Hydrotherapy with Post-Op ACL Patients

SwimEx hydrotherapy with ACL patients allows them to perform functional activities in a safe environment, often earlier in the rehabilitation process. This helps build confidence as patients will eventually perform the same activities on land. Unloading healing tissue allows for earlier integration of functional activities post-operatively. Hydrostatic pressure can help to keep swelling to a minimum and provide kinesthetic feedback during activity.

CAUTION: It is contraindicated to put an open wound in the water, so please wait until sutures are removed, and healing of skin is close to complete OR assure a sealed wound/limb before submerging.  

Hydrotherapy exercises: Post-op ACL sample progression

1. Early stage (0-4 weeks)

The primary goals of these early-stage exercises are to protect the graft, minimize swelling, increase range of motion, improve quad control, and normalize walking. Early terminal knee extension and aggressive hamstring activation is cautioned in patients with a hamstring graft.

Walking exercises: Patients can begin walking and marching on the underwater treadmill. With the laminar flow on at a low setting, patients will often get a nice body lean. A high marching movement will also encourage proper body lean.

Flutter kick progression: This flutter kick progression for post-op ACL patients helps with knee extensions and is a good rehab starting point. Progressing to a flutter kick with the laminar flow on will require the patient to continuously move. Using the deep part of the pool for a vertical flutter kick continues the work on knee extension, ankle plantar flexion, and it gets the patient’s cardiovascular system going.

Single leg balance progression: In the first phase of this SL balance progression, there is no current turned on, and the patient is simply trying to maintain balance with their hands on their hips. Turning on the laminar flow increases the challenge. Depending on desired goals, changing the patient’s position in the pool modifies the flow impact.

Squats progression: Having the patient perform single leg squats at 50% depth helps to build confidence without concerns of falling. Try adding upper body motion using a dumbbell. As the patient pushes against the laminar flow, stability and core stabilization is required.

Knee extensions: Patients can also benefit from simple knee extension exercises with the SwimEx laminar flow turned off, using resistance on the ankle.

2. Middle stage (4-10 weeks)

The primary goals of these middle stage exercises are to increase hip, quad, ham and gastroc/soleus strength. Patient should also improve gait and function, add additional planes of movement, and build cardiovascular fitness.

Underwater treadmill exercises: Lateral walking and backwards walking on the underwater treadmill improves patient strength. The added progression of skipping on the treadmill is an easy way to introduce light jumping to post-op ACL patients.

Line hop progression: A line hop progression starting with two legs and progressing to one is a way to introduce functional movement activities. One advantage of starting this progression in the water is that patients can use their hands to counter balance themselves.

Jogging on treadmill: Jogging on the treadmill while increasing the current flow will challenge the patient. The 99-speed SwimEx laminar flow gives athletic trainers and physical therapists tremendous versatility when working with patients.

Running on slanted running pad: Using the angled pads in the SwimEx helps to improve running form. Sprinting on the pad with the flow turned up high gives a good knee drive and hip drive.

Core rotations progression: With the current on a low speed, start with a simple core rotation using the hands and arms as resistance. Increase the speed to challenge the patient. Add a dumbbell (making sure to keep it underwater) and have the patient perform core rotations as fast as possible with the flow turned on. This progression helps both the core and the shoulders.

Lateral hops on pad: The side running pads create a good angle for skier jumps, or lateral hops.

3. Later stage (10-16 weeks)

The primary goals of these later stage exercises are to challenge functional capacity by increasing loads and movement patterns. During this time, the patient is preparing to transition to land-based activities. While strength gains will be best achieved with land-based activities, the aquatic environment allows more aggressive functional activities with low concern for reinjury. This is a great time to increase confidence in limb function.

It should be noted that exercises from earlier stages can be modified by increasing the speed of the treadmill and/or the laminar flow.

SL hop to stabilization exercise: Transition the patient to performing a single leg hop step (forward) onto the platform with stabilization and a squat stand at the end. Progress from double leg to single leg.

Lateral hop stabilization: A lateral hop to stabilization onto the platform can be used in both directions.

Single leg bounding on a slanted pad: Patients can be challenged with a single leg bounding activity on the slanted pad. The laminar flow helps to encourage good body lean and form.

Advanced core rotations: Adding a kickboard to core rotations increases surface area and resistance in the load. You can modify the exercise by keeping the board just a little bit under water, or increase difficulty by having the kickboard completely under water.

Tuck jumps: An easy plyometric activity is to have the patient do tuck jumps on two legs. The goal of this exercise is to have them be quick off the bottom of the pool. A progression would be to perform on a single leg.

Backboard touch simulation: For this exercise, the patient performs a two-legged jump, grabs a ball, lands, and explodes back up.

Jump with pivot: Increase exercise difficulty by adding a counter-movement pivot. The patient jumps to grab the ball and pivots before handing the ball back.

These water exercises are low-impact and can be performed earlier in a rehabilitation progression and with lower levels of pain compared to similar activity on land. Studies have shown that patients who use water therapy as part of their ACL rehab often experience better improvements in swelling and activities of daily living.

~ Authored by Connie Peterson, PhD, LAT, ATC, athletic trainer at James Madison University.

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