Blood Flow Restriction and Its Function in Post- Operative Anterior Cruciate Ligament Reconstruction Therapy: Expert Opinion



1 Johns Hopkins University, BA, USA

2 Rock Valley Physical Therapy, USA

3 Midwest Orthopaedics at Rush, Chicago, USA

4 Morrison Community Hospital, USA


An increasingly popular method for post-operative rehabilitation of an ACL reconstruction, as a substitute for traditional
therapy, is blood flow restriction therapy (BFR). BFR therapy utilizes a pneumatic cuff to simulate strenuous exercise
in an effort to stimulate muscle recruitment, mitigate atrophy, and promote hypertrophy in patients with load-bearing
limitations. Because this is a relatively new form of therapy, there is a lack of established literature and protocol that
is preventing widespread use of the therapy. This article will seek to confirm the value and validity of the utilization of
BFR therapy. In order to validate the utilization of BFR, an evaluation of the science underlying BFR will be discussed
as well as the technique and exercises preformed during therapy. Furthermore, analysis of other BFR literature will be
utilized to lend further credence to the obtained conclusions. Based on the literature, BFR therapy mitigates atrophy
through type II muscle recruitment while also stimulating hypertrophy in patients, supporting its use post-operatively.
Moreover, positive results from BFR case series also lend credence to its value as a substitute for traditional therapy
in patients who have weight-bearing limitations, specifically those who are recovering from anterior cruciate ligament
Level of evidence: V


1. Ratamess NA, Alvar BA, Evetoch TE, Housh TJ, Ben
Kibler W, Kraemer WJ, Triplett NT. Progression
models in resistance training for healthy adults.
Medicine and science in sports and exercise. 2009;
2. Meyer RA. Does blood flow restriction enhance
hypertrophic signaling in skeletal muscle?. Journal
of applied physiology. 2006; 100(5):1443-4.
3. Kouzaki M, Yoshihisa T, Fukunaga T. Efficacy of
tourniquet ischemia for strength training with low
resistance. European journal of applied physiology
and occupational physiology. 1997; 77(1-2):189-91.
4. Takarada Y, Takazawa H, Sato Y, Takebayashi S,
Tanaka Y, Ishii N. Effects of resistance exercise
combined with moderate vascular occlusion on
muscular function in humans. Journal of applied
physiology. 2000; 88(6):2097-106.
5. Hylden C, Burns T, Stinner D, Owens J. Blood flow
restriction rehabilitation for extremity weakness: a
case series. J Spec Oper Med. 2015; 15(1):50-6.
6. Abe T, Sakamaki M, Fujita S, Ozaki H, Sugaya M, Sato
Y, et al. Effects of low-intensity walk training with
restricted leg blood flow on muscle strength and
aerobic capacity in older adults. Journal of geriatric
physical therapy. 2010; 33(1):34-40.
7. Adams GR, Cheng DC, Haddad F, Baldwin KM. Skeletal
muscle hypertrophy in response to isometric,
lengthening, and shortening training bouts of
equivalent duration. Journal of Applied Physiology.
8. Gundermann DM, Walker DK, Reidy PT, Borack 
MS, Dickinson JM, Volpi E, et al. Activation of
mTORC1 signaling and protein synthesis in human
muscle following blood flow restriction exercise
is inhibited by rapamycin. American Journal of
Physiology-Endocrinology and Metabolism. 2014;
9. Nielsen JL, Aagaard P, Bech RD, Nygaard T, Hvid LG,
Wernbom M, et al. Proliferation of myogenic stem
cells in human skeletal muscle in response to lowload
resistance training with blood flow restriction.
The Journal of physiology. 2012; 590(17):4351-61.
10. Cook SB, Clark BC, Ploutz-Snyder LL. Effects of
exercise load and blood-flow restriction on skeletal
muscle function. Medicine and science in sports and
exercise. 2007; 39(10):1708-13.
11. Takarada Y, Sato Y, Ishii N. Effects of resistance
exercise combined with vascular occlusion on
muscle function in athletes. European journal of
applied physiology. 2002; 86(4):308-14.
12. Yamanaka T, Farley RS, Caputo JL. Occlusion training
increases muscular strength in division IA football
players. The Journal of Strength & Conditioning
Research. 2012; 26(9):2523-9.
13. Schoenfeld BJ. Is there a minimum intensity threshold
for resistance training-induced hypertrophic
adaptations? Sports Medicine. 2013; 43(12):1279-88.
14. DePhillipo NN, Kennedy MI, Aman ZS, Bernhardson
AS, O’Brien LT, LaPrade RF. The role of blood flow
restriction therapy following knee surgery: expert
opinion. Arthroscopy: The Journal of Arthroscopic &
Related Surgery. 2018; 34(8):2506-10.