March 15, 2023 10 min read

Integrating water-based therapies into a rehabilitation program after a lower limb fracture can aid recovery and accelerate athletes in their return to sport as well as everyday activity. The buoyancy and resistance properties of water provide a unique environment that reduces impact on joints, while still allowing for effective mobility and strength exercises.  

The key benefit is that in the water, you can float while improving mobility in a non-weight-bearing environment. This is particularly helpful post-surgery for lower limbs and rehabilitation for fractures.

An example of this is rehabilitation after a broken ankle. After an injury like this, you can start to recover much sooner than on land, since it doesn’t require being weight bearing, just floating. Weight can be added gradually by controlling the depth of the water. Also high intensity exercise can be integrated much earlier without impacting the injury area (using suspended Aquatic exercises) offsetting the sedentary nature and associated mental health, additional weight and addressing reversibility, which can occur when someone is sedentary after an lower limb injury. This is particularly important due to the long recovery times of such fractures. 


Lower limb fractures are relatively common in sports at any level, from high school to elite and professional athletes. The terms 'bone fracture' and 'broken bone' are essentially the same thing, but a fracture is the medical term for a break.

There are two common types of fractures in sports: a complete fracture and a stress fracture. Stress fractures are common in sports that involve lots of running and jumping, think, soccer, running, netball and basketball. Stress fractures can happen over time, they are from overuse or repetitive motions. They are more likely to occur in long thin bones, a specific example is those of the foot. A standard fracture is caused by an accident or injury and a complete break in the bone. It is usually sudden rather than developing over time. 

Lower limb fractures in sports represent serious injuries, often requiring significant rest and rehabilitation.


1. Tibia and Fibula Fractures: Frequent fractures in athletes include the tibia or fibula bones. These bones form the lower leg. Athletes in contact sports, like football or rugby, might sustain these fractures due to direct hits. Stress fractures, resulting from overuse, commonly affect distance runners and are often located in the tibia.

2. Femoral Fractures: The femur is the thigh bone, and while it's one of the strongest bones, it can fracture under extreme trauma. Such fractures are less common in sports, but when they occur, they're often in high-impact or collision sports.

A femoral neck stress fracture accounts for 3% of sports-related injuries. It is most common in long-distance runners and since it is close to the hip, it may feel like hip pain. A complete femur fracture is uncommon in sports; these are mostly from vehicle accidents or falling accidents. For example, older persons or those with osteoporosis are more likely to suffer from a femur fracture.

3. Metatarsal Fractures: The metatarsals are the long bones in the foot. Direct trauma or repetitive impact can cause fractures. Footballers sometimes sustain a 'Jones fracture' in the fifth metatarsal.  

4. Hip Fractures: Rare in young athletes, these can be devastating. They're more often seen in older individuals due to falls, but in sports, high-velocity trauma, such as in motor racing or skiing, might be responsible.

5. Ankle Fractures: Ankle fractures are not uncommon either. These can range from simple to complex, depending on the force and angle of impact. Sports involving jumping, twisting, or sudden directional changes, like basketball or soccer, can lead to such injuries.

Recovery from a lower limb fracture can range from weeks to months. It's crucial for athletes to undergo proper rehabilitation to restore strength, flexibility, and proprioception. Moreover, protective gear and proper training techniques can help reduce the risk. 


Based on the severity, some fractures will heal with rest and rehabilitation. On the other hand, some more complicated breaks may require surgery or pins to hold the healing bone in place.

Regardless, after a fracture, rehabilitation is crucial. However, there are undoubtedly challenges associated with traditional land-based methods. For example, after an injury or surgery, someone cannot always put weight on a healing fracture, so walking or standing may rule out some components of land-based rehab. In an aquatic environment, however, these exercises can be done with the support of the water. Aquatic therapy is often employed as an alternative or as an adjunct treatment to physio in lower limb rehabilitation settings.

Adequate rehab after a fracture is vital because it effects movement and everyday activities. It is also important for an athlete as typically they are extremely eager to get back out on the field or court as soon as physically possible, especially if it is a career athlete. Oftentimes, the process is more rushed than necessary, and recurring injuries are an issue in elite athletes. A recurring injury is when an athlete has an injury in the same area of the bone or the same joint more than once. In a review of these recurrences, authors noted that the rate ranged from 5-21%, but reporting is not very consistent and there is a need for better reporting to obtain a more reliable figure. In a study of high school athletes, recurring injury was also a notable problem, with 10.5% of athletes suffering from the same injury more than once.


Healing will vary based on the bone fractured, the health of the individual, where the fracture is, and the cause. There are three phases of bone healing: inflammatory, reparative, and remodelling.

Inflammatory: This is the phase where water therapy may be the most helpful, because there may be too much inflammation for land-based therapies. The body is working hard to get blood and vital nutrients to the injury site for healing, hence the inflammation. Activities like water cycling can also assist in reducing inflammation.

Reparative: The tissues are healing, so this is when there needs to be a healing environment that’s stable so that bones can re-grow and are repaired in the right way. Pool therapy is also helpful during this phase because it can be a bit safer for training before everything is healed properly.

Remodelling: The remodelling stage occurs at about six weeks post-fracture. This is when the bone isn’t healed yet, so it may appear a bit deformed on an X-ray. Again, aquatic exercises may still be seen as safer since the break is still prone to re-injury, but this is also a time when land-based and weight-bearing activities are reintroduced.

Appropriate rehabilitative practices can influence each phase. Healing takes time, but with careful rehab, recovery time can be decreased. Water Therapy typically starts when open woulds have closed. Water provides a rehab setting that decreases pain and inflammation and allows for safe and controlled movements during fracture recovery. 


Aquatic therapy has been used for centuries; it’s sometimes referred to as hydrotherapy, pool therapy or water-based therapy. It can be used in the prevention, management, and rehabilitation of musculoskeletal issues.

There are numerous advantages to using aquatic therapy for musculoskeletal injuries, which includes fractures. Aquatic therapy is an increasingly popular modality for recovery from orthopaedic injuries . In a 1989 study, Thein and Brody determine the benefits of water properties for injuries including buoyancy, hydrostatic pressure, resistance, and temperature.


Buoyancy removes the pressure of gravity on injured limbs, so individuals can start rehab faster since they don’t need to be able to stand yet. This is why the support from the water is very helpful for those with injuries that affect weight-bearing activities.


Hydrostatic pressure is excellent for swelling of injuries. This is especially important for the initial stages of the rehabilitation process.


Water provides natural resistance, however, there is equipment meant for the water like weights and resistance bands to increase the intensity of workouts. Therapy centres or pools may have equipment like underwater bikes and treadmills.


Sometimes rehab can be done in pools or bodies of water that are heated. Heated aquatic therapy has additional benefits since heat relaxes the muscles and loosens joints, making them ready to work.

Aquatic therapy is important for its therapeutic and pain reduction properties, but it’s also beneficial in that athletes can remain active by training strength and cardio in the water. This way, returning to their sport isn’t as difficult as it could be. At least some level of physical fitness is maintained even throughout their recovery process.

Furthermore, the strengthening and range of motion (ROM) exercises done during aquatic therapy are beneficial for injury recovery. Together, these attributes are important for any athlete looking to get back into the game at full capacity in a shorter period of time.

Another positive aspect of aquatic therapy is that it helps to remove psychological barriers related to injury recovery and rehabilitation. It’s not uncommon for someone’s mind to impede their recovery. Fear of pain can very much inhibit someone’s progress in their therapy journey.

Exercises can be fully non-weight bearing with the assistance of equipment, but can easily progress to more weight bearing by decreasing the depth (the more shallow the more weight bearing).


An important study in this space is a systematic review and meta-analysis of eight trials, totalling 287 participants with orthopaedic injuries. Based on the review, there were not significant issues regarding healing during aquatic therapy post-injury. Also, the study authors concluded that it is as effective as land-based physical therapy with the added benefits mentioned above.

This article outlines a four-phase return to sport recommendation after a hip replacement in athletes, which includes aquatic therapy as a part of phase two (weeks 3-10). Much of the focus during this phase is on weight-bearing activities and removing walking aids, like crutches. This is why aquatic therapy is especially important for athletes with lower limb injuries.

Since lower limb stress fractures are quite common and problematic for runners, there are published guidelines for runners returning to the sport, which include water running and antigravity treadmill training. Water running for athletes is a common form of both training and rehabilitation with underwater treadmills like the Hydrorider Easyline Treadmill delivering the best biomechanics. 

Running in the water has shown to be great for reducing force on injury or joint. Running in water at hip depth reduces the forces exerted on the body by approximately 34% to 38%, compared to running on solid ground. When the water reaches chest level, the force reduction increases to between 44% and 47%.




The primary focus in the initial stages of recovery is on resolving pain and swelling and reducing muscle atrophy. The benefits of water therapy really stand out in this phase. Gentle movements and stretches are much easier in water compared to on land. Gentle is the key word here, and is of high importance in the initial phase. The benefits of buoyancy are apparent since there is reduced weight-bearing. Still, the athlete is putting in the necessary work, but with less pain.

Hydrostatic pressure is also important at this point, because of its influence on swelling and circulation. Pressure reduces swelling and increases blood flow, and blood delivers vital nutrients to the injury site and is needed for adequate healing.


The step is to focus on strength imbalances, motor patterning, and physical reconditioning. The therapist can utilize the water’s natural resistance to strengthen muscles without stressing the fracture site.

Neuromuscular training like this is imperative because it’s essentially how our brain and body communicate with each other. There are various injury-specific exercises that involve retraining the mind-to-muscle connection after an injury.

Proprioceptive training in water for balance and coordination is especially important for athletes before going back out onto the field or court. It’s great to recover, but some athletes report that the injury site doesn't feel the same as before, and this can be an issue for balance and coordination. Proprioception is the sensory experience of how we connect to our bodies in space.

Proprioceptive exercises, such as balance training on wobble boards or stability discs, help to re-engage and strengthen the neuromuscular pathways responsible for joint stability and coordination. These exercises challenge the individual to maintain equilibrium, thereby improving their ability to detect and correct shifts in body position.

By consistently incorporating proprioceptive training into the recovery process, athletes can regain their previous levels of balance, coordination, and agility, ensuring a safer and more effective return to their desired activities.


This is the part of rehab where there is an emphasis on sports-specific movements. Additionally, water creates a safe environment for practice before transitioning to land.

It is a great precursor to land-based training. It is the transition from basic movements to functional and sport-specific drills. For example, soccer players may do different drills than basketball players. Pool tools and equipment can also be used to enhance training.


A big mistake made by athletes is returning to sport too soon after an injury. This is understandable and must be particularly challenging for elite and professional athletes. There are certain protocols and criteria that highlight the importance of this terminal phase of rehabilitation after a sport-related injury.

Before an athlete can return to sport, they must be assessed based on functional benchmarks to determine readiness. They will have to complete exercises without significant pain, swelling, or muscle soreness. Once tests can be done, athletes may combine land-based and aquatic therapy and it’s time to gradually integrate land-based exercises and reduce dependency on aquatic therapy and ready for land-based activity and sport-specific training. 

Having said this, the level of impact in high impact sports may need to be monitored and offset by a high intensity water fitness exercise like water cycling on an ongoing basis to stop stress fractures or the injury from reoccurring.


The advantages and importance of aquatic therapy include hydrostatic pressure, buoyancy, resistance, and temperature for rehabilitating from a lower limb fracture and returning to sport. The most notable benefit is in the initial phases of rehab since it allows injured individuals who aren't necessarily able to stand or bear weight due to a lower limb injury can do so in the water. This can speed up the recovery process since it can be initiated at an earlier. It can also offset the sedentary secondary issues that develop from lower limb fractures like mental health, additional weight and reversibility.

Aquatic Therapy and specialised aquatic equipment like a Hydrorider and an Underwater Treadmill can be a crucial part of a multi-faceted approach to rehabilitation post lower limb fracture. It's no surprise that Water Specialists like Water Resist are being integrated into rehabilitation teams.

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