The first week after ACL reconstruction can feel a bit overwhelming. Your knee is swollen, your quadriceps may feel like they have completely switched off, and even simple things such as getting around the house can take more effort than expected.
The main priorities early on are actually quite simple: rest, manage swelling, gently get the knee moving, start activating the quadriceps and repeat those basics regularly throughout the day.
This is not the stage to rush ahead into harder strengthening. Your knee has just had surgery, so the aim is to settle things down and start rebuilding normal movement and muscle control.
At PhyxYou Physiotherapy in Port Macquarie, early ACL rehabilitation is generally about getting the basics right first. Your surgeon’s instructions should always guide the process, particularly if you have had another procedure at the same time, such as a meniscus repair.
Start by giving the knee time to settle
One of the biggest mistakes early after ACL reconstruction is trying to do too much because you are keen to get started.
There is plenty of hard work coming later in rehab. The first few days are more about recovering from the surgery itself.
That does not mean staying completely still. Usually, it is better to alternate between short periods of gentle movement and exercise, then allow the knee time to rest.
In practice, that might mean doing your prescribed exercises, getting up for a short period, then returning to a position where the leg is supported and elevated.
If the knee becomes noticeably more painful or swollen after activity, that can be a sign that you have probably pushed a little too far for that stage.
Early ACL rehab does not need to look impressive. It needs to be consistent.
Get on top of swelling early
Swelling is very common after ACL reconstruction.
The knee has been through surgery, so some swelling is expected. The problem is that a very swollen knee can make everything else more difficult.
A swollen knee may feel harder to bend, harder to fully straighten and much more difficult to walk on comfortably. It can also make it harder to properly contract the quadriceps.
That is why swelling management tends to take up a fair bit of attention in the first week.
Compression and elevation
Compression can be useful in the early stages. Depending on your surgeon and physiotherapist’s advice, this might involve a compression bandage, garment or another form of compression.
It should feel supportive rather than uncomfortably tight.
Elevation can also help while you are resting. Instead of spending long periods sitting with the foot hanging down, spend some time with the leg supported and elevated.
The exact position can matter, particularly if you are also working on restoring full knee extension, so your physiotherapist may adjust how you are positioning the leg.
Ice
Ice can also be useful for pain and comfort after surgery.
It is usually better used for shorter periods rather than leaving it on for a long time, and it should not be placed directly onto the skin.
Current ACL rehabilitation guidelines suggest ice is particularly useful for reducing pain and may also reduce the need for pain medication, although its effect on swelling appears to be more modest. (bjsm.bmj.com)
So rather than thinking of ice as the main swelling treatment, it is better viewed as one part of the overall plan.
Keep the knee moving, but do not force it
It is very normal to feel protective of the knee straight after surgery.
It may feel stiff, swollen and unfamiliar, and bending it can be uncomfortable.
Even so, gentle movement is usually part of early ACL rehabilitation.
Current ACL rehabilitation guidelines recommend starting active knee movement early after surgery, provided it is done within the restrictions set by the surgeon. (bjsm.bmj.com)
The goal here is not to force the knee.
You may be given simple exercises to gradually work on:
- Straightening the knee
- Bending the knee
- Moving the leg more comfortably
- Regaining confidence with basic movement
Exactly how far you are allowed to bend the knee, and how much weight you can put through it, depends on the operation you have had.
This becomes particularly important if another structure has been repaired. A meniscus repair, for example, may come with its own restrictions around knee movement or weight-bearing.
This is one of the reasons following someone else’s ACL programme from social media can be misleading. Two people can both have an ACL reconstruction and still have very different instructions during the first few weeks.
Start getting the quadriceps working again
One thing we pay a lot of attention to early is quadriceps activation.
After ACL reconstruction, the quadriceps can be surprisingly difficult to contract. You may feel like you are trying to tighten the thigh but not getting much response.
Swelling around the knee contributes to this.
A very simple exercise commonly used early is a quad set.
The idea is to tighten the muscles at the front of the thigh while the leg is supported. It does not look like much, but at this stage, the quality of the contraction matters more than making the exercise complicated.
Current ACL rehabilitation guidelines support the use of isometric quadriceps contractions during the first two weeks after surgery. (bjsm.bmj.com)
For some people, a few good contractions repeated regularly through the day can be more useful than trying to complete a long exercise session.
Your physiotherapist can also check whether you are actually getting a good quadriceps contraction, rather than simply pushing through the foot or tightening other muscles around the leg.
NMES can be useful if the quadriceps are struggling
For some patients, we may also use neuromuscular electrical stimulation, or NMES.
This involves placing pads over the quadriceps and using electrical stimulation to help create a stronger muscle contraction.
Usually, the idea is not to sit there and let the machine do all the work.
A better approach is often to try to actively contract the quadriceps at the same time as the stimulation.
This can be useful when the muscle is difficult to activate after surgery.
Evidence-based ACL rehabilitation guidelines recommend NMES during the early phase after ACL reconstruction to assist quadriceps activation and reduce early muscle loss. (bjsm.bmj.com)
It is still an addition to exercise, not a replacement for it.
Your physiotherapist can work out whether NMES is appropriate and help with settings and pad placement.
What about compression therapy such as Normatec?
Some people also use intermittent pneumatic compression systems such as Normatec.
These use sleeves around the leg that repeatedly inflate and deflate.
They can be comfortable during the early phase when you are spending more time resting and may form part of your swelling-management routine.
They are not essential, though.
The basics still matter more: rest, appropriate movement, quadriceps activation, compression, elevation and time.
If you are using a compression device after surgery and are unsure whether it is suitable for you, check with your medical team or physiotherapist first.
What can the first week actually look like?
You do not need a complicated schedule.
For many people, a simple routine works well:
Rest when the knee needs it.
Spend some time with the leg elevated and use your recommended compression strategy.
Use ice for comfort if needed.
Keep it brief, protect the skin and use it as part of your overall recovery plan.
Do your movement exercises.
Work gently on the range your surgeon and physiotherapist have given you.
Practise your quad sets.
Focus on getting a good contraction rather than chasing huge numbers of repetitions.
Then repeat.
A few short sessions spread through the day are often much more manageable than trying to cram everything into one large rehab session.
Do not compare your first week with someone else’s
It is very easy to look online and wonder why somebody else seems further ahead.
One person may be walking more comfortably within a few days. Another may have more swelling or less knee movement.
That does not automatically mean one person is doing better than the other.
Different grafts may have been used. One person may have had additional surgery. Surgeons may also use different restrictions depending on the exact procedure.
A more useful question is:
Am I progressing appropriately for my operation?
That is where having an individual plan helps.
When does physiotherapy help?
Physiotherapy often starts very early after ACL reconstruction.
The first appointment is not necessarily about loading the knee heavily. It is usually about making sure the early foundations are moving in the right direction.
A physiotherapist may look at:
- How much swelling you have
- How well the knee is straightening and bending
- How well you can contract the quadriceps
- How you are walking and using crutches
- Whether your exercises are being performed correctly
- Whether NMES could be useful
- How the knee is responding to activity
- Whether your programme fits your surgeon’s restrictions
- As the knee settles, the programme gradually becomes more challenging.
Strengthening, running, jumping and return-to-sport work all come later. The first week is about putting you in a good position to eventually get there.
When should you contact your medical team?
Some pain, bruising and swelling are expected after ACL reconstruction, but your surgical team should give you information about what is normal and what needs reviewing.
Contact your surgeon or medical team if something feels significantly different from what you were told to expect.
Seek prompt medical advice if you develop symptoms such as increasing redness or discharge around the wound, fever, unusual or increasing calf pain or swelling, chest pain or difficulty breathing.
If you are unsure, it is worth asking.
Keep week one simple
There is a lot involved in ACL rehabilitation, but you do not need to tackle all of it immediately.
In the first week, focus on the things that matter most:
Rest. Manage the swelling. Gently move the knee. Activate the quadriceps. Repeat.
Those simple things might not feel like much, but they are the building blocks for the harder rehabilitation that comes later.
If you have recently had an ACL reconstruction and would like help working through the early stages, you can book an assessment with PhyxYou Physiotherapy in Port Macquarie. We can assess how your knee is progressing, work within your surgeon’s recommendations and help guide you through the next stage of your rehabilitation.
