If you are heading for ACL surgery, one of the biggest questions is which ACL graft is best. The graft you choose can completely change your recovery experience. While surgeons often have their preferences, this is your knee, your rehab, your sport, and your confidence. You should feel confident asking questions and making an informed choice rather than simply going with what is easiest for them.
I have worked with thousands of ACL patients, and what I see in real-life rehab is often very different from what people are told before surgery. Here is my honest breakdown of each ACL graft option — the pros, cons, and what actually happens in recovery.
Patellar Tendon (BTB) ACL Graft
Bone-to-bone healing makes this graft strong and well integrated, which is why it is often called the gold standard. However, anterior knee pain and patellar tendinopathy are common issues. If you kneel for work, such as tradespeople, firefighters, or nursery staff, this graft can cause long-term problems. Extension often returns quickly, but flexion and quad strength can lag behind. If rehab starts too slowly there is a real risk of ongoing tendon pain.
Rehab tip: Start quad isometrics early and keep a close eye on patellar stiffness and swelling from week one.
Hamstring ACL Graft
This is probably the most common graft I see in clinic. It works well for many patients, but hamstring recovery is slower than most expect, especially the inner hamstring which often gets overlooked. Numbness around the scar and lingering posterior weakness are also common if targeted strength work is not done.
This may not be the best choice for sprinters, athletes with a history of hamstring tears, or people with ongoing posterior chain injuries.
Rehab tip: Prioritise inner hamstring strength and do more than just Romanian deadlifts.
Quadriceps Tendon ACL Graft
This graft has become more popular again in recent years due to its strength and solid fixation. However, it can be challenging to rehab. Many patients tell me they regret choosing this graft because rebuilding quad size and strength can be slow. Stiffness and tightness are also common, and kneeling is often painful for a long time afterwards.
Rehab tip: If you already have tight quads before surgery, consider other grafts to avoid making recovery harder.
Allograft (Donor Tissue) ACL Graft
An allograft can seem appealing because there is less surgical trauma and early recovery can feel easier. However, integration takes longer and many people return to sport too soon simply because the knee feels fine before it has fully healed. This is not usually a graft failure problem — it is a rehab discipline problem.
Rehab tip: Always complete strength and hop testing before returning to sport, no matter how good the knee feels.
Peroneus Longus ACL Graft
Still relatively new in the UK but more common overseas, the peroneus longus graft is an interesting option. The scar is small and early recovery can be smooth, with some patients returning to sport quickly. However, there is not yet enough long-term data, and it may not be ideal if you have ankle problems or plantar fasciitis.
Rehab tip: Follow the research as more long-term outcomes are published before deciding.
How to Choose the Best ACL Graft for You
No ACL graft is perfect. The right choice depends on your injury history, sport, work demands, and rehab setup. Before surgery, think about whether you have had patellar pain, hamstring tears, or the need to kneel daily. Ask your surgeon if they have discussed options like LET or ITB tensioning, as these can affect stability and long-term outcomes.
If you want a recovery plan that works for any graft type, my Complete ACL Recovery Guide covers BTB, hamstring, quad, allograft, peroneus longus, LET procedures, and meniscal surgery. It follows the exact structure I use in clinic with clear strength phases, progress testing, mobility targets, and support so you can stop guessing and start progressing.