If you have torn your ACL and surgery is on the table, one of the first decisions you and your surgeon will make is which graft to use. Over the last decade, the quadriceps tendon (quad tendon) graft has gone from a niche option to one of the most talked-about choices in ACL reconstruction. Some patients now arrive at clinic convinced it is "the best graft". Is it?

This guide looks at what the latest research actually says, how the quad tendon compares with hamstring and bone–patellar tendon–bone (BTB) grafts, who benefits most from it, what surgery and recovery involve, and what ACL reconstruction typically costs in India. If you are still unsure whether you need surgery at all, start with our guide on ACL tear grades and treatment.

The short answer: is the quad tendon graft superior?

Not universally. High-quality evidence shows the quadriceps tendon, hamstring and BTB grafts give similar knee stability, function and graft survival for most patients. The quad tendon's real advantages are its thick, predictable size and lower kneeling pain than BTB, which make it the better choice for specific patients rather than everyone.

Key takeaways

The quad tendon graft is a strip of the thick tendon just above the kneecap, taken through a small 2 to 3 cm incision with modern minimally invasive instruments.
Large 2024–2026 meta-analyses of randomised trials found no meaningful difference in graft failure between quad, hamstring and BTB grafts in the general population.
In young athletes (25 and under), hamstring grafts fail more often; quad tendon and BTB both perform better, though the quad tendon data are still less mature than BTB.
The quad tendon causes less anterior knee and kneeling pain than BTB, and it spares the hamstrings, which matters for sprinters and footballers.
It is a strong choice for revision surgery, thin hamstring tendons and high-demand pivoting athletes.
Return to pivoting sport takes 8 to 9 months, the same as other grafts.
ACL reconstruction in India typically costs ₹1.5 to 3.5 lakh, depending on hospital, implants and any combined procedures.

Why ACL graft choice matters

The anterior cruciate ligament (ACL) sits deep in the centre of the knee and stops the shin bone from sliding forward under the thigh bone and rotating unstably. Once it tears completely, it does not heal back on its own. For anyone who wants to return to running, cutting and pivoting sports, or simply wants a knee that does not "give way" on stairs, reconstruction with a new graft is usually recommended.

The graft is tissue, usually from your own body (an autograft), threaded through tunnels drilled in the thigh bone and shin bone to do the job the original ACL did. Surgeons have three main autograft options:

Hamstring tendons from the back of the thigh
Bone–patellar tendon–bone (BTB), the central third of the tendon below the kneecap with a small bone block at each end
Quadriceps tendon, from the thick tendon above the kneecap, with or without a small bone block from the patella

Each differs in thickness, how it heals into bone, and what it costs the "donor site" it is taken from. That is why graft choice is one of the most important decisions in planning your surgery, alongside understanding how an ACL tear differs from a PCL or LCL tear.

What is quadriceps tendon ACL reconstruction?

The quadriceps tendon connects the large muscle at the front of the thigh to the top of the kneecap. It is one of the thickest tendons in the body, so the surgeon can take a central strip of it and still leave plenty of tendon to straighten the knee normally.

In the past, quad tendon harvest needed a long incision above the kneecap, which kept it less popular than hamstring grafts. Modern minimally invasive tendon harvesters changed that. These tube-shaped cutting instruments, available in diameters of roughly 8 to 11 mm, core out a strip of tendon through a small 2 to 3 cm incision. The graft can be all-soft-tissue (no bone) or taken with a small patellar bone block at one end, depending on the surgeon's technique and the patient's needs.

Fixation commonly uses:

An adjustable-loop cortical button on the thigh bone (femoral) side, with a reinforced suture tape stitched into the graft end to hold it securely
A bio-composite interference screw or a second cortical button on the shin bone (tibial) side
In some cases an all-inside technique, with buttons on both sides and smaller tunnels that preserve more bone

Quad tendon vs hamstring vs BTB: how do they compare?

Factor	Quadriceps tendon	Hamstring tendon	BTB (patellar tendon)
Graft thickness	Large, consistent and predictable	Moderate; can be thin in some patients	Moderate; fixed width with bone blocks
Incision	Small (2–3 cm) with minimally invasive harvest	Small (3–4 cm)	Longer, at the front of the knee
Anterior knee and kneeling pain	Low to moderate	Low	Highest of the three
Strength after surgery	Temporary quadriceps deficit; hamstrings preserved	Temporary hamstring deficit; quadriceps stronger early	Quadriceps weakness common early
Graft-to-bone healing	Tendon-to-bone (or bone-to-bone at one end if a bone block is used)	Tendon-to-bone at both ends	Bone-to-bone at both ends; generally fastest fixation
Graft failure, general population	Comparable to the others	Comparable to the others	Comparable to the others
Graft failure, young athletes (≤25)	Low in early data; evidence still maturing	Highest of the three	Low; most established evidence
Best suited for	Revision surgery, thin hamstrings, high-demand athletes, those who kneel or sprint	Many first-time recreational patients	Elite and young pivoting athletes, revision cases

What does the latest research say?

The honest picture from the most recent evidence is "equally good, with different strengths", not "one graft wins".

Overall outcomes are similar. A 2025 meta-analysis of 12 randomised controlled trials (636 patients) published in Knee Surgery, Sports Traumatology, Arthroscopy found no difference in graft failure between quad, hamstring and BTB grafts, rated as high-certainty evidence. A separate meta-analysis of 11 randomised trials reported very low failure (about 0.7%) and reoperation rates (about 2.3%) across all three grafts, with no significant difference between them.

Knee stability is similar. A meta-analysis of 15 randomised trials found no significant difference in objective knee stability between quad tendon and hamstring grafts at one or two years, or between quad tendon and BTB at one year, and reported lower donor-site problems with the quad tendon than with BTB.

Some studies favour the quad tendon over hamstrings. A 2024 meta-analysis of 21 studies (2,964 patients) in the Journal of Orthopaedics and Traumatology found the quad tendon was associated with roughly half the risk of graft failure compared with hamstrings. Most of the included studies were retrospective, so this is weaker evidence than the randomised trials above.

Young athletes are where the differences show. A 2026 meta-analysis in The American Journal of Sports Medicine focusing on patients aged 25 and under reported pooled failure rates of about 11% for hamstring, 5% for BTB and 2.5% for quad tendon grafts. Hamstrings failed significantly more often than BTB, but the quad tendon estimate had a wide margin of uncertainty because fewer studies exist, so the authors still favoured BTB for this group. In practice, many surgeons now consider quad tendon and BTB the two leading options for young pivoting athletes.

Strength recovery differs by graft. As you would expect, patients with a quad tendon graft keep better hamstring strength, while hamstring-graft patients regain quadriceps strength sooner. Your sport and rehabilitation goals should shape which trade-off suits you.

A note of caution. A 2025 ISAKOS review found that many randomised trials comparing the quad tendon with other grafts are statistically fragile, meaning a handful of different outcomes could change their conclusions. The quad tendon is a proven, reliable graft, but claims that it is definitively "the best" go beyond what the evidence supports today.

Who is a good candidate for a quad tendon graft?

A quadriceps tendon graft is often the preferred choice for:

Revision ACL surgery, after a previous hamstring or BTB graft has failed
Patients with thin hamstring tendons seen on MRI or during surgery
Young, high-demand athletes in football, kabaddi, basketball, badminton and other pivoting sports who need a thick, strong graft
Sprinters and athletes who rely on hamstring power, since it leaves the hamstrings untouched
People who kneel often at work, in prayer or in daily life, who want to avoid the kneeling pain associated with BTB
Combined procedures, such as ACL reconstruction with meniscus repair, where graft size and reliable fixation matter

It may be less suitable for patients with pre-existing quadriceps tendon problems or significant quadriceps weakness, and a small number of patients report some discomfort at the harvest site when kneeling, though usually less than with BTB.

How the surgery is performed: step by step

Pre-operative planning. Your surgeon reviews your MRI, examines knee stability and discusses graft choice. Sometimes the final decision is made during surgery after checking hamstring size.
Anaesthesia. Surgery is usually done under spinal or general anaesthesia.
Diagnostic arthroscopy. A small camera confirms the ACL tear and checks the meniscus and cartilage for associated damage, as in a standard knee arthroscopy.
Graft harvest. A small vertical incision is made above the kneecap and a strip of quadriceps tendon of the required length and diameter is taken, leaving the rest of the tendon intact.
Graft preparation. The graft is sized and its ends are reinforced with high-strength suture so it can be fixed securely.
Tunnel drilling. Anatomic tunnels are drilled in the thigh bone and shin bone to match the original ACL attachment points for the best rotational stability.
Graft passage and fixation. The graft is passed through the tunnels and fixed with a cortical button on the femoral side and a screw or button on the tibial side.
Tensioning and closure. The graft is tensioned and tested through a full range of motion before the small incisions are closed.

The procedure typically takes 60 to 90 minutes, and most patients in India stay in hospital for one to two days.

Benefits of the quad tendon graft

Thick, predictable graft size, useful when hamstrings are small
Small, cosmetically favourable incision with minimally invasive harvest
Less anterior knee and kneeling pain than BTB
Preserves the hamstrings, which protect the ACL and power sprinting
Works for both first-time and revision ACL reconstruction

Risks and possible complications

As with any ACL reconstruction, your surgeon should explain the risks in detail. These include:

Temporary quadriceps weakness or tightness above the kneecap in early recovery
Numbness or a small hollow at the harvest site, which usually improves
General surgical risks such as infection, blood clots and stiffness
A rare risk of patella fracture when a bone block is taken, which is why surgeon experience matters
Graft re-tear, especially if return to sport happens before strength and stability tests are passed

Recovery timeline and rehabilitation

Recovery follows much the same pattern as other ACL grafts, with extra early focus on reactivating the quadriceps.

Timeframe	What to expect
Weeks 0–2	Weight bearing as tolerated with crutches; brace if your surgeon uses one; focus on reducing swelling and regaining full straightening
Weeks 2–6	Weaning off crutches, gentle range-of-motion work, quadriceps activation exercises
Weeks 6–12	Closed-chain strengthening, stationary cycling, balance training; most patients walk normally without a brace
Months 3–5	Progressive strength training; straight-line jogging once strength and stability criteria are met
Months 5–7	Sport-specific drills, supervised cutting and pivoting, agility training
Months 8–9	Return to full contact or pivoting sport after passing strength and hop tests

Physiotherapy is central throughout. See our guides on physical therapy for ACL tear and ACL surgery recovery do's and don'ts, and on knee brace versus knee sleeve for ACL tear for the return-to-activity phase.

Cost of quad tendon ACL reconstruction in India

The final cost depends on several factors:

Hospital and city. Metro cities such as Bangalore, Mumbai and Delhi tend to cost more, though surgeon experience matters more than location.
Implants. Premium fixation implants (cortical buttons, reinforced sutures and bio-composite screws) are a meaningful part of the bill.
Room type and length of stay. A general ward costs less than a private room; most patients go home within one to two days.
Combined procedures. Meniscus repair, cartilage treatment or additional ligament work increases the total.
Insurance. Most major health insurance plans in India cover ACL reconstruction as a medically necessary procedure.

As a general guide, ACL reconstruction in India, including quad tendon grafts, typically costs ₹2.7 lakh to ₹3.5 lakh. This is an indicative range, not a quotation. The most reliable way to get an accurate figure is a consultation, where your surgeon reviews your MRI and gives a personalised estimate.

Why choose Sports Orthopedics Institute for your ACL reconstruction?

Sports Orthopedics Institute is led by Dr. Naveen Kumar L.V, Chief of Orthopaedics and Sports Medicine at Manipal Hospital, with fellowships and qualifications from the UK, Italy and Portugal and more than 27 years of experience in advanced arthroscopy and joint reconstruction. With over 10,000 surgical procedures performed, the team is experienced with every ACL graft option, including quadriceps tendon, hamstring and BTB grafts, so your graft is chosen for your knee, your sport and your goals rather than by habit.

Every patient is guided through pre-surgical planning, the procedure and a structured rehabilitation pathway with close follow-up, from week one to return to sport.

Frequently asked questions

Is the quadriceps tendon the best graft for ACL reconstruction?

There is no single best graft for everyone. Randomised trials show similar stability, function and failure rates for quad tendon, hamstring and BTB grafts. The quad tendon is often the best choice for revision surgery, thin hamstrings and high-demand athletes.

Is a quad tendon graft better than a hamstring graft?

For most adults, outcomes are similar. In young athletes, hamstring grafts tend to fail more often, so a quad tendon or BTB graft is frequently preferred in that group.

Is a quad tendon graft better than a BTB graft?

They perform similarly for stability and failure. The quad tendon generally causes less kneeling and front-of-knee pain, while BTB has the longest track record in young elite athletes.

How painful is quad tendon harvest?

Most patients have manageable discomfort that improves within a few weeks. Long-term, it is generally less painful than BTB harvest, particularly when kneeling.

How long does recovery take after quad tendon ACL reconstruction?

Most patients walk without a brace by about 6 weeks, jog at 3 to 4 months and return to pivoting or contact sport at 8 to 9 months, once strength and hop tests are passed.

Does taking the quad tendon weaken the knee permanently?

No. Only a central strip is taken, and in most patients quadriceps strength returns close to normal within 4 to 6 months with consistent physiotherapy.

Can the quad tendon be used for revision ACL surgery?

Yes. It is one of the most commonly used grafts for revision surgery because of its large, predictable size, and it keeps the hamstrings available for future procedures.

What is the cost of quad tendon ACL reconstruction in India?

Typically ₹2.7 lakh to ₹3.5 lakh, depending on the hospital, city, implants and whether procedures such as meniscus repair are done at the same time.

Is ACL reconstruction covered by health insurance in India?

Most major insurers cover it as a medically necessary orthopaedic procedure. Coverage varies by policy, so confirm with your insurer.

Conclusion

The quadriceps tendon has earned its place as a first-line ACL graft, not just a back-up for revision cases. But the evidence does not crown it the outright winner. Quad tendon, hamstring and BTB grafts all deliver good results in experienced hands; the right one for you depends on your age, anatomy, sport, kneeling needs and whether this is a first or revision surgery. That decision is best made in a detailed consultation with an experienced knee surgeon.

Considering ACL reconstruction? Book an appointment with Sports Orthopedics Institute for a personalised assessment and graft recommendation.

This article is for general educational purposes and does not replace a consultation with a qualified orthopedic surgeon. Every knee and every ACL tear is different, and treatment should be personalised after a physical examination and imaging review.

References

Quadriceps, hamstring and patella tendon autografts for primary ACL reconstruction demonstrate similar clinical outcomes, including graft failure, joint laxity and complications: a systematic review with meta-analysis of randomised controlled trials. Knee Surg Sports Traumatol Arthrosc. 2025.
Zhang XF, Liu P, et al. Efficacy and safety of quadriceps tendon autograft versus bone–patellar tendon–bone and hamstring tendon autografts for ACL reconstruction: a systematic review and meta-analysis. J Orthop Traumatol. 2024.
Quadriceps tendon autograft provides comparable stability and functional outcomes with lower donor-site morbidity than bone–patellar tendon–bone: a systematic review and meta-analysis of 15 RCTs. Knee Surg Sports Traumatol Arthrosc. DOI: 10.1002/ksa.70499.
Petit CB, Hussain ZB, et al. Graft failure rates in bone–patellar tendon–bone, hamstring, and quadriceps tendon autografts in patients younger than 25 years: a meta-analysis. Am J Sports Med. 2026. DOI: 10.1177/03635465261415842.
Randomized controlled trials comparing quadriceps tendon autografts with hamstring or BTB autografts in ACL reconstruction are statistically fragile: a systematic review. ISAKOS Congress 2025.

Is the Quadriceps Tendon Really Superior to Other Grafts for ACL Reconstruction?