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ACL Grafts: Which is Best? A Strength Coach’s Perspective

Posted Nov 15 2010 1:53am

A few weeks ago, I came across this recent study of different ACL grafts.  It found that there was no difference in follow-up success rates at two-year mark between hamstrings and patellar tendon grafts.  The patellar tendon group did, however, exhibit more anterior knee pain – which isn’t a surprise because it’s not uncommon to see longer term tendinosis in athletes with patellar tendon grafts even after their “rehabilitation period” is over.  That said, I would be interested to see what would happen if they:

a) evaluated those patellar tendon graft subjects who received soft tissue treatments as part of their rehabilitation versus those who didn’t (my experience says that the anterior knee pain goes away sooner when manual therapy is present) .

b) evaluated those who went to effective strength and conditioning programs immediately post-rehabilitation versus those who didn’t (my hunch would be that those who continued to activation/strengthen the posterior chain would have experienced less anterior knee pain).

c) looked at performance-based outcomes at ~12-18 months in the hamstrings group, as these folks have more “intereference” with a return to normal training because of the graft site (you want to strengthen the posterior chain, but can’t do that as soon if you are missing a chunk of the hamstrings).  My experience has been that patellar tendon patients can do a lot more with their strength and conditioning program sooner than those who have hamstrings grafts.

It’s not to necessarily say that one is better than the other, as they both have their pros and cons – but I think this study potentially casts patellar tendon grafts in a less favorable light when the truth is that hamstrings grafts can have just as many complications down the road.  Above all else, the best ACL grafts are the ones that the surgeon is the most comfortable using – so pick your surgeon and defer to his expertise.

As an interesting aside to this, I remember Kevin Wilk at an October 2008 seminar saying that 85% of ACL reconstructions in the U.S. are performed by doctors that do fewer than 10 ACL reconstructions per year.  So, don’t just find a surgeon; find a surgeon that does these all the time and has built up a sample size large enough to know which ACL graft site is right for you, should you (unfortunately) ever “kneed” one (terrible pun, I know).

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