Chronic ankle instability (CAI) is a common dysfunctional state in the basketball population accompanied
by pain, weakness and proprioceptive deficits which greatly affect performance. Research evidence has
supported the use of blood flow restriction (BFR) training as an effective treatment strategy for improving
muscle strength, hypertrophy and function following injury in a variety of patient populations. In manag-
ing CAI, it is important to address proximal and distal muscle weakness, pain, and altered proprioception
to reduce the likelihood of re-occurring ankle injury. The ability to mitigate acute and cumulative strength
and muscle volume losses through the integration of BFR after injury has been supported in research lit-
erature. In addition, applications of BFR training for modulating pain, improving muscle activation and
proximal muscle strength have recently been suggested and may provide potential benefit for athletes with
CAI. The purpose of this clinical commentary is to discuss background evidence supporting the implemen-
tation of blood flow restriction training and use a theoretical model for managing CAI as well as to suggest
novel treatment strategies using this method.
Key Words: Ankle instability, blood flow restriction, strength training
Level of Evidence: 5
THEORETICAL APPLICATIONS OF BLOOD FLOW
RESTRICTION TRAINING IN MANAGING CHRONIC
ANKLE INSTABILITY IN THE BASKETBALL ATHLETE
John Faltus, DPT, SCS, ATC, CSCS1
Johnny Owens, MPT2
Corbin Hedt, PT, DPT, SCS, CSCS3
1 University Physical Therapy and Sports Medicine at Clemson
University, Clemson, SC, USA
2 Owens Recovery Science, San Antonio, TX, USA
3 Houston Methodist, Houston, TX, USA
Conﬂ ict of interest:
Author Johnny Owens is a shareholder of Owens Recovery
Science and is a medical consultant for Delﬁ Medical
Innovations Inc. Owens Recovery Sciences has a ﬁ nancial
relationship with Delﬁ Medical Innovations Inc. Johnny
Owens is a medical consultant for the Major Trauma Research
Consortium (METRC). Other authors declare they have no
conﬂ ict of interest in the authorship and publication of this
manuscript or ﬁ nancial interest in the subject matter
discussed in this article.
John Faltus, DPT, SCS, ATC, CSCS
UPTSM, 205 Fike Rec Center,
Clemson University, Clemson SC 29634
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 552
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 553
BACKGROUND AND PURPOSE
Chronic ankle instability (CAI) consists of charac-
teristic sequelae including recurrent sprain, pain,
instability and avoidance of activities1 and is typi-
cally defined as mechanical or functional instabil-
ity.2 Mechanical instability is anatomical laxity in
the stabilizing structures around the ankle mortise
where functional instability is a subjective feeling of
giving away despite the lack of displacement beyond
the normal physiological range of talar motion.3 It
can be a particularly debilitating condition in the
athletic population, with an associated high risk for
re-injury.4,5,6 Time loss from sport due to this injury
is typically associated with increased pain and crep-
itus as well as decreased strength, proprioception,
range of motion and balance.7,8 Multiple proprio-
ceptive impairments have been linked to persistent
functional instability including altered muscle spin-
dle activation of the peroneal musculature, abnor-
mal reflex responses to inversion or supination and
proximal kinetic chain deficits as exhibited by pres-
ence of neural inhibition and associated weakness
in the hip abductors.9,10,11 Furthermore, deficits in
postural control and ankle arthro-kinematic motion
quality were identified in athletes with CAI using
accelerometry.12 Repeat episodes of ankle sprains
commonly occur in CAI and appear to further exac-
erbate instability, associated functional deficits and
the ability to maintain a competitive status.5
The multidirectional and repetitive movement
aspects associated with the sport of basketball can
predispose these athletes to ankle injuries. While
jump landing has been identified as the most com-
mon mechanism of injury in this population, change
of direction, cutting and pivoting movements also
contribute to injury occurrence.5 Over half of total
time missed due to injury in this population has
been attributed to ankle injury.13 Both elite and rec-
reational basketball players of both genders with a
previous ankle injury have also been identified as
being at 4.9 times greater risk for subsequent ankle
injury.5 Therefore, it appears that CAI leads to sig-
nificant time lost in sport and previous injury can
result in greater re-injury risk.
Increased pain associated with CAI greatly affects
a basketball athlete’s ability to return to sport and
perform at an elite level. CAI typically presents with
articular changes and chondral lesions within the
ankle joint which can manifest as chronic pain.14
The combination of altered somatosensory afferent
signaling and efferent motor control deficits result-
ing from ankle ligament sprains negatively affects
the ability to produce desired protective motor
responses in the event of an inversion mechanism.15
The resulting injury pathology then can further
exacerbate faulty mechanical patterns and subse-
quent pain presentation associated with repetitive
injury and articular changes.15
Muscle inhibition which occurs following an ankle
sprain has been documented.8 Perron et al. have
found that significant strength deficits exist up to six
months following injury and may contribute to the
high recurrence of lateral ankle sprain.16 Further-
more, increased resting motor thresholds have been
demonstrated in the peroneus longus muscle, bilat-
erally, in subjects with CAI.17 This would indicate
deficits in corticomotor excitability of the peroneus
longus to control subsequent inversion mechanisms
which may result in re-injury.17 Decreased cortico-
motor excitability was also moderately correlated
to self-reported function which would indicate that
subjects’ perceptions of functional limitations likely
manifests in resulting neuromuscular deficits and
poor motor control.17
Altered neuromuscular recruitment and motor con-
trol patterns are not strictly isolated to the ankle joint
in presentations of CAI. Proximal muscle weakness
can contribute to functional deficits which persist
following an ankle sprain.9 In particular, weakness
of the gluteal musculature can contribute to altered
landing mechanics as a result of poor shock absorp-
tion and decreased force attenuation throughout the
lower quarter.18 In the case of basketball athletes,
landing has been identified as a common mecha-
nism of injury for ankle sprains so failing to address
these limitations is problematic.5 Therefore, it is
important to focus on the entire kinetic chain dur-
ing the rehabilitation process with strategies which
effectively address these underlying neuromechani-
cal deficiencies and altered movement patterns.
The purpose of this clinical commentary is to dis-
cuss background evidence supporting the imple-
mentation of blood flow restriction training and
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 554
into the intervention. Giles at al found that, when
compared to standard quadriceps strengthening, low
load exercise with BFR greatly reduced pain in daily
living in subjects with patellofemoral pain (PFP)
following an eight-week program.32 The conceptual
understanding for these changes is that subjects
were able to improve quadriceps muscle strength
with BFR while tolerating loads lower than those
required to make similar gains utilizing traditional
quadriceps strengthening activities.32 Given the
association of quadriceps muscle weakness and PFP
and the increases of knee extensor torque with sig-
nificantly decreased reported pain in this BFR study
group, it has been hypothesized that BFR training
can potentially modulate pain through central and
neural adaptations which influence strength gains.32
Additionally, subjects with anterior knee pain dem-
onstrated an acute reduction in pain immediately
after BFR resisted quad exercises up to 45 minutes
post treatment.33 Although, mechanisms behind
a potential reduction in pain through the applica-
tion of BFR have not been elucidated, intensity of
exercise may play a role in the endogenous opioid
response.34 Despite BFR being performed under low
loads, when performed under continuous occlu-
sion (ie..no deflation cycles during rest periods), the
metabolic stress produced in the working muscle is
similar to exercise at much higher loads.35 This may
allow patients in the early stages of rehabilitation
or with chronic painful injuries to promote cortical
release of opioids to allow for tolerance of rehabilita-
tion programs. Although not directly related to pain
inhibition, increases in corticomotor excitability
have been demonstrated for up to 60-minutes post
continuous BFR exercise possibly due to altered sen-
sory feedback via group III and IV afferents.36 Future
BFR studies are warranted that assess pain in clinical
populations and the peripheral and central mecha-
nisms of pain modulation that may be involved.
The work by Brandner et al. provides promise as to
the applications of BFR as a potential neuromodu-
lator.36 Following an acute bout of upper extremity
exercise utilizing BFR, corticomotor excitability of
the biceps brachii rapidly increased and remained
elevated for up to 60 minutes post exercise.36 It
is theorized that these adaptations result from
use a theoretical model for managing chronic ankle
instability in the basketball athlete to suggest novel
treatment strategies using this method.
DESCRIPTION OF TOPIC: THEORETICAL
APPLICATIONS FOR CAI
The inability to utilize loads sufficient to induce
strength and hypertrophy responses after ankle
injury due to pain or healing processes may limit
rehabilitation progression. Recently, blood flow
restriction (BFR) training has emerged as a novel
treatment technique due to its ability to create robust
muscle anabolic responses similar to high load train-
ing while utilizing very low loads.19 BFR has shown
to be an effective treatment strategy for diminish-
ing disuse atrophy and weakness during periods of
immobilization as well as increasing strength and
hypertrophy in post-op patient populations.20,21,22
Additionally, BFR has been shown to enhance func-
tion in blast trauma patients and injured military per-
sonnel23 as well as improve performance outcomes
as part of a comprehensive strength and condition-
ing program in the high-performance athlete.24,25
American College of Sports Medicine guidelines rec-
ommend utilization of 60-80% of a one rep max (1
RM) load targeting major muscle groups 2-3 days per
week in order to achieve strength and hypertrophy
gains from resistance training.26 However, similar
gains utilizing BFR have been shown within a two-
week training period at loads of much lower intensity
(20-30% 1 RM).27,28 Although the exact mechanism
is not fully understood, increased muscular fatigue
under hypoxia, cellular swelling and upregulation of
muscle protein synthesis via mammalian target of
rapamycin complex 1 and mitogen-activated protein
kinases (MTORC1/MAPK) which are responsible for
protein synthesis and cell signaling, have been sug-
gested to play a role.29,30,31 While most of these afore-
mentioned studies focused on the lower extremity
in general and post-operative conditions, currently
no studies examining the utilization of BFR with CAI
have been published.
Chronic Pain Management
Chro nic pain which results from CAI can be debili-
tating if not properly managed. Recently published
clinical trials that have assessed pain have reported
significant reductions in pain if BFR is incorporated
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 555
of BFR (Table 1) to attenuate muscle atrophy and
weakness commonly associated with disuse.20,21 For
optimal motor control in these early stages of rehab,
it is important integrate external focus of atten-
tion strategies which have been shown to increase
muscle excitability.43,44 These strategies may include
use of a metronome for repetition pacing or bio-
feedback, especially during exercises which actively
recruit the peroneal and gluteal muscles which have
been identified as commonly inhibited and weak-
ened muscle groups in CAI.9,17,43,44
The proprioceptive, balance and motor control deficits
associated with CAI have been well documented.8,15,17
Exercises which challenge the proprioceptive system
on both stable and unstable surfaces with altered
visual and somatosensory feedback have been effec-
tive for reducing the recurrence of ankle sprains.45
Examples would include single leg static balance on
an unstable surface, multidirectional weight shifting
activities and reactive drills (Figures 2 and 3). These
exercises can target basketball specific demands by
integrating passing (Figure 3), ballhandling and reac-
tive movement drills utilizing verbal or visual cues,
with resources such as a light reactive system (Fig-
ure 2) or a laser pointer, in order to emphasize an
external focus of attention. Exercise progressions
would include band-resisted movements replicating
basketball specific patterns such as jab steps, close
increased excitability of corticospinal circuits which
results in long-lasting adaptations similar to those
which occur following heavy-load resistance train-
ing.36 Further research evidence is needed to suggest
whether utilization of BFR can potentially improve
motor recruitment and neural excitability of inhib-
ited or weak musculature following injury, such as
CAI as addressed conceptually in this commentary.
Kinetic Chain Considerations and Proximal
BFR training would appear to be an effective treat-
ment strategy that can be implemented to improve
proximal muscle strength. Abe et al. found signifi-
cant increases in gluteal muscle strength and hyper-
trophy following a two-week BFR program compared
to a control group, implementing BFR with exer-
cises that included the low load squat and leg curl.37
Despite distal occlusion, proximal gains may result
from fatigue of musculature below the cuff requiring
more recruitment of synergistic proximal muscles,
a backflow effect into musculature above the area
of restriction or a potential systemic effect second-
ary to the anabolic cascade created by BFR.38,39,40,41
Potential benefits of proximal effects from this train-
ing strategy may allow safe implementation during
both early rehabilitation and return to sport specific
exercises which challenge proprioception and bal-
ance to incorporate proximal and distal effects.
DISCUSSION: CLINICAL INTEGRATION
With a comprehensive understanding of the research
evidence behind BFR training, one can then attempt
to translate this information into applied clinical
practice. Loenneke et al. proposed a clinical integra-
tion model which advocates for utilization of BFR
throughout various phases of injury rehabilitation.42
The four proposed phases of BFR implementation
include: 1) BFR alone during periods of bed rest, 2)
BFR combined with low-workload walking exercise,
3) BFR combined with low-load resistance exercise,
and 4) low-load BFR training combined with tradi-
tional high-load resistance exercise.42 In cases of pro-
longed immobilization or restricted weightbearing
where BFR walking may not be appropriate, low-load,
resisted, open kinetic chain exercises, such as ankle
ROM, leg lift (Figure 1) and bridge variations may
be used safely and effectively with implementation
Figure 1. Open kinetic chain leg lift variation for hip muscle
strengthening with BFR (Delﬁ Medical Innovations Inc. Van-
couver, BC Canada).
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 556
Table 1. Integration of BFR with Rehabilitation for Ankle Instability.
Figure 2. BFR static single leg balance on unstable surface
with integration of light system (Dynavision D2 -Dynavi-
sion International, LLC West Chester Township, OH; Delﬁ
Medical Innovations Inc. Vancouver, BC Canada)
Figure 3. BFR single leg stability with reactive passing com-
ponent (BOSU® Ashland, OH; Delﬁ Medical Innovations Inc.
Vancouver, BC Canada).
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 557
As the athlete progresses back into sport specific
activities, BFR training can still play an integral role
in developing strength and performance attributes
when combined with a traditional strength and con-
ditioning program. Implementation of BFR would
follow a high load-low load model whereas BFR
exercises would be implemented intra-session in a
low-load strategy following traditional high load resis-
tance exercises to enhance hormonal responses and
strengthening benefits following the session.49 An
example as it applies to the lower extremity would be
completing modified bodyweight squats or leg press
exercise at 20% maximal load utilizing BFR at the end
of a lifting session which consisted of near maximal
(80% max) squat and deadlift exercises. This strategy
would be especially beneficial in transferring BFR
training adaptations which occurred during the rehab
process over to individualized strength and condition-
ing programs that are implemented upon return to
play in athletes with CAI. Lastly, nutritional consid-
erations must be addressed in the rehabilitating an
athlete using BFR as part of a comprehensive perfor-
mance enhancement program. Due to the increased
protein synthesis response following BFR training, it
is important the athlete consume 20-35 grams of pro-
tein post-activity for muscle tissue healing and recov-
ery.50 Whey protein is preferred due to both its rapid
digestion and absorption as well as greater leucine
content which further enhances protein synthesis.50
Safety is of paramount concern when considering
rehabilitation programs for injured individuals. BFR
utilizes non-traditional methods of building strength
and inducing muscle hypertrophy, so reasonable
vigilance is required of rehabilitation professionals
to maintain safety.
In the instance of tourniquet systems, research on
safety and efficacy has consistently been moni-
tored with technological advancements.51,52,53 In
the surgical environment, tourniquets are applied
for upwards of several hours at a time to provide a
bloodless operating field.51 Generally, it is suggested
that tourniquet time is minimized as much as pos-
sible during surgeries such as total knee arthro-
plasty (TKA) to mitigate risks such as deep vein
thrombosis (DVT), wound infection, hematoma, and
out steps, drop step squats and lateral slides (Figure
4). These exercises can be safely integrated with BFR
training to further enhance proximal strengthening
and neuromuscular control (Table 1).
BFR training can both complement and enhance
the conditioning aspects of a return to play rehab
program. A BFR treadmill walking protocol, per-
formed six days per week for two weeks, resulted in
significant improvements in maximal aerobic capac-
ity, maximal ventilation and anaerobic capacity in
male collegiate basketball athletes.46 The protocol
consisted of five periods of three-minute working
sets at 4-6 km/h and 5% grade with 60 second inter-
set rest.46 Similar findings occurred, in addition to
increased size and strength of the leg muscles, fol-
lowing both BFR cycling and low-intensity walking
programs.47,48 This indicates that, when utilized as
part of a non-impact conditioning program, BFR
training can improve overall cardiovascular fitness
when combined with aerobic activity. This is espe-
cially important during rehab phases where limita-
tions in mobility and dynamic loading do not permit
the athlete to run or perform on-court conditioning
activities. Athletes with CAI who sustain recurrent
ankle injuries would likely benefit from such a pro-
gram during periods when dynamic loading activi-
ties are limited in order to promote tissue healing
and recovery from acute injury.
Figure 4. BFR band resisted drop step squat (Delﬁ Medical
Innovations Inc. Vancouver, BC Canada).
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 558
have demonstrated positive efficacy and good safety
with very few ill effects. Under skilled supervision
and with appropriate equipment, BFR can be used as
a safe alternative to traditional high-intensity exercise
to develop strength and muscular hypertrophy.
BFR training could theoretically be safely and
effectively implemented as part of a rehabilitation
program addressing deficits associated with CAI.
Benefits of BFR training include minimizing mus-
cle weakness and atrophy associated with the acute
phase of injury, potentially modulating pain related
to injury conditions, facilitating tissue healing and
enhancing muscle hypertrophy and strength gains
when combined with low load exercise. Evidence
also suggests that BFR training can enhance both
aerobic and anaerobic properties when integrated as
part of a cycling or walking protocol. These strategies
and suggestions provided in this commentary could
be especially helpful in cases of CAI where recurrent
injury due to both local and proximal weakness, pain,
and both decreased proprioception and function con-
tribute to periods of low loading or limited sports spe-
cific activities during rehab where tissue healing and
recovery is prioritized. Safety of the athlete should be
prioritized through utilization of appropriate medical
devices by trained medical personnel.
1. Guillo S, Bauer T, Lee J et al. Consensus in chronic
ankle instability: aetiology, assessment, surgical
indications and place for arthroscopy. Orthop
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ecchymosis.53 Similar risks can be expected during
BFR training as with the use of tourniquet devices
including pneumatic cuffs and straps. However, at
lower levels of constriction and reduced tourniquet
time, these risks are likely minimal.
Research on safety during BFR and exercise is cur-
rently limited, however several measures have
been examined with regard to outcomes of exercise
with BFR training versus regular exercise. A recent
review by Loenneke and colleagues examined
peripheral blood flow hemodynamics with BFR and
determined that changes in blood flow appear to
occur in a “similar fashion as regular exercise”.54 Fur-
thermore, Lida et al observed certain central cardio-
vascular responses to BFR and found that subjects
exhibit elevated cardiac markers (blood pressures,
heart rate) in occlusive protocols compared to con-
trol groups.55 However, these values are still far less
than those performing high intensity exercise, and
low-intensity exercise (20% 1RM) with occlusion
may be a safe alternative.55
The potential for thrombosis and clotting can be a
serious risk when considering patients in a rehabilita-
tive state. Complete vascular occlusion can be expe-
rienced with strenuous, high-intensity exercise with
tourniquets and has been shown to increase the for-
mation of thrombus.56 However, reported issues of
thrombosis with BFR are as little as 0.06% in some
studies.57 Others have found that neither prothrombin
time (PT) nor D-dimer levels increased following BFR
training.58 This may be due to the fact that occlusion
levels during most researched BFR protocols do not
promote maximal occlusion, given that the device has
a means of pressure regulation. suggesting cuff pres-
sures be relative to cuff width and limb circumference
to protect the neurovasculature of the extremity.54,59,
60 Nerve conduction velocity (NCV) can be affected
significantly by tourniquet pressure, giving rise to fur-
ther research into electrophysiological changes dur-
ing BFR.61 The use of wide tourniquets significantly
reduces pressures needed for vascular occlusion and
has been recommended in clinical settings.62 Addition-
ally, personalized BFR utilizes Doppler technologies
to individualize tourniquet pressures for each patient,
providing further safety benefit.63
Ultimately, further investigation into BFR protocols
and their safety is warranted. However, most protocols
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 559
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50. Tang J, Moore D, Kujbida G, Tarnopolsky M, Phillips
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