Blood Flow Restriction: Why + How


Guest Blog, featuring Wes Riggs, PT, DPT      

Owner/Director of Pro Active Physical Therapy Aurora-Southlands 

Blood flow restriction training (BFR) involves using an FDA approved tourniquet to occlude 50-80% of venous blood flow.

Why BFR?

BFR shows amazing potential in the sports medicine world by allowing a patient to improve hypertrophy (muscle growth) and strength without stressing or overloading their joints.BFR has been shown to require a substantiallyadult architecture athlete boardwalk shorter period of physical activity to achieve the same muscle growth results (3-6 weeks vs 8-12 weeks)As a patient, this will allow you to rehabilitate more aggressively and decrease muscle atrophy, even when you have load/weight bearing restrictions secondary to your surgical healing process.

How does it work?

By reducing blood flow, one can create positive effects that will allow for a hypertrophy and strength response to the muscles that you would traditionally need a heavy load to achieve. BFRSportscare(Photocred:

Studies show that working out at 80% of your one repetition maximum lift allows for hypertrophy, with BFR, working out at just 20% of this 1 rep max allows for the same hypertrophy response

The Science

  • BFR allows for the use of Type 2 fast-twitch muscle fibers faster and more effectively
  • Increase in muscle protein synthesis
  • Increase in lactate to help with motor recruitment
  • Increase in growth hormone (by 1.7x) and other anabolic (positive) muscle growth factors
    • Growth hormone plays a role in collagen synthesis which could help with bone healing and plays a role in joint and tendon health
  • Increased cell swelling, increased satellite cell pool to allow for muscle memory
  • Decreased myostatin which leads to an increased ability for muscle hypertrophy and a decreased chance for fibrosis after injury
  • BFR creates an analgesic affect to reduce pain

Side Effects

  • Fatigued muscle
  • Mild soreness
  • Small chance of residual swelling in limb
  • Studies show no greater risk of blood clot

About the author…

Wes Riggs, PT, DPT
Owner/Director Pro Active Physical Therapy Aurora-Southlands

Wes has been practicing physical therapy for over 13 years after receiving his clinical doctorate from Regis University. He received his undergraduate degree from Ohio Wesleyan University where he also pitched for the varsity baseball team. Wes founded the Aurora-Southlands branch of Pro Active Physical Therapy in 2009.

Wes has advanced certifications in Functional Trigger Point Dry Needling, Blood Flow Restriction Therapy, Active Release Technique and Graston Soft Tissue Mobilization. He has extensive experience treating a wide variety of orthopedic injuries, sports injuries (youth to professional/Olympic) and neuromuscular impairments across age groups and ability levels. Wes’ clinical interests include, injury rehabilitation and prevention in athletes, overuse injuries in youth athletes and treating sub occipital headache pain. Wes also volunteers his time working with the Colorado Avalanche as well as the Grandview High School and Cherokee Trail High School sports teams. Outside of work Wes enjoys spending time with his wife Lyndsie, daughter Harper and all varieties of sports.

Recovery Lab: The Science of Recuperation

Science and technology are at the forefront of athletic recovery and healing. Recovery labs are popping up around the country, offering athletes of all levels the opportunity to seek the ultimate level of recuperation.

bath clean holiday hotel

These centers boast a myriad of technology in the hopes of reducing recovery time and optimizing return to the next athletic endeavor. Recovery labs have seen tremendous growth, especially in active cities and mountain towns. Despite the escalation of the centers, one must ask, do they help?


First up to investigate – Whole Body Cryotherapy (WBC)

Local cryotherapy is the application of cold with the purpose of dropping tissue temperature to promote local vasoconstriction to control edema, as well as the reduction of pain and muscular spasm.

WBC has been advocated by some to use this modality with athletes to aide in muscle soreness recovery, with supporters stating it returns players more quickly to the field. However, no stringent scientific studies on whole body cryotherapy and their impact on return to play exist. Conversely, local cryotherapy (example, ice pack or cooling/compression knee sleeves) as a modality has a long history with scientific evidence to indicate the use of cryotherapy following injury to decrease pain and edema in the acute setting.

Of note, the FDA has not cleared or approved any WBC device/unit for medical treatment of any specific medical conditions.

“The FDA is also concerned that patients who opt for WBC WBC FDAtreatment—especially in place of treatment options with established safety and effectiveness—may experience a lack of improvement or a worsening of their medical conditions.”



Return to Sport after ACL Surgery

man snowboarding during daytime

Returning to Sport After an ACL Injury

Anterior cruciate ligament (ACL) tears are among the most common orthopaedic sports injuries in the United States. More than 100,000 ACL reconstructions are performed annually with the goal of restoring knee stability and kinematics. After patients complete a systematic progression through phase of rehabilitation, the final hurdle of returning to their preferred sport or activity awaits them. Fitness professionals have the distinct opportunity in helping clients complete this return successfully.

Overview of ACL Reconstruction Rehabilitation

Individuals work tirelessly to progress through each phase of recovery. Early-on, the emphasis is on the return of motion and reduction of swelling. As time progresses, their focus turns to strengthening of the lower extremity musculature, followed by programming to facilitate return to sport. Historically, these recovery phases were time based (the athlete would move to the next phase at a specific number of weeks after surgery); but modern rehabilitation now utilizes criteria to determine readiness to advance. These athletes must meet certain criteria, for example, range of motion and functional strength tests, before moving forward.

Getting into the Gym Early

An additional focus of modern rehabilitation is consideration of the mental impact of injury on the athlete. Surgeons, myself included, and rehabilitation providers now place more emphasis on understanding how being sidelined can influence an athlete’s confidence and may change their typical socialization patterns since they are no longer practicing and playing with their teammates.

man holding round black dumbells

While an athlete moving through the early stages of recovery will not be able to do their full team or sport workout, I believe there is benefit derived from getting to the gym early. The upper body and core may continue to be challenged through consistent workouts as long as special attention is paid to keeping the operative knee safe. A creative fitness professional can maintain the restrictions needed for a full and healthy ACL recovery, but keep the athlete mentally and physically engaged in the gym – with other athletes – working out other areas of their mind and body. This modern method entails a collaborative team approach including the surgeon, treating providers and fitness professionals, but I believe this method will optimize the mental well-being of the athlete and ultimately aide in their recovery.

Recovery and Performance

Fitness professionals are in a unique field and have a wonderful opportunity to prepare athletes for that last hurdle after ACL surgery. Agility and sport-specific drills can be challenging for an athlete to maintain proper form and neuromuscular control. During such drills, attention is focused on providing verbal cueing to best prepare the athlete for game-time demands.

person balancing using one hand

Video analysis, even via a cellular phone camera, is a great tool to implement, as it may be difficult for some athletes to incorporate verbal feedback with visual feedback. In my office, I also perform a series of functional movement and strength tests during the later stages of recovery – this data helps me provide useful information to patients, therapists and trainers and guides the eventual decision to determine readiness to play.


MCL Injury: Return to Play

man athlete sport weights

The large majority of medial collateral ligament (MCL) injuries can be managed without surgery, however, a subset of individuals with  MCL complex injuries benefit from an an atomic repair or reconstruction. Successful return to play necessitates on strict adherence to the post-operative rehabilitation protocol and a focused return to play protocol.

Surgeons assess the recovery of strength compared to the contralateral lower extremity, as well as clinical and objective knee stability. Formal testing may be performed with sport-specific functional tests, such as the Vail Sport Test™; however, no single test exists to meet the functional and sport needs of each athlete, requiring an individualized approach by the  surgeon and the rehab professional.

Multiple factors must be considered. An athlete’s preferred sport may be affected  by geography; for example, flat land versus mountain-based activity, and the demands these activities place on the recovered extremity must be considered.

action activity adult attack

Further, functional testing provides an inaccurate marker for risk of injury because the analysis is performed under non-fatigued conditions. Fatigue protocols may be introduced to return to sport testing, however, we must also acknowledge these additions never mimic a real-world, game day setting perfectly.

At the most basic level, return to sport is appropriate when the athlete can demonstrate appropriate strength on functional testing and proper alignment and control with agility and dynamic movements, as well as objective knee stability on clinical examination.


Weight Lifting Modifications

Weight Lifting Modifications for Anterior Instability
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Exercises to Avoid
  • supine lat pull-overs
  • behind-the-neck pull-downs
  • incline bench presses
  • behind-the-neck bar squats
  • shoulder presses
Exercise Modifications

Bench Presses: Alternate between decline and flat bench; use a narrower grip; hand weights off to trainer.

Rows: Use internal rotation grip.

Lat Pull-Downs: Perform anterior only.

Shoulder Presses: Use Smith machine or power rack.

Bar Squats: Hold bar anterior or use center-of-mass bar.

Exercise Progression

Promote muscular strength, coordination and proprioception. Although many important muscles should be included in the progression, focus particularly on strengthening the internal rotators and adductors.

  • pectorals
  • subscapularis
  • latissimus dorsi
  • anterior deltoids
Primary Exercises
man holding barbell
  • short-arc military presses, 30 degrees of motion
  • prone horizontal abduction in internal rotation
  • forward flexion to 90 degrees
  • prone shoulder extension
  • shrugs
  • sidelying external and internal rotation
  • supine punches
  • biceps curls
Closed-Chain Exercises

Perform weight-bearing arm exercises to engage the glenohumeral joint, stimulate joint receptors and create coordinated contractions of the surrounding muscles.

  • balance board (plank position)
  • push-ups, progressing from modified to traditional to medicine ball exercises, beginning with one hand on the ball and one on the floor, and progressing to both hands on the ball


ACL Injury Prevention

adult athlete cramps field
Photo by Pixabay on

ACL Prevention Programming

The medical community has demonstrated evidence that well designed and supervised injury prevention programs reduce the risk of ACL rupture. ACL injury prevention programs are becoming a mainstay of preparation for sports and recreation with today’s active adolescents and adults.

Those who are already at risk for injury (females or those in pivoting/cutting, high risk sports) are particularly likely to see marked reduction in their risk when engaged in such programs. Since some of the risk factors are non-modifiable (for example, gender), effort focuses on modifiable risk factors, such as neuromuscular control. Maximizing strength, neuromuscular control and technique are the goals of a fruitful ACL injury prevention program, with visual and verbal feedback as a key component of the client’s success.

A safe and effective ACL injury prevention program includes appropriate instruction and supervision.    Ideally, in order to prevent bad habits early-on, ACL prevention programs are initiated at or prior to the onset of puberty. Prevention programs should begin at least 6 weeks prior to the athletic season, with a maintenance program incorporated in-season.

Programming begins with a dynamic warm-up, followed by strength training, plyometrics, agility drills and technique training. Strength training focuses on improving the strength of the core, hip, and gluteal and thigh musculature. Strengthening programs in isolation do not reduce the number of ACL injuries, yet when combined with plyometric training there is a significant reduction in ACL injuries, specifically female athletes.

Plyometric training focus on improving landing biomechanics while incorporating balance training attempts to eliminate or minimize limb asymmetries, which is a potential risk for ACL injury. Cutting and jumping drills comprise the technique training portion. Each of the aspects of training should include frequent feedback cueing, if possible, via video analysis.


The program begins with a dynamic warm-up instead of static stretching to prepare the client’s muscles and joints for the day’s exercises. Strengthening of the quadriceps, hamstrings, hip abductors and core is essential to any ACL injury prevention program. When designing the strength training portion of the program, fitness professionals should think creatively about their client’s preferred sport or recreational activity and how those muscle will be utilized. For example, programming may emphasize eccentric loading reps when working with clients who need to do quick decelerations or stops. Alternatively, an athlete may need to come out more explosively from a static position, such as with a running back, therefore, the chosen exercises should reflect that need.

Plyometric and balance exercises may include single or double-legged hops, box jumps or box drops. These drills may be performed at timed intervals (for example, 30 seconds) or repetition-based (10 repetitions of single-leg hops). Verbal and visual cueing will enable the client to improve their functional and jump landing mechanics. Progression of plyometric and balance drills should remove supports the client uses to perform the exercises.

action air balance beach
Photo by Rafael on

For example, once a simple single leg balance exercise has been mastered, the client can close their eyes to remove the assistance they receive through their visual sense. Another technique would be to have them do a ball toss while remaining in single leg stance to draw their visual sense to the ball instead of a focused point in the distance.

Agility and sport-specific drills are the most difficult exercises for a client to maintain proper joint mechanics and neuromuscular control. During drills such as running backward, stop and start shuttle runs or crisscross lateral running, the fitness professional must be highly focused on providing verbal cueing as these drills most closely represent the real-world demands when returning to sport.

topless man wearing grey and black shorts sprinting on concrete road
Photo by The Lazy Artist Gallery on

Video analysis, even via a cellular phone camera, is a great tool to implement, as it may be difficult for some clients to incorporate verbal feedback with visual feedback. The choice of agility drills is dependent on the clients preferred sport or activity, and should attempt to simulate those activities. Proper mechanics emphasize symmetric lower extremity takeoff and landing for bilateral limb exercises, suitable trunk control and proper knee alignment during takeoff and landing for bilateral and unilateral drills. Proper knee alignment includes knees aligned over toes and toes pointed in a forward direction.

When the athlete is in-season, a maintenance program begins. Maintenance programming should not be performed on game days; instead, perform the program prior to practice or conditioning two to three times per week while in-season.

Author Bio: Catherine A. Logan, MD, MBA, MSPT is an orthopedic surgeon specializing in sports medicine in . She’s also a team physician for the U.S. Ski & Snowboard Association. Logan was a physical therapist and personal trainer for 7 years before attending medical school. She focuses her research on post-surgical rehabilitation protocols and return to play.