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. 2025 Aug 21;30(4):e70099. doi: 10.1002/pri.70099

Acute Effect of Percutaneous Tibial Nerve Stimulation on Postural Control: A Randomized Controlled Trial

Miguel Rodríguez‐Rosal 1, Alberto Sánchez‐Sixto 1, Francisco Álvarez‐Barbosa 2,✉, Moisés de Hoyo Lora 2,3
PMCID: PMC12370166  PMID: 40839635

ABSTRACT

Introduction

Ankle sprains are common severe injuries leading to changes in muscular activity and postural control impairments. Postural control integrates neural components, including cognitive processing. Due to its relevance, neuromodulation techniques such as percutaneous tibial nerve stimulation (PTNS) have gained attention for improving balance, proprioception, and stability. However, the effects of PTNS on postural control remain insufficiently investigated. This study evaluated the acute effects of PTNS on postural control in healthy individuals.

Methods

Ninety‐four healthy participants (mean age 22.85 ± 5.02 years, BMI 23.8 ± 3.52) were recruited. Baseline postural control assessments were conducted, followed by random assignment to three groups: (1) PTNS (EXP), (2) sham (SHAM), and (3) control (CON). The EXP group received biphasic electrical stimulation (10 Hz, 250 μs, maximum tolerable intensity for 1.5 min). Postural control was measured using a force platform at baseline, and 0, 2, 24, and 48 h post‐intervention. Participants performed two single‐leg stance tests with eyes open and closed. Center of pressure (CoP) displacement and anteroposterior (Ampl_AP) and mediolateral (Ampl_ML) amplitudes were analyzed.

Results

Both the EXP and SHAM groups showed significant reductions in the CoP displacement area with eyes closed at 24 and 48 h post‐intervention compared to baseline. The SHAM group also exhibited significant reductions in Ampl_AP at these time points. No significant changes were observed in the control group.

Discussion

Percutaneous tibial nerve stimulation (PTNS) improves single‐leg postural control with eyes closed at 24 and 48 h, similar to sham (SHAM). No significant differences were observed between groups.

Trial Registration

ISRCTN177653522

Keywords: balance, electrical stimulation, neuromodulation, percutaneous tibial nerve stimulation, postural control

1. Introduction

Physical exercise is widely acknowledged for its positive effects on health and well‐being (Medrano‐Ureña et al. 2020), yet it also presents the risk of injury. Athletes frequently experience sports‐related injuries (Hägglund et al. 2009) with the knee and ankle being the most commonly injured joints in physically active individuals (Viljoen et al. 2021). Among these injuries, ankle sprains are particularly severe in men (Bailey et al. 2023), and sprains are the most common in sporting activities (Garrick 1977) and among the physically active population (Gribble et al. 2016). When an injury occurs, it often leads to changes in muscle activity, potentially resulting in structural changes in the muscles themselves (Nielsen et al. 2023). Additionally, alterations in kinematic patterns due to these injuries can affect postural control (Gribble et al. 2012).

Postural control refers to the ability to maintain the center of mass (CoM) within the base of support of the ankle, both before and after voluntary movements or external perturbations, whether expected or unexpected (Wikstrom et al. 2004). It is a complex motor function resulting from the integration of various neural components, including cognitive processes (Coelho and Teixeira 2017). When any of these components are compromised, postural instability may occur (Coelho and Teixeira 2017). The central nervous system plays a key role in maintaining balance by integrating inputs from the musculoskeletal, visual, and vestibular systems (Maurer et al. 2006). Some studies suggest that vision can influence postural control (Esteves et al. 2022), and compensatory mechanisms may occur at the motor and somatosensory cortex levels to sustain balance performance at the ankle (N. Liu et al. 2024), with vision being one of the most significant systems in this regard (Esteves et al. 2022). As a result, research has explored nerve stimulation treatments to improve balance, proprioception, strength, and range of motion in affected individuals (Alahmari et al. 2020).

Neuromodulation, a technique that influences neural interfaces, is based on inhibiting, stimulating, modifying, or regulating electrical or chemical activation changes in the central, peripheral, or autonomic nervous systems (Krames et al. 2009). Research has shown that percutaneous nerve stimulation enhances muscular activity (Álvarez‐Prats et al. 2019). One such technique, percutaneous tibial nerve stimulation (PTNS), involves using an acupuncture needle to target specific conditions by inserting a needle electrode near the posterior tibial nerve (de la Cruz‐Torres et al. 2019). This nerve provides sensory input to the midfoot and heel, and motor innervation to intrinsic foot muscles (Kiel and Kaiser 2025). PTNS has been used to treat various pathologies (Tahmasbi et al. 2024) including urinary symptoms (Liapis et al. 2023), and has shown improvements when compared with placebo (Sarveazad et al. 2019) and transcutaneous treatments (Sevim et al. 2023). Despite promising results, the exact mechanism behind PTNS remains unclear (Cooperberg and Stoller 2005).

Although studies suggest that PTNS improves muscular activity in certain muscles, including the quadriceps (Álvarez‐Prats et al. 2019) and the posterior tibialis (long flexor muscle of the big toe) (de la Cruz‐Torres et al. 2019), the influence of visual systems on postural control when neural stimulation is applied remains unexplored (Esteves et al. 2022) Moreover, there are limitations in objectively assessing postural control when such techniques are employed. Therefore, the objective of this study was to examine the acute effect of PTNS on postural control in healthy individuals.

2. Methods

2.1. Study Design

The study received approval from the Ethics Committee of CEU Cardenal Spínola University (approval number CS‐11‐090725). The trial was prospectively registered in the International Standard Randomised Controlled Trial Registry (ISRCTN) under registration number ISRCTN177653522 on December 13, 2024. The recruitment period spanned from December 16, 2024 to February 12, 2025.

2.2. Subjects

The sample size was determined using G*Power software (Faul et al. 2007) based on input parameters including effect size (d = 0.2), α error = 0.01, and 1‐β error = 0.99. The required sample size for detecting a medium effect was calculated to be at least 84 participants, with a final target of 117 participants to account for possible dropout. Participants were randomly assigned to three groups using a computer program (Random.org) with a 1:1:1 allocation ratio. The therapist conducting the intervention was blinded to group assignments. Group one received PTNS (EXP; n = 34), group two received a sham intervention (SHAM; n = 34), and group three served as the control group (CON; n = 28). A total of 94 healthy participants were analyzed, with an average age of 22.85 ± 5.02 years and a body mass index (BMI) of 23.8 ± 3.52.

Inclusion criteria were: healthy young adults engaging in at least 150 min of moderate aerobic activity per week or at least 20 min per week of vigorous physical activity (López‐Martínez et al. 2013). Exclusion criteria included: any pathology that could alter sensorimotor control, previous injuries that affected balance, and psychological apprehension scores above a certain threshold (Cabello et al. 2005), contraindications for invasive physiotherapy techniques, epilepsy, and certain medical conditions (Garrido and Muñoz 2016). Figure S1 displays the Consolidated Standards of Reporting Trials (CONSORT) flow diagram and the participant flow throughout the trial. The procedure was approved by the ethics committees of CEU Cardenal Spínola University, where the measurements were conducted. All participants were male to eliminate gender differences, and the tests were performed barefoot to avoid discrepancies due to footwear.

2.3. Procedure

Postural control was evaluated using a force platform (Prieto et al. 1996). An initial evaluation was performed before the intervention. Subsequent measurements were repeated at 0, 2, 24 and 48 h after the intervention. All evaluations were carried out by a blinded research team member, unaware of group assignments.

2.4. Materials

2.4.1. Balance Test

Postural control was measured using a force platform (Accupower; AMTI, Watertown, MA, USA) with a sampling frequency of 1000 Hz. Participants stood on one leg with their hands on their hips and their gaze fixed on a point 2 m away. The tests were initially conducted with eyes open, followed by testing with eyes closed. For each condition, three attempts were made. Each test lasted 30 s, followed by a 1 min rest period. Only the final 20 s of each trial were analyzed (Prieto et al. 1996). The average values and standard deviations (SD) from the three trials were calculated and utilized for each specified condition. Furthermore, a sensitive analysis was performed using the most successful attempt, referencing those with the smallest displacement area of the center of pressure (CoP). The displacement of center of pressure (CoP) was analyzed using linear variables (Duarte and Freitas 2010), such as total displacement (DOT), total displacement area (Area), mediolateral displacement (Displ_ML) and anteroposterior displacement (Displ_AP), and the amplitude of the center of pressure in the mediolateral (Ampl_ML) and anteroposterior (Ampl_AP). The digitized output (Hufschmidt et al. 1980) signals from the force platform amplifiers using Matlab for time series analysis (version R2020a, Mathworks, USA).

2.5. Intervention

2.5.1. EXP Group

Participants in the EXP group received PTNS, using a biphasic electrical current (10 Hz frequency, pulse width of 250 μs, at the maximum tolerable intensity for 1.5 min), sufficient to induce visible muscle contraction (Garrido and Muñoz 2016). A certified medical device was used for this procedure (Physio Invasiva; PRIM Physio, Madrid, Spain). Participants were placed in the prone position with their feet hanging off the treatment table. The posterior tibial nerve was located using ultrasound (Logic; GE Healthcare, Chicago, IL, USA) for needle insertion (0.30 mm × 40 mm). The skin was cleaned with 99% isopropyl alcohol, and the procedure was performed by a physiotherapist with 8 years of invasive therapy experience.

2.5.2. SHAM Group

In the SHAM group, needle insertion was performed using the same methodology as in the EXP group, but no electrical current was applied. A “deep non‐acupoint needling” technique was used to simulate the sensation of needle insertion without stimulation (Zeng et al. 2022).

2.5.3. CON Group

The CON group received no intervention and only underwent the balance test at the specified time points.

2.6. Statistical Analysis

Jamovi software (version 1.6.15) was used for statistical analysis. Statistical methods included the calculation of means, standard deviations, and correlations. The normal distribution of the pre‐intervention variables was assessed using the Shapiro‐Wilk test, and homogeneity among groups (EXP vs. SHAM vs. CON) was verified using Levene's test. Treatment efficacy was evaluated with a 3 (group: EXP vs. SHAM vs. CON) x 5 (time: Pre vs. 0 vs. 2 h vs. 24 vs. 48 h) factorial ANOVA with Bonferroni adjustments. For non‐normally distributed data, the Mann–Whitney U test was employed. The effect size was calculated using partial eta squared (η 2), with the following interpretations: η 2 > 0.01 (small effect), η 2 > 0.06 (medium effect), and η 2 > 0.14 (large effect) (O’brien and quantity 2007). Statistical significance was accepted at p < 0.05.

3. Results/Findings

A statistically significant decrease was observed in the EXP group when participants performed the test with their eyes closed in the specified area at 24 and 48 h post‐intervention compared with pre‐stimulation measurement. Similar results were found in the SHAM group for the same area and the Ampl_AP variable at these time points. No significant changes were observed in the CON group. These results are presented in Table S1. However, no statistically significant differences were detected when comparing the groups.

A secondary analysis revealed that there were no differences in the test with eyes open either within group or between groups. However, when tests were conducted with eyes closed, a significant reduction in the contact area was observed at both 24 and 48 h following PTNS and SHAM stimulation, with a medium effect size (partial eta squared = 0.125). Additionally, a decrease in Ampl_AP was noted at both time points after placebo stimulation with eyes closed.

For a clearer comparison, Figures S2 and S3 present the graphs of the different tests performed with eyes open and closed, highlighting the variables where significant differences were observed.

4. Discussion

Our results suggest that PTNS and deep puncture without current improved postural control when the test is performed with eyes closed. This may occur because postural control relies on the integration of musculoskeletal, vestibular, and visual (Maurer et al. 2006). Closing the eyes reduces sensory input, requiring greater reliance on the musculoskeletal and/or vestibular systems (Esteves et al. 2022), and closing the eyes reduces the sensory input available for maintaining postural control, requiring increased reliance on the musculoskeletal and/or vestibular systems. This intervention appears to have a greater impact on these systems, a finding not observed in the control group or in any cases when the eyes were open.

Similar improvements were seen in a previous study (de la Cruz‐Torres et al. 2019), showing better balance and reduced fatigue following tibial nerve stimulation using the same protocol. Both EXP (p = 0.004 and p = 0.028) and SHAM (p < 0.001 and p = 0.012) groups, with partial eta squared (η 2 = 0.125), showed reduced CoP displacement while balancing on one leg with eyes closed. These results align with a study where balance improvements were found in patients with ankle issues (Beyraghi et al. 2024), suggesting that CNS stimulation improves anticipatory balance capabilities.

The placebo effect is likely attributable to the “needle sensation” evoked during needle insertion, which modulates autonomic nervous system activity (Z. Liu et al. 2024). Sham acupuncture has been demonstrated to elicit quantifiable neurophysiological alterations (Rodrigues et al. 2023) N. Liu et al. (2024) reported that this sensation activates responses in the autonomic nervous system, likely through stimulation of Aδ and C fibers (N. Liu et al. 2024), which play a critical role in activating the sympathetic nervous system (Ma 2022). However, the technique employed—known as nonacupoint deep puncture (Zeng et al. 2022)— may induce responses comparable to those elicited by other placebo interventions involving needle insertion.

Our findings were observed during a single‐leg stance with their eyes closed, as postural control is a complex function involving cognitive processing (Horak 2006). The central nervous system regulates muscle activity to maintain balance through inputs from the musculoskeletal, visual, and vestibular systems (Maurer et al. 2006). Stergiou et al. (2006) suggest that the static control adjustments reflect the flexibility of the motor control system to adapt to environmental changes. When one system is compromised, reliance on the others increases, potentially causing postural instability (Coelho and Teixeira 2017; Horak 2006), emphasizing the need to investigate how visual input affects control (Esteves et al. 2022), as it can compensate for somatosensory deficits (Wikstrom et al. 2017).

This is, to our knowledge, the first study to show significant improvements in CoP displacement following both EXP and SHAM interventions with eyes closed, using a force platform. Percutaneous stimulation may require lower intensities than transcutaneous methods (Williamson and Andrews 2005), but the lack of more substantial findings may be due to the intensity used. Studies show inadequate intensity fails to reduce pair or increase pain thresholds (Vance et al. 2022) and adjustment based on tolerance are common (Liebano et al. 2024). Our study used a fixed 1.5 min stimulation at a non‐adjustable intensity, avoiding modification.

A key strength of our study is the use of a force platform, considered the gold standard for assessing postural control (Wang et al. 2024) with excellent inter‐rater reliability (ICC = 0.93; SEM = 0.45) in postural control quantification (Riemann et al. 1999). We replicated the test with eyes open and closed, as recommended (Esteves et al. 2022), to evaluate visual system restriction on postural control. However, balance depends on integrating visual, vestibular, somatosensory, and neuromuscular systems (Esteves et al. 2022), and it remains unclear whether a single intervention targeting one system is enough to modify others for effective control.

This study included only male participants based on data showing a higher prevalence of ankle sprains in men in certain sports (Bailey et al. 2023). Hormonal factors in females may influence ligament strength, muscle recruitment, and neuromuscular control (Ericksen and Gribble 2012); therefore, the findings may not be generalizable. The effects of percutaneous tibial nerve stimulation (PTNS) on postural control are still not fully understood, and the invasive nature of percutaneous techniques complicates the establishment of a true placebo group. Nevertheless, significant improvements were observed with the “nonacupoint deep puncture” technique, underscoring the methodological challenges in designing effective placebos. Although parameters such as stimulation frequency, intensity, and duration may represent limitations of the present study, the methodology employed is consistent with protocols used in similar investigations (de la Cruz‐Torres et al. 2019) and is supported by relevant literature (Garrido and Muñoz 2016). Future studies should extrapolate these findings to other populations, including females and individuals engaged in various types of physical activity. Furthermore, additional research is required to investigate the effects of different stimulation intensities and durations to identify optimal parameters for modulating sensory and motor nerve function (Álvarez et al. 2022). The long‐term effects of PTNS on neuromuscular function and postural control should also be examined.

In conclusion, the results indicate that percutaneous stimulation of the tibial nerve (PTNS) significantly reduces the area required for postural control on one leg with eyes closed at 24‐ and 48‐h post‐intervention, similar to sham placebo (SHAM). SHAM also reduces Ampl_AP at these time points, but no significant changes are observed in control (CON). No significant intergroup differences were found.

5. Implications of Physiotherapy Practice

Percutaneous tibial nerve stimulation (PTNS) appears to improve balance in healthy individuals under eyes‐closed conditions, showing significant differences compared with the control group. Similar effects were observed in the sham condition, which involved needle insertion without electrical stimulation using a “deep non‐acupoint technique.” The response in this group is consistent with those reported in other validated models of simulated needling, which have been shown to elicit neurophysiological changes. Both interventions led to improvements in balance‐related outcomes, highlighting the need for further research to clarify the specific mechanisms of PTNS and its clinical relevance in physiotherapy.

Author Contributions

M.R.R. and F.A.B. contributed to the conceptualization and design of the study. M.R.R. and A.S.S. were responsible for data collection and analysis. F.A.B. and M.d.H.L. provided supervision and critical revision of the manuscript. All authors (M.R.R., A.S.S., F.A.B., M.d.H.L.) contributed to drafting, reviewing, and approving the final version of the manuscript.

Ethics Statement

Ethics Committee CEU Cardenal Spínola University, Approval No. CS‐11‐090725, Date 02/09/2024.

Consent

Informed consent was obtained from all participants.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Figure S1: CONSORT flow diagram of participant recruitment.

PRI-30-e70099-s001.jpg (98.3KB, jpg)

Figure S2: Differences in anteroposterior amplitudes with eyes open (a) and with eyed closed (b). #: Pre vs. 24H, p < 0,05; *: Pre vs. 48H, p < 0,05.

PRI-30-e70099-s002.jpg (79.2KB, jpg)

Figure S3: Differences in area with eyes open (a) and with eyes closed (b). #: Pre vs. 24H, p < 0,05; *: Pre vs. 48H, p < 0,05.

PRI-30-e70099-s003.jpg (71.2KB, jpg)

Table S1: Mean and SD of force platform variables with eyes open and eyes closed before and after PTNS, SHAM, and CON interventions at 0, 2, 24, and 48 hours DOT= total displacement of center of pressure; Area = total displacement area; Ampl = Amplitude; AP = anteroposterior; ML = mediolateral; # = PRE Vs 24H p < 0.05; * = PRE Vs 48H p < 0.05.

PRI-30-e70099-s004.docx (49.7KB, docx)

Rodríguez‐Rosal, Miguel , Sánchez‐Sixto Alberto, Álvarez‐Barbosa Francisco, and de Hoyo Lora Moisés. 2025. “Acute Effect of Percutaneous Tibial Nerve Stimulation on Postural Control: A Randomized Controlled Trial.” Physiotherapy Research International: e70099. 10.1002/pri.70099.

Funding: The authors received no specific funding for this work.

Data Availability Statement

The authors have nothing to report.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Figure S1: CONSORT flow diagram of participant recruitment.

PRI-30-e70099-s001.jpg (98.3KB, jpg)

Figure S2: Differences in anteroposterior amplitudes with eyes open (a) and with eyed closed (b). #: Pre vs. 24H, p < 0,05; *: Pre vs. 48H, p < 0,05.

PRI-30-e70099-s002.jpg (79.2KB, jpg)

Figure S3: Differences in area with eyes open (a) and with eyes closed (b). #: Pre vs. 24H, p < 0,05; *: Pre vs. 48H, p < 0,05.

PRI-30-e70099-s003.jpg (71.2KB, jpg)

Table S1: Mean and SD of force platform variables with eyes open and eyes closed before and after PTNS, SHAM, and CON interventions at 0, 2, 24, and 48 hours DOT= total displacement of center of pressure; Area = total displacement area; Ampl = Amplitude; AP = anteroposterior; ML = mediolateral; # = PRE Vs 24H p < 0.05; * = PRE Vs 48H p < 0.05.

PRI-30-e70099-s004.docx (49.7KB, docx)

Data Availability Statement

The authors have nothing to report.

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