Blood Flow Restriction Training in Musculoskeletal Rehabilitation: Clinical Applications, Safety, Risk Stratification, and Practical Implementation - A Narrative Review

Wojciech  Ziębka; Oliwia Dziewięcka; Michał Błażuk; Dominik Zając; Damian Broda; Wiktoria Mikulska; Natalia Sak; Kamila Tasior; Katarzyna Sikora; Julia Wilanowska; Aleksandra Broda

doi:10.12775/QS.2026.65.73916

Authors

Wojciech Ziębka A. Falkiewicz Specialist Hospital in Wroclaw, Poland https://orcid.org/0009-0000-6835-6773
Oliwia Dziewięcka A. Falkiewicz Specialist Hospital in Wroclaw, Poland https://orcid.org/0009-0008-7784-1680
Michał Błażuk Karol Jonscher Municipal Medical Center in Lodz, Poland https://orcid.org/0009-0001-6959-0526
Dominik Zając Central Clinical Hospital of UCC WUM, Warszawa, Poland https://orcid.org/0009-0004-0415-5322
Damian Broda 10th Military Clinical Hospital with Polyclinic in Bydgoszcz, Poland https://orcid.org/0009-0003-2825-2082
Wiktoria Mikulska Medical University of Silesia, Katowice, Poland https://orcid.org/0009-0000-3246-2945
Natalia Sak Provincial Specialist Hospital named after Blessed Father Jerzy Popieluszko in Wloclawek, Poland https://orcid.org/0009-0009-3601-3771
Kamila Tasior Medical University of Silesia, Katowice, Poland https://orcid.org/0009-0001-2731-8831
Katarzyna Sikora University Clinical Hospital No. 4 in Lublin, Poland https://orcid.org/0000-0002-6955-3549
Julia Wilanowska Medical University of Silesia, Katowice, Poland https://orcid.org/0009-0009-4928-9435
Aleksandra Broda Medical University of Warsaw, Warsaw, Poland https://orcid.org/0009-0000-4701-7983

DOI:

https://doi.org/10.12775/QS.2026.65.73916

Keywords

blood flow restriction training, blood flow restriction resistance exercise, exercise rehabilitation, musculoskeletal regeneration, risk stratification, exercice therapy

Abstract

Background: Blood flow restriction training (BFRT) combines exercise with proximal cuff pressure and is used when higher-load resistance exercise is temporarily unsuitable or poorly tolerated.

Aim: To summarize the rationale, clinical applications, safety, risk stratification, cardiovascular and hemodynamic issues, arterial occlusion pressure (AOP), limb occlusion pressure (LOP), device factors, and practical use of BFRT in musculoskeletal rehabilitation.

Material and methods: PubMed, Scopus, and Web of Science were searched narratively, with Google Scholar as a supplementary source, for publications available to 1 June 2026. Clinically relevant reviews, meta-analyses, randomized trials, position statements, and practice-oriented papers were prioritized. No protocol was registered, and no formal risk-of-bias assessment or quantitative synthesis was performed.

Results: Low-load BFRT may improve strength and muscle mass more than comparable low-load exercise without blood flow restriction (BFR), but it has not shown consistent superiority over conventional high-load resistance training. Evidence is condition-specific and limited by heterogeneous protocols, comparators, outcomes, and incomplete adverse-event reporting; data in medically complex patients are limited. Safe use requires screening, risk stratification, individualized pressure prescription, and monitoring. AOP and LOP are related but not fully interchangeable, and values vary with the individual, limb, cuff, device, posture, detection method, and assessment conditions.

Conclusions: BFRT may serve as an adjunctive or bridging low-load strategy in selected patients when higher-load strengthening is temporarily limited. It should support progressive rehabilitation rather than replace conventional resistance training, with decisions guided by patient risk, tolerance, goals, and evidence certainty.

References

[1] Patterson SD, Hughes L, Warmington S, Burr J, Scott BR, Owens J, et al. Blood flow restriction exercise: considerations of methodology, application, and safety. Front Physiol. 2019;10:533. https://doi.org/10.3389/fphys.2019.00533.

[2] Cognetti DJ, Sheean AJ, Owens JG. Blood flow restriction therapy and its use for rehabilitation and return to sport: physiology, application, and guidelines for implementation. Arthrosc Sports Med Rehabil. 2022;4(1):e71-e76. https://doi.org/10.1016/j.asmr.2021.09.025.

[3] Pearson SJ, Hussain SR. A review on the mechanisms of blood-flow restriction resistance training-induced muscle hypertrophy. Sports Med. 2015;45(2):187-200. https://doi.org/10.1007/s40279-014-0264-9.

[4] Hughes L, Paton B, Rosenblatt B, Gissane C, Patterson SD. Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. Br J Sports Med. 2017;51(13):1003-1011. https://doi.org/10.1136/bjsports-2016-097071.

[5] Lorenz DS, Bailey L, Wilk KE, Mangine RE, Head P, Grindstaff TL, et al. Blood flow restriction training. J Athl Train. 2021;56(9):937-944. https://doi.org/10.4085/418-20.

[6] Koc BB, Truyens A, Heymans MJLF, Jansen EJP, Schotanus MGM. Effect of low-load blood flow restriction training after anterior cruciate ligament reconstruction: a systematic review. Int J Sports Phys Ther. 2022;17(3):334-346. https://doi.org/10.26603/001c.33151.

[7] Lin Q, Yu D, Zhang Y, Chen X, Qin J, Wu F. Impact of low-load blood flow restriction training on knee osteoarthritis pain and muscle strength: a systematic review and meta-analysis of randomized controlled trials. Front Physiol. 2025;16:1524480. https://doi.org/10.3389/fphys.2025.1524480.

[8] Jørgensen SL, Kierkegaard-Brøchner S, Bohn MB, Høgsholt M, Aagaard P, Mechlenburg I. Effects of blood-flow restricted exercise versus conventional resistance training in musculoskeletal disorders: a systematic review and meta-analysis. BMC Sports Sci Med Rehabil. 2023;15(1):141. https://doi.org/10.1186/s13102-023-00750-z.

[9] Butt J, Ahmed Z. Blood flow restriction training and its use in rehabilitation after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. J Clin Med. 2024;13(20):6265. https://doi.org/10.3390/jcm13206265.

[10] Burton I, McCormack A. Blood flow restriction resistance training in tendon rehabilitation: a scoping review on intervention parameters, physiological effects, and outcomes. Front Sports Act Living. 2022;4:879860. https://doi.org/10.3389/fspor.2022.879860.

[11] Tiss B, Layouni S, Ghali H, Ceylan Hİ, Nticha I, Jemni S, et al. Blood flow restriction training in knee arthroplasty: a systematic review of current evidence on postoperative muscle strength and function. Medicina (Kaunas). 2025;61(10):1879. https://doi.org/10.3390/medicina61101879.

[12] Li X, Xiao F, Ren H, Peng Y, Feng F, Dong Q. The effects of blood flow restriction training on early muscle strength and mid-term knee function following anterior cruciate ligament reconstruction: a systematic review and meta-analysis. J Orthop Surg Res. 2025;20(1):273. https://doi.org/10.1186/s13018-025-05673-8.

[13] Erickson LN, Owen MK, Casadonte KR, Janatova T, Lucas K, Spencer K, 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(2):227-237. https://doi.org/10.1249/MSS.0000000000003573.

[14] He J, Zhang L, Wu Q, Zhang J. Credibility of blood flow restriction training in patients with knee osteoarthritis: a systematic review and meta-analysis. Orthop J Sports Med. 2025;13(2):23259671241300145. https://doi.org/10.1177/23259671241300145.

[15] Nascimento DC, Rolnick N, Neto IVS, Severin R, Beal FLR. A useful blood flow restriction training risk stratification for exercise and rehabilitation. Front Physiol. 2022;13:808622. https://doi.org/10.3389/fphys.2022.808622.

[16] Minniti MC, Statkevich AP, Kelly RL, Rigsby VP, Exline MM, Rhon DI, et al. The safety of blood flow restriction training as a therapeutic intervention for patients with musculoskeletal disorders: a systematic review. Am J Sports Med. 2020;48(7):1773-1785. https://doi.org/10.1177/0363546519882652.

[17] Huang R, Ma Y, Yang Z, Wang Z, Zeng C, Qin Y, et al. Hemodynamic analysis of blood flow restriction training: a systematic review. BMC Sports Sci Med Rehabil. 2025;17(1):46. https://doi.org/10.1186/s13102-025-01084-8.

[18] Suggitt JO, Eaves BE, Spranger MD. What are the cardiovascular responses during blood flow-restricted resistance exercise? Front Physiol. 2024;15:1417855. https://doi.org/10.3389/fphys.2024.1417855.

[19] Weatherholt AM, VanWye WR, Lohmann J, Owens JG. The effect of cuff width for determining limb occlusion pressure: a comparison of blood flow restriction devices. Int J Exerc Sci. 2019;12(3):136-143. https://doi.org/10.70252/RWVU7100.

[20] Bommasamudram T, Nayak KR, Clarkson MJ, Kadavigere R, Russell AP, Warmington SA. A comparison of blood flow restriction devices to assess limb occlusion pressure in supine and standing positions. Front Sports Act Living. 2025;7:1654522. https://doi.org/10.3389/fspor.2025.1654522.

[21] Loenneke JP, Fahs CA, Rossow LM, Sherk VD, Thiebaud RS, Abe T, et al. Effects of cuff width on arterial occlusion: implications for blood flow restricted exercise. Eur J Appl Physiol. 2012;112(8):2903-2912. https://doi.org/10.1007/s00421-011-2266-8.

[22] Hughes L, Rolnick N, Franz A, Owens J, Swain PM, Centner C, et al. Blood flow restriction: methods and apparatus still matter. Br J Sports Med. 2025;59(9):623-625. https://doi.org/10.1136/bjsports-2024-109365.

[23] Jessee MB, Mattocks KT, Buckner SL, Dankel SJ, Mouser JG, Abe T, et al. Mechanisms of blood flow restriction: the new testament. Tech Orthop. 2018;33(2):72-79. https://doi.org/10.1097/BTO.0000000000000252.

[24] Lixandrão ME, Ugrinowitsch C, Berton R, Vechin FC, Conceição MS, Damas F, et al. Magnitude of muscle strength and mass adaptations between high-load resistance training versus low-load resistance training associated with blood-flow restriction: a systematic review and meta-analysis. Sports Med. 2018;48(2):361-378. https://doi.org/10.1007/s40279-017-0795-y.

[25] Centner C, Lauber B. A systematic review and meta-analysis on neural adaptations following blood flow restriction training: what we know and what we don’t know. Front Physiol. 2020;11:887. https://doi.org/10.3389/fphys.2020.00887.

[26] Miller BC, Tirko AW, Shipe JM, Sumeriski OR, Moran K. The systemic effects of blood flow restriction training: a systematic review. Int J Sports Phys Ther. 2021;16(4):978-990. https://doi.org/10.26603/001c.25791.

[27] 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(2):260-273. https://doi.org/10.1177/19417381211070834.

[28] Charles D, White R, Reyes C, Palmer D. A systematic review of the effects of blood flow restriction training on quadriceps muscle atrophy and circumference post ACL reconstruction. Int J Sports Phys Ther. 2020;15(6):882-891. https://doi.org/10.26603/ijspt20200882.

[29] García-Rodríguez P, Pecci J, Vázquez-González S, Pareja-Galeano H. Acute and chronic effects of blood flow restriction training in physically active patients with anterior cruciate ligament reconstruction: a systematic review. Sports Health. 2024;16(5):820-828. https://doi.org/10.1177/19417381231208636.

[30] Colombo V, Valenčič T, Steiner K, Škarabot J, Folland J, O’Sullivan O, et al. Comparison of blood flow restriction interventions to standard rehabilitation after an anterior cruciate ligament injury: a systematic review. Am J Sports Med. 2024;52(14):3641-3650. https://doi.org/10.1177/03635465241232002.

[31] Ferraz RB, Gualano B, Rodrigues R, Kurimori CO, Fuller R, Lima FR, et al. Benefits of resistance training with blood flow restriction in knee osteoarthritis. Med Sci Sports Exerc. 2018;50(5):897-905. https://doi.org/10.1249/MSS.0000000000001530.

[32] Peng P, Lu Y, Wang Y, Sui X, Yang Z, Xu H, et al. Effect of low-intensity blood flow restriction training on nontraumatic knee joint conditions: a systematic review and meta-analysis. Sports Health. 2025;17(2):226-235. https://doi.org/10.1177/19417381241235147.

[33] Zeitlin C, Shepherd M, Lack SD, Neal BS. Blood flow restriction training compared to conventional training in people with knee pain: a systematic review with meta-analysis. Phys Ther Sport. 2025;74:65-74. https://doi.org/10.1016/j.ptsp.2025.05.004.

[34] Grantham B, Korakakis V, O’Sullivan K. Does blood flow restriction training enhance clinical outcomes in knee osteoarthritis: a systematic review and meta-analysis. Phys Ther Sport. 2021;49:37-49. https://doi.org/10.1016/j.ptsp.2021.01.014.

[35] Yang H, Xiong L, Wang P, Zeng Y, Zhao Z, He C, et al. Comparative efficacy and safety of blood flow restriction training for knee osteoarthritis: a network meta-analysis. Am J Phys Med Rehabil. 2025;104(12):1086-1094. https://doi.org/10.1097/PHM.0000000000002824.

[36] Rodziewicz B, Fidut M, Kacperski M. Blood flow restriction training in postoperative musculoskeletal rehabilitation. Journal of Education, Health and Sport. 2026;91:70722. https://doi.org/10.12775/JEHS.2026.91.70722.

[37] Xu X, Liu Q, Peng L. Effect of blood flow restriction resistance training on elbow joint muscle strength. Quality in Sport. 2024;28:56999. https://doi.org/10.12775/QS.2024.28.56999.

[38] Anderson KD, Rask DMG, Bates TJ, Nuelle JAV. Overall safety and risks associated with blood flow restriction therapy: a literature review. Mil Med. 2022;187(9-10):1059-1064. https://doi.org/10.1093/milmed/usac055.

[39] de Queiros VS, Dantas M, Rodrigues Neto G, da Silva LF, Assis MG, Almeida-Neto PF, et al. Application and side effects of blood flow restriction technique: a cross-sectional questionnaire survey of professionals. Medicine (Baltimore). 2021;100(18):e25794. https://doi.org/10.1097/MD.0000000000025794.

[40] Murphy M. Blood flow restriction training: a tool to enhance rehabilitation and build athlete resiliency. Arthrosc Sports Med Rehabil. 2025;7(2):101022. https://doi.org/10.1016/j.asmr.2024.101022.

[41] Angelopoulos P, Tsekoura M, Mylonas K, Tsigkas G, Billis E, Tsepis E, et al. The effectiveness of blood flow restriction training in cardiovascular disease patients: a scoping review. J Frailty Sarcopenia Falls. 2023;8(2):107-117. https://doi.org/10.22540/JFSF-08-107.

[42] Jessee MB, Buckner SL, Dankel SJ, Counts BR, Abe T, Loenneke JP. The influence of cuff width, sex, and race on arterial occlusion: implications for blood flow restriction research. Sports Med. 2016;46(6):913-921. https://doi.org/10.1007/s40279-016-0473-5.

Blood Flow Restriction Training in Musculoskeletal Rehabilitation: Clinical Applications, Safety, Risk Stratification, and Practical Implementation - A Narrative Review

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