Balboni JM, Madhira K, Martinez V, Tung WS, Kennedy JG, Gianakos AL. Effect of blood flow restriction on muscle strength and stability following foot and ankle injury: A systematic review. World J Orthop 2025; 16(6): 106804 [DOI: 10.5312/wjo.v16.i6.106804]
Corresponding Author of This Article
Julia M Balboni, Department of Orthopaedic Surgery, University of New England College of Osteopathic Medicine, 11 Hills Beach Road, Biddeford, ME 04005, United States. jbalboni@une.edu
Research Domain of This Article
Orthopedics
Article-Type of This Article
Systematic Reviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Orthop. Jun 18, 2025; 16(6): 106804 Published online Jun 18, 2025. doi: 10.5312/wjo.v16.i6.106804
Effect of blood flow restriction on muscle strength and stability following foot and ankle injury: A systematic review
Julia M Balboni, Karthik Madhira, Victor Martinez, Wei-Shao Tung, John G Kennedy, Arianna L Gianakos
Julia M Balboni, Department of Orthopaedic Surgery, University of New England College of Osteopathic Medicine, Biddeford, ME 04005, United States
Karthik Madhira, Department of Orthopaedics, New York Institute of Technology College of Osteopathic Medicine, Glen Head, NY 11545, United States
Victor Martinez, Department of Orthopedic Surgery, University of Texas Health San Antonio, San Antonio, TX 78229, United States
Wei-Shao Tung, Department of Orthopaedics, Massachusetts General Hospital, Boston, MA 02114, United States
John G Kennedy, Department of Orthopedic Surgery, NYU Langone Health, New York, NY 10002, United States
Arianna L Gianakos, Department of Orthopaedic Surgery, Yale University School of Medicine, New Haven, CT 06510, United States
Author contributions: Balboni JM and Gianakos AL designed the research study; Balboni JM, Madhira K, and Martinez V performed the research; Tung WS contributed analytic tools; Balboni JM, Madhira K, Martinez V, and Tung WS analyzed the data; Balboni JM wrote the manuscript with support from Gianakos AL and Kennedy JG; Gianakos AL and Kennedy JG critically reviewed the manuscript for important intellectual content. All authors have read and approved the final manuscript.
Conflict-of-interest statement: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Julia M Balboni, Department of Orthopaedic Surgery, University of New England College of Osteopathic Medicine, 11 Hills Beach Road, Biddeford, ME 04005, United States. jbalboni@une.edu
Received: March 7, 2025 Revised: April 1, 2025 Accepted: May 7, 2025 Published online: June 18, 2025 Processing time: 103 Days and 14 Hours
Abstract
BACKGROUND
Poor musculoskeletal recovery following foot and ankle injury can result in chronic instability and persistent muscle weakness. Preliminary evidence has shown that blood flow restriction (BFR) rehabilitation can increase muscle strength and stability, helping to restore physical function and prevent repeated injury.
AIM
To determine whether BFR is more effective than traditional rehabilitation in improving muscle strength, size, and stability after foot and ankle injury.
METHODS
A systematic review and meta-analysis were performed. Articles were retrieved from MEDLINE, EMBASE, and CENTRAL databases. Included studies compared the effectiveness of BFR rehabilitation to traditional foot and ankle rehabilitation exercises. Eligible patients were those with a history of foot or ankle injury. Muscle strength, size, and dynamic balance were assessed by comparing improvements in peak torque, cross-sectional area, and percent muscle activation. Methodological quality assessments were performed using the PEDro scale and Methodological Index for Non-Randomized Studies (MINORS).
RESULTS
Ten studies met the inclusion criteria. Five studies were of good to excellent quality according to the PEDro scale, and 5 studies were of moderate quality as per the MINORS criteria. Two studies compared the effect of BFR and non-BFR rehabilitation on muscle strength; the overall mean difference between the BRF and non-BFR groups was 0.09 [95%CI: (0.05, 0.12), P < 0.0001]. Two studies analyzed muscle activation following BFR and non-BFR rehabilitation; the overall mean difference between the BRF and non-BFR groups was 0.09 [95%CI: (0.05, 0.12), P < 0.0001]. Data on dynamic balance was synthesized from two studies; the mean difference between the BFR and control groups was 1.23 [95%CI: (-1.55, 4.01); P = 0.39].
CONCLUSION
BFR rehabilitation is more effective than non-BFR rehabilitation at improving muscle strength and activation following foot and ankle injury. Additional studies are needed to develop a standardized BFR training protocol.
Core Tip: Blood flow restriction (BFR) involves limiting blood flow to an actively exercising muscle with the goal of inducing an acute hypoxic state. When used in combination with traditional rehabilitation exercises, BFR can improve strength and stability in patients with a history of foot or ankle injury. Our meta-analysis investigated whether rehabilitation involving BFR is more effective than traditional rehabilitation in improving muscle strength, size, and stability after foot and ankle injury.
