The Effects of Blood Flow Restriction on Muscle Activation and Hypoxia in Individuals With Chronic Ankle Instability

in Journal of Sport Rehabilitation
Restricted access

Purchase article

USD  $24.95

Student 1 year subscription

USD  $74.00

1 year subscription

USD  $99.00

Student 2 year subscription

USD  $141.00

2 year subscription

USD  $185.00

Context: Muscle dysfunction is common in patients with chronic ankle instability (CAI). Blood flow restriction (BFR) may enhance muscle responses during exercise and provide an opportunity to enhance muscle adaptations to ankle rehabilitation exercises; however, there is no evidence examining the effect of BFR on muscle function in CAI patients. Objective: Examine the effects of BFR on muscle activation and oxygen saturation during submaximal ankle eversion and dorsiflexion exercises in individuals with CAI. Design: Cross-over study design. Setting: Laboratory setting. Patients (or Other Participants): Nineteen young adults with a history of CAI. Interventions: Participants performed 4 sets (30, 15, 15, and 15) of eversion and dorsiflexion resistance exercises at 30% of maximum voluntary isometric contraction during 2 conditions, BFR and control. For BFR, a cuff was applied above the knee at 80% of blood flow occlusion. For control, the cuff was not inflated. Main Outcome Measures: Fibularis longus and tibialis anterior electromyography muscle activation, lower-leg muscle oxygen saturation, and ratings of perceived exertion were recorded during exercises. Results: Average grand mean muscle activation was 5.6% greater during eversion (P = .03) and 7.7% greater during dorsiflexion (P = .01) resistance exercises with BFR compared with control; however, the magnitudes of the effects of BFR were only clinically important during the dorsiflexion exercises. Lower-leg muscle oxygen saturation was 31% to 44% lower (P < .001) during BFR exercises. Ratings of perceived exertion were significantly higher during BFR exercises (P < .001). Conclusions: Greater muscle activation and hypoxia were present during submaximal resistance exercise with BFR in participants with CAI. Greater muscle activation and hypoxia during BFR exercises may be important acute responses mediating the training-related muscle adaptations that have been observed with BFR. The presence of these acute responses in CAI patients supports further research examining BFR as a potential ankle rehabilitation tool.

Killinger and Goetschius are with Adrian College, Adrian, MI, USA. Lauver is with Coastal Carolina University, Conway, SC, USA. Donovan is with University of North Carolina Charlotte, Charlotte, NC, USA.

Goetschius (jgoetschius@adrian.edu) is corresponding author.
  • 1.

    Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311–319. PubMed ID: 17710181 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Roos KG, Kerr ZY, Mauntel TC, Djoko A, Dompier TP, Wikstrom EA. The epidemiology of lateral ligament complex ankle sprains in national collegiate athletic association sports. Am J Sports Med. 2017;45(1):201–209. PubMed ID: 27573356 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries in basketball: injury rate and risk factors. Br J Sports Med. 2001;35(2):103–108. PubMed ID: 11273971 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E. Recovery from a first-time lateral ankle sprain and the predictors of chronic ankle instability: a prospective cohort analysis. Am J Sports Med. 2016;44(4):995–1003. PubMed ID: 26912285 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Gribble PA, Delahunt E, Bleakley CM, et al. Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the international ankle consortium. J Athl Train. 2014;49(1):121–127. PubMed ID: 24377963 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Hubbard-Turner T, Turner MJ. Physical activity levels in college students with chronic ankle instability. J Athl Train. 2015;50(7):742–747. PubMed ID: 25898110 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Simon JE, Docherty CL. Health-related quality of life is decreased in middle-aged adults with chronic ankle instability. J Sci Med Sport. 2018;21(12):1206–1209. PubMed ID: 29803734 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Wisthoff B, Matheny S, Struminger A, et al. Ankle strength deficits in a cohort of collegiate athletes with chronic ankle instability. J Sport Rehabil. 2019;1–6. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9.

    Donnelly L, Donovan L, Hart JM, Hertel J. Eversion strength and surface electromyography measures with and without chronic ankle instability measured in 2 positions. Foot Ankle Int. 2017;38(7):769–778. PubMed ID: 28391722 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Thompson C, Schabrun S, Romero R, Bialocerkowski A, van Dieen J, Marshall P. Factors contributing to chronic ankle instability: a systematic review and meta-analysis of systematic reviews. Sports Med. 2018;48(1):189–205. PubMed ID: 28887759 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Feger MA, Snell S, Handsfield GG, et al. Diminished foot and ankle muscle volumes in young adults with chronic ankle instability. Orthop J Sport Med. 2016;4(6):2325967116653719. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12.

    Koldenhoven RM, Feger MA, Fraser JJ, Saliba S, Hertel J. Surface electromyography and plantar pressure during walking in young adults with chronic ankle instability. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1060–1070. PubMed ID: 26856315 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Feger MA, Donovan L, Hart JM, Hertel J. Lower extremity muscle activation during functional exercises in patients with and without chronic ankle instability. PM R. 2014;6(7):602–611. PubMed ID: 24412672 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Hertel J. Sensorimotor deficits with ankle sprains and chronic ankle instability. Clin Sports Med. 2008;27(3):353–370. PubMed ID: 18503872 doi:

  • 15.

    Pietrosimone BG, McLeod MM, Lepley AS. A theoretical framework for understanding neuromuscular response to lower extremity joint injury. Sports Health. 2012;4(1):31–35. PubMed ID: 23016066 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Donovan L, Hertel J. A new paradigm for rehabilitation of patients with chronic ankle instability. Phys Sportsmed. 2012;40(4):41–51. PubMed ID: 23306414 doi:

  • 17.

    Scott BR, Loenneke JP, Slattery KM, Dascombe BJ. Exercise with blood flow restriction: an updated evidence-based approach for enhanced muscular development. Sport Med. 2015;45(3):313–325. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18.

    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. PubMed ID: 28259850 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Takarada Y, Takazawa H, Sato Y, Takebayashi S, Tanaka Y, Ishii N. Effects of resistance exercise combined with moderate vascular occlusion on muscular function in humans. J Appl Physiol. 2000;88(6):2097–2106. PubMed ID: 10846023 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Kacin A, Strazar K. Frequent low-load ischemic resistance exercise to failure enhances muscle oxygen delivery and endurance capacity. Scand J Med Sci Sports. 2011;21(6):e231–e241. PubMed ID: 21385216 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Kim D, Loenneke JP, Ye X, et al. Low-load resistance training with low relative pressure produces muscular changes similar to high-load resistance training. Muscle Nerve. 2017;56(6):E126–E133. PubMed ID: 28224640 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Abe T, Kearns CF, Sato Y. Muscle size and strength are increased following walk training with restricted venous blood flow from the leg muscle, Kaatsu-walk training. J Appl Physiol. 2006;100(5):1460–1466. PubMed ID: 16339340 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Ozaki H, Sakamaki M, Yasuda T, et al. Increases in thigh muscle volume and strength by walk training with leg blood flow reduction in older participants. J Gerontol A Biol Sci Med Sci. 2011;66(3):257–263. PubMed ID: 20974731 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Clarkson MJ, Conway L, Warmington SA. Blood flow restriction walking and physical function in older adults: a randomized control trial. J Sci Med Sport. 2017;20(12):1041–1046. PubMed ID: 28483555 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Scott BR, Slattery KM, Sculley DV, Dascombe BJ. Hypoxia and resistance exercise: a comparison of localized and systemic methods. Sports Med. 2014;44(8):1037–1054. PubMed ID: 24715613 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Lauver JD, Cayot TE, Rotarius T, Scheuermann BW. The effect of eccentric exercise with blood flow restriction on neuromuscular activation, microvascular oxygenation, and the repeated bout effect. Eur J Appl Physiol. 2017;117(5):1005–1015. PubMed ID: 28324168 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Yanagisawa O, Sanomura M. Effects of low-load resistance exercise with blood flow restriction on high-energy phosphate metabolism and oxygenation level in skeletal muscle. Interv Med Appl Sci. 2017;9(2):67–75. PubMed ID: 28932500 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Suga T, Okita K, Morita N, et al. Intramuscular metabolism during low-intensity resistance exercise with blood flow restriction. J Appl Physiol. 2009;106(4):1119–1124. PubMed ID: 19213931 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Simon J, Donahue M, Docherty C. Development of the Identification of Functional Ankle Instability (IdFAI). Foot Ankle Int. 2012;33(9):755–763. PubMed ID: 22995264 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Carcia CR, Martin RL, Drouin JM. Validity of the foot and ankle ability measure in athletes with chronic ankle instability. J Athl Train. 2008;43(2):179–183. PubMed ID: 18345343 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 31.

    Godin G, Shephard RJ. A simple method to assess exercise behavior in the community. Can J Appl Sport Sci. 1985;10(3):141–146. PubMed ID: 4053261

  • 32.

    Robertson RJ, Goss FL, Rutkowski J, et al. Concurrent validation of the OMNI perceived exertion scale for resistance exercise. Med Sci Sports Exerc. 2003;35(2):333–341. PubMed ID: 12569225 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Crum EM, O’Connor WJ, Van Loo L, Valckx M, Stannard SR. Validity and reliability of the Moxy oxygen monitor during incremental cycling exercise. Eur J Sport Sci. 2017;17(8):1037–1043. PubMed ID: 28557670 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Moritani T, Sherman WM, Shibata M, Matsumoto T, Shinohara M. Oxygen availability and motor unit activity in humans. Eur J Appl Physiol Occup Physiol. 1992;64(6):552–556. PubMed ID: 1618195 doi:10.1007/BF00843767

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.

  • 36.

    Yasuda T, Fukumura K, Fukuda T, et al. Effects of low-intensity, elastic band resistance exercise combined with blood flow restriction on muscle activation. Scand J Med Sci Sports. 2014;24(1):55–61. PubMed ID: 22734915 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37.

    Ohta H, Kurosawa H, Ikeda H, Iwase Y, Satou N, Nakamura S. Low-load resistance muscular training with moderate restriction of blood flow after anterior cruciate ligament reconstruction. Acta Orthop Scand. 2003;74(1):62–68. PubMed ID: 12635796 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38.

    Tennent DJ, Hylden CM, Johnson AE, Burns TC, Wilken JM, Owens JG. Blood flow restriction training after knee arthroscopy: a randomized controlled pilot study. Clin J Sport Med Off J Can Acad Sport Med. 2017;27(3):245–252. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 39.

    Staunton CA, May AK, Brandner CR, Warmington SA. Haemodynamics of aerobic and resistance blood flow restriction exercise in young and older adults. Eur J Appl Physiol. 2015;115(11):2293–2302. PubMed ID: 26142277 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 40.

    Lagally KM, Robertson RJ, Gallagher KI, et al. Perceived exertion, electromyography, and blood lactate during acute bouts of resistance exercise. Med Sci Sports Exerc. 2002;34(3):552–559. discussion 560. PubMed ID: 11880823 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41.

    Loenneke JP, Thiebaud RS, Abe T. Does blood flow restriction result in skeletal muscle damage? A critical review of available evidence. Scand J Med Sci Sports. 2014;24(6):e415–e422. PubMed ID: 24650102 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 42.

    Neto GR, Novaes JS, Salerno VP, et al. Acute effects of resistance exercise with continuous and intermittent blood flow restriction on hemodynamic measurements and perceived exertion. Percept Mot Skills. 2017;124(1):277–292. doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43.

    Donovan L, Hart JM, Hertel J. Effects of 2 ankle destabilization devices on electromyography measures during functional exercises in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2015;45(3):220–232. PubMed ID: 25627150 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 178 178 96
Full Text Views 17 17 6
PDF Downloads 16 16 5