Summary of the best evidence on blood flow restriction training for patients after anterior cruciate ligament reconstruction surgery.
Yao Wang, Fei Wang, Bin Xu and 1 others
An evidence summary of 18 sources supports using blood flow restriction with low-load exercise (20–40% 1RM) for post-ACL-surgery patients who can't tolerate heavy lifting.
Protocols are practical but rest on small, hard-to-blind trials — treat as a useful option, not a proven standard.
Key findings
1BFR training combined with low-load resistance (20–40% 1RM) at 40–80% of limb occlusion pressure has been shown to enhance muscle strength and functional outcomes in post-ACLR patients who cannot tolerate high-load training.
2Training should be delivered under multidisciplinary supervision (orthopedic surgeons and rehabilitation therapists), and must be avoided in patients with severe cardiovascular disease, active or high-risk deep venous thrombosis, diabetes, or coagulation disorders.
3The underlying evidence is of moderate certainty: most RCTs had fewer than 40 participants per group, blinding is inherently difficult because patients feel the cuff and therapists know the pressure, and only 4 of 13 included reviews formally assessed publication bias.
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What it does not show
Most underlying RCTs had fewer than 40 participants per group, risking overestimated effects or missed clinically meaningful differences. Blinding of participants and therapists is inherently impossible in BFR training (patients feel the cuff; therapists set the pressure), so performance and detection bias remain a concern across the literature. Only 4 of the 13 included systematic reviews formally assessed publication bias, and 2 of those found asymmetry suggesting positive-result studies may be overrepresented. Considerable heterogeneity in BFR protocols (fixed vs. individualised pressure, different measurement methods, varying frequencies and durations) limits direct comparability across studies. Moderate overlap (CCA 6.07%) among the 13 included reviews means some primary studies were counted more than once in the synthesis. Search was restricted to Chinese- and English-language publications and excluded all gray literature, introducing potential language and publication bias. Follow-up in the underlying studies rarely exceeded 6 months, so long-term durability of strength gains is unknown. The search was current only to April 2025; newer evidence is not captured.
Declared interests
Funded by the Shanghai Shenkang Hospital Development Center's Municipal Hospital Medical Technology Promotion and Optimization Management Task (Grant No. SHDC22023243); funder named as Tongji University. No industry sponsorship, no conflicts of interest declared by the authors.
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