Treating Inversion With Submersion

A program of aquatic exercises can be an effective rehabilitation tool for treating a common sports injury, the inversion ankle sprain.

By Andrew Spence

Andrew Spence, MEd, ATC, CSCS, is an Assistant Athletic Trainer at the State University of New York, College at Oneonta.

Training & Conditioning, 11.5, July/August 2001,

Few people would argue that active motion is less than fundamental in all phases of rehab. But many athletic trainers and physical therapists struggle with how to get a recently injured athlete to start actively exercising when he or she is experiencing pain with any type of weightbearing activity. There is also the fact that the healing itself can be hindered if an injured area is stressed—as with full weightbearing activities—too early.

Aquatic rehabilitation may help. When an athlete is placed in a pool, the impact and load forces on the injured area are greatly reduced. This allows the athlete to perform active exercises that he or she may not be able to do on land.

In this article, I describe a series of aquatic exercises that can be used to rehabilitate one of the most common injuries in sport: the inversion ankle sprain. Many of these exercises can be used as part of a rehabilitation protocol for any lower-extremity injury.

The Ankle and The Water
An inversion ankle sprain is the most common type of ankle sprain, due to the design of the ankle. The joint is in its least stable position when the foot is plantarflexed (when you go up on your toes). The lateral malleolus creates a bony block that will limit ankle eversion (the ankle rolling out). As a result, inversion is the motion the ankle is likely to fall towards. When this occurs, the lateral ligaments may be stretched or torn.

The initial treatment for an ankle sprain is, of course, RICE (Rest, Ice, Compression, and Elevation). This will help decrease the pain and swelling associated with the injury. If the sprain is severe, referral may be needed to rule out a fracture before the rehabilitation process begins.

Once a fracture has been ruled out, even if the athlete cannot walk, it is important to get the ankle moving to prevent negative effects such as reduced range of motion and the possibility of developing Achilles tendinitis. If the athlete is non-weightbearing, atrophy may occur not only in the ankle, but the entire leg. As the saying goes, “If you don’t use it, you lose it.”

With these potential problems in mind, this becomes a perfect time for aquatic rehabilitation. As long as the ankle doesn’t show signs of a fracture, you can get the athlete in the pool right away. Depending on his or her tolerance, the athlete can start right in with non-impact activities using a flotation device in the deep end of the pool, and possibly even low-impact activities, such as walking in the shallow end.

Any body of water that is at least waist deep can be used to do therapy. Lap pools, therapy pools, or diving pools are the most commonly utilized. Different types of aquatic tools can be incorporated, such as a flotation jogging belt, diving brick, kick board, bucket with rope, elastic bands, and submerged boxes, but, as you’ll see, you don’t need a lot of fancy equipment to conduct rehab in the pool.

The Rehab Program
As the athlete performs these exercises, make sure he or she is not in pain. If the athlete experiences pain, have him or her move to another exercise or modify the one being done to make it less painful. If the athlete cannot swim or is uncomfortable in deep water, either avoid that part of the therapy or give the athlete flotation support.

This program is broken down into non-impact (deep water) and low-impact (shallow water) exercises. There is some repetition in the program between the two types of exercises. The advantage of this repetition is that the muscles are stressed at different angles depending on whether or not the athlete is planting his or her feet on the pool floor. The SAID (specific adaptations to impose demands) principle states that the body will respond to the stresses that are placed upon it. So the repetition of some exercises should yield varied positive results.

While performing these exercises, make sure the athlete works as hard as possible within pain-free limits. This will ensure the greatest benefits. The length of the program may vary individually, but will typically run 30 to 45 minutes. Rest periods after each exercise should not exceed one minute.

Non-Impact Exercises
These exercises are done in the deep end of the pool. Here, the athlete can stress the injured ankle without any impacting forces. The deep water can act as both a starting place for the injured athlete to regain some motion immediately following the injury and as a site for advanced rehabilitation and conditioning. The only difference between the two scenarios is that, in the latter, the athlete performs the exercises with greater intensity, for a longer period of time, or both.

Walking (supported): For an athlete who has little range of motion, walking in the deep water with flotation support will be very beneficial. The water allows him or her to walk and move through a range of motion that cannot be achieved on land.

Instruct the athlete to walk around an imaginary square in the deep end of the pool. The square may cover the entire deep area or three to four lanes. The square allows the athlete to continuously exercise without stopping to turn around (as would be the case if he or she had to walk across the pool and back).

The athlete should almost feel like he or she is riding a bike. Emphasize moving the affected ankle through a full pain-free range of motion. The speed at which the athlete walks is not a concern. Have him or her do at least two or three laps before moving on.

Jogging (supported, unsupported, elastic band): If there is no pain associated with walking, have the athlete begin jogging with flotation support around the perimeter of the square. It may take the athlete a little time to master the skill of aqua jogging. One common problem is the athlete leaning too far forward. If this occurs, he or she will appear to be actually swimming rather than jogging. Make sure the athlete stands up tall and simulates the actual act of running. It may look as if the athlete is not going anywhere but he or she will get a good workout nonetheless. Follow the same directions as with walking. Time each lap and have him or her complete two or three laps.

Once the athlete has regained some strength and range of motion in the ankle, have him or her jog in the deep end of the pool without the flotation support. Another variation that requires the athlete to do more work is to tether him or her with an elastic band. This can be done either to the flotation vest or around his or her waist if he or she isn’t using a flotation device. With the band, have the athlete jog for time, such as 30 seconds, followed by 30 seconds recovery consisting of just jogging in place without the band’s resistance. Have him or her complete two or three sets.

Jogging/sprinting (bucket/elastic band around waist): Next, incorporate sprinting while jogging. To tolerance, have the athlete jog the widths and sprint the lengths of the box. Time the athlete and have him or her complete two or three laps. Emphasize form when sprinting. If the athlete is bent over, he or she may not get the full benefit of the exercise.

To add resistance, attach a bucket to the athlete’s waist. The faster he or she runs, the greater the resistance.

To modify this exercise, again, attach a fixed elastic band to the back of the flotation support and have the athlete jog and sprint. Start out by having the athlete jog constantly for 45 seconds then sprint for 15 seconds. For the next minute, instruct him or her to jog 30 seconds and sprint 30 seconds. Lastly, have the athlete to jog 15 seconds and sprint for 45 seconds.

Treading (brick): Upon completion of the running exercises, have the athlete tread water. This may last five minutes or longer. To add resistance, instruct the athlete to take his or her hands out of the water. This will force the athlete to use the legs to stay afloat. Follow the same pyramid as described above (tread 45 seconds, hands out 15 seconds; tread 30 seconds, hands out 30 seconds; etc.). If the athlete is struggling, limit the amount of time the hands are out of the water. Additional resistance can be introduced by having the athlete hold a brick while treading water.

Swimming/Kicking (kick board): The last deep-water exercise has the athlete alternating between kicking on his or her stomach and back while using a kick board. Instruct the athlete to kick around the perimeter of the imaginary square using different kicks while lying on his or her stomach. Have the athlete start out with the standard flutter kick, completing two or three laps. The athlete should then repeat using the breast-stroke kick (frog kick). The different kicks will place different stresses on the ankle. This is vital in the healing process. After two or three laps, have the athlete roll over onto his or her back (hugging the kick board) and repeat using the same kicks.

To modify this exercise, add fins. This may place more resistance against the foot and help with ankle strengthening and improved range of motion.

Low-Impact Exercises
Low-impact exercises are done in the shallow water. This allows the athlete to bear weight with less stress than he or she will encounter out of the pool, but with the added benefit of providing foot contact with the floor of the pool. This provides a good progression for the athlete who has been on crutches or has had a hard time walking. Performing low-impact exercises in the shallow end will help the athlete re-learn how to walk. Additionally, the low-impact exercises will help to re-train the proprioceptors that have been affected by the injury.

Low-impact exercises are broken down into straight-ahead and functional activities. For both, use the same imaginary square as described above (but now in the shallow end of the pool). In this case, the square will go from shallow to deep water, placing additional water resistance on the lower extremities as the athlete moves.

Straight-Ahead Activities
Walking and Jogging: Start off by having the athlete walk the perimeter of the imaginary square. Then, as long as there is no pain, have the athlete progress to jogging the square. Have him or her try to jog the square in a specific time, such as completing one lap in less than two minutes. This motivates the athlete as he or she progresses through therapy. Have him or her repeat two or three laps or more as tolerated.

Sprinting: Next, have the athlete jog the widths and sprint the lengths. Again, establish a time that it takes to accomplish one lap and have the athlete attempt to reproduce the same time—or produce better times—each lap. To add resistance, as before, tie a bucket around the athlete’s waist. The athlete should complete two or three laps.

Lunges: Lunges may be done near the wall in the shallow end. Have the athlete alternate the lead leg, performing two to three sets of 30 seconds each with each leg. To add resistance, have the athlete hold a brick while performing lunges.

Step-Up: Next, submerge a bucket or a milk crate in the shallow end by the edge of the pool (using stairs that enter the pool will also work). Have the athlete step-up onto the bucket and then back off. He or she should perform two or three sets of 30 seconds each, alternating the lead leg after each rep.

Jumps: Finally, have the athlete perform two-legged jumps onto the bucket. Place the bucket against the wall so it doesn’t move as he or she jumps onto it. The athlete should get onto the bucket and return to the pool floor as quickly as he or she can. Again, have him or her complete two or three sets of 30 seconds.

Functional Activities
Cross-Over (Carioca or Grape-vine) and Side-Step: The following activities are functional exercises. Within the confines of the imaginary square, have the athlete execute the cross-over or carioca going across the pool, then backpedal down the lane, side-step across the pool, and sprint forward. Each timed lap should be the same time or better, if possible, than the previous lap. The athlete should complete two or three laps depending on how he or she is responding to the work.

Bounding: Next, instruct the athlete to bound the perimeter of the square. Bounding will emphasize the landing part of running. This will create powerful contractions in the quads as well as greater contact time on the bottom of the pool, which is beneficial for the injured ankle. This will help to provide input in re-training the proprioceptors of the ankle. Have the athlete complete two or three laps.

Zig-Zag: Have the athlete stand on a lane line at the shallow end of the pool, then run or sprint across the pool to the adjacent lane line at a 45-degree angle. When he or she touches the lane, have him or her cut at a 45-degree angle back to the original lane. The athlete should continue this zig-zag pattern for a specified distance, such as 20 feet, measured along the lane line. Have him or her complete two or three sets in about 30 seconds each.

Figure 8: Find a spot on the shallow end of the pool that will act as the center of the number 8. Instruct the athlete to run figure 8’s of different sizes (large to small). This will apply different amounts of stress to the affected ankle. Have him or her perform two or three sets of 30 seconds each, trying to complete as many figure 8’s as possible in that time.

Injury is inevitable in sports. The key is to rehabilitate the athlete as quickly and safely as possible. Water provides a medium that is unique and beneficial for rehabilitation, simply because the human body weighs less when in the water. Because of this, the athlete can perform exercises that he or she would not normally be able to do on land. In addition, the medium provides resistance in all planes of motion and a massaging effect that may be therapeutic for injured tissues. For many athletes late in their rehab, the pool also provides a welcome change of venue. For these reasons, aquatic therapy should be an essential part of any rehabilitation program.

Many of the above exercises and drills are also excellent for conditioning non-injured athletes. The author has a comprehensive program for conditioning a group of athletes in the pool. For more information, go to our Web site, at and click on “Team Treading” under Bonus Editorial.