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



We implemented a blood flow restriction resistance training (BFR-RT) intervention during an 8-week rehabilitation programme in anterior cruciate ligament reconstruction (ACLR) patients within a National Health Service setting.


To compare the effectiveness of BFR-RT and standard-care traditional heavy-load resistance training (HL-RT) at improving skeletal muscle hypertrophy and strength, physical function, pain and effusion in ACLR patients following surgery.


28 patients scheduled for unilateral ACLR surgery with hamstring autograft were recruited for this parallel-group, two-arm, single-assessor blinded, randomised clinical trial following appropriate power analysis. Following surgery, a criteria-driven approach to rehabilitation was utilised and participants were block randomised to either HL-RT at 70% repetition maximum (1RM) (n = 14) or BFR-RT (n = 14) at 30% 1RM. Participants completed 8 weeks of biweekly unilateral leg press training on both limbs, totalling 16 sessions, alongside standard hospital rehabilitation. Resistance exercise protocols were designed consistent with standard recommended protocols for each type of exercise. Scaled maximal isotonic strength (10RM), muscle morphology of the vastus lateralis of the injured limb, self-reported function, Y-balance test performance and knee joint pain, effusion and range of motion (ROM) were assessed at pre-surgery, post-surgery, mid-training and post-training. Knee joint laxity and scaled maximal isokinetic knee extension and flexion strength at 60°/s, 150°/s and 300°/s were measured at pre-surgery and post-training.


Four participants were lost, with 24 participants completing the study (12 per group). There were no adverse events or differences between groups for any baseline anthropometric variable or pre- to post-surgery change in any outcome measure. Scaled 10RM strength significantly increased in the injured limb (104 ± 30% and 106 ± 43%) and non-injured limb (33 ± 13% and 39 ± 17%) with BFR-RT and HL-RT, respectively, with no group differences. Significant increases in knee extension and flexion peak torque were observed at all speeds in the non-injured limb with no group differences. Significantly greater attenuation of knee extensor peak torque loss at 150°/s and 300°/s and knee flexor torque loss at all speeds was observed with BFR-RT. No group differences in knee extensor peak torque loss were found at 60°/s. Significant and comparable increases in muscle thickness (5.8 ± 0.2% and 6.7 ± 0.3%) and pennation angle (4.1 ± 0.3% and 3.4 ± 0.1%) were observed with BFR-RT and HL-RT, respectively, with no group differences. No significant changes in fascicle length were observed. Significantly greater and clinically important increases in several measures of self-reported function (50–218 ± 48% vs. 35–152 ± 56%), Y-balance performance (18–59 ± 22% vs. 18–33 ± 19%), ROM (78 ± 22% vs. 48 ± 13%) and reductions in knee joint pain (67 ± 15% vs. 39 ± 12%) and effusion (6 ± 2% vs. 2 ± 2%) were observed with BFR-RT compared to HL-RT, respectively.


BFR-RT can improve skeletal muscle hypertrophy and strength to a similar extent to HL-RT with a greater reduction in knee joint pain and effusion, leading to greater overall improvements in physical function. Therefore, BFR-RT may be more appropriate for early rehabilitation in ACLR patient populations within the National Health Service.

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Data availability statement

The datasets generated and analysed during the study are not publicly available due to the nature of patient confidentiality but are available from the corresponding authors on reasonable request with permission.


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Author information




LH, BR, CG, BP and SP contributed to study conceptualisation, writing and review of the manuscript. LH and SP contributed to data analysis. LH, DM, TC, GF, JD and BP contributed to data collection. The final version of this manuscript was read and approved by all the listed co-authors.

Corresponding authors

Correspondence to Bruce Paton or Stephen David Patterson.

Ethics declarations


This study was supported by Delfi Medical Innovations Inc. who provided a pneumatic variable contour cuff and PT device for the study.

Conflicts of interest

Dr. Luke Hughes, Dr. Benjamin Rosenblatt, Prof. Fares Haddad, Prof. Conor Gissane, Mr. Daniel McCarthy, Mr. Thomas Clarke, Mr. Graham Ferris, Miss. Joanna Dawes, Dr. Bruce Paton and Dr. Stephen David Patterson have no conflicts of interest that are directly relevant to the content of this article.

Ethical approval and consent to participate

Ethical approval for the research was granted by the NHS Health Research Ethics Committee and University Ethics Committee. Written informed consent was obtained from each of the participants in compliance with the Declaration of Helsinki (2013).

Additional information

Bruce Paton and Stephen David Patterson are joint senior/corresponding authors.

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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 49, 1787–1805 (2019).

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