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Impact of high external load resistance and low external load resistance training with blood flow restriction on anterior cruciate ligament volume in healthy female and male adults: A randomized controlled trial

Osterloh J, Mau-Moeller A, Knaack F, Holl N, Lappe C, Polei S et al. · Research Square · 2026

This study compared two types of resistance training—heavy weights versus light weights with blood flow restriction—to see how they affected anterior cruciate ligament (ACL) volume and quadriceps muscle volume in healthy adults over 16 weeks. Light weights combined with blood flow restriction increased ACL volume more than heavy weights alone, with the effect being stronger in men, while both training methods increased quadriceps muscle volume compared to no training.
Takeaway: Consider adding blood flow restriction training to your routine if you want to maximize ACL size as a potential injury prevention strategy, especially if you're male.
Abstract (source)

Abstract

Background: Anterior cruciate ligament (ACL) volume is positively correlated with quadriceps femoris (QF) muscle volume. Given that a smaller ACL size is associated with higher risk for injuries, this study investigated the effect of hypertrophy-focused high external load resistance training (HLRT) and low external load resistance training combined with blood flow restriction (LLRT-BFR) on ACL and QF volume.

Methods: Sixty healthy adults (n = 33 females) were randomly assigned to two training groups (HLRT or LLRT-BFR, 16 weeks, 3 sessions/week) and a control group (CG). ACL and QF volume were assessed by 3-Tesla magnetic resonance imaging before and after the interventions. Analysis of covariance with baseline-adjustment was conducted using per-protocol (n = 47) and intention-to-treat (n = 60) analyses, with sex as additional factor, followed by Tukey post-hoc tests (p ≤ 0.050) and the calculation of effect sizes.

Results: Per-protocol analysis indicated a group effect (p = 0.044, η p 2 = 0.155) with a higher ACL volume in the LLRT-BFR compared to the HLRT group (p = 0.041, d = 1.007) and a non-significantly higher ACL volume, with a nearly large effect size, compared to the CG (p = 0.142, d = 0.758). This effect was predominantly observed in male participants (p ≤ 0.094, d ≥ 1.670). Moreover, a group effect was found for QF volume (p p 2 = 0.545) with higher values in both training groups compared to CG (p 2.000).

Results of the per-protocol and the intention-to-treat analyses were consistent.

Conclusions: ACL volume was increased after LLRT-BFR compared to HLRT and CG, predominantly in males, while OF volume was higher after both interventions. These

Findings: open new perspectives for ACL injury prevention. Trial Registration: The trial was prospectively registered in the German Clinical Trial Register (DRKS00031249) on 17/02/2023 and adhered to the published protocol (https://drks.de/search/de/trial/DRKS00031249).

Randomized controlled trialResistance Training & Hypertrophy
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