Aquatic-Based Rehabilitation and Training for

the Elite Athlete

)ill M. Thein, MPT, ATC'
Lori Thein Brody, MS, PT, SCS, ATC*

A
thletes of all ages enjoy Elite athletes are competing for longer seasons, training more hours, and taking less time off.
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participating in sport-
ing activities. Children
and adolescents partici-
pate in youth sports
teams, while adults enjoy events such
as running races, triathlons, and
adult sport leagues. This type of rec-
reational sportsenthusiast comprises
the majority of the athletic popula-
tion. However, a small percentage of
Copyright © 1998 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
This schedule may predispose the elite athlete to overuse injuries. When an injury occurs, aquatic-
based rehabilitation may expedite the recovery process, as effective cardiovascular and musculo-
skeletal training may be accomplished by aquatic exercise. The pool may be used both during
rehabilitation and postrecovery as an adjunctive tool. Knowledge of the unique physical properties
of water, as well as the physiological responses to immersion both at rest and during exercise, will
aid the physical therapist when designing a rehabilitation or training program for the athlete.
Understanding the principles of movement in water will provide a foundation for creative use of
water's unique properties.
Key Words: aquatic, training, rehabilitation
' Clinical Physical Therapist, University of Wisconsin Clinics Research Park, Sports Medicine Center,

athletes chooses to pursue a higher 621 Science Drive, Madison, WI 5371 1

and more demanding level of train- Senior Clinical Specialist, University of Wisconsin Clinics Research Park, Sports Medicine Center,
ing and competition. Some athletes Madison, WI
excel in a sport early in adolescence No grant monies were provided for this paper.
and focus exclusively on those physi-
cal skills. Master-level athletes are
continuing to compete well into the
fifth and sixth decades of life. Ath-
period of recovery to be beneficial. PHYSICAL PROPERTIES O F WATER
They may regain mobility, strength,
letes of this caliber level are training
Journal of Orthopaedic & Sports Physical Therapy®

harder, competing more often, and

taking less time to taper. As such, the
elite athlete frequently suffers from
overuse injuries, particularly soft tis-
sue injuries, such as tendinitis, bursi-
tis, and stress fractures. Selfcare for
the average athletic population may
include temporary rest and discontin-
ued training. Research has shown
that 3 weeks of inactivity can lead to
a significant loss of cardiovascular
fitness, where 6 weeks of rest can
lead to a decrease of as much as 14-
16% of maximal oxygen consumption
(10.1 1,27). Because of such losses
and demanding competition sched-
ules, the elite athlete is often under
time constraints for injury rehabilita-
tion. As such, many athletes have
found utili7ation of a water-based
program during their "active rest"
and maintain or improve cardiovascu-
lar endurance, all while "resting"
their injury. The pool may also be
used to increase flexibility, speed,
balance, and coordination in the
noninjured athletic population.
The purpose of this paper is to
discuss aquatic-based rehabilitation
and training for the elite athlete. The
physical properties of water will be
reviewed, and current research re-
garding aquatic-based vs. land-based
cardiovascular conditioning programs
will be discussed. Extremity and core
body strengthening exercises will be
reviewed, as will balance and coordi-
nation exercises. Lastly, recommenda-
tions regarding transition from aquat-
ic-based programs to resuming
competitive sports will be made, and
sample training programs will be sug-
gested.
Buoyancy
Archimedes' principle of buoy-
ancy states that a body partially or
completely immersed in a fluid will
experience an upward thrust equal to
the weight of the fluid that was dis-
placed. Buoyancy is defined as the
upward thrust acting in the opposite
direction of gravity; it is related to
the specific gravity of the immersed
object (5). Specific gravity is the ratio
of the mass of one substance to the
mass of the same value of water (5).
Therefore, by definition, the specific
gravity of water is 1.0 and any body
with a specific gravity of less than 1.0
will float. The average values for the
human body range from 0.97 to 0.95,
thereby causing most humans to float
(12). However, many individuals still
have difficulty floating due to their

Volume 27 Number 1 January 1998. JOSPT


body composition and body fat distri-
bution. They may rest just below the
water's surface or their legs may sink
while their trunk remains at the sur-
face. This is of particular importance
in treating the elite athlete who may
be very lean. Buoyant equipment may
be necessary on the trunk or at vari-
ous points along the limb to main-
tain equilibrium in the pool.
Buoyancy may be used in rehabil-
itation in three ways: as assistance, as
support, and as resistance. Assisted
exercise occurs when movements are
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toward the surface of the water.
These exercises are commonly used
to increase mobility, such as when
allowing the arm to passively abduct
toward the surface (20). Buoyancy-
supported exercises are movements
that are perpendicular to the upward
thrust of buoyancy and parallel to the
bottom of the pool. Typically, the
limb will float just below the surface
Copyright © 1998 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
of the water, but this depends upon
the limb's density and floatation de-
vice use. Examples of buoyancy-sup
ported exercise include horizontal
abduction and adduction of the
shoulder with the athlete in standing.
Lastly, buoyancy-resisted exercises
directly oppose the upward thrust of
buoyancy. Buoyancy-resisted hip ex-
Journal of Orthopaedic & Sports Physical Therapy®
tension is performed standing in 90"
of hip flexion and extending the hip
to neutral (Figure 1A). In the above
example, the hip extensor muscles
would become buoyancy-assisted if
the hip were to extend past neutral
(Figure 1B).
Hydrostatic Pressure
Pascal's law states that, at any
given depth, the pressure from the
liquid is exerted equally on all sur-
faces of the immersed object (5). As
the density and depth of the liquid
increases, so does the volume of liq-
uid overhead and, therefore, the hy-
drostatic pressure. As such, hydro-
static pressure may be used in
rehabilitation to reduce effusion or
to allow the athlete to exercise an
injured extremity without an increase
JOSFT Volume 27 Number 1 Janua~y1998
FIGURE 1. A) Buoyancy-resisted hip extension from
90Qf flexion to neutral. B) Buoyancy-assisted hip
extension beyond neutral.
in effusion. Hydrostatic pressure is
also responsible for the cardiovascu-
lar changes seen with immersion and
has a significant impact on exercise
training parameters.
Viscosity
Viscosity is defined as the friction
occurring between individual mole-
cules in a liquid, causing resistance to
flow (5). Viscosity is only noticeable
when there is motion through the
liquid and acts as resistance to move-
ment because the liquid molecules
adhere to the surface of the body
(5). Because water is more viscous
than air, there is resistance to most
movement in the water regardless of
buoyancy.
CLINICAL COMMENTARY
FIGURE 2. Eddie currents behind the walking individ-
ual create a negative pressure and drag posteriorly.
Fluid Dynamics
Two different types of water flow
exist: laminar flow and turbulent
flow. Laminar flow, defined as the
smooth flow of water molecules, has
the least amount of resistance be-
cause the water molecules are all trav-
eling the same direction and speed.
Turbulent flow is interrupted flow, as
when laminar flow encounters an
object, causing water molecules to
rebound in all directions. Turbulent
flow can be visualized as the white
water and air bubbles next to the
skin when a body is moved through
the water (Figure 2).
The shape of the object moving
the water also effects drag. A tapered,
streamlined object will produce mini-
mal disruption of flow, while an un-
streamlined object will create rapid
disruption of flow, causing turbu-
lence (30). For example, forward
walking is more resistive than walking
sideways, and shoulder internal and
external rotation with the forearms
pronated creates less drag than per-
forming the same exercise in forearm
neutral.
Muscle contraction type is a key
consideration when designing an ex-
ercise program with increasing resis-
tance based upon viscosity. Exercises
performed against the water's resis-
 Temperature
recomrnendations for
intense training of the
elite athlete should be
between 26 and 28°C.
tance most always elicit concentric
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muscle contractions. Consider perfor-
mance of the above shoulder internal
and external rotation exercise; the
movements elicit reciprocal concen-
tric contractions of the rotator mus-
cles. Eccentric muscle contractions
can be elicited using buoyancy if
enough floatation is used. For exam-
ple, the upward abduction motion of
the arm away from the side will elicit
Copyright © 1998 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
an eccentric contraction of the shoul-
der adductors if a large floatation
bell is held in the hand. Additionally,
eccentric contractions in the lower
extremity can be achieved if the wa-
ter is shallow enough to minimize
buoyancy. For example, lunges in
hipdeep water can elicit eccentric
quadricep muscle contractions.
Journal of Orthopaedic & Sports Physical Therapy®
Effect of Depth of lmmersion on
Weight Bearing
Weight bearing is effected by the
depth of water owing to buoyancy.
This becomes an important issue in
rehabilitation, especially when reha-
bilitating athletes with lower extrem-
ity injuries. In general, at the seventh
cervical vertebral level, the xyphoid,
and the anterior superior iliac spine,
female athletes will bear 8, 28, and
47% of their body weight, respec-
tively. Male athletes are approxi-
mately 8, 35, and 54% weight bearing
at the same levels (30). However,
these numbers reflect static weight
bearing, and increasing to a fast walk-
ing speed can increase weight bear-
ing by as much as 76% (22). Decreas-
ing the depth of water is one way to
Right atrial venous pressure
Heart blood volume
Cardiac output
Stroke volume
Central venous pressure
Heart rate
Systemic blood pressure
TABLE 1. Cardiovascular responses to immersion at rest (2,4,9,13,15,16,23,24,29,30).
progress lower extremity weight bear-
ing.
PHYSIOLOGIC RESPONSES TO
AQUATIC EXERCISE
Physiological Responses of Water
Immersion
When humans are immersed in
water, physiologic changes occur,
both at rest and during exercise. As
such, it is important that the physical
therapist is aware of these differences
so training programs may be appro-
priately modified. Changes that occur
at rest during water immersion are
the result of hydrostatic pressure and
include, most importantly, a cephalad
redistribution of blood flow (2). In-
cluded in these alterations is an in-
crease in right atrial venous pressure,
which results in a Frank Starling re-
flex and a subsequent increase in
stroke volume (2,4,13,16,23,28). Hor-
monal changes and diuresis have
been observed with sustained periods
of water immersion (l4,15,18,21,24)
(Table 1).
lmmersion and Exercise Response
Several studies have been con-
ducted to determine if central blood
volume continues to remain elevated
during exercise in water. Christie et
al (9) studied 10 men performing
upright bicycle ergometry both on
land and immersed in water to the
suprasternal notch. Subjects exercised
at 40, 60, 80, and 100% VO,, while
numerous cardiac responses were
observed. Although VO,,,, did not
differ between groups, other cardiac
Increase (8-1 2 mm Hg)
Increase (180-2 50 ml)
Increase (25%+)
Increase (25%)
Increase
Remains the same or decreases slightly
Remains the same or increases slightly
responses were significantly greater
during water exercise than on land.
Cardiac preload was elevated both at
rest and during water exercise, sug-
gesting that the centralization of pe-
ripheral blood flow exists despite the
redistribution of blood known to oc-
cur during exercise. Sheldahl (29)
studied two groups of nine males per-
forming supervised bicycle ergometry
3 times/week for 12 weeks, one
group on land, the other immersed
to the suprasternal notch. Results
showed a similar increase in stroke
volume and decrease in heart rate
and blood pressure as well as a simi-
lar increase in VO,, in both
groups. The authors concluded that
exercise training is not affected by
the cephalad shift in blood volume
during water exercise.
These two studies highlight the
issue of immersion and exercise. As
cardiovascular changes are immer-
sion-related, exercise prescription in
deep water becomes difficult. Deep
water running is commonly used in
the rehabilitation of athletic injuries
and has been extensively studied. A
study of 10 trained males running at
four submaximal loads and maximal
intensity in both deep water and on
land showed that submaximal work-
load heart rates and VO,, were
lower during water running (31).
The authors believed the lower sub-
maximal heart rate relative to VO,
may be due to increased stroke vol-
ume, which is an effect of increased
central blood volume or increased
preload.
A similar study of 12 female cross-
country runners compared VO,,
on a treadmill with deep water im-
Volume 27 Number 1 January 1998 JOSPT

mersion (7). Results found VOnmax
values to be 17% lower in water when
compared with land, a finding similar where Group I exercised on land,
to previous studies. Peak heart rate
Studies have found the
heart rate- VO,
relationship and the
rate of perceived
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exertion in deepwater
running to be skill
dependent.
responses while water running were 17
beats/minute lower than those during
a treadmill run. The authors suggested
Copyright © 1998 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
the lower heart rate response was due
to increased stroke volume and the
cooling effects of the water.
An important factor in deep wa-
water running is the skill of the ath- rate. Since Group I11 demonstrated
lete. Studies have found the heart
rate-V02 relationship and the rate of
perceived exertion in deepwater run- heart rate 20 beats/minute lower
ning to be skill dependent (6,31).
Journal of Orthopaedic & Sports Physical Therapy®
Those individuals who were less
skilled used greater arm movement
to maintain position in the water,
thereby increasing their heart rate
and rate of perceived exertion. A pe-
riod of technique training should
precede any testing or establishing of mands
a training heart rate.
Training heart rate should be
established in the pool rather than
attempting to apply land-based heart
rates to pool exercise (34). In gen-
eral, heart rates during deep water
exercise will be approximately 17
beats/minute lower than comparable
exercise on land (26).
Effects of Water Temperature
Water temperature can have a
profound effect on the cardiovascular 36°C.
JOSPT Volume 27 Number 1 January 1998
response to exercise. Avellini et al (3)
studied three groups of five males,
and Groups I1 and I11 exercised in
32°C or 20°C water, respectively.
Maximal oxygen consumption was
tested before and after the training
period on land via a treadmill and
cycle ergometer. Subjects trained on
a cycle ergometer 5 days/week for 1
hour at 75% VO,, which was ad-
justed throughout the study. Results
showed that the water groups exer-
cised at a lower heart rate for a pre-
scribed VO,, level than the land
group. Maximal oxygen consumption
increased for all three groups, but no
significant difference was found be-
tween groups. The authors hypothe-
sized that the lower water tempera-
ture caused vasoconstriction in the
periphery to decrease heat loss, forc-
ing blood centrally, enhancing ve-
nous return and increasing stroke
volume. Since cardiac output at the
same VO, is similar when exercising
on land or in water, the exercise
could be achieved at a lower heart
similar improvements in maximal
aerobic power while exercising at a
than Groups I and 11, the authors
concluded that training in cold water
enhanced stroke volume and de-
creased heart rate, increasing exer-
cise efficiency.
In contrast, exercising in warm
water can increase cardiovascular de-
above those of exercise alone.
Choukroun and Varene (8) studied
the effects of water temperature on the
cardiovascular system of subjects at
rest Subjects were immersed to the
neck in 25". 34". and 40°C water and
cardiovascular demands were mea-
sured. Cardiac output increased signifi-
cantly at 40°C. Gleim and Nicholas
(19) studied the effects of water tem-
perature on individuals exercising in
waistdeep water. The authors found
that the centralization of peripheral
blood flow was overcome by the ther-
mal stimulus to increase heart rate at
CLINICAL COMMENTARY
Owing to the potential for heat
illness, temperature recommenda-
tions for intense training of the elite
athlete should be between 26 and
28°C to prevent any heat-related
complications.
REHABILITATION
Cardiovascular Training
With utilization of a pool for
training, the athlete's goal of main-
taining or improving cardiovascular
function can be achieved while rest-
ing an injury. This is particularly use-
ful for the athlete with weight bear-
ing or impact restrictions. Because of
the physiologic changes incurred
while immersed, it is recommended
that the athlete train at a heart rate
17 to 20 beats/minute lower than
they do on land. The rate of per-
ceived exertion is often unreliable
due to the effects of skill and com-
fort on perceived exertion.
As with any exercise session, an
appropriate warm-up and cool down
are essential. These should be per-
formed in the pool and may consist
of walking, bicycling, or performing
calisthenics in the water, followed by
stretching. A variety of cardiovascular
exercises may be performed and may
replicate a movement pattern used in
their sport or challenge muscles in
need of training for their sport. Deep
water running and cross-country ski-
ing may be performed with the ath-
lete tethered to the side of the pool
or free floating (Figure 3). When
teaching deep water running, have
the athlete "run off the bottomn of
the shallow end into the deep end,
trying to maintain form. Once the
feet leave the bottom, some forward
progress will be made owing to slight
forward lean, but excessive lean
which begins to mimic a swimming
stroke should be avoided. Deepwater
running requires minimal range of
motion at the shoulders and a large
range of hip and knee motion when
performed optimally. Of course, the
 CLINICAL COMMENTARY
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FIGURE 3. Deep water running while tethered can be
used in a pool with limited space.
technique may be modified as
needed for special circumstances.
Cross-country skiing is an excel-
lent cardiovascular training tool, em-
phasizing leg and trunk extension
(Figure 4). Both the shoulders and
the hips move through a large range
Copyright © 1998 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
of motion, making this activity ideal
in sports with such requirements. Un- kick may be added, keeping in mind
like deepwater running where the
knees go through a large range of
motion, the knees stay relatively
straight throughout the cross-country assistance, with the arms held behind intensity, long duration cardiovascu-
ski motion and motion occurs pri-
marily at the hips. Again, the tech-
nique may be modified based upon
Journal of Orthopaedic & Sports Physical Therapy®
the athlete's specific needs.
Once the athlete has mastered
these cardiovascular training tech-
niques, more advanced techniques,
such as vertical kicking, may be incor- when teaching the athlete a deep
porated. Vertical kicking may be per- water technique or if safety is a con-
FIGURE 4. Deep water cross-country skiing is a good training techniques. The therapist
cardiovascular and musculoskeletal training exercise. must be aware of the amount of im-
pact and suggest appropriate
shoewear.
The fundamental guidelines for
cardiovascular training should be at
the core of program design. Twenty-
five minutes, five times per week or
more, is recommended as a mini-
mum, while the elite athlete may
need a longer training period, de-
pending upon the season and sport.
Like land-based exercise, the pool
can also be used for inteml training.
A number of stations or a variety of
exercises performed within a single
session can alleviate boredom and
assure a well-rounded workout. Ankle
floats, arm paddles, or gloves and fins
will increase the lever arm and resis-
tance. The athlete should be re-
FIGURE 5. Vertical kicking maintaininggoodpostural minded to increase speed to further
alignment without a m assistance. increase resistance.
Most importantly, the physical
formed with or without fins and therapist should make the program
should be initiated with a small flut- as sports-specific as possible. For ex-
ter kick. Once mastered, a dolphin ample, the sprinter can perform in-
terval sprinting, working at peak oxy-
that it requires a high level of dy- gen consumption, with intermittent
namic lumbar control. Kicking jogging for recovery. In contrast, the
should be performed without arm marathon runner might perform low
the back or hands out of the water lar exercise, maintaining the work-
(Figure 5). This training technique is load at 70-80% maximal oxygen
particularly effective for those ath- consumption. Likewise, a football
letes needing trunk stabilization or lineman may shallow water sprint
performing rapid movements in a with a plow for & to 10-second inter-
small range of motion. vals, with light jogging during recov-
Floatation vests may be used ery to replicate the demands of his
sport.
cern. When possible, the vest should
be discontinued to increase the diffi- Stretching
culty of the workout. When choosing
a belt or vest, it is prudent to assess The athlete may perform any or
the device for the primary location of all of their stretching routine in the
floatation. Some belts provide the water. A warm water pool (32"-35°C)
greatest floatation posteriorly, which provides a relaxing environment,
places the athlete in an excessive for- which may allow for increased soft
ward lean. A more symmetrical belt tissue extensibility. Additionally, the
or vest is recommended. buoyancy of the water makes stretch-
If weight bearing is allowed, the ing easier to perform and optimal
athlete may exercise in shoulderdeep positions easier to maintain (Figures
water. Shallow water running and 6A and B). The duration of the
cross-country skiing are both effective stretch can vary; however, a low in-
tensity, long duration (20-30 sec-
onds) stretch has proved to be most
Volume 27 Number 1 January 1998 JOSFT
 - - - - . - - - - - - -C-O. M M E N -T A .R Y
muscular coordination, and stretch-
ing and elongation through the legs,
trunk, and upper extremities. A snor-
kel may improve the skill of those
individuals with adequate swimming
technique who have difficulty coordi-
nating the breathing. Backstroke
swimming negates the breathing ob-
stacles, produces elongation through
the body, and provides resistance to
the neck, back, and leg extensor mus
cles. Remember that the athlete does
not necessarily have to be able to swim
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for 25 minutes for their training ses-
sion; the swimming may be just one
component of an interval program. For
example, an athlete performing inter-
vals may compliment deepwater run-
ning (working hip and knee flexor
muscles) with backstroke swimming
(working extensor muscles).
FIGURE 6. A) Hamstring stretching and B) gluteal Shoulder strengthening exercises
stretching can be easily accomplished in the pool. usually performed on land can be
Copyright © 1998 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
performed in the pool. These may
beneficial in promoting lasting include glenohumeral flexion/exten-
changes (25). sion and abduction/adduction from
0" to 90" in shoulderdeep water, hor-
izontal abduction/adduction at 90"
Resistive Training
of abduction, elbow flexion and ex-
Continued strength training dur- tension, and shoulder internal and
ing the rehabilitation process is criti- external rotation. Additionally, com-
cal for the elite athlete. By utilizing bination patterns such as propriocep
Journal of Orthopaedic & Sports Physical Therapy®
equipment and implementing the tive neuromuscular facilitation diago-
basic principles of water, the physical nals may be used. Potential problems
therapist may create a complete with some upper extremity exercises
aquatic strengthening program for are: I) resistive exercise can be per-
the athlete, which may be performed formed only through a partial range
minimizing risk of reinjury. Although of motion in a standing position, and
some athletes may focus primarily on
2) the mechanics are different for
an injured extremity, all extremities
some exercises compared with their
should be trained as should the core
land-based counterparts. For exam-
body. Fortunately, since water acts as
ple, shoulder horizontal abduction
resistance for all body parts sub-
mersed, many of the exercises below and adduction performed at 90" of
load multiple areas and many include abduction is resisted in the transverse
the core body. plane but supported in the sagittal
plane. That is, the athlete no longer
has to hold the arm abducted against
Upper Extremity Training gravity while performing the horizon-
An excellent but often over- tal component of the exercise. How-
looked upper extremity training tech- ever, the trunk muscles must cocon-
nique is swimming. Not only does it tract to stabilize the body against the
train the upper extremity, but it p r e destabilizing forces to a greater de-
vides cardiovascular benefits, neuro- gree than required on land.
JOSPT Volume 27 Number 1 January 1998
CLINICAL
FIGURE 7. Resistive tubing can be used to train the
throwing motion while challenging trunk balance in
shallow water.
Overhead activity can be per-
formed using a few techniques. Resis-
tive tubing may be used in the pool
as it is on land. Although there is
little additional benefit to performing
this type of exercise in the pool, it
can be incorporated as part of a total
training program that is performed
in one location. For example, an ath-
lete may practice the throwing m e
tion while standing in waistdeep wa-
ter, using Thembandm as resistance.
In this case, the water is providing
core body resistance while the Thera-
band resists arm movement (Figure
7). Secondly, exercise may be per-
formed in supine, in prone using a
snorkel, or standing forward flexed
in shallow water with the face out of
the water. A variety of resistive and
stabilization activities can be per-
formed in this position. In supine,
with the arms abducted to 135",
rapid alternating shoulder flexion
and extension can be performed
through a small range of motion.
Similarly, rapid alternating shoulder
internal and external rotation can be
performed at 90" of abduction (Fig-
ure 8). Both of these exercises are
effective in athletes with shoulder insta-
bility, as they require muscular cocon-
traction for stabilization of the upper
quarter. Elite athletes may perform
sets of 30-50 repetitions or to fatigue.
Athletes who perform sports re-
quiring closed kinetic chain move-
ments, such as gymnasts and wres-
tlers, can benefit from closed chain
 CLINICAL
- -
COMMENTARY
--.
FIGURE 8. Rapid alternating shoulder internal and ex-
ternal rotation at 90' of abduction in supine is a dy-
namic stabilization exercise safely performed in the
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pool.
exercises. Dips at the side of the
pool, using triceps, deltoids, and
scapular stabilizers, and overhead
push-pull in the supine o r prone po-
sition, utilizing latissimus dorsi, del-
toids, and triceps, may be performed
(Figure 9).
When performing open chain
Copyright © 1998 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
upper extremity training, equipment
such as gloves, paddles, o r resistive
bells may be used to increase resis-
tance. Kickboards may be used as
resistance and held underwater in
front of the athlete, performing a
"push-pull" motion for scapular pro-
traction/retraction to strengthen
rhomboids, trapezius, and serratus
Journal of Orthopaedic & Sports Physical Therapy®
anterior. The clinician should realize
that a small increase in equipment
surface area in the upper extremity
translates into a significant increase
in the resistance. Sports-specific
equipment can be used in the
aquatic rehabilitation program. The
baseball player may use an old bat to
reproduce the swinging motion,
FIGURE 9. Closed chain activities, such as an over-
head push-pull, can be performed using the pool's
edge.
FIGURE 10. Sports-specific activities, such as the ten-
nis swing, can be duplicated using aquatic equipment.
while the tennis player may practice
forehand and backhand with an old
racket or various pieces of aquatic
equipment (Figure 10).
Lower Extremity Training
A variety of both open and
closed chain exercises can be per-
formed in the pool. Lower extremity
strengthening exercises can be per-
formed completely nonweight bear-
ing using many of the open chain
activities mentioned in cardiovascular
training techniques. Vertical kicking
is especially effective for increasing
lower extremity muscle endurance.
Swimming or kicking in prone or
supine with fins are excellent lower
extremity muscle endurance exer-
cises. Sitting on a floatation device
while performing repetitive knee flex-
ion and extension with or without
fins is a very fatiguing quadriceps and
hamstring exercise and proves benefi-
cial for those involved in kicking
sports, such as football and soccer
(Figure 11). Fins increasing surface
area o r ankle cuffs increasing buoy-
ancy are particularly effective means
to increase resistance in an open
chain. Resistive boots can increase
the resistance as much as four-fold,
and exercises using boots are useful
in sports requiring power, such as fig-
ure skating and gymnastics (17,32).
To strengthen the quadriceps
and gluteals in a closed kinetic chain,
FIGURE 11. Resisted seated knee flexion and exten-
. .
sion fatigues the quadriceps and hamstrings while
challenging trunk balance on an unstable surface.
exercises such as lunges, step downs,
and squats should be incorporated.
Owing to buoyancy, the quadriceps
eccentric work with most aquatic ex-
ercise is decreased relative to compa-
rable land-based exercise. Floating
squats, where the athlete stands on a
floatation board and pushes down
requires coordination and eccentric
control. Athletes who require explo-
sive push-offs, such as track and base-
ball as well as athletes in jumping
sports, will benefit from jumping
drills. Two-footed jumping is pro-
gressed to single leg jumping and
eventually to jumping with 90° turns.
These jumping drills are especially
useful with figure skaters, gymnasts,
and volleyball, soccer, and basketball
players, where jumping and turning
are essential skills. Tethered push-offs
and tethered side-tmide jumping are
also useful jumping drills (Figure
12). Shock absorptive shoes may be
necessary for these activities.
Core Strengthening
Core body strengthening is criti-
cal for any athlete. Baseball players
must be able to transfer kinetic en-
ergy from their lower extremity to
Volume 27 Number 1 January 1998 JOSPT

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FIGURE 12. Side-to-side tethered jumping are impad
activities which can be initiated in the pool.
the arm via their trunk musculature.
The soccer player must be able to
twist and rotate at the trunk while
kicking o r passing the soccer ball.
Core body strengthening is often
overlooked and can easily be ad-
dressed in the pool. Because any u p
Copyright © 1998 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
per or lower extremity exercise must
be stabilized by the trunk in the
pool, most of these exercises also
train the core. For example, standing
leg kicks in a sagittal plane require
both single leg balance and core
strength to avoid being displaced by
the movement of the leg against the
water. Similarly, bilateral shoulder
Journal of Orthopaedic & Sports Physical Therapy®
flexion and extension causes poste-
rior and anterior (respectively) dis-
placement of the body, which must
be countered by the abdominal and
trunk extensor muscles. Cross-country
skiing is an excellent total body work-
out, stressing the body from the
shoulders through the trunk down
both legs.
Specific core body strengthening,
such as leg lifts at the side of the
pool, should also be included. By lift-
ing the legs straight, the focus is on
the rectus abdominus, while lifting
side-to-side in a "V" fashion (straddle
lifts or jumps) works primarily the
abdominal oblique muscles. Eccentric
work of the abdominal muscles may
be performed with a soccer ball by
doing trunk flexion/extension and
slowly allowing the ball to return to
the surface of the water (Figure 13).
JOSPT Volume 27 Number 1 January 1998
FIGURE 13. Abdominal strengthening can be per-
formed in a standing position using a ball as resis-
tance.
Sports-specific exercises, such as
trunk rotations with the arms extend-
ed, may benefit the soccer player,
golfer, or quarterback, who require a
lot of rotation for their sport. Modifi-
cations may be made to mimic the
specific sport (Figure 14). Resisted
water walking/jogging with kick-
boards may be helpful to the football
lineman. Figure skaters as well as
long and triple jumpers may increase
core body strength via pike jumping.
Balance and Proprioception
Balance and proprioception are
important to any athlete and should
be part of any thorough rehabilita-
tion program. Balance is controlled
by sensory input, central processing,
and neuromuscular responses (33).
Proprioception is defined as position
sense that orients the body or specific
body parts to space or other objects
(1). Balance and proprioception may
be trained in a water-based program.
Examples of balance exercises in-
clude hip flexion/extension and cir-
cumduction in waistdeep water while
standing on the injured leg, progress-
ing to shallower water. Other nonim-
pact balance activities include single
leg balance on the injured leg while
altering the center of gravity by mov-
CLINICAL COMMENTARY
FIGURE 14. Sports-specificcore activities, such as the
golf swing, challenge trunk muscles in functional po-
sitions.
ing the upper extremity, as in a push-
pull motion with a kickboard or with
rotation of the upper extremity while
using water paddles as resistance. In-
crea.ing knee flexion on the weight-
bearing leg will increase the chal-
lenge to these muscles (Figure 15).
Additionally, athletes may close their
eyes, relying more heavily on neuro-
muscular rather than visual input. If
impact is allowed, single leg hopping
activities, where the athlete works on
bent knee landings and "sticking"
their landing, may be performed.
The athlete may hop side-to-side, for-
ward and backward, and with rota-
tion, again progressing to shallow
water as tolerated. A step may also be
used to train the athlete to hop to
and from different levels. These exer-
cises can be made more sports-spe-
FIGURE 15. Balance activities are easily performed
using the upper extremities as resistance.
 CLINICAL COMMENTARY
cific by incorporating the drills used
in practice directly into the pool.
Return to Sport
Although aquatic-based programs
may be made very sports-specific for
the injured athlete, many athletes
have difficulty mentally if they cannot
train specifically for their particular
sport. The biggest mistakes made by
most athletes are returning too
quickly after injury, training too hard
too soon, and failing to allow ade-
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quate time for recovery. By employ-
ing an extensive, intense water-based
program that challenges the elite ath-
Shoulder:
horizontal abductionladduction
intemaVextemalrotation
alternate rows at 90" of abduction
Copyright © 1998 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
intemallextemal rotation in supine
overhead flexionkxtension in supine
Elbow flexion and extension
Lower extremity training
Shallow water lunge jumps
Vertical kicking
Seated knee flexiodextension sprints with fins
Buoyancy-resisted knee extension
Buoyancy-resisted knee flexion in sitting
Journal of Orthopaedic & Sports Physical Therapy®
Coretraining
Pike jumps
Tuck jumps
Side-to-side hops
Leg lifts
Ball push downs
Trunk rotations with paddles
Balance tnining
Eyes closed hip flexiodextension
Eyes closed hip abdudiodadduaion
Passing standing on a single leg shoulder
internallexternal rotation at 90" of abduction
Combination drills
Single leg tubing resisted: overhead shoulder
flexion
Supine kick with fins
Prone kick with fins
Side-lying kick with fins
training
Cardiov;~~cuhr
ID-mile swim
Deepwater running
Deepwater cross-country skiing
TABLE 2. Sample training program for a vollevhall
plaver.
40
lete, the injury will receive necessary
recovery time while the athlete con-
tinues to train and condition. Some
injuries, such as stress fractures and
postoperative rehabilitation, may
have specific guidelines for return to
sport and impact activities. Others,
such as tendinitis and muscle strains,
are often symptom-limited and the
physical therapist must rely on sub-
jective input and the athlete's re-
sponse to functional testing. Regard-
less of the injury, gradual return to
sport and impact activities is crucial
to prevent reinjury.
Prior to resuming land impact
activities, the lower extremity- or
spine-injured athlete should be put
through a battery of sports-specific
tests in shallow water to assess readi-
ness for impact. Athletes should be
able to complete the test without sig-
nificant increase in pain, muscle sore-
ness, or swelling. Once the athlete
tolerates the battery of tests, he/she
may start a land-based impact pro-
gram, continuing the water-based
program on alternate days. Ideally,
the athlete should increase their time
on land slowly, with no increase in
pain, altered biomechanics, or signifi-
cant muscle soreness. Land-based
programs may continue to be compli-
mented by pool programs as long as
the athlete and clinician feel neces-
sary. Oftentimes, even upon return-
ing to preinjury status, athletes may
enjoy continuing to train in the pool
1-2 times/week for variety and to
give their extremities a much needed
TABLE 3. Sample training program for a iigure skater.
break, especially from impact. Sample
training programs for various athletes
are included in Tables 2-4. garding aerobic and anaerobic sports-
specific conditioning. Stretching fre-
SUMMARY quency and duration and concentric
and eccentric strength training were
Rehabilitation of the elite athlete discussed. Balance and proprioception
in a water-based program was dis- activities were suggested and progres-
cussed. The physiologic changes in- sion to impact and return to sport cri-
curred by the body while immersed, teria were discussed. The pool is an
both at rest and during exercise, were effective medium for many aspects of
reviewed. Recommendations regarding the elite athlete's training and rehabili-
both weight-bearing and nonweight- tation program. An understanding of
bearing cardiovascular conditioning the differences between land-based and
were made as well as suggestions re- water-based exercise allows the clini-
Volume 27 Number 1 January 1998 JOSPT

careioMscular mining
Shallow water tethered interval training
1:2 workrest intervals (15-second interval)
Stabilization
Single leg:
shoulder horizontal abduaion/adduaion
with paddles
shoulder flexion/extension with paddles
Kicking with fins sitting on a floatation device
Stabilizer trunk twists with paddles
Floating squats without arm support
Core training
Pike lifts at pool side
Knee tucks with rotation at pool side
Straddle jumps
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lunge jumps
sports-specific
10-secondplow pushes forward and back
Direction change running drill
Frontal and sagittal plane jump drills on
aqua step
Coordination quick feet over pool lines
TABLE 4. Sample training program for a iootball
lineman with a history oi low back pain.
Copyright © 1998 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
cian to establish a comprehensive and
effective training program for the elite
athlete. JOSPT
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