Effectiveness of Aquatic Exercise in Improving Lower Limb Strength in Musculoskeletal Conditions: A Systematic Review and Meta-Analysis
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Updated: Mar 14, 2026
Lower Limb Biomechanical Analysis of Healthy Participants
Published on: April 15, 2020
Sophie Heywood1, Jodie McClelland2, Benjamin Mentiplay3
1Faculty of Health Sciences, School of Exercise Science, Australian Catholic University, Melbourne, VIC, Australia; The Melbourne Sports Medicine Centre, Melbourne, VIC, Australia.
Objective:
To investigate the effectiveness of aquatic exercise in improving lower limb strength in people with musculoskeletal conditions.
Data Sources:
A systematic search used 5 databases, including MEDLINE, CINAHL, Embase, SPORTDiscus, and The Cochrane Library.
Study Selection:
Randomized controlled trials evaluating aquatic exercise with a resistance training component for adults with musculoskeletal conditions compared with no intervention or land-based exercise were identified. Fifteen studies from the initial yield of 1214 met these criteria.
Data Extraction:
Data related to participant demographics, study design, and methods, interventions, and outcomes, including numerical means and SDs, were extracted independently by 2 reviewers.
Data Synthesis:
Nine of the 15 studies were of high quality, scoring at least 6 on the Physiotherapy Evidence Database Scale. Limited consideration of the prescription of resistance in the aquatic exercise and application of resistance training principles existed. Low- or very low-quality evidence indicates there was no difference in average effect between aquatic exercise and no exercise in improving hip abductor strength (standardized mean difference [SMD], .28; 95% confidence interval [CI], -.04 to .59), knee extensor strength (SMD, .18; 95% CI, -.03 to .40), knee flexor strength (SMD, .13; 95% CI, -.20 to .45), or lower limb endurance (SMD, .35; 95% CI, -.06 to .77). Low-quality evidence indicates no difference in average effect between aquatic and land exercise for knee extensor (SMD, -.24; 95% CI, -.49 to .02) or flexor strength (SMD, -.15; 95% CI, -.53 to .22).
Conclusions:
It is likely that the inadequate application of resistance in water is a significant contributor to the limited effectiveness of aquatic exercise interventions in improving hip and knee muscle strength in people with musculoskeletal conditions. Future research is needed to quantify resistance with aquatic exercises and to determine if using opportunities for greater resistance in aquatic rehabilitation and appropriate resistance training principles can be more effective in improving muscle strength.
