Principles Over Protocols: ACL Rehab for a Division 1 Basketball Player

Picture this – you’re a new clinician and you’ve just learned that you’ll be working with your first ever Anterior Cruciate Ligament (ACL) reconstructive surgery patient. You feel nervous and unsure. You need answers. So, you go to Google and search up some ACL rehab protocols, only to discover that they all are a little different from one another. Is one of them more appropriate? How do you possibly decide between all of them?

Rehab will be much more difficult to navigate if we blindly follow protocols. Not every patient will recover at the same rate and some exercises may need to be progressed or regressed depending on the patient and the context. This is why you should be choosing principles over protocols.

Principles offer flexibility, context, and critical thinking. While protocols provide structure, they often follow rigid timelines that don’t account for individual differences in healing, sport demands, or setbacks. Principles, on the other hand, guide clinicians to make informed, adaptive decisions—allowing rehab to stay patient-centered, responsive, and effective even when the plan needs to change.

In this blog, we will discuss some key principles that you can apply to every ACL case. Expert ACL rehab physio Laura Opstedal created a Case Study on an elite college basketball player who had an ACL reconstruction (ACLR), with bone patellar tendon bone (BPTB) autograft. We’ll use lessons from Laura’s Case Study to illustrate important ACL rehab principles.

If you’d like to see exactly how expert physio Laura Opstedal manages an elite basketballers’s ACLR rehab, check out her full Case Study HERE. With Case Studies you can step inside the minds of experts and apply their strategies to get better results with your patients. Learn more here.

Early post-operative rehab: Focus on a “quiet knee”

One of the most important early-stage principles after ACLR is achieving a “quiet knee.”
A quiet knee is one that has minimal swelling, full extension, restored flexion, and a normal gait pattern without compensation.

Think of the ACLR as the second trauma to the knee—the first being the ACL tear itself. In this highly inflammatory environment, managing swelling and regaining range of motion must take precedence over aggressive strengthening or functional tasks. Essentially, we are trying to build a comfortable foundation – a healthy feeling and functioning knee joint – that can be built upon with resistance training.

So, we have the principle of achieving a quiet knee and restoring range of motion. There are dozens of ways to help restore knee extension, but certain exercises may feel better for different patients. In this clip from her Case Study, see Laura demonstrate one exercise she has found helpful, along with some other early rehab goals:

Mid-stage rehab: Restore strength and emphasize the quadriceps

Once the knee is quiet and basic movement patterns are restored, the next principle is rebuilding strength and muscle mass—with a major focus on quadriceps strength.

Quadriceps weakness is one of the most stubborn deficits after ACLR. A strong knee extensor mechanism is critical to support high-force tasks like deceleration, jumping, and cutting—especially for athletes returning to pivoting sports like basketball!

At this stage, you aren’t simply following a 12-week “strength phase” protocol—you are actively monitoring performance, fatigue, symptoms, and readiness for progression. In this video from her Case Study, Laura discusses entering this strength phase and some key indicators you can look for in your patient to determine if they be ready to face more external loads:

As you may have noticed at the end, Laura discusses how different iterations can be used for the example workout plan – this is because there are no magic exercises! Exercises are just tools that allow us to pursue the goals we deem important – a key principle to remember for this stage of ACL rehab!

Late-stage rehab: Train the biomechanical demands of sport

As strength, power, and range of motion normalize, the principle shifts again: preparing the athlete for the specific biomechanical demands of their sport.

This is where ACL rehab becomes highly individualized. Someone who just wants to get back to walking their dog may have achieved this goal already. But, for a basketball player, we must prepare them to be able to not just survive the demands of the sport, but to thrive as a player. Too often, we think about what a movement in a sport looks like (kinematics) and forget about the forces involved (kinetics). Both have a role in rehab, but don’t forget about the external and internal forces that the athlete will have to endure.

A good example of this is deceleration. The shape, or what deceleration looks like, may resemble something like a single leg squat – something that an athlete in the late stages of rehab can likely already achieve. However, this is quite different from actually decelerating. When we understand the kinetics, we see that decelerating can be more challenging than accelerating for an ACL patient. Why? Well, let’s have Laura explain in this clip from her Case Study, as well as provide some examples on how to train both acceleration and deceleration.

To summarize, the principle of training for the biomechanical demands of the sport, it is important that movements and forces involved in the athletes sport, prepare their tissues to be able to express these forces through training, and then reintegrate their physical preparedness into more sport specific movements.

Wrapping up

Laura Opstedal’s Case Study is a perfect example of why principles matter more than protocols in ACL rehab. Her adaptive approach—focusing on restoring a quiet knee, rebuilding quad strength, and preparing the athlete for the true demands of basketball—shows how real-world rehab requires flexibility and critical thinking.

🎥 Want to see how she managed an elite Division 1 basketball player’s ACL recovery, setbacks, and return to play? Watch Laura’s full case study HERE.