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BY

THE JOURNAL

OF

BONE

AND JOINT

SURGERY, INCORPORATED

Peroneal Nerve Palsy Following

Acupuncture Treatment
A CASE REPORT
BY MASAKI SATO, MD, HIROMU KATSUMOTO, MD, KOUI KAWAMURA, MD,
HIROSHI SUGIYAMA, MD, AND TSUTOMU TAKAHASHI, MD
Investigation performed at the Department of Orthopaedic Surgery, Asahi General Hospital, Asahi-City, Chiba, Japan

cupuncture is an increasingly popular treatment method

used to relieve pain. Adverse events related to acupuncture have been reported1-3 rarely. The purpose of this
report is to describe what we believe to be the first case of peroneal nerve palsy caused by penetration and breakage of an
acupuncture needle. Our patient was informed that data concerning the case would be submitted for publication.
Case Report
sixty-two-year-old woman was admitted to our hospital
with a left dropfoot and anterior pain and numbness in
the left leg. There was no history of spinal disorder or diabetes mellitus. Initially, the patient had a spontaneous onset of
acute posterior pain in the left leg. Her general practitioner
diagnosed sciatica and prescribed bed rest. One week later,
because of persistent symptoms, she received the first of a series of acupuncture treatments, and the pain decreased after
several treatments. During the sixth treatment, she felt a sudden radiating pain in the anterior part of the left leg when the
acupuncture needle was inserted. A burning sensation and
numbness in the anterior part of the left leg occurred immediately after this treatment. When the patient was stepping
out of the bathtub on the following night, she noticed a left
dropfoot for the first time, and she experienced difficulty
with walking. The pain, burning sensation, numbness, and
weakness in the left leg persisted. After receiving additional
acupuncture treatments, she consulted a neurologist, who diagnosed an L5 radiculopathy and referred her to the orthopaedic department.
On physical examination in our department, sensation
was diminished on the dorsum and lateral side of the left
great toe and on the dorsal aspect of the web space between
the great and second toes but was otherwise normal. The
strength of the tibialis anterior and extensor hallucis longus
muscles was graded 1 of 5, but the strength of the peroneus
longus and flexor hallucis longus muscles was graded 5 of 5.
The Tinel sign was positive just posterior to the fibular head.
A small brown discoloration was noted in this area, which, according to the patient, was where an acupuncture needle had
been inserted. Radiographs showed a metallic needle-like object, approximately 1 cm in length, lying near the fibular head

(Fig. 1), and magnetic resonance imaging demonstrated metallic artifact in the same area. Examination of the lumbosacral spine revealed normal findings. Compound muscle action
potentials of the peroneal nerve in the left leg showed a remarkable decrease in amplitude distal to the level of the fibular head (Fig. 2).
Surgery was performed two weeks after the presumed

Fig. 1

Lateral radiograph showing a fractured acupuncture needle (arrow)

near the fibular head.


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P E RO N E A L N E R VE P A L S Y F O L L OW I N G
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peroneal nerve was identified and was traced distally. No foreign body was visible at first, but something firm could be palpated within the nerve. On reflection of the nerve, a broken
needle was found just proximal to the point of division of the
deep and superficial peroneal nerves (Fig. 3). No scar tissue or
sign of infection was identified about the nerve. The needle
fragment, which was 12 mm in length and had penetrated the
nerve by approximately 5 mm, was removed without difficulty.
On the day after the surgery, sensation and strength remained
unchanged, but the pain and numbness had disappeared. The
patient was provided with a dorsiflexion assist ankle-foot
orthosis. Four months after the operation, the strength of the
tibialis anterior muscle was graded 4 of 5, and that of the extensor hallucis longus muscle was graded 2 of 5. The hyperesthesias remained unchanged. The gait had become normal, and
use of the orthosis was discontinued. Ten months after the operation, the tibialis anterior and extensor hallucis longus muscles had improved in strength and were graded 5 of 5 and 4 of
5, respectively, but the hyperesthesias remained unchanged.
Discussion
cupuncture points are cutaneous areas containing relatively high concentrations of free nerve endings, nerve
bundles, and nerve plexuses4, but no major peripheral nerves.
The acupuncture point most commonly used for sciatic pain
relief 5 is located at point 34 on the gallbladder meridian,
which is on the anterior side of the fibular head. The Japanese
call this point yoryosen (Fig. 4), and the World Health Organization defines it as Yanglingquan. We speculate that the
acupuncture needle was inserted incorrectly in our patient,
posterior to the fibular head and close to the peroneal nerve,
which is where the skin discoloration was found. The acu-

Fig. 2

Compound muscle action potentials of the left peroneal nerve, recorded from the extensor digitorum brevis, showed a remarkable decrease in amplitude. The sites of stimulation included the ankle (a) and
the region distal to the fibular head (b).

nerve injury. A skin incision was extended from the medial side
of the biceps tendon to the posterior aspect of the fibula. The

Fig. 3

Anatomical view. The base of the

fractured acupuncture needle is
held by the forceps. The tip of the
needle is penetrating the common
peroneal nerve. The distal aspect
of the wound is to the left in the
photograph.


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nally 40 mm in length. Even a disposable needle can break.

Acupuncture needles rarely break7, but they may damage a
spinal nerve root8,9 or a peripheral nerve10. We are aware of two
case reports of peripheral nerve injuries caused by acupuncture in the literature10,11, but peroneal nerve palsy caused by the
breakage of an acupuncture needle in the nerve has not been
previously described, to our knowledge. However, with the increasing use and growing popularity of acupuncture as a therapeutic intervention, the number of adverse events will likely
also increase.
Although the facts of our case do not allow us to state
whether nerve injury can result simply from penetration of the
acupuncture needle without breakage, our case does demonstrate that the breakage of even a fine acupuncture needle can
cause injury to a peripheral nerve. Compound muscle action
potentials of the peroneal nerve in our patient showed a remarkable decrease in amplitude, indicating probable axonopathy and wallerian degeneration of the nerve12, conditions that
require a lengthy recovery period. Clinicians should be aware of
the potential for this complication following acupuncture treatments. In addition, we believe that acupuncturists should always check used needles as they are removed from a patient to
be certain that the needle has been removed in its entirety.

Fig. 4

Location of yoryosen and the scar where the acupuncture needle

was inserted.

puncture needle penetrated the peroneal nerve and broke with

the tip remaining in the nerve. Although we do not know how
the needle actually broke, it may have been broken as a result
of muscular contraction due to sudden radiating pain during
treatment6.
Acupuncture needles are typically left in acupuncture
points such as yoryosen for ten minutes without manipulation. In our patient, the acupuncture needle was disposable,
made of stainless steel, and 0.16 mm in diameter and origi-

Masaki Sato, MD
Hiromu Katsumoto, MD
Koui Kawamura, MD
Hiroshi Sugiyama, MD
Tsutomu Takahashi, MD
Department of Orthopaedic Surgery, Asahi General Hospital, I-1326,
Asahi-City, Chiba 289-2511, Japan
The authors did not receive grants or outside funding in support of their
research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such
benefits from a commercial entity. No commercial entity paid or
directed, or agreed to pay or direct, any benefits to any research fund,
foundation, educational institution, or other charitable or nonprofit
organization with which the authors are affiliated or associated.

References
1. Ernst E, White A. Life-threatening adverse reactions after acupuncture?
A systematic review. Pain. 1997;71:123-6.

7. Umlauf R. Analysis of the main results of the activity of the acupuncture

department of faculty hospital. Acupunct Med. 1988;5:16-8.

2. Norheim AJ, Fonnebo V. Adverse effects of acupuncture. Lancet. 1995;

345:1576.

8. Isu T, Iwasaki Y, Sasaki H, Abe H. Spinal cord and root injuries due to glass
fragments and acupuncture needles. Surg Neurol. 1985;23:255-60.

3. Vickers A, Zollman C. ABC of complementary medicine. Acupuncture. BMJ.

1999;319:973-6.

9. Kondo A, Koyama T, Ishikawa J, Yamasaki T. Injury to the spinal cord produced by acupuncture needle. Surg Neurol. 1979;11:155-6.

4. Kendall DE. A scientific model for acupuncture: Part I. Am J Acupunct. 1989;

17:251-68.

10. Southworth SR, Hartwig RH. Foreign body in the median nerve: a complication of acupuncture. J Hand Surg [Br]. 1990;15:111-2.

5. Gellman H. Acupuncture treatment for musculoskeletal pain: a textbook for

orthopaedics, anesthesia, and rehabilitation. 1st ed. New York: Taylor and
Francis; 2002. p 137.

11. Sobel E, Huang EY, Wieting CB. Drop foot as a complication of acupuncture injury and intragluteal injection. J Am Podiatr Med Assoc. 1997;87:
52-9.

6. Rogers PAM. Serious complications of acupuncture: or acupuncture

abuses? Am J Acupunct. 1981;9:347-51.

12. Oh SJ. Clinical electromyography: nerve conduction studies. 2nd ed. Baltimore: Lippincott Williams and Wilkins; 1993. p 479-95.