Hydrotherapy in ACL rehabilitation
Aquatherapy and Hydrotherapy-Balneotherapy are terms used interchangeably to indicate a modality of treatment performed in an aquatic environment. This page will attempt to assimilate the current literature for incorporating hydrotherapy into conventional rehabilitation of Anterior Cruciate Ligament (ACL) Injury, conservatively or alongside Anterior Cruciate Ligament (ACL) Reconstruction (ACLR).
Outcome measures of ACL rehabilitation:
- Instability episodes 
- Pain 
- Issues with:
- Swelling, walking, climbing, stairs, kneeling, squatting, running, lateral motion, cutting, jumping 
- Measures of knee function:
- Graft rupture (post-ACLR only) 
- Contralateral ACL injury 
- Lachman and pivot-shift 
- Passive range of motion (knee flexion & extension), muscle strength, thigh circumference (thigh girth, thigh muscle mass, knee joint swelling) 
- Active range of motion (knee flexion & extension) 
- 6 minute walk test (6MWT) 
Advantages of Hydrotherapy in ACL/R Rehabilitation
- Early weightbearing 
- Postural and gait exercises in a supported environment 
- Water resistance induced muscular conditioning 
Outcomes of Hydrotherapy + Conventional Rehabilitation vs. Conventional Rehabilitation Only:
After 2 weeks post-ACLR, patients who underwent 3 weeks of combined hydrotherapy with conventional rehabilitation, had superior outcomes in proprioception, walking, muscle strength in the short and medium term, compared to participants exclusively in conventional rehabilitation programme . Another trial found that ACLR patients placed through 9 weeks of aquatic rehabilitation immediately post-surgery had better clinical parameters in muscle strength and mass circumference, pain, swelling, and range of motion compared to those on land rehabilitation .
A smaller case study of 3 subjects demonstrated no risk of harm in utilizing hydrotherapy to accelerate rehabilitation of ACLR .
Considerations for ACL hydrotherapy rehabilitation design:
|Accelerated Hydrotherapy Programme |
|Gait Retraining||Gait training|
|Quadriceps and hamstring strengthening||Closed kinetic chain exercises, Open kinematic chain exercises|
|Strengthening & endurance training||Running, Cycling, Deep-water running techniques|
|Hip and calf maintenance and strengthening||Hip exercises and calf raises, kicking and vertical kicking|
|Balance and proprioception (perturbation protocol)||Balance and proprioception exercises|
|Plyometric training||Jumping, running, shuttle runs, side steps with increased speed|
|Sports-specific rehabilitation||Agility exercises making use of a ball|
Video Examples of Hydrotherapy Protocols & Case Studies:
Gait Retraining and Lower Limb Mobility Exercises - Sports Med Mumbai
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- Momberg BL, Louw Q, Crous L. Accelerated hydrotherapy and land-based rehabilitation in soccer players after anterior cruciate ligament reconstruction: a series of three single subject case studies. South African Journal of Sports Medicine. 2008 Dec 1;20(4):109-14.
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- Peultier-Celli L, Mainard D, Wein F, Paris N, Boisseau P, Ferry A, Gueguen R, Chary-Valckenaere I, Paysant J, Perrin P. Comparison of an innovative rehabilitation, combining reduced conventional rehabilitation with balneotherapy, and a conventional rehabilitation after anterior cruciate ligament reconstruction in athletes. Frontiers in surgery. 2017;4:61.