ACL Reconstruction: Which ACL Graft is Best for You?

ACL Reconstruction: Which ACL Graft is Best for You?

From being an all-year-round athlete in high school, any injury to my body was the one thing I feared the most. I tore my ACL in high school from a sports injury and had to make the difficult decision of choosing the right graft. Through this blog, I hope to educate young athletes and ACL patients a better understanding of each graft option and how physical therapy plays a big role in recovery.

What is an ACL injury?

ACL injuries are one of the most common knee injuries in the US.  Anterior Cruciate Ligament (ACL) is a tissue that connects the thigh bone and shinbone to help stabilize the knee joint. ACL injuries typically occur during a quick change of direction, land from a jump or even slowing down to a complete stop. Women are 2-8 times more likely to tear their ACL than men. Women are more prone to ACL tears due to their anatomical and biomechanics differences. A females pelvis is wider than men and this results to different mechanic functions in their lower extremities. Women also have different landing/pivoting movements causing the knees to absorb more impact an can lead to ACL injuries. Tears and/or ruptures of the ACL lead to ACL Reconstruction Surgery Procedure. 

What is ACL Reconstruction?

A torn ACL cannot heal on its own as there is no direct blood supply to this ligament. If one wishes to continue to participate in physical activities that require running, jumping, and quick change of direction activities, they are great candidates for ACL reconstruction. Therefore older patients that are less active may not need this procedure as they can continue to participate in a low activity lifestyle.  ACL reconstruction is a surgical procedure that replaces the torn ligament. It can be replaced from the patient’s own hamstring, quadricep, patellar tendon, or an allograft (tissue from a donor). 

What to consider when choosing your ACL graft?

Choosing the best graft option for your ACL takes a lot of consideration. Although all graft options are successful choices for ACL reconstruction, not all choices will be the best match for you. In order to make the right choice, it’s important to consider the pros and cons of each option and select the best graft based on your physical and health needs.  

Patellar Tendon

The patellar tendon is located in the middle of the knee that connects the thigh bone and shinbone. About one-third of the tendon is used as a graft for ACL reconstruction. Patellar autograft is recommended for young athletes that wish to return to a high level of activity.

  • Has a lower risk of retear
  • Better knee stability 
  • Increased risk of anterior knee pain 
  • Increased pain in kneeling positions due to

Hamstring Graft

The hamstring muscle is a group of muscles located in the thigh that connects from the hip to the knee. The semitendinosus hamstring muscles (posterior and medial of the thigh) and gracilis tendon are combined to reconstruct the ACL. Hamstring graft works successfully with patients are still have open growth plates (bones that are still growing).

  • Reduced risk of anterior knee pain 
  • Reduced risk of knee stiffness
  • Higher risk of decreased hamstring strength

Quadriceps Tendon

The quadriceps tendon is located right above the knee cap, which connects from the quadriceps muscle to the kneecap. Similar to the patellar tendon, about one-third of the quad tendon is used as the graft. This graft is thicker in size in comparison to other graft options.

  • Limited research 
  • Delayed quadricep activity
  • Recommended for failed ACL reconstruction from other autografts

Allograft – tissue from a donor

Allografts are tissues used from other human donors (also known as cadavers). Tissues options from an allograft can be hamstring muscle, Achilles tendon, patellar tendon, or quadriceps tendon. Allografts are best recommended for older patients that are less active

  • Less risk of anterior knee pain
  • Increased quadriceps recovery
  • Higher risk of disease transmission
  • Decreased strength in graft from additional sterilization of tissue

What happens after ACL Reconstruction?

One might wonder how long after surgery it will take to fully recover from this procedure. Recovery time for ACL Reconstruction varies for every individual depending on their surgical technique, the severity of the injury, and progression at physical therapy. The ideal recovery time after ACL surgery is about 9-12 months to fully recover and return to an active lifestyle.

Physical Therapy plays an important role in having a successful recovery after ACL Reconstruction. There are several phases after surgery every ACL patient must stay consistent with to be on the right track for full recovery.  Your physical therapist will follow your rehabilitation protocol to ensure goals in each phase are met before progressing. Your physical therapist will create an exercise program that may change week by week as you progress to different phases. Here is a Rehabilitation Protocol example for ACL Reconstruction.

Phase I: Immediate Post-Op  (0-2 weeks after surgery)

  • Reduce swelling and minimize pain
  • Protect graft and gradually restore mobility

Phase II: Intermediate Post-Op (3-5  weeks after surgery)

  • Protect graft
  • Normalize gait (standing and walking)
  • Maintain full knee extension (knee straightening) and restore full knee flexion (knee bending)

Phase III: Late Post-Op (6-8 weeks after surgery)

  • Protect graft
  • Maintain full knee ROM (range of motion)
  • Progress strengthening and promote proper movement patterns
  • Avoid post-exercise pain and swelling

Phase IV: Transitional (9-12 weeks after surgery)

  • Maintain full knee ROM
  • Progress strengthening
  • Promote proper movement patterns

Phase V: Early Return To Sport (3-5 months after surgery)

  • Safely initiate sport-specific training

Phase VI: Unrestricted Return To Sport (6+ months after surgery)

  • Continue strengthening
  • Safely progress to full sport

It’s important to remember that graft choices are not the same for everyone, as they should be individualized based on the patient’s age, activity level, and future goals. It has been 7 years since my ACL reconstruction and I am happy to say that I made the right choice for myself by choosing the patellar tendon for my graft. With the help of my surgeon, physical therapist, and family support I fully returned to high-level sports a year after my surgery. Although I do have some anterior knee pain when in kneeling positions due to the initial graft location, I have a better understanding of the risks I took by choosing my graft. I encourage everyone to research and ask their orthopedic surgeon about their options before making their decision.

Article exclusively written for

Authored by Joanna Perez-Moreno


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