From Crutches to Marathon in 10 Days

Water-based rehab facilitates a faster return from acute ankle injury

Vol. 27 • Issue 8 • Page 13

Aquatic Therapy

Her days were numbered – 10 and counting before running the marathon. After five months of training, she was excited and ready. That’s when she sprained her ankle.

As I watched her hobble into the clinic with hopes of still running the race, I knew my marathon as her therapist had just begun. She was a 21-year-old right-handed female. She came to me using bilateral crutches and a controlled ankle movement (CAM) boot, and was diagnosed with a grade 2 inversion ankle sprain. I didn’t think she had a chance, but I had to try.

Radiographs taken in the emergency room came back negative for any fracture, and the physician placed her in a boot with crutches. Her sprain involved the anterior talofibular and calcaneofibular ligaments. The ligament was intact but injured.

I supported this finding with my exam. I also found that her active range of motion was about 75% of her non-injured ankle with no pain, and she was able to bear about 10% of her body weight.

Faster and Safer Injury Rehab

Ankle sprains are one of the most common sports injuries. Defined as micro-tearing of ligaments, they typically involve pain and/or instability of the ankle joint. Ankle sprains can occur a variety of ways: collisions, planting, stepping awkwardly, or any other unexpected and sudden movement. Symptoms include swelling, tenderness, bruising, pain, the inability to bear weight, skin discoloration and stiffness.

Typical physical therapy treatment involves bracing and taping, along with rest, ice, compression and elevation (RICE) in the initial phase, followed by active range of motion, then strengthening.

Treating an ankle can take weeks depending upon the severity of the injury. But what if the patient requires a faster recovery time? Or what if they’re in-season and need to continue training during recovery?

Hydrotherapy allows patients to bear less weight while they work on weight-bearing activities. It’s a supportive treatment option to work on range of motion, proprioception, strength, and functional movements earlier in the rehab process without risking further injury. The natural properties of water make patients lighter, limiting pain and instability while simultaneously improving biomechanics to achieve more efficient rehabilitation results.

How I Did It

I used the following four steps to establish this particular treatment plan.

Determine whether hydrotherapy is the right course of action. A full health assessment must always be performed prior to hydrotherapy treatments. Patients with multiple health conditions can sometimes complicate accurate diagnosis. Reasons to avoid hydrotherapy include urinary infections, cardiac failure or unstable cardiac conditions, incontinence, infectious diseases, uncontrolled seizures, skin conditions, fever, infections, open wounds/incisions with no protection, bandages, or oozing wounds.

Create attainable goals that can be met and re-established quickly. In this case, we only had 10 days to progress from crutches to a marathon. For example, walk in a 5-foot area for 10 minutes with no pain, then progress to a 4-foot area for 10 minutes with no pain.

Plan the treatment. Usually my sessions change by 1-2 variables between sessions, but due to time restraints I needed to break this rule. My plan was to progress weight-bearing status and duration, and to stress the ankle joint by walking in the pool, walking on land, jogging in the pool, and jogging on land.

Progress, progress, progress. This patient’s ankle had to be tested continuously to see what it could handle. This was the only way to determine whether she could handle a marathon.

For this situation, I knew that hydrotherapy gave me a big advantage. I could start exercises earlier compared to land-based protocols as she continued training.

One key in this particular case was to stress the ankle joint, but not too much. You do not want to irritate the ankle more, or you lose time, which could be detrimental. The pool gave me more options to get her moving earlier without undue stress. Also, the added benefit of hydrostatic pressure helped decrease ankle swelling.

Training Regimen

The general guideline I use in the pool is: If an individual is up to their neck in water, they are only 10% weight-bearing, shoulder=25%, and waist=50-60%.

The pool at my facility is built for hydrotherapy. It has three distinct depths (4, 5, and 6 feet) along with an integrated treadmill, stairs, and water current that has up to 99 different speeds. All these features were incorporated into the treatment plan.

  • Wednesday (the initial evaluation): I started with massage, a compression stocking, walking in the 5-foot area of our pool for 10 minutes, then ice.
  • Thursday: Massage, joint mobilizations to ankle, and then walking on the treadmill in the pool at speed 10 for 15 minutes.
  • Friday: Massage, joint mobilizations, walking on treadmill in pool at speed 15 with current at speed 30 for 30 minutes.
  • Saturday and Sunday: I wasn’t in the clinic but advised her to use the elliptical machine at a slow pace for 20 minutes, then ice.
  • Monday: Massage, joint mobilizations, jogging on treadmill in pool at speed 30 with current at speed 45 for 20 minutes.
  • Tuesday: Massage, joint mobilizations, jogging on treadmill in pool at speed 30 with current at speed 45 for 10 minutes.
  • Wednesday: Massage, joint mobilizations, jogging on treadmill in pool at speed 30 with current at speed 45 for 5 minutes. I then added jogging on a slanted floor area in the pool with current at speed 80 for 20 minutes.
  • Thursday: Massage, joint mobilizations, jogging on treadmill in pool at speed 30 with current at speed 45 for 5 minutes, jogging on slant in pool with current at speed 80 for 40 minutes.
  • • Friday and Saturday: Rest.
  • Sunday: The race.


During and after each session, the athlete experienced no increase in pain or swelling over the subsequent 24 hours. She did an amazing job of icing five times per day and wore a compression sock around the clock to keep swelling down.

The Result

Training for and running a marathon has its risks and rewards. While marathons continue to increase in popularity, the American College of Sports Medicine reports that 50-70% of first-time marathoners drop out before their race. Most training programs run 16 weeks and require 3-6 days of running and 12-52 miles per week. It’s a big commitment, both mentally and physically.

Running generates up to 8 times more impact on joints than walking, and the force on the lower body can be up to six times the individual’s body weight. If performed incorrectly, running with poor mechanics and muscle imbalances will stress joints and can cause injury.

In the end, my patient did not break her personal best, but she was ecstatic that she finished the race. While this feel-good story ended well, it’s also a solid example of how hydrotherapy can effectively rehabilitate and condition a patient during recovery.

Based on this case, it might be in the best interest of marathon runners to incorporate hydrotherapy into their training to limit stress on the lower body. This could lead to fewer injuries and dropouts among first-time runners.

Sidebar: Why Water Works

Three simple properties of water create an environment that supports, resists and assists movement. Because of them, a patient will experience less pain and increased confidence to regain the strength they need to master proper mechanics and continue treatment.

Hydrostatic pressure. This is the pressure of a fluid – in this case water – against an object. When someone enters the water, hydrostatic pressure creates a uniform support system around all immersed body parts. The deeper a person goes, the greater the support. This lowers joint stress, helps reduce swelling, improves circulation, and reduces lactic acid that leads to sore muscles.

Buoyancy. The ability or tendency to float in water. A person’s body literally feels lighter in water, providing relief to chronic discomfort. This “lightness” provides a mechanical advantage to perform rehab exercises correctly without the inhibition of pain or ankle instability.

Viscosity. A fluid’s resistance to flow. The level of resistance is based on the thickness of the fluid and the speed and surface area of the moving object. The larger the object, the greater the resistance or drag. Moving against a water flow creates resistance, while moving with it creates assistance. Both can be used for effective exercises.

– Jaeson Kawadler


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