Which ACL Graft Is Best? BTB vs Hamstring vs Quad vs Allograft (From a Rehab Specialist)

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If you’re heading for ACL surgery, the graft you choose can completely change your recovery.

And while surgeons often have their preferences, let’s be clear: this is your knee. It’s your rehab, your sport, your confidence. Don’t just go along with whatever’s easiest for them — ask questions. Get informed.

I’ve worked with thousands of ACL patients, and what I’ve seen in clinic is often very different from what people get told pre-op.

So let’s break it down properly — the pros, cons, and what actually happens in real-life rehab.

🔹 Patellar Tendon (BTB) Graft – Pros and Cons

Bone-to-bone healing makes this graft strong and well-integrated — it’s often called the “gold standard.”
But I’ll be honest — anterior knee pain and patellar tendinopathy are common.

If you kneel for work (think tradespeople, firefighters, nursery staff), this graft can cause real problems long-term.

Yes, you often get knee extension back fast, but flexion and quad strength are a different story.
And if rehab starts too slowly? You’re at serious risk of tendon pain around the patella.

Real advice: Start quad isometrics early. Keep an eye on patellar stiffness and swelling from week one.

🔹 Hamstring Graft – Recovery Challenges to Know

Probably the most common graft I see in clinic.
It works well for many, but hamstring recovery is slower than people think — especially inner hamstring (which is often missed).

I also see a lot of numbness around the scar and lingering posterior weakness, particularly when people haven’t been coached on proper strength work.

Not the best choice for:

  • Sprinters

  • Athletes prone to hamstring tears

  • People with a history of posterior chain injuries

Real advice: Prioritise inner hamstring strength, not just big RDLs. Rehab needs to be detailed, not generic.

🔹 Quadriceps Tendon Graft – Is It Worth It?

This one’s on the rise again — strong graft, big tissue, and solid fixation.

But let me say this clearly: it’s tough to rehab.

I’ve had multiple patients tell me they regretted choosing this graft. Why?

  • Quads are harder to rebuild

  • Post-op stiffness and tightness are common

  • Kneeling is painful for a long time

This was popular years ago, then it faded, and now it’s coming back — but I’m still seeing ongoing issues, especially with patients struggling to get quad bulk back.

Real advice: If you already have tight quads, avoid this graft. It can make things 10x harder.

🔹 Allograft (Donor Tissue) – Is It Safe?

On the surface, this graft seems great — no muscle trauma, quicker early recovery, and less pain.

But don’t be fooled: integration is slower, and a lot of people return to sport too soon because it feels fine before it’s actually healed.

I’ve had patients thrive on it, and others come back way too fast and end up back at square one.

My opinion: It’s not the graft that fails — it’s that people skip the hard work.
They think they’re ready just because it doesn’t hurt.

Real advice: Don’t skip strength testing just because the graft “feels good.” Respect the process.

🔹 Peroneus Longus Graft – A New Option

This one’s still emerging but I’m really interested in it.
Used more overseas and now becoming more common in the UK, especially among patellar tendon patients who need a different option.

The scar is tiny, and early recovery is smooth. I’ve seen fast returns to sport with it.

But… I haven’t seen the outcomes beyond 12 months yet myself, so still watching that space.

Also, not ideal if you’ve got ankle issues — especially plantar fasciitis or chronic instability.

Real advice: Keep an eye on long-term data. It’s promising, but we need more.

How to Choose the Right ACL Graft for You

The truth is: no graft is perfect.
What matters is your history, your sport, and your rehab setup.

Before surgery, I always check:

  • Have you had patellar pain before?

  • Do you struggle with recurrent hamstring tears?

  • Do you need to kneel daily for work?

  • Did your surgeon even mention LET or ITB tension?

You’d be shocked how often these things get missed.
And it’s the therapist who has to clean it up after surgery.

ACL Rehab Built for All Graft Types (Including LET + Meniscal Surgery)

I built the Complete ACL Recovery Guide to support every graft type — including:

  • ✅ BTB

  • ✅ Hamstring

  • ✅ Quad

  • ✅ Allograft

  • ✅ Peroneus Longus

  • ✅ LET procedures

  • ✅ Meniscal surgery add-ons

It’s the exact structure I use in clinic — clear strength phases, progress testing, mobility targets, and rehab support that adapts to you.

If you’re feeling unsure, stuck, or just not seeing the progress you hoped for:

👉 Grab the guide here