Hydrotherapy in ACL rehabilitation

Original Editor - Falcone Tseng

Top Contributors - Falcone Tseng, Kim Jackson and Wanda van Niekerk


Aquatherapy and Hydrotherapy 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 [1]
  • Pain [1]
  • Issues with:
    • Swelling, walking, climbing, stairs, kneeling, squatting, running, lateral motion, cutting, jumping [1]
  • Measures of knee function:
    • Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) [1][2]
    • International Knee Documentation Committee (IKDC) form, Lysholm and Tegner scores[1]
    • Knee Injury and Osteoarthritis Outcome Score (KOOS4) [2]
  • Graft rupture (post-ACLR only) [3]
  • Contralateral ACL injury [3]
  • Lachman and pivot-shift [4]
  • Passive range of motion (knee flexion & extension), muscle strength, thigh circumference (thigh girth, thigh muscle mass, knee joint swelling) [5][6]
  • Active range of motion (knee flexion & extension) [7]
  • 6 minute walk test (6MWT) [7]

Advantages of Hydrotherapy in ACL/R Rehabilitation

In principle:

  • Early weightbearing [7]
  • Postural and gait exercises in a supported environment [8]
  • Water resistance induced muscular conditioning [8]

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 [9]. 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 [5].

A smaller case study of 3 subjects demonstrated no risk of harm in utilizing hydrotherapy to accelerate rehabilitation of ACLR [7].

Considerations for ACL hydrotherapy rehabilitation design:

Accelerated Hydrotherapy Programme [7]
Goal: Treatment:
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:

ACL Hydrotherapy Rehabilitation Progression Timeline, Principles, & Advantages - Hydroworx

Acute Partial ACL & PCL Injury in Male Recreational Basketball Player (conservative management) - Hydroworx

ACL-R Patellar Autograft (5.5 weeks post-op with regression) - Hydroworx

ACL-R in Female Soccer Goalie (4 weeks post-op with delayed rehabilitation) - Hydroworx

Unhappy Triad in Female Volleyball Player (8 weeks post-op) - Hydroworx

Gait Retraining and Lower Limb Mobility Exercises - Sports Med Mumbai


  1. 1.0 1.1 1.2 1.3 1.4 Fithian DC, Paxton EW, Stone ML, Luetzow WF, Csintalan RP, Phelan D, Daniel DM. Prospective trial of a treatment algorithm for the management of the anterior cruciate ligament-injured knee. The American journal of sports medicine. 2005 Mar;33(3):335-46.
  2. 2.0 2.1 Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute anterior cruciate ligament tears. New England Journal of Medicine. 2010 Jul 22;363(4):331-42.
  3. 3.0 3.1 Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy. 2005 Aug 1;21(8):948-57.
  4. Kostogiannis I, Ageberg E, Neuman P, Dahlberg LE, Fridén T, Roos H. Clinically assessed knee joint laxity as a predictor for reconstruction after an anterior cruciate ligament injury: a prospective study of 100 patients treated with activity modification and rehabilitation. The American journal of sports medicine. 2008 Aug;36(8):1528-33.
  5. 5.0 5.1 Zamarioli A, Pezolato A, Mieli E, Shimano A. The significance of water rehabilitation in patients with anterior cruciate ligament reconstruction. Physiotherapy. 2008 Apr 1;16(2):3-6.
  6. Tovin BJ, Wolf SL, Greenfield BH, Crouse J, Woodfin BA. Comparison of the effects of exercise in water and on land on the rehabilitation of patients with intra-articular anterior cruciate ligament reconstructions. Physical Therapy. 1994 Aug 1;74(8):710-9.
  7. 7.0 7.1 7.2 7.3 7.4 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.
  8. 8.0 8.1 Torres-Ronda L, i del Alcázar XS. The properties of water and their applications for training. Journal of human kinetics. 2014 Dec 1;44(1):237-48.
  9. 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.