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Pool Power: Aquatic Training & Rehab for the Elite Athlete

Byline: Andrea Salzman, MS, PT

According to the 2008 Superstudy® of Sports Participation, over 7.2 million people participated in non-swimming aquatic exercise in the United States in 2007. 

But until recently, aquatic exercise was seen as the “kinder, gentler” sport -- one reserved for the elderly, the pregnant, the injured, and the disabled. Workout maxims such as “go to failure” or “feel the burn” did not echo loudly -- if at all -- in natatoriums throughout the country. The pool was not for the well, nor the fit.

“The national incidence rate for stress fracture in NCAA Division III college athletes can run 4-14%. In elite, Division I athletes, it can soar to over 35%. Their workouts are killing them.” 

Killgore coaches the Cross Country and Track & Field teams at Linfield and insists all his athletes use the pool while healthy before they ever need the pool injured. His incidence rate of stress fractures? Less than 1%.

“It’s a mistake to keep the pool as a secret back-up plan,” laughs Killgore. “I make my athletes experience the pool from the beginning of the season. They practice their running form in the pool. They do speed drills, plyometric training and core stabilization tasks in the pool. They establish a base [of water-time] just like they establish a base of running time.” 

Killgore believes by using the pool early on, he trains each athlete’s neuromotor system to know what is expected of it in water. In essence, he is creating an engram or muscle memory for the athlete to use if ever injured. 

His entire Track & Field team – which includes the #1 and #2 ranked NCAA Division III decathletes in the country – spends 4-6 days in the pool each week. 

Killgore even developed a special shoe for athletes to use during aquatic workouts. His recent research showed that the shoe can increase caloric expenditure by 9% during a 30 minute workout (results pending publication in the Journal of Strength and Conditioning Research). Better yet? Killgore believes it helps athletes gain proprioceptive awareness of where their feet are in space. 

“We wanted to stay subtle with the shoe,” reports Killgore. “If I ramped up the frontal surface area too much, I would have a shoe with a whole lot of drag. That would increase the resistance, yes, but to the detriment of other things, like the patellar tendon. I didn’t want to overshoot.” 

His team’s normal training day might run 3-4 hours, the first 20-40 minutes of which take place in an 81° F. swimming pool. No matter what their specialty – jumping, hurdling, sprinting, or distance running – these college athletes clock hours in the pool. Shallow water butt-kickers, high-knee drills, goose stepping, vertical acceleration training, sprints, striders, racing form drills… they all translate to shallow or deep water work. 

Progression from Water to Land

There comes a time when all good men -- and women -- must get out of the pool. 

Beth Scalone, PT, DPT, OCS works predominantly with student athletes and weekend warriors, not professionals, but she has established a national reputation as an excellent aquatic therapist and seminar instructor. She believes the pool makes all the difference in getting her clients back from the brink of injury. But she knows full-well that sport – indeed, life itself – must take place under gravity’s sway. 

Her pool at North County Water and Sports Therapy Center, (San Diego, California) has a zero-depth entry and runs from 0’-7’ deep. It’s kept at a relatively (by therapy standards) chilly 82° F., which allows her to perform higher level cardiovascular workouts.

Many of her athletes start in the pool almost immediately after injury or surgery. 

Take the post-meniscectomy patient. “Once those scope sites are closed, pool becomes a part of therapy 2-3 times per week,” Scalone reports. Her rehab clients will spend 60 minutes in therapy -- ½ on land and ½ in water. 

Assuming her client has good trunk stabilization skills, Scalone will start her therapy sessions in deeper water with gentle jogging, range of motion, and non-weight bearing leg strengthening. 

From there, as tissues heal, she moves to shallow-water closed-chain work such as squats and lunges. When determining if a client is ready to progress from pool to land-based exercise, Scalone suggests therapists consider the following “tests”:

  • Can the client maintain good alignment of the kinetic chain during the movement? 

  • Is the motion pain-free?

  • Has the injured tissue healed adequately to handle the additional gravitational forces and weight bearing stresses?

  • Has the client demonstrated the ability to perform several repetitions of the movement without losing quality or control of the motion?

After a client is ready to begin strength training, ROM, stair work -- even linear running -- on land, there may still be a place for aquatic-based plyometric work. Because the water is buoyant, athletes can perform bounding, hopping, sprints, and other ballistic power moves in the water with a 50-75% weight-bearing reduction. 

But there comes a moment when the athlete wants to return to “normal” – a moment when the therapist must determine if it is safe to resume the rigors of gravity-based work. 

Before making that final decision to “86” all pool-time, Scalone suggests therapists ask these questions to determine if plyometrics can be safely performed out of the protective environment of the pool:

  • Does the client have nearly normal ROM?

  • Does the client have footwear with good shock absorbing qualities? Will the plyometric drill take place on a cushioned surface?

  • Has the client participated in a strength rehabilitation program for minimal of 2 to 4 weeks?

  • Can the client demonstrate eccentric strength and control in a closed chain exercise?

  • (For UE plyometrics): Does the client have at least 80% of normal strength and 90-95% ROM?

  • (For LE plyometrics): Can the client perform single leg stance for 30 seconds with eyes open and eyes closed without noticeable shaking or wobbling?

  • (For dynamic jumping): Can the client demonstrate single ¼ to ½ squat without wobbling?

Note: younger clients (under 16) should avoid advanced levels of land-based plyometric exercise involving large shock intensity like depth jumps.

Scalone believes athletes are a joy. They are self-directed and want to get better fast – unfortunately, sometimes too fast, possibly to the detriment of their bruised and battered bodies. 

Indeed the pool can be the therapist’s trump card. Once played, the whole game changes; the rules of rehab can be re-written. Workouts once verboten for the injured athlete can take place without fear of additional trauma. 

And what could be better than that? 

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