How do you work with athletes that are injured and out of competition and practice for extended periods of time? In addition to rehabbing the injured body part, there are other goals that can be accomplished during this time away from competition and practice.

In the video clip below Fred Hale, assistant strength and conditioning coach at Eastern Michigan University, discusses his approach to dealing with injured athletes.

Coach Hale begins by discussing how difficult it is for injured athletes. Many of them have worked very hard in preparation for the season and when an  injury occurs, they can have a tough time. Many times the injury causes them to miss practice and games. In some cases the athlete is devastated to find out that they will miss the entire season.

Many of these individuals identify themselves as athletes. When that is taken away from them it can be very difficult for them. They will obviously have physical limitations that can be tough to handle. They also may have some things to deal with mentally. They may be depressed, angry, frustrated and might feel disconnected from the team. They might even exhibit changes in eating and study habits.

Many times it is the strength and conditioning/training staff that will be spending the most amount of time with injured athletes. Coach Hales states that it is important to show that you care and that this could be a time to “get really strong and comeback stronger than ever”

He begins by immediately testing, putting together a plan and setting goals. This is a time to do three things in addition to rehab:

• Increase hypertrophy
• Gain gtrength
• Fix imbalances in non-injured areas

Coach Hale also discusses his workout structure and how the determine set/reps based on goals and Time Under Tension schemes

This clip is from Coach Hales presentation entitled  Coming From Within: Working with Injured Athletes at Glazier Athletic Performance Clinic. For more information about how to gain access to his entire presentation, as well as hundreds of other great clinic presentation, click the link Glazier Athletic Performance Clinics

The YouTube video below has audio, so please make sure that your volume is turned up and that you have access to the site. Note some schools block access to YouTube.

 

This article was contributed by Training and Conditioning

It’s been almost 20 years since sports medicine professionals first tried an accelerated approach to rehabbing surgically repaired ACLs. The debate about its safety continues.

By R.J. Anderson

R.J. Anderson is an Assistant Editor at Training & Conditioning. He can be reached at: rja@MomentumMedia.com.

Thirty years ago, when an athlete tore an anterior cruciate ligament (ACL) the prognosis was pretty simple: His or her career was over. Fifteen years ago, most athletes with the same injury could hope to return to their sport in a year. These days, when an athlete tears an ACL, some doctors will clear them to rejoin the team in as few as eight weeks.

Advances in surgical techniques combined with adaptations in rehab protocols have produced some amazing comebacks. Basketball players who suffer an ACL injury during the summer are ready for practice in November. Soccer athletes who go down with an ACL in a preseason game are rejoining their teams for postseason competition.

However, as some sports medicine professionals continue to push the envelope on athletes returning to play, others wonder about the wisdom of this trend. Are there drawbacks to athletes resuming competition so soon after surgery? Has ACL rehab become too accelerated?

There are no clear-cut answers. With little clinical data available to detail the short- and long-term consequences of ACL rehab, identifying when an ACL graft is ready to absorb the pounding of competitive athletics is really just an orthopedic surgeon’s best guess.

“There aren’t great randomized controlled trials that say, ‘Aggressive is great’ or ‘Conservative is great,'” says James Oñate, PhD, ATC, Assistant Professor in the Graduate Athletic Training Program and Director of the Sports Medicine Research Laboratory at Old Dominion University, who defines an accelerated program as taking three months or less and a conservative approach as taking nine months or longer. “There is, however, a lot of personal and anecdotal information out there.”

Pros & Cons
Donald Shelbourne, MD, Orthopedic Surgeon at the Shelbourne Clinic at Methodist Hospital in Indianapolis, is widely credited with pioneering some of the most accelerated rehabs following ACL reconstruction. Though his athletes are back competing in very short periods of time after surgery, Shelbourne doesn’t want his approach labeled as “aggressive.”

“Aggressive is a misnomer,” says Shelbourne. “We’re not trying to be aggressive, we’re trying to be restorative and get the patient’s motion back as quickly as possible. Rehab can take a long time when people go to therapy with restricted motion, poor strength, or a swollen knee.

“Our goal is for our athletes to have two knees that are the same as they were before the injury–how long that takes doesn’t matter,” adds Shelbourne. “If you’re an athlete and I say you can’t play sports for six months, what’s that based on? What happens in five months, three weeks and six days that makes it so you can’t play sports, but the next morning you can?”

Shelbourne’s clinic has been using an accelerated approach for 17 years on over 5,000 athletes. “Since 1989 we’ve allowed people to go on their own timetable. We’ve documented every patient and haven’t found any correlation between returning in any certain time period and having problems,” says Shelbourne. “When you deal with athletes, you can’t use generalities and vague guidelines. People who recommend a certain time period are not basing their recommendations on facts–certainly not any clinical data.”

Once motion and strength are symmetrical for each leg and there’s no pain or swelling, Shelbourne believes the athlete is ready to return to practice with his or her team. “Everybody makes it way too complicated,” he says. “An ACL rehab program should have a simple goal of getting motion and strength back to normal as soon as possible. We shouldn’t have all of these theoretical rules. There’s no reason to restrict motion and there’s no reason to restrict strength if there isn’t any pain or swelling.”

While Shelbourne preaches simplicity, other surgeons aren’t so sure. Because the biology of ACL repairs is largely unknown, many sports medicine professionals prefer a more conservative timetable before returning an athlete to competition.

“I don’t think two months is enough of a trial,” says Russell Zelko, MD, Orthopedic Consultant to Cornell University’s athletic program. “I think it takes far longer to strengthen that ligament–I would say six months minimum. Rehab only addresses the structural integrity of the graft to a certain degree. To me, it’s more a matter of time, similar to how a fracture heals.

“I don’t think a return-to-play decision should be based on the mere fact that you look fully rehabilitated,” Zelko continues. “It needs to be based on other factors, like the biology of the repair and how long it takes for the ACL to revitalize. When you do an ACL reconstruction using other tissue, that tissue essentially dies and has to revascularize. The leg may be functionally rehabilitated, but the graft itself may not be ready to take the stress of going back to participation after only a couple of months.”

Shelbourne counters that following a standard six-month time frame before releasing an athlete is based on arbitrary criteria. “In our research, we’ve documented the incidence of athletes having a re-injury or injuring an opposite knee, and we’ve found there’s no time period that indicates a higher rate of incidence. So why wait?” he asks. “We’ve never had a patient break their graft because they went back too soon. Once you’re symmetric, you have the same chance of getting hurt whether it’s two, four, six, or 10 months post-surgery. Give the athlete a goal of being symmetric. If they reach it, let them go back and play.

“We published a paper on this 16 years ago, but a lot of people still say, ‘Patients who go back before six months are at risk of breaking their graft,'” Shelbourne adds. “It’s like the old adage that you shouldn’t go swimming until an hour after you’ve had lunch. Has anybody ever documented that?”

Luga Podesta, MD, Physical Medicine and Rehabilitation Specialist at Ventura Orthopedics, Head Team Physician for the Los Angeles Avengers of the Arena Football League, and a consultant to the Los Angeles Dodgers, feels there are psychological factors that need to be taken into account before releasing an athlete to return to play after an ACL surgery, and thus is not a proponent of accelerated rehabs. If there is a swelling setback because of being a little too aggressive and returning to competition too soon, Podesta feels it can destroy the athlete’s confidence.

“That’s a huge factor for all my patients, including my professional athletes,” says Podesta. “As much as they want to push and get back, it’s often tough to have them back playing at a high level, even at six months, because they’re reluctant to try certain types of cuts and movements.

“They’re still in an injured mindset and they’re constantly thinking about their knee,” Podesta adds. “And in trying to protect that knee, they open themselves up for other types of injuries.”

The Process
For ACL reconstruction surgeries, Shelbourne uses the contra lateral patellar tendon technique, in which the tendon graft is harvested from the non-injured knee, and his rehab protocols address the donor and the ACL graft sites separately. Despite having to follow a different rehab program for each knee, Shelbourne’s patients often move through the process quickly, with some athletes returning to practice two months post-surgery. For Shelbourne, returning a patient’s injured knee to pre-injury ROM levels as soon as possible is the number one goal during the early stages of rehab and the key to a successful outcome.

In the days leading up to surgery, Shelbourne’s physical therapists work with each patient to make sure they can bend their knee at least 140 degrees. After the surgery, patients stay in the hospital overnight then are sent home to spend the next five days in bed with their knee wrapped in a cold compression cast and elevated over their heart while using a Continuous Passive Motion (CPM) device to extend and flex the knee.

“If you can prevent swelling and hemarthrosis and not lose motion or allow any pain to occur, then the patient is going to recover more quickly,” says Shelbourne. “If a patient is allowed to walk around immediately after surgery, they may be lucky to have 90 degrees of flexion after one week. They’ll probably have a lot of swelling, walk with a limp, and can’t possibly envision going back to sports in six weeks.”

After spending a week off their feet, Shelbourne’s patients begin traditional knee flexibility and strengthening exercises. “If someone wants to get back to sports quickly, their biggest challenge is regaining the strength in the grafted leg where the patellar tendon was taken from,” says Shelbourne. “If the patient is really motivated, they can get that strength back to a symmetric level within six weeks. Of course, if they get swelling or lose motion during that time, we back them off.”

Jeff Pierce, ATC, Head Athletic Trainer at Villanova University, says that his approach to ACL rehabs has become more accelerated over the past five years. This shift intensified even more after rehabbing one of his athletes who was operated on by James Andrews, MD, Co-Founder of the Alabama Sports Medicine and Orthopaedic Center in Birmingham, Ala.

“Before we worked with Dr. Andrews, we thought we were somewhat aggressive in our approach,” says Pierce. “But after seeing what he does, we realized how much more aggressive we could get. Dr. Andrews and his group are not afraid to work through a patient’s discomfort. For instance, the first day post-surgery they have patients in the clinic bending their knee to 90 degrees–that blew me away.

“The goal is for the athlete to not lose any strength or motion, so we work on regaining motion and initiate the strength building phase right away,” continues Pierce. “The athletes also do straight-leg raises and use Russian Stimulation to electrically activate the quad. They perform hamstring curls within the limitations of the range of motion to keep the patella moving so it doesn’t adhere. To help control swelling, when the athletes aren’t working out they wear temperature-controlled compression wraps.”

During the second week, Pierce says protocol typically calls for standing weight shifts and mini squats to 30 degrees. At the two-week mark, if the athlete is pain-free and doesn’t have any swelling in the knee, Pierce adds weight to the exercises–typically one to two pounds at first, and progresses from there. From weeks four to seven, athletes begin to do pool work, step-ups, closed-chain activities, and leg presses using minimal weight.

Injured athletes attend rehab sessions twice a day for about an hour and a half per session, depending on how the knee responds. “If there is an increase in swelling, we back off,” Pierce says. “But that’s not something we’ve seen yet with athletes who have followed this protocol.”

Bill Knowles, ATC, CSCS, Athletic Trainer and Director of iSPORT TRAINING at the Vermont Orthopaedic Clinic in Rutland, Vt., feels a key to an accelerated process is introducing balance and proprioception work, closed chain exercises, and functional training during the first eight weeks post surgery. “To me, the goal of an accelerated rehab program should be to increase the preparation period prior to return to sport,” says Knowles, who calls this the reconditioning period.

“I try to run progressive programs that give the athlete a longer period of time–even if it’s a month or two–to train for competition. It allows them to slowly work up to training at a higher level, which better prepares them and decreases the risk of injury because they spend more time practicing and conditioning for their sport.

“You can do all the sport-specific training you want, but you won’t know how well you’ve progressed until you start working in a high intensity environment using unplanned movements,” adds Knowles, who works with high school, college, professional, and Olympic athletes. “You need a fairly significant volume of that kind of work to best prepare your athlete for performance and to decrease the risk of re-injury, which can mean two, four, or six weeks of practice before the first game. It really depends on the individual and the severity of their injury.”

For Shelbourne, allowing a patient to return to play is based on having both legs symmetric in ROM and strength at pre-injury levels. However, even though he may clear athletes to return to their teams, they do not practice every day, and for the first four months, Shelbourne tells them to expect some swelling and loss of motion from time to time. To build up their strength and limit swelling, Shelbourne restricts an athlete’s participation to one day on, one day off, then progresses them to two days on and one day off.

“It’s like spring training for baseball players–it takes a while before you’re really ready to compete at the same level as before you got hurt,” says Shelbourne. “But you are able to do it safely.”

Sumpter’s Story
Pierce first used Andrews’s rehab protocols with Curtis Sumpter, a star forward on Villanova’s men’s basketball team. Sumpter re-ruptured his left ACL during a practice on Oct. 19, 2005, six months after the initial tear during an NCAA Tournament game the previous March.

After the first injury, Sumpter, then a junior and a highly regarded NBA prospect, underwent allograft reconstruction surgery. “The first time around, Curtis’s body just didn’t accept the allograft and the tendon never vascularized,” says Pierce. “For Curtis’s second surgery, we went to see Dr. Andrews [who did not perform the initial surgery]. He said the rupture was an unexplainable complication that can happen with an allograft procedure and also he told us we couldn’t have done anything during rehab that would have prevented it.”

In November 2005, Andrews performed an autograft procedure on Sumpter’s knee. Immediately after the surgery, Andrews and his staff began the aggressive rehab.

After following Andrews’s rehab protocols for three months, Sumpter was deemed physically able to rejoin his teammates during their February postseason run. His knee was considered healed, and Andrews felt there was little risk of re-injury. However, Sumpter lacked explosiveness and had a very difficult choice to make: join his teammates in a reduced role and play in the NCAA Tournament, thus forfeiting his final year of eligibility, or take a medical redshirt and return stronger and more confident next season.

“We explained to Curtis and his family that he had not played since October and the likelihood of him picking up where he left off would be very slim,” says Pierce. “We also told him what to expect if he tried to come back right away–possibly developing patella tendonitis, fusions in the knee, swelling that would allow him to be on the floor one day, then have to sit out for the next two. We told him it would be a constant battle all the way through.”

After a few practices and much deliberation, Sumpter realized that he wasn’t ready to compete at an elite level and he decided not to return for the 2006 postseason. “There’s no question he made the right decision,” Pierce says. “At that point, we slowed things down and started working toward getting him ready for the next season.”

After a spring and summer of ramping up his workouts, Sumpter returned for the 2006-07 season in great shape and with the confidence he had before the initial injury. He played over 30 minutes a game, averaged 17.4 points per contest, and led the Wildcats to a berth in the NCAA Tournament.

No Cookie Cutters
According to Oñate, there are no easy solutions to the aggressive vs. conservative rehab debate. “I sit on the fence on this issue because I don’t think there is a right or wrong answer for every athlete,” he says. “There’s not a lot of evidence heavily weighted toward one side or the other. It’s a boxing match, and both sides are throwing good punches.”

Oñate feels there are instances that call for an aggressive plan. In those cases, he stresses a need for open lines of communication between the surgeon, athlete, athletic trainer, physical therapist, and anyone else involved in the process such as strength coaches, parents, and sport coaches. “There should be a game plan among all of them,” he says. “That plan starts with assessing the patient’s goals and adjusting the rehab program accordingly.”

Knowles agrees that the key is learning how to customize a plan for each athlete. With so much new information available, it’s up to the athletic trainer and orthopedic surgeon to design a protocol that fits the patient’s needs. “No matter which program you follow, you must have a strong strength and conditioning background and know how to manage an athlete,” Knowles says.

Oñate stresses it’s important to understand that ACL rehab is a process, not a program. “And a process should constantly evolve,” he says. “It can’t be one size fits all.”

SIDEBAR: One-Year Rule
Brian Roberts, MS, ATC, Director of the Center for Medicine and Sport in Chino, Calif., says in the last five years, he’s encountered an increase in high school athletes–especially girls’ soccer players–re-rupturing ACL grafts. And he blames the re-injury surge on overzealous parents and coaches pushing young, elite-level athletes to return to play before they are physically and mentally ready.

“Part of the reason why the incidence rate has risen is the athletes don’t appreciate the amount of time it takes for a graft to vascularize and heal the way it’s supposed to,” says Roberts, who works with high school, college, and professional athletes. “And unfortunately, in this age of HMOs, a lot of the athletes aren’t getting great post-op rehab. Kids are being discharged too early, they’re not following up with an athletic trainer, and in many cases, they’re not getting the functional drills and assessment tools they need to return at full strength.

“Another problem is that we don’t really have clear criteria that indicates when a graft is ready to be stressed,” he continues. “Coaches and parents see that the kids are able to run, and they assume the natural progression is for them to start playing again. In many cases, that’s just not true.”

As a result, Roberts began telling his patients that the return-to-play time after an ACL tear is one year post-surgery. Doing so, he says, has helped decrease the re-rupture rate.

“In this profession, you can’t be afraid to be a bad guy when holding somebody out longer than they’d like,” says Roberts. “I get calls from coaches all the time asking when a kid can return. So I ask the coach, ‘Are you prepared to assume the responsibility for that player if they return too early and hurt themselves?'”

This article was provided by Training and Conditioning

A study conducted by the University of Wisconsin School of Medicine and Public Health and funded by the National Federation of State High School Associations (NFHS) Foundation revealed that high school athletes who specialize in a single sport sustain lower-extremity injuries at significantly higher rates than athletes who do not specialize in one sport.

The study was conducted throughout the 2015-16 school year at 29 high schools in Wisconsin involving more than 1,500 student-athletes equally divided between male and female participants. The schools involved in the study represented a mixture of rural (14), suburban (12) and urban (3) areas, and enrollments were equally diverse with 10 small schools (less than 500 students), 10 medium schools (501-1,000 students) and nine large schools (more than 1,000 students).

“While we have long believed that sport specialization by high school athletes leads to an increased risk of overuse injury, this study confirms those beliefs about the potential risks of sport specialization,” said Bob Gardner, NFHS executive director. “Coaches, parents and student-athletes need to be aware of the injury risks involved with an overemphasis in a single sport.”

Athletes who specialized in one sport were twice as likely to report previously sustaining a lower-extremity injury while participating in sports (46%) than athletes who did not specialize (24%). In addition, specialized athletes sustained 60 percent more new lower-extremity injuries during the study than athletes who did not specialize. Lower-extremity injuries were defined as any acute, gradual, recurrent, or repetitive-use injury to the lower musculoskeletal system.

“While we have long believed that sport specialization by high school athletes leads to an increased risk of overuse injury, this study confirms those beliefs about the potential risks of sport specialization,” said Bob Gardner, NFHS executive director. “Coaches, parents and student-athletes need to be aware of the injury risks involved with an overemphasis in a single sport.”

Among those who reported previously sustaining a lower-extremity injury, the areas of the body injured most often were the ankle (43%) and knee (23%). The most common type of previous injuries were ligament sprains (51%) and muscle/tendon strains (20%).

New injuries during the year-long study occurred most often to the ankle (34%), knee (25%), and upper leg (13%), with the most common injuries being ligament sprains (41%), muscle/tendon strains (25%), and tendonitis (20%).

In addition, specialized athletes were twice as likely to sustain a gradual onset/repetitive-use injury than athletes who did not specialize, and those who specialized were more likely to sustain an injury even when controlling for gender, grade, previous injury status, and sport.

Thirty-four (34) percent of the student-athletes involved in the Wisconsin study specialized in one sport, with females (41%) more likely to specialize than males (28%). Soccer had the highest level of specialization for both males (45%) and females (49%). After soccer, the rate of specialization for females was highest for softball (45%), volleyball (43%), and basketball (37%). The top specialization sports for males after soccer were basketball (37%), tennis (33%), and wrestling (29%).

The study, which was directed by Timothy McGuine, PhD, ATC, of the University of Wisconsin, also documented the effects of concurrent sport participation (participating in an interscholastic sport while simultaneously participating in an out-of-school club sport), which indicated further risk of athletes sustaining lower-extremity injuries.

Almost 50 percent of the student-athletes involved in the survey indicated they participated on a club team outside the school setting, and 15 percent of those individuals did so while simultaneously competing in a different sport within the school. Seventeen (17) percent of the student-athletes indicated that they took part in 60 or more primary sport competitions (school and club) in a single year. Among those student-athletes in this group who sustained new lower-extremity injuries during the year, 27 percent were athletes who specialized in one sport.

The student-athletes involved in the study were deemed “specialized” if they answered “yes” to at least four of the following six questions: 1) Do you train more than 75 percent of the time in your primary sport?; 2) Do you train to improve skill and miss time with friends as a result?; 3) Have you quit another sport to focus on one sport?; 4) Do you consider your primary sport more important than your other sports?; 5) Do you regularly travel out of state for your primary sport?; 6) Do you train more than eight months a year in your primary sport?

Although some sports (field hockey, lacrosse) are not offered in Wisconsin and were not included in the study, the study concluded that since specialization increased the risk of lower-extremity injuries in sports involved in the survey it would also likely increase the risk of injuries in sports that were not a part of the study.

The above content is a press release from the NFHS.

At the University of Florida, rehabbing athletes can be found lifting low loads with a tourniquet fastened around their injured limbs. Called blood flow restriction training, this method is getting them back to activity faster and stronger.

This article first appeared in the July/August 2016 issue of Training & Conditioning.

By Paul Silvestri and Johnny Owens

Paul Silvestri, MS, LAT, ATC, is Associate Director of Sports Health and Head Athletic Trainer for Football at the University of Florida. He can be reached at: PaulSi@gators.ufl.edu.

Johnny Owens, MPT, is Medical Director of Owens Recovery Science, Inc., and a Clinical Researcher at the San Antonio Military Medical Center (SAMMC). Previously, he was the Chief of Human Performance Optimization at the Center for the Intrepid in the SAMMC. Owens has been practicing blood flow restriction training since 2011.

Blood flow restriction (BFR) training, or “tourniquet training,” first came to my attention while I was watching ESPN in November 2014. A segment was highlighting the eye-popping results BFR training was producing for wounded soldiers at the Center for the Intrepid in the San Antonio Military Medical Center. By lifting low loads with a tourniquet applied to their injured limbs, the soldiers were able to promote muscle hypertrophy and function. The technique had been implemented by Johnny Owens, MPT, then the Chief of Human Performance Optimization at the Center for the Intrepid, and the co-author on this article.

Not long after, I again heard about the positive outcomes seen when using BFR—this time in reference to injured elite athletes. In early 2015, the Houston Texans became the first NFL team to adopt BFR training, and rehabbing players like Jadeveon Clowney and Brian Cushing were the beneficiaries.

Once I saw the dramatic impact tourniquet training made on both wounded soldiers and NFL athletes, I contacted Johnny about bringing it to the University of Florida. The UF Sports Health staff strives to stay on the cutting edge of medical care, and BFR would allow us to further our mission of offering innovative treatments.

After researching the technique and getting trained by Johnny, we became the first college athletic department to implement BFR training with Delfi Medical’s PTS Personalized Tourniquet System in August 2015. Since then, it has become an integral part of our rehab approach. In this article, Johnny will cover the science and methods behind tourniquet training, and I’ll outline how we use it at UF to minimize strength losses in athletes’ injured limbs.

BFR BASICS

During the quiescent period of recovery, athletes are susceptible to anabolic resistance in their injured arm or leg because the limb isn’t being used. As illustrated in a 2013 study in The Journal of Clinical Endocrinology & Metabolism, local protein synthesis within the limb can decrease by as much as 30 percent during this time, correlating to a 350-gram loss of muscle tissue and a 30 percent decline in muscle strength.

Traditional resistance training guidelines recommend lifting loads greater than 65 percent of a one-rep max over 12 to 16 weeks to regain this lost strength. Obviously, serious injuries prevent athletes from doing this. However, using BFR, athletic trainers may be able to manipulate an injured athlete’s muscle protein synthesis into a positive state without compromising their vulnerable joints or soft tissue.

For instance, a 2007 study in the Journal of Applied Physiology demonstrated a 46 percent rise in muscle protein synthesis three hours post-BFR training for injured athletes. A work-matched control group without occlusion saw no change. Similarly, a 2010 study in the same journal revealed a 56 percent rise in muscle protein synthesis three hours after BFR training.

Improved muscle protein synthesis can correlate to increases in muscle girth and the amount of work a muscle can perform in an injured limb. To illustrate, a study in the Journal of Special Operations Medicine found muscle power grew by 50 to 80 percent in injured athletes after they practiced BFR.

So how does BFR training work? The first step is securing a pneumatic tourniquet (similar to those used during surgery) at the most proximal point of an injured leg or arm. Vascular flow is then detected via a Doppler-like system to determine the necessary occlusion pressure for the limb, which is defined as the amount of pressure needed to completely eliminate blood flow into the limb. Eighty percent pressure in the lower extremities has demonstrated the highest muscle recruitment, while 40 to 50 percent in the upper extremities has shown similar results.

Administering pressure to the limb reduces vascular inflow and completely occludes venous outflow, creating a hypoxic environment within the target muscle. Exercising at light loads (20 to 30 percent of one-rep max) in this state produces a significant hypertrophy effect.

WHY IT MAY WORK

Although the exact mechanism behind the gains seen with BFR training is still not fully understood, several theories have been presented. One prevailing hypothesis is the recruitment of larger, fast-twitch motor units during the hypoxic state created by the tourniquet. Several papers supporting this idea have demonstrated higher intramuscular electromyographic signal output when performing exercise under vascular occlusion compared to low-load training without a tourniquet.

Another hypothesis is that as the muscle utilizes the anaerobic pathway during resistance training with BFR, its metabolic accumulation may trigger hypertrophic changes. This was seen in a 2014 study in Clinical Physiology and Functional Imaging that compared the accumulation of substances such as lactate—a byproduct of anaerobic metabolism—between BFR, high-intensity training (HIT), and standard low-load training. The BFR group demonstrated a significant rise in lactate and similar levels of metabolic stress as the HIT group. The systemic response from this metabolite accumulation with BFR has also been shown to include significant increases in substances such as growth hormone, insulin-like growth factor, and myogenic stem cells.

A third theory is that the muscle pump effect seen after tourniquet training may play a role in hypertrophy gains. BFR produces muscle swelling and a plasma volume fluid shift. As shown in a 2006 study published in Acta Physiologica, these effects could help augment muscle size by activating the protein synthesis pathway via MTORC1.

Other studies have supported this theory by demonstrating the ability of occlusion alone to mitigate atrophy compared to controls. The cellular swelling created by a tourniquet in the absence of exercise was enough to induce muscle protein synthesis. This phenomenon has been observed in subjects after an ACL repair, as well.

SAFETY FIRST

Since BFR is still a relatively new rehab tool, some athletic trainers are skeptical about it. One concern is the safety of tourniquet training.

Numerous studies have analyzed this topic, including a recent investigation that surveyed Japanese institutions about observed side effects with BFR training. The most commonly cited risk was temporary bruising around the tourniquet site (reported by 13 percent of patients). A dull pain or discomfort due to the tourniquet was reported in nine percent of patients, while transient numbness of the treated extremity occurred in 1.2 percent of the population. Other side effects included lightheadedness, a temporary cold feeling in the extremity, venous thrombus, and pulmonary embolism, but these were all experienced in fewer than one percent of patients.

Due to the nature of the technique, there is a theoretical possibility of developing compartment syndrome or deep venous thrombosis with BFR. However, previous studies have shown no increased risk of either when comparing BFR therapy to other exercise and rehabilitation regimens. In addition, investigations measuring clotting factors from the European Journal of Applied Physiology and the Journal of Bone and Joint Surgery did not find any increase after BFR. In fact, fibrinolytic (anti-clotting) factors were demonstrated to increase after tourniquet training.

The easiest way to ensure safety when practicing BFR is to acquire the correct equipment and operate it properly. It is critical that clinicians use a classified and regulated Class I FDA-approved device when introducing BFR. Don’t use a device that has not been listed with the FDA as appropriate for occluding blood flow. For example, utilizing items like knee wraps and blood pressure cuffs may cause injury and leave the clinician susceptible to liability.

At UF, we use the PTS Personalized Tourniquet System for BFR. Third-generation tourniquet systems like the PTS incorporate advanced safety features to minimize complications, including personalized limb occlusion pressure, automatic shut off if pressure gets too high, the ability to ensure blood flow is not completely restricted, and sensors to monitor ongoing pressure changes. Furthermore, the system’s wide tourniquet cuffs have a variable contoured fit that increases their surface area and significantly reduces pressure gradients, which has been demonstrated to reduce the potential for skin or nerve injury.

APPLICATION AT UF

Before we could start incorporating BFR at UF, our Sports Health staff underwent an eight-hour education and training session with Johnny. The first half of the day covered the science and history of BFR, while the second half addressed its application and general use.

Armed with this knowledge, we could then educate UF athletes about BFR one-on-one prior to using it with them. We explained the science and application process, benefits of BFR, and what they would experience before and after training. Since tourniquet training differs from other rehabilitation techniques that we have used, we felt it was important to lay out the basics for athletes who would be practicing it.

Some of our athletes were skeptical about using BFR at first, but because of the relationships we’ve built with them, they were willing to trust us and try it out. Occasionally, I would apply a tourniquet to my arm or leg and demonstrate the training to ease their concerns.

The protocol for BFR fits easily into our broader rehabilitation programs. In most cases, we begin BFR training after the initial inflammatory phase of injury is controlled. Athletes then do one five- to 20-minute BFR session a day, three to five times per week. There is no science-based consensus regarding how long each session should last. Rather, we base it on the organization of each rehabilitation protocol. For example, athletes might do BFR for a longer period of time on days when they don’t have any other weightlifting or conditioning scheduled.

Almost all of our standard rehabilitation exercises can be performed with the tourniquet applied. Athletes generally perform four sets of each exercise prescribed in a 30/15/15/15 rep count, with a 30-second break in between each set. The 30/15/15/15 rep count is based on research conducted by Johnny and his team—they found this is the optimal count for maximum benefits. Following the BFR training session, the athlete continues with the rest of their rehab plan for that day.

To date, we have successfully used BFR with a variety of injuries, including lateral ankle sprains, post-op meniscectomies, ACL reconstructions, AC joint sprains, and patella tendonitis. The overall feedback from athletes has been overwhelmingly supportive. Any trepidation went out the window once they started treatment and quickly saw results. Eventually, we had injured athletes asking to use BFR as soon as they walked into the athletic training room to start their rehab. This marked the first time in my career that a new training technique created such a widespread positive buzz among players. (See “Success Stories” below for examples of UF athletes who used BFR.)

Lately, we’ve started using BFR even more frequently, and we continue to see more rapid improvements in muscle size, joint range of motion, and overall function compared to using conventional treatments alone. In the future, we hope to utilize the science behind the technique to promote recovery and decrease stress in athletes who have a history of knee or shoulder injuries. For example, we could use it on athletes with chronic knee problems during the season to reduce the load on the joint.

In just a year, BFR has changed our approach to rehabilitation at UF. As the clinical research surrounding it grows more and more, we look forward to expanding our use of this unique treatment.

To view a list of references for this article, go to Training-Conditioning.com/References.

Sidebar:

SUCCESS STORIES

The first athlete to use blood flow restriction (BFR) training at the University of Florida had a high-grade tear of the biceps femoris. Like we do with all injuries, we incorporated conventional methods of treatment, including RICE, controlled range of motion, a progression to concentric and eccentric strengthening, and a functional return-to-play program. We estimated the athlete would return to play in four to six weeks.

However, by adding BFR into the regimen, we were able to return the athlete to full competition after only three weeks. This eye-opening result was backed up by systematic diagnostic ultrasound imaging (US).

In previous biceps femoris tears, US revealed slow integral changes (about 10 to 20 percent improvement) in the area of injury when examined on a weekly basis. With the UF athlete using BFR, we were able to document approximately 30 percent improvement in muscle tissue repair using the same parameters. Obviously, given our sample size of one, we couldn’t say that BFR was the sole reason for these results, but it was definitely encouraging.

Our excitement about the potential for BFR increased following the recovery of an athlete who had undergone an anterior Bankart repair in his right shoulder. This was his third shoulder surgery in three-and-a-half years, but the recovery was different this time because we added BFR.

Due to the low loads used during tourniquet training, we were able to introduce strengthening during the athlete’s six-week immobilization period. This, in turn, allowed him to progress to more advanced strength movements earlier in his rehabilitation.

Having gone through two shoulder rehabs previously, the athlete said he could tell the difference once he started incorporating BFR. He stated that his shoulder felt stronger than ever, and his confidence levels were high when he returned to play.