Efficacy of Blood Flow Restriction in Post-Anterior Cruciate Ligament Reconstruction Rehabilitation: A Systematic Review and Meta-Analysis of RCTs
DOI:
https://doi.org/10.65406/3.1/38-46/2026Keywords:
BFR, ACLR, Hypoxic training, KAATSU training, Occlusion training, Vascular occlusion training (VOT)Abstract
Background: Anterior cruciate ligament repair (ACLR), is a cause of quadriceps weakness and atrophy which may delay rehabilitation and return-to-sports. Blood Flow Restriction training has attracted attention as a possible supplement to accelerate the rate of healing of strength without compromising the integrity of the graft in conjunction with low load resistance training and partial vascular occlusion.
Methods: Up until October 2025, a search of the literature was conducted thoroughly in the databases of the PubMed, Scopus, Embase, Web of Science, PEDro and Cochrane Library. Patients, setting and design Included randomised controlled trials (RCTs) comparing BFR-based rehabilitation with traditional therapy for individuals who had undergone ACLR; Two-dimension reviewers used PRISMA 2020 to independently extract data. The Cochrane Risk of Bias 2.0 tool and the PEDro Scale were used for the methodological quality evaluations. RevMan 5.4 was used for quantitative synthesis and effect size was calculated as mean difference (MD) or SMD and 95% confidence interval (CI).
Results: A total of 1926 records were identified and following screening and duplicate removal, 12 RCTs fulfilled the eligibility for inclusion. Sample sizes varied from 17 to 48 participants and the intervention period varied between 4-12 weeks. There was pooled evidence that BFR training led to a significantly greater improvement in quadriceps muscle strength (SMD = 0.78, 95% CI: 0.45 - 1.10, p < 0.001) and muscle hypertrophy (SMD = 0.54, 95% CI: 0.28 - 0.80, p < 0.01) than conventional rehabilitation.
Conclusion: Blood Flow Restriction (BFR) training is a safe and effective adjunctive training method for quadriceps strength, muscle hypertrophy, and functional recovery of patients receiving rehabilitation from ACL reconstruction.
References
1. Papalia R, Torre G, Papalia G, Campi S, Maffulli N, Denaro V. Arthroscopic primary repair of the anterior cruciate ligament in adults: A systematic review. British Medical Bulletin 2019;131:29-42.
2. Buckthorpe M, La Rosa G, Della Villa F. Restoring knee extensor strength after anterior cruciate ligament reconstruction: A clinical commentary. International Journal of Sports Physical Therapy 2019;14:159.
3. Hornikel B. The efficacy of blood flow restriction during high intensity resistance exercise. The University of Alabama; 2021.
4. Patterson SD, Brandner CR. The role of blood flow restriction training for applied practitioners: A questionnaire-based survey. Journal of sports sciences 2018;36:123-30.
5. Nyakayiru J, Fuchs CJ, Trommelen J, et al. Blood flow restriction only increases myofibrillar protein synthesis with exercise. Medicine and science in sports and exercise 2019;51:1137.
6. Colapietro MA, Lee JZ, Vairo GL. Survey of blood flow restriction training applications in sports medicine and performance practice across north america. The Journal of Strength & Conditioning Research 2024;38:856-63.
7. Sun L, Yang Y, Luo J. Can blood flow restriction induce cross-education of muscle strength and volume? A systematic review and meta-analysis. Journal of Athletic Training 2024.
8. Erickson LN, Owen MK, Casadonte KR, et al. The efficacy of blood flow restriction training to improve quadriceps muscle function after anterior cruciate ligament reconstruction. Med Sci Sports Exerc 2025;57:227-37.
9. Okoroha KR, Tramer JS, Khalil LS, et al. Effects of a perioperative blood flow restriction therapy program on early quadriceps strength and patient-reported outcomes after anterior cruciate ligament reconstruction. Orthopaedic Journal of Sports Medicine 2023;11:23259671231209694.
10. Jack RA, Lambert BS, Hedt CA, Delgado D, Goble H, McCulloch PC. Blood flow restriction therapy preserves lower extremity bone and muscle mass after acl reconstruction. Sports Health 2023;15:361-71.
11. Li X, Li J, Qing L, Wang H, Ma H, Huang P. Effect of quadriceps training at different levels of blood flow restriction on quadriceps strength and thickness in the mid-term postoperative period after anterior cruciate ligament reconstruction: A randomized controlled external pilot study. BMC Musculoskeletal Disorders 2023;24:360.
12. Jung W-S, Kim S-H, Nam S-S, Kim J-W, Moon H-W. Effects of rehabilitation exercise with blood flow restriction after anterior cruciate ligament reconstruction. Applied Sciences 2022;12:12058.
13. Vieira de Melo RF, Komatsu WR, Freitas MSd, Vieira de Melo ME, Cohen M. Comparison of quadriceps and hamstring muscle strength after exercises with and without blood flow restriction following anterior cruciate ligament surgery: A randomized controlled trial. Journal of Rehabilitation Medicine 2022;54:jrm00337.
14. Curran MT, Bedi A, Mendias CL, Wojtys EM, Kujawa MV, Palmieri-Smith RM. Blood flow restriction training applied with high-intensity exercise does not improve quadriceps muscle function after anterior cruciate ligament reconstruction: A randomized controlled trial. The American Journal of Sports Medicine 2020;48:825-37.
15. Hughes L, Rosenblatt B, Haddad F, et al. Comparing the effectiveness of blood flow restriction and traditional heavy load resistance training in the post-surgery rehabilitation of anterior cruciate ligament reconstruction patients: A uk national health service randomised controlled trial. Sports Med 2019;49:1787-805.
16. Park HS, Song JS, Kim EK. Effects of low-intensity resistance exercise with blood flow restriction after high tibial osteotomy in middle-aged women. Medicine (Baltimore) 2022;101:e32294.
17. Tennent DJ, Hylden CM, Johnson AE, Burns TC, Wilken JM, Owens JG. Blood flow restriction training after knee arthroscopy: A randomized controlled pilot study. Clinical Journal of Sport Medicine 2017;27.
18. Ke J, Zhou X, Yang Y, et al. Blood flow restriction training promotes functional recovery of knee joint in patients after arthroscopic partial meniscectomy: A randomized clinical trial. Frontiers in Physiology 2022;Volume 13 - 2022.
19. Mason JS, Crowell MS, Brindle RA, Dolbeer JA, Miller EM, Telemeco TA, Goss DL. The effect of blood flow restriction training on muscle atrophy following meniscal repair or chondral restoration surgery in active duty military: A randomized controlled trial. J Sport Rehabil 2022;31:77-84.
20. Colapietro M, Portnoff B, Miller SJ, Sebastianelli W, Vairo GL. Effects of blood flow restriction training on clinical outcomes for patients
with acl reconstruction: A systematic review. Sports Health 2023;15:260-73.
21. Mitchell E. The use of blood-flow restriction to enhance high-intensity endurance performance and skeletal muscle adaptation. Loughborough University; 2019.
22. Pearson SJ, Hussain SR. A review on the mechanisms of blood-flow restriction resistance training-induced muscle hypertrophy. Sports medicine 2015;45:187-200.
23. DePhillipo NN, Kennedy MI, Aman ZS, Bernhardson AS, O'Brien L, LaPrade RF. Blood flow restriction therapy after knee surgery: Indications, safety considerations, and postoperative protocol. Arthroscopy techniques 2018;7:e1037-e43.
24. Patterson SD, Hughes L, Warmington S, et al. Blood flow restriction exercise: Considerations of methodology, application, and safety. Frontiers in physiology 2019;10:533.
Downloads
Published
License
Copyright (c) 2026 Journal of Interdisciplinary Research in Allied Health and Pharmacy (JIRAP) – Lahore UBAS
This work is licensed under a Creative Commons Attribution 4.0 International License.
cc BY
