovery in Mountain Ultra-Endurance Running: A Case Study. doi:10.5281/zenodo.17721261 The athlete reported partial pain relief but did not adhere to rest recommendations, continuing intensive training. 3.2. 2nd injury - December 2023 Table 2. Points and meridians used in the treatment sessions, as well as the treatment procedure Timing & Session Point/Meridian Selection (or Auriculotherapy Region) Procedure Target Meridian/Ear Point Rationale NRS Before NRS After During race (acute phase) Auriculotherapy: calf, stomach, liver, spleen, shenmen To relieve pain and digestive complaints Auricular points mapped to lower limb (calf), digestion (stomach, spleen), Liver for muscle-tendon regulation, shenmen to modulate pain and emotional/physiological stress; engages vagus and cranial nerves for systemic pain/digestive modulation in acute demand. 9 8 During race (acute phase) Lymphatic drainage massage Reduce oedema and clear lactic acid Method enhances peripheral circulation, mobilises tissue fluid, and improves recovery in acute musculoskeletal overload scenarios. — — 4 sessions weekly, 15 days postrace LI4, LR3, GB30, SP6, ST36, GB34 (bilateral use) Muscular recovery, pain, overall Qi /blood support LI4 (disperses Qi stagnation), LR3 (Liver Qi movement), GB34 (tendon/muscle pain), ST36 & SP6 (digestive & stamina), GB30 (deep gluteal, sciatica relief). Rationale: synergy for pain, recovery, and resolving both local and systemic stasis after endurance injury. 7 0 The pain was resolved fully after multiple sessions. 3.3. Follow-up: February 2024-May 2024 Table 3. Points and meridians used in the treatment sessions, as well as the treatment procedure. Timing & Sessions Point/Meridian Selection Procedure Target Meridian-Based Rationale ROF Before ROF After 16 weekly sessions (general support) BL62, SP3, GB34, KI3, LR8, LR3, ST36, SI3 (bilateral) Nourish Qi, blood, Yang; support stomach, spleen, kidney, liver BL62 and SI3 harmonise Du pathway (Yang Qiao/Wei); GB34, LR3, LR8 support Liver-blood and muscle recovery; ST36 and SP3 strengthen Spleen, Ki3 nurtures kidney essence and Yang. Synergistic protocol for restoring energy and organ function post-endurance stress. 6 3 3.4. Treatment after acute Heat Stroke – July 2024 – August 2024 Table 4. Points and meridians used in the treatment sessions, as well as the treatment procedure. Schedule Point/Meridian Selection Procedure Target Meridian-Based Rationale NRS/ROF Before NRS/ROF After 3 sessions weekly GV20, KI6, CV6, LI11 Heat exhaustion cooling, Yin support, and Qi regulation GV20 (Baihui) stimulates brain and clears Yang heat; KI6 nourishes Kidney Yin and moistens dryness postheat; CV6 (Qihai) boosts Yuan Qi and circulation; LI11 (Quchi) is a strong heat-clearing point, reduces fever and inflammation by releasing excess heat from the body. — — Subsequent tongue changes reflected increased moisture, evidencing therapeutic effect. Journal of Complementary Therapies in Health 2026: 4(1). 6 of 9 Alonso H.P., Manso R.M., Ribeiro M.S., de Freitas A.D. Nascimento I.S., Faria J.F. Effects of Complementary and Integrated Therapies on Performance and Recovery in Mountain Ultra-Endurance Running: A Case Study. doi:10.5281/zenodo.17721261 3.5. Recovery and Maintenance: September-December 2024 Table 5. Points and meridians used in the treatment sessions, as well as the treatment procedure. Timing & Sessions Point/Meridian Selection Procedure Target Meridian-Based Rationale ROF Before ROF After 16 weekly sessions CV4, CV6, CV12, ST36, SP6, KI3 + moxibustion Strengthen spleen and kidney function Points CV4, CV6, and CV12 support Ren Mai (Conception Vessel) for central Qi and Yin-Yang balance; CV12 aids upper digestion and spleen ST36 and SP6 enhance digestion, Qi and blood production; KI3 supports Kidney essence and Yang; Moxa adds warming and Yang reinforcement. 9 0 Post heat stroke, the athlete undertook multiple races ranging from 49 km to 300 km with intermittent digestive complaints and fatigue. Treatment focused on strengthening spleen (BP) and kidney (KI) function using acupuncture points CV4, CV6, CV12, ST36, SP6, and KI3, complemented by moxibustion and phytotherapy. Throughout the treatment period, the athlete reported progressive improvements in perceived fatigue and exhaustion levels. Given the athlete's daily exposure to cold environments, treatment emphasised expelling internal cold, supporting Qi and Yang of spleen and kidney, primarily via acupuncture with moxibustion Points included KI3, SP6, ST36, CV4, and CV6. Phytotherapeutic intervention included a formula known as Qi Hai Yao Fang (Sea of Qi), a modern traditional Chinese medicine formulation designed to supplement and invigorate the Qi and Yang of the spleen and kidney, support digestive and metabolic functions, and address chronic deficiency syndromes, combined with Ashwagandha. In this period, the athlete completed multiple races without injury, reporting improved energy and physical conditioning post-treatment. 4. Laboratory Findings and Supplementation Serum analysis in March 2024, revealed vitamin D deficiency, elevated cortisol, and normal but low-end testosterone levels for an athlete. Supplementation with Chinese phytotherapy (Qi Hai Yao Fang), Ashwagandha (for cortisol modulation), vitamins (D, K2), marine minerals, zinc, EPA, and DHA were initiated to address biochemical imbalances. Table 6. Integrative mapping between Western physiological findings and corresponding TCM syndromes. Western Medical Finding TCM Syndrome TCM Syndrome Interpretation Elevated cortisol, chronic fatigue Kidney Jing/ Yin Deficiency Loss of deep vital energy and regulatory essence; manifests as exhaustion, poor recovery, hormonal dysregulation. Low testosterone Kidney Yang Deficiency Impaired warming and activating energy; causes cold intolerance, low vitality, and poor hormonal output. Vitamin D deficiency, cold exposure Spleen/Kidney Yang Deficiency Weak transforming and activating force; results in metabolic slowing, susceptibility to cold, low resilience. Poor digestion, persistent fatigue, lab abnormalities (spleen, kidney) Spleen Qi Deficiency, Kidney Qi Deficiency Deficient energy for nutrient assimilation and reserve replenishment; manifests as fatigue, weakness, impaired recovery. Oedema, musculoskeletal complaints post-exertion Qi stagnation, Liver Qi disharmony Blockage in energy movement and regulation; causes swelling, muscle pain, emotional irritability. 5. Final remarks Ultra-endurance trail running ranks among the most physiologically demanding athletic endeavours, demanding sustained cardiovascular, metabolic, musculoskeletal, and psychological adaptations under extreme and variable environmental conditions. The Journal of Complementary Therapies in Health 2026: 4(1). 7 of 9 Alonso H.P., Manso R.M., Ribeiro M.S., de Freitas A.D. Nascimento I.S., Faria J.F. Effects of Complementary and Integrated Therapies on Performance and Recovery in Mountain Ultra-Endurance Running: A Case Study. doi:10.5281/zenodo.17721261 present case illustrates these challenges, emphasising the cascading impacts of intense prolonged exertion compounded by environmental factors such as heat stress, dehydration, and terrain complexity. As these unique stressors precipitate multi-system perturbations encompassing energy metabolism, endocrine regulation, immune function, and neuromuscular integrity, standard sports medicine approaches targeting isolated clinical manifestations often fail to adequately address the complex, interdependent dysfunctions evident in ultra-endurance athletes. Consistent with the introduction, the multifactorial nature of fatigue, systemic inflammatory activation, and musculoskeletal overload in ultra-trail performance necessitates multimodal assessment and individualised intervention. Conventional injury management and nutritional support (while foundational) leave a gap in addressing chronic fatigue syndromes, subclinical immune dysregulation, and autonomic imbalances frequently emerging during ultra-endurance competition cycles. Moreover, this case supports emerging evidence for the complementary use of TCM techniques, which offer holistic frameworks integrating organ system energetics with symptom amelioration. Notably, acupuncture and moxibustion interventions targeting the Spleen, Kidney, Liver, and Stomach meridians address fundamental TCM pathogeneses consistent with Western markers identified in the athlete, such as vitamin D deficiency and cortisol excess. These therapies potentially restore Qi and Yang, enhance microcirculation, alleviate inflammation and oedema, and support psychological resilience, domains which are aligned with the pathophysiology of overtraining syndrome and chronic fatigue states. The patient’s progressive subjective fatigue reduction as quantified by ROF scores and functional recovery verifies the physiological and psychophysical value of integrating TCM with standard protocols. The addition of phytotherapeutic agents, including Ashwagandha for cortisol modulation, and tonic warming formula, Qi Hai Yao Fang can potentiate metabolic homeostasis and endocrine normalisation, underscoring the necessity of tailored nutritional supplementation in comprehensive ultra-endurance athlete care. The combined biochemical improvements and clinical amelioration observed advocate for early, preventive screening and intervention strategies encompassing nutrient status and hormonal balance. This case further delineates a prospective protocol emphasising continuous, multidimensional monitoring including precise ROF, detailed musculoskeletal evaluation, biochemical screening, and dynamic therapeutic adjustment. Such a protocol enables preemptive mitigation of overtraining risks, supports sustained athletic performance, and may extend athletic longevity. Future randomised controlled trials should explore integrative approaches combining TCM and evidence-based conventional medicine, specifically characterising mechanistic pathways, dose-response relationships, and long-term outcomes. Additionally, sport-specific adaptations of TCM diagnostic frameworks and treatment regimens merit refinement to optimise efficacy and athlete acceptance. Given the rising popularity and competitive intensity of ultra-endurance trail running, this integrative care model could become a pivotal anchor in athlete health management, reducing injury burdens, improving recovery trajectories, and enhancing performance through multidimensional synergy. To the best of our knowledge, there are no other studies regarding the use of TCM on performance and recovery in mountain ultra-endurance running. 6. Conclusion This case study highlights the complex physiological demands and multisystem challenges faced by ultra-endurance trail runners, especially under extreme environmental conditions such as heat stress and prolonged exertion. The integrative therapeutic approach, combining conventional sports medicine practices with TCM, including acupuncture, moxibustion, and phytotherapy, demonstrated promising outcomes in managing musculoskeletal injuries, fatigue, and systemic imbalances. Journal of Complementary Therapies in Health 2026: 4(1). 8 of 9 Alonso H.P., Manso R.M., Ribeiro M.S., de Freitas A.D. Nascimento I.S., Faria J.F. Effects of Complementary and Integrated Therapies on Performance and Recovery in Mountain Ultra-Endurance Running: A Case Study. doi:10.5281/zenodo.17721261 The targeted modulation of key meridians and organ systems facilitated symptom relief, improved functional capacity, and enhanced subjective fatigue perception. Supplementation with phytochemicals and micronutrients addressing identified biochemical deficiencies complemented the treatment spectrum. This holistic protocol underscores the potential benefits of integrating Eastern and Western therapeutic frameworks to optimise athlete recovery, minimise injury risk, and sustain high-level performance in ultra-endurance trail events. Nevertheless, further rigorous, controlled investigations are warranted to validate these findings and refine standardised integrative protocols tailored to the unique needs of ultra-endurance athletes. Effective multidisciplinary management combining objective monitoring and personalised interventions represents a vital evolution in the care of athletes undertaking the physiological extremities of ultra-endurance trail running. Credit author statement: All authors contributed equally and have read and agreed to the published version of the manuscript. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of Interest: The authors declare that there are no conflicts of interest. Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. Data Availability Statement: The original contributions presented in this study are included in the article. Further inquiries can be directed to the corresponding author. References 1. Trailrunners.run. History of Trail Running 2022 [Available from: https://trailrunners.run/history]. 2. The Running Mate. The History of Modern Trail Running 2017 [Available from: https://www.therunningmate.run/historymodern-trail-running]. 3. Marathon Coach. History of ultra-trail running [Available from: https://marathon-coach.online/history-of-ultra-trail-running]. 4. Scheer V, Tiller NB, Doutreleau S, Khodaee M, Knechtle B, Pasternak A, et al. 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