What Is Quad Tendon ACL Reconstruction and Who Is It For?

Overview

Quadriceps tendon autograft uses a strip of the patient's own quadriceps tendon, taken from just above the kneecap, to rebuild a torn ACL. Dr. Raffo, who performs a high volume of ACL reconstructions for patients across Montgomery County and the Bethesda area, uses quadriceps tendon as his default graft for most primary reconstructions in active patients under 30 because of its favorable failure-rate profile and low donor-site morbidity.

Who this is for

• Most active patients under 30 undergoing primary ACL reconstruction are reasonable candidates for a quadriceps tendon graft, including athletes returning to pivoting and cutting sports.
• Patients concerned about kneeling pain or anterior knee discomfort — a common tradeoff with patellar tendon grafts — are often steered toward quadriceps tendon.
• Patients with a very thin or previously harvested quadriceps tendon, or those who have already had a quadriceps tendon graft on the same knee, are not candidates and need an alternative autograft or allograft.
• High-level contact and collision athletes, and revision surgery patients, are more often steered toward bone-patellar tendon-bone; see the BPTB autograft page for that discussion.

How I approach it

I've made quadriceps tendon my default primary graft because, in patients 25 and younger, the pooled failure rate is 2.5%, compared with 5.1% for bone-patellar tendon-bone and 11.1% for hamstring (Petit et al., AJSM 2026). I'm candid with patients that this comparison is not as settled as it looks at first glance — the confidence interval on that 2.5% figure runs from 0.5% to 11.2%, and the statistical comparison against hamstring only approached significance (P=.06) while the comparison against BPTB did not reach it (P=.4) (Petit et al., AJSM 2026). What tips the decision further in favor of quadriceps tendon for most of my patients is what it spares them: unlike patellar tendon harvest, it does not carry the same elevated risk of severe kneeling difficulty.

The operation

The quadriceps tendon graft is harvested through a small incision above the kneecap, typically taking a partial-thickness strip of tendon with or without a small bone block from the patella. The native ACL remnant is debrided arthroscopically, femoral and tibial tunnels are drilled, and the graft is passed and fixed under tension, reproducing the ligament's native footprint. The knee is inspected for meniscal tears at the same time, since concomitant meniscal injury is common at ACL reconstruction. If risk factors for graft failure are present, a lateral extra-articular tenodesis may be added through a separate small incision in the same setting.

Risks and honest tradeoffs

• Graft failure. In patients 25 and younger, the pooled quadriceps tendon failure rate is 2.5% (95% CI 0.5–11.2%), rising to 9.1% in studies with at least 5 years of follow-up (Petit et al., AJSM 2026; Kurkowski et al., AJSM 2025).
• Quadriceps strength deficit persists for years. Across grafts generally, quadriceps strength averages roughly 76% of the uninjured leg at 6 months and 85% at 1 year, not approaching 90% until close to 5 years (Girdwood et al., BJSM 2025) — a relevant consideration when the graft itself is harvested from the quadriceps mechanism.
• Second ACL injury occurs in roughly 15% of patients overall, rising to 21% under age 25 (Wiggins et al., AJSM 2016), a risk that is a function of age and sport more than graft choice.
• Osteoarthritis is not prevented by graft choice. Roughly 36% of patients have radiographic osteoarthritis at approximately 10 years after ACL reconstruction regardless of graft (Webster & Hewett, Clin J Sport Med 2022).
• Donor-site discomfort at the harvest site above the kneecap occurs but has not been quantified with the same registry-level detail as patellar tendon kneeling pain in the evidence reviewed for this page.

Recovery and rehabilitation

Recovery follows the same criteria-based framework used for all ACL grafts. Early active motion and weightbearing begin immediately after surgery. Open-chain quadriceps strengthening is delayed for the first several weeks to protect the healing quadriceps tendon donor site as well as the graft, and progressive closed-chain strengthening follows.

• Weeks 0–2: Early motion and weightbearing; swelling control; focus on regaining full extension.
• Weeks 3–6: Closed-chain quadriceps strengthening; open-chain quadriceps exercise avoided during this window.
• Weeks 8–16: Return to running once pain, motion, and strength criteria are met, typically at 8 to 10 km/h (Rambaud et al., BJSM 2018).
• Months 6–9: Sport-specific agility work and formal strength and hop testing.
• Month 9 and beyond: Return to cutting and pivoting sport only after passing a strength and hop-test battery (Grindem et al., BJSM 2016).

1. Weeks 0–2

   Early motion and weightbearing; swelling control; focus on regaining full extension.

2. Weeks 3–6

   Closed-chain quadriceps strengthening; open-chain quadriceps exercise avoided during this window.

3. Weeks 8–16

   Return to running once pain, motion, and strength criteria are met, typically at 8 to 10 km/h (Rambaud et al., BJSM 2018).

4. Months 6–9

   Sport-specific agility work and formal strength and hop testing.

5. Month 9 and beyond

   Return to cutting and pivoting sport only after passing a strength and hop-test battery (Grindem et al., BJSM 2016).

Alternatives I considered

For patients concerned about the quadriceps tendon's less mature long-term data, I discuss bone-patellar tendon-bone as the alternative with the most mature registry track record, particularly its 5-year revision rate of 2.8% (Gifstad et al., AJSM 2014), against the tradeoff of a roughly threefold higher rate of severe kneeling difficulty (Rahardja et al., AJSM 2023). For a narrow group of patients with a fresh, proximal tear who want to preserve their native ligament, I also discuss bridge-enhanced ACL restoration; see the ACL reconstruction hub for that discussion.