Objective <p>This study aimed to determine the repeatable effect of acupotomy on specific acupoints of paralyzed limbs in stroke patients with hemiplegia, using musculoskeletal ultrasound combined with acupuncture.</p> Methods <p>102 patients with limb motor dysfunction post-cerebral stroke were randomly divided into two groups: the treatment group (T group) received ultrasound-guided acupotomy plus a basic treatment regimen (51 patients) and the control (C) group underwent the basic treatment regimen (51 patients) over 4 weeks, with a 6-month follow-up period. The T group was treated with ultrasound-guided acupotomy on the first day. Both groups received the same basic treatment. The primary outcome, the improvement in limb function, was evaluated using the Shangtianmin Hemiplegia Function Rating Scale score from baseline to 6 months. The secondary outcome measures included the neurological deficit scale, activities of daily living scale, modified Ashworth scale, and safety evaluation.</p> Results <p>The mean total Shangtianmin Hemiplegia Function rating scale score improved (<i>p</i> &lt; 0.001) after the first ultrasound-guided acupotomy treatment compared with baseline. After 6 months, the mean score of the upper limb in the T group was 8.86 ± 2.86, and in the C group, it was 6.08 ± 3.99 (difference, 2.78; 95% confidence interval, 1.42–4.15, <i>p</i> &lt; 0.001). The mean score of the lower limb was 10.35 ± 1.80 in the T group and 6.86 ± 3.04 in the C group (difference, 3.49; 95% confidence interval, 2.51–4.47, <i>p</i> &lt; 0.001).</p> Conclusions <p>The function of the hemiplegic limb is significantly improved under ultrasound-guided acupotomy treatment combined with acupuncture.</p> Trial registration <p>Chinese Clinical Trials Register, ChiCTR1900028395, Registered 20 December 2019. <a href="https://www.chictr.org.cn/showproj.aspx?proj=47018">https://www.chictr.org.cn/showproj.aspx?proj=47018</a>. Approved no. of the ethics committee: 2019NL-169-02.</p>