Patellar vs Hamstring

Patella vs Hamstring for ACL sugeryChoosing between patella vs hamstring as a graft for ACL surgery can be a difficult decision. At a glance the options seem fairly balanced, with pros and cons on either side, but our two polls have shown a slight leaning toward hamstring graft. Below is what people commonly say among the choices:


1. PATELLAR GRAFT – the old-school gold standard and choice of many athletes.
Pros: The patellar graft is strong, as the graft from the knee tendon includes bone which ‘fuses’ into your knee nicely. It also resembles the size and length of the ACL (anterior cruciate ligament) that is needed and is technically easier for a surgeon to do this. Fast recovery.
Cons: May give you knee pain. Many people complain that kneeling or bending the knee causes pain that wasn’t there before.
Summary: Patellar graft may be the best choice for young people who are engaged in professional or high-impact sports and are willing to risk having knee pain for perhaps the rest of their life. It may not be a good choice for a working man, such as a carpenter, who bends their knees a lot, crawling in tight spaces, or walking up and down stairs all day.

2. HAMSTRING GRAFTconsidered a newer technique that claims comparable strength to the patellar graft, but without the knee pain.
Pros: Less or no knee pain, comparable strength to patellar.
Cons: Slightly weaker hamstring muscle- 90% of normal strength. Some people complain that the hamstrings stretched out and no longer becomes tight. May take longer rehab.
Summary: Hamstring graft is the best choice for someone middle of the road, who does physically active sports, but not professionally or extremely competitive. This person is not as much in a time-crunch to recover, and the priority is in not having knee pain.

3. ALLOGRAFT (graft from a frozen cadaver) – the doctor likely takes a patellar graft from the cadaver to use in the knee of the patent.
Pros: Fast recovery from surgery, as you don’t sustain any injury by having a graft taken out of your own body.
Cons: Weaker- a low percentage of patients have the allograft break, requiring a 2nd ACL surgery. Has a slight risk of getting a disease transmitted through the blood & body part from someone else.
Summary: Allograft is the best choice for someone aged 45+ or someone who does not plan to do any substantial physical sports, and is willing to take the risk of implanting someone else’s body part.

Note: Doctors generally specialize in either patellar graft only or hamstring graft, and generally don’t perform both. So, when you choose a doctor, you’re also choosing what graft you want. To change grafts, you likely have to change your doctor completely. Because of a higher technical skill involved in the hamstring graft, it may mean you will find more competent doctors performing it.

Reputable doctors may contradict each others’ opinions. One may say patellar graft is best, the other may say the hamstring graft is best. Online research suggests there’s no strong winner on either side, but perhaps a slight leaning towards the hamstring graft.

Doctor A says:

  • Hamstring graft is the most popular choice for professional athletes today
  • There’s less risk of graft complication
  • No knee pain with hamstring graft, where as, the patellar commonly results in a lifetime of pain when kneeling
  • Hamstring graft is stronger than the patellar, because of 4 dense strands bound together, instead of just 1 with the patellar
  • Neither grafts ‘grow back’, so better to go with the hamstring, since it’s a very large size and taking such a small portion of it only results in a hardly detectable loss of strength 5% – 10%, but it’s easily regained through basic physical therapy
  • The drilling hole in the bone can be smaller when using the hamstring graft, because of the efficient configuration of the 4 strands in the hole. A smaller hole, results in a stronger bone
  • Patellar grafts can loosen/weaken the knee and lead to patella arthritis
  • Patellar grafts are ‘old school’ – a thing of the past. This surgeon used these grafts years ago, but not since the advancements in hamstring grafts, which are now superior
  • Tiger Woods had a hamstring graft
  • Hamstring grafts are the best

Doctor B says:

  • Patellar graft is a larger and stronger tendon that’s 10mm, instead of a 8mm hamstring graft
  • Patellar graft is the most popular choice among athletes today
  • An annual survey of hundreds of orthopedic surgeons shows that patellar grafts are most popular
  • Patellars are the ideal size and length
  • The hamstring is too small, too long, and requires a more technical procedure with greater opportunity for error
  • The hamstring may stretch/loosen and may not fasten to the bone correctly over time
  • The patellar actually grows back and regenerates itself in 8 months, where as, the hamstring will be gone forever and be noticeably weaker
  • Tiger Woods only got a hamstring graft only because the surgeon he chose invented his own hamstring graft technique which he wanted to promote
  • Patellar grafts are best

As you can see, there’s good reason to hesitate when making a choice with potential long-term health ramifications.

272 thoughts on “Patellar vs Hamstring”

  1. Hi, I have exactly the same problem! I can’t decide which one to do and if it even matters? Did you choose yet? Have you had the surgery? Any advice you can give would be greatly appreciated! Thanks!

    1. hii,
      im 20 year old.I had my acl reconstructed and my cartilage repaired 16 days ago using the hamstring graft, pain in minimal nothing compared to the pain i had when i first sustained the injury playing football. after 2 or 3 days i stoped takeing the meds and have little pain. I am pretty much completely off the crutches now walking with a limp. Best thing to do is hit the gym before surgary and be aggressive and you will come through the surgary much stronger ready to go. i was at the gym every day cycleing between 10 20k doing sqats with weight on my back dead lifts and would sometimes do a 3k jog. after surgary i had 4 or 5 basic exercises last week i got loads more then i went to the british grand prix and the knee swelled up quite a lot. the next day after some iceing the swelling went the the real physio kicked in.

    2. Make a list of priorities….what are your goals? If your goal is short term recovery and don’t mind the potential risk of arthritis/tendonitis/pain, go with the patellar. For instance, Adrain Peterson’s goals were to get back on the field ASAP with a strong/sturdy knee. Keep in mind he has financial obligations that influence his decision. He went with the best decision for him. Risking the loss of strength in his hamstring, and the time it would take to regain that strength has a cost/risk. If you don’t have a recovery time line in which you NEED(not want) to return to sport, want less risk of potential pain (long term), can remain patient and disciplined…go with the hamstring. It is a longer recovery time to build back up the hammy, if that isn’t a problem for you then go for it! I’ve learned after having multiple recons that the quickest solution isn’t the best in the long run. Choosing the procedure is only part of the battle. Make sure the surgeon is researched as well as the type of patients they treat! Are they old? Young? Active? Go with someone that has treated patients similar to you and the lifestyle you live. Lastly, the most important (that gets overlooked) is research your Physical Therapist! If you’re an athlete you better go to someone who has worked with athletes + may be a certified strength & conditioning specialist! There are some therapists that will just run you through the motions…yes it happens. Post surgery your body may develop habits or movement patterns compensating for areas that should be working. If the therapist does not catch it OR you do not continue to work on those flaws during your continuing PT/fitness regimen, it will only be a matter of time before you are on the sidelines again. Make sure the PT+fitness program is relative to the lifestyle/sport/activities you plan on returning too! Crawl before you walk! Patellar or hamstring you’ll be fine, it really comes down to who is doing the surgery, who is your DPT, and you!

  2. Hello, thanks for your post.

    I decided to go with the hamstring graft. In my research, I kept seeing the words ‘increased knee pain’ consistently used in association with the patellar graft. It makes sense, being immediately at the knee joint- perhaps more of a moving part. Patellar arthritis is another concern, a few people I spoke to warned about. And the surgeon who practiced patellar grafts for many years who changed to hamstring because of better results, seemed the most credible. I never met anyone who did hamstring for many years and changed to patellar. I think the only reason why the hamstring isn’t the clear choice in ACL grafts is because surgeons are apprehensive in promoting it, being a more technical surgery.

  3. Hi Samantha,

    I recently had a hamstring graft done on my knee, and I haven’t regretted it. It takes a little longer to heal, but you’ll have less wound pain, smaller scars, and better long-term results. I highly recommend the hamstring graft. I, too, was given a choice. Good luck!

    Eddie C.

  4. I had a hamstring graft with a maniscus repair Dec 2/08 and was off crutches in 7 days and no brace! I met a lady same age(44) at a store and she had a patellar graft and is on crutches for 3 weeks! Seems like a long time making rehab that much more difficult. I would rather take a couple extra months to heal and have more movement now. Also, I have heard the knee pain lasts forever too with patellar grafts.

      1. I tore my Left ACL in 97 and had the hamstring surgery. I tore
        my left “ACL” again in 2002 and had the cadaver surgery. And I tore that to shreds this last year and just recently had the patellar surgery. I’m 12 days post op and walking with virtually no pain. And mind you I don’t play professional sports. Just do triathlons and some roller hockey. I havent played a contact sport since I blew my ACL in 97. Sooo…. Good luck.

        1. when I first tore my acl and lateral meniscus playing hoops they did a hamstring graft. I did all the rehab. I hadn’t been thru it before so I was ignorant. after about 1 year I went back cuz things didn’t seem right and it hurt. the new md said it was torn gain and it probably never took. then had the patellar graft. he s9. this was all about 6 years ago. I am worried longterm about not having meniscus (he said about 15% medial left). right or wrong, I blame it on that stupid hamstring graft. hamstrings never been as strong. maybe it is easier for surgeons to screw up on (and this was a pac12 university team md). I do have a little patellar tendon pain but at least it holds.

    1. I am a 17 and have already had ACL surgeries on both knees. My friend who had the hamstring graft was on crutches for a month while I was only using them for less than two weeks. The second time I was on them for only 8 days. The length of time you’re on crutches depends on how aggressive your rehab schedule is and who your physical therapist is. I have had minimal knee pain from both of my patellar tendon grafts and am very happy with them.

      1. My son had ACL surgery and meniscus surgery using his Patellar surgery. He is about 14 weeks post op. The first 10 days were very bad with so much pain. His doctor didn’t want him on crutches after 2 weeks. He had a brace and a cane. By three weeks off everything. He just started light running and has some pain and soreness. His sport is ice hockey.

  5. Thanks for sharing that. It’s great info to know. I did lots of internet research on hamstring vs patella grafts and never really found anything conclusive, but the more individual experiences like this I hear, the more it seems to lean towards hamstring graft being the best choice.

  6. I think the hamstring graft is the best choice. I’ve met several people who did the patellar graft and have frequent knee pain. I had this done 5 weeks ago now. So far so good.

  7. I play college basketball and tore JUST my ACL on Feb. 5 (my 20th birthday by the way). I was able to walk the night I tore my ACL and I rode the bike/elliptical for 50min (I’m in freakishly good shape), did strengthening and stretching exercises everyday up until my surgery. I was told that the strong you got your Quads and Hamstring before surgery the easier rehab would be.
    My surgery was March 3rd, and I chose the patellar graft. The first night I fell asleep and forgot to take the pain med and was in so so much pain, but besides that I haven’t really had any problems. I was off the crutches on the 3 days after my surgery and I’m now able to ride the stationary bike for cardio, do exercises and I’ve shot the basketball everyday! It hasn’t even been 2 weeks yet!
    I chose the patellar graft because I’m a basketball player, I already have arthritis, so I’m going to have knee pain anyway. And also it’s my first ACL surgery so I won’t know the difference between the 2 anyway!
    I’m sorry if I’m of no help, but just thought I would let you know my experience. It’ll be 2 weeks tomorrow and I’m ready to work hard to get better. Hope I helped!!

      1. That’s similar to my story, I had a full year to strength in my leg. I also had the patella graft. And it feel’s great, I don’t feel no pain. But like you people are saying, in the long run I’ll most likely feel it. But either way with an ACL tear your going to develop arthritis whether you like it or not. So my honest opinion I recommend go the patella graft for those who play physical sports such as H.Duncan and myself.

        1. My son needs ACL reconstruction but I am leary of the patellar graft due to his history of Osgood-Schlatter disease and patellar tendonitis that he needed 2 rounds of PRP to heal. Anyone gone through the same situation?

    1. Thanks for the info. My daughter just tore her right ACL last week. First game of the season. The ortho that examined her does the hamstring graft but her coach has a friend that does the other and can rehab at the local college. Thinking with another year of high school ball and possible college as well patella might be the best bet for her.

    2. You were off crutches in 3 days post op? That’s impressive. I’ve had 3 acl surgeries and always wanted to toss the crutches away after the first few days also, however swelling and the incision being somewhat relatively fragile I was hesitant and more so used the the crutches as partial weight bearing. This was also 5 years ago though, which now a days in medicine mind as well be 10 years. When the docs said sit on your butt for 2 weeks do leg raises, rest, ice, compress, elevate. Methods and philosophy have changed for sure. I will be getting my 4th acl surgery in a few months( had bone graft done in May) finally did extensive research, ditched my old surgeon and went with a great surgeon. Using the hamstring (first 3 were cadaver, I know why didn’t I have the research then!) Any how I am very confident in this upcoming surgery and I am extremely active and in very good shape also. I play ice hockey (not at the moment without an acl : /, cross train, run, row, weight train etc. I am hoping to have quick recovery like you. I would like to know some more about your rehabilitate process. Did you use anti inflammatories, ice or cooling kit, compression, how was your range of motion progress etc?

  8. I have actually had one of each. I tore my left ACL playing high school sports and had the patellar graft. A few years later I tore my right ACL and had the hamstring. Not only was the hamstring extremely easy to recover from with minimal pain, but it rarely causes me any sort of pain now (10 years later). I am in CONSTANT knee pain from the patellar graft! Not only can I not kneel on that knee, but it pretty much hurts constantly. I had the same surgeon for both procedures. However, that being said…the hamstring graft is not as stable. All things considered, I’d rather have a little less stability than live with this horrible knee pain.

  9. Great posts on here. I’m at 2 months post surgery and have virtually no knee pain and can walk around fine without any limp. Went on a light 3 mile hike a couple days ago on uneven terrain and was fine and can ride a bike around ok. Have 140 degree knee bend. I’ve just passed where I was pre-surgery and post-ACL tear. My knee doesn’t feel unstable, but am careful twisting or turning around- done in several small steps.

  10. I am a 41 year old professional male and completely tore my right ACL playing indoor soccer on 2/27/09. I am fairly active and elected to have the surgery. After extensive research (including speaking with others who have had ACL tears and repair) and discussion with my Orthopedic Surgeon, I decided to do the hamstring graft. I had my surgery on 4/1/09 – missed only 3 days of work. I have started PT and also using the CPM Machine. The hamstring is a little sore, but knee pain is minimal at best – I might even say non-existent. I am still on crutches and utilize a brace – I’m playing it safe more than anything else. Maybe it is still too early to tell, but I think and feel I made the right decision. One other note, I think surgeon selection is criticall. I chose a surgeon who currently is a college (NCAA – Div I) head orthopedic surgeon (for all sports), presently teaches at the medical school level, and had prior experience working with an NFL team.

    1. is your surgeon Dr Edward W at UofM? I am trying to find the best surgeon in Michigan and am having a hard time finding that answer…

    2. Hey,
      As I was reading through comments, your situation seemed more closely to mine. Just curious to know how you are doing these days? Do you still feel the hamstring was the best route? Are you still active?

    3. Hello Dean. I thought I would ask how your hamstring tissue has held up. We are very similar, in I’m 42 and play soccer a few times a week and will hopefully be back to that after surgery and rehab. Trying to figure out which tissue is best for my ACL reconstruction.

  11. I tore my right ACL wrestling in 1995, I had reconstruction using the patellar methos. The surgery is painful, but not unbarable. The front of the knee is still sensative (kneeling), not painful, just feels a little funny. The results have been very good, not other issues with this knee. I also had latteral miniscus repair on the left knee in 1994. I recently tore my left ACL in 2008. I think I will opt for the hamstring reconstruction because I am not in full contact sports anymore and would like a less pain recovery. I think the patellar method probably produces a stronger more robust reconstruction. But I am older and only want to trust the knee again and be capable of working out, running, backyard sports, and snowboarding. I will know more after the surgery.

    1. My son tore his acl playing lacrosse. He had surgery June 3. He is a wrestler and junior in high school. He wants to wrestle starting in January, which would be 7 months post op. What is your opinion about him wrestling in January, since you tore yours wrestling. He had patellar tendon graft and is doing great. Way ahead of schedule with pt. He has been practicing with team but no live wrestling yet. Please advise.

  12. I just tore my ACL and have a Grade I tear in my MCL. I was wondering if anyone has had the surgery and gone back to playing sports. I am definitely not ready to give up sports and I owe a girl for an illegal clip in the backfield (Women’s pro football), which is what caused this. Anyone have any suggestion for which is the best surgery as far as continuing to play sports?

    Thanks!

    1. Hey Murph,
      I had a girl slide tackle me in womens RECREATIONAL soccer (where slide tackles are completely illegal). She wrecked my ACL. That was 4 years ago. I would never – never – never – seek vengeance for this kind of stupidity. You will just mess up your karma and keep having misfortunate things befall you!!! I’m not saying that either of us was asking to be clipped or slide tackled. But, honestly, what comes around goes around. Leave well enough alone! Read some Eckhart Tolle! and MOVE ON!!!

      1. I was tackled in soccer Men’s over 30 league from behind and my knee gave out under me and it sounded like packing bubble wrap. I knew something was wrong when I didn’t do the normal get up and brush off. I had patellar ACL recons. back in ’98 on the right knee, plus miniscus tear. It was painful. I think I will opt for the hamstring graft this time. Thanks every1 for the helpful info!

  13. I have read all the posts and find this blog very informative, so thought I would add a reply. I am 40, and tore my left ACL playing flag football in Aug 2008. I am active and was playing at a high level. I am scheduled for patellar reconstruction in 4 days. My wait time has been a bit lon