Episode 103 | Managing Your ACL Graft Donor Site after ACLR

What is up team, and welcome back to another episode. Today, we are talking about ACL graft donor sites–how to manage them right after you have an ACL reconstruction surgery, so we can make sure that we set you out on a good path. ACL grafts are a very common topic in this space. Autograft versus allograft, what are they? Autograft, consider that as taking that from your own body. Allograft is from a cadaver, typically, not from your body. Autografts are what is usually associated with donor sites because the autograft is taken from your own body. There is a piece that is taken from a specific donor site. That is where they typically take a tendon; tendons connect muscle to bone. And so they take a tendon or piece of the tendon and they will eventually turn that into your new ACL ligament. Ligament connects bone to bone. Tendon: muscle to bone. 

And there’s a big difference here and it’s important to understand this, to understand the donor sites and where it’s taken and how we can manage that. The three big autografts that we’ll see, the sites are the big three: hamstring, quadriceps, and patella. The quadriceps tendon is usually taken at the top of the kneecap towards your quad. The patellar tendon is taken below your kneecap, where that little patellar tendon is. And then you have your hamstring, usually on the inner side. It’s usually a combination of one of your hamstring muscles called the semitendinosus and potentially combined with your gracilis.

For example, for both of my ACL surgeries, my surgeon did a hamstring graft. He took my semitendinosus on both sides in order to make my ACL graft. And what I’ll see quite often are people coming in later to work with us, having issues with their donor site. It might be discomfort, it might be pain, and it might be some weird sensory issues. Now, there’s a number of reasons why that could be. It could be impacting that sensory nerve, like the saphenous nerve that can impact. It could be because there was a pre-existing injury or underlying thing going on., But really, most people have issues with it because, well, you had trauma to that area that the donor site was impacted and the graft was taken. And maybe it hasn’t been loaded, and so it’s basically gotten weak or lost its ability to really do its job. That’s what typically happens in most cases. 

I’ll give you an example. One of the guys I saw recently had a hamstring graft multiple weeks out. He could barely bend his knee. Now, we had passive knee flexion to roughly 90 to 100 degrees. But he could barely bend his knees actively to do that because he got a hamstring graft. His hamstring was weaker. And I think he had some hesitation loading it. And also there was a protocol in place that was basically telling him not to load his hamstring at all. 

Now, there’s a give or take in this process of loading your hamstring. Early in the process with, let’s say a hamstring graft, which we can kind of talk about here in a little bit more detail. But the thing to think about here is when you have ACL surgery, you have two trauma points if you will. And we’re going to keep this super simple. You have the bone drilling and the new ACL reconstruction. They’re putting the screws in or whatever material they need, to anchor the ACL itself, and they have to get the ACL. And the way they do that is by going into that donor side area, the quad, the hamstring, or the patellar tendon, and they’re going to get that little piece of tendon and they’re going to try and get that graft in order to turn it into your new ACL. 

Then, you have to think about that donor site that is left behind after that, that’s a second trauma if you will. And so that’s where that patellar tendon, quad, or hamstring is impacted. For the patellar or quad, you have a form of what we call tendinopathy. People will typically hear tendonitis or tendinosis. But tendinopathy is this big umbrella term where it’s basically saying there’s a pathology of that tendon. And so that’s what we’re dealing with when you think about when that graft is taken.

The hamstring tendon is a very interesting place because you’re actually impacting the muscle. For some semitendinosus, they’ve done research on where sometimes that muscle will shrivel up, it’ll dissipate, it might connect to other connecting muscles, so there might be a connection to the semimembranosus. These are just different parts of your hamstring muscle as a group. It’s a very interesting tendon and graft that is taken. And that is something that could be considered maybe like a Grade III muscle strain combined with maybe a tendinopathy where that tendon is impacted. And especially if they take the whole thing, then yeah, that’s losing that specific part of your hamstring.

Grade III basically means if you imagine that bruising that you see and people tear a complete tendon and a muscle, that’s kind of what a hamstring graft is, basically. That’s what we’re looking at. You got to think of it as like, okay, you have the ACL reconstruction. If you get an autograft, there’s another form of something going on that we have to manage. how do we do that? In most protocols, most surgeons will often recommend actually to avoid loading the area for a while which is fair. But this has changed over the recent years, but still see a lot of protection around it. 

For this recent athlete I saw, there was no loading for the hamstring for six weeks. That’s a very long time to shut your hamstrings down. If any of you know, as soon as you have an ACL injury or especially after surgery, your leg turns into a hot dog and you lose all your muscle mass. Our goal is basically how can we reduce that from happening and how can we regain our strength as quickly as possible. Part of that is trying to introduce some load, but we have to be very strategic about it. This means that we view this almost like a tendinopathy or a muscle-type strain to a certain degree. Then we need to manage it like so. Doesn’t mean that we have to go hot out of the gate with heavy strength work loading it as hard as we can, pushing to the max. We’re just going to build up very slowly with a general framework of isometrics, eccentric, concentric, and then we’re going to work into some rate and speed of loading type work. But really the main focus initially post-op is we’re going to get into some level of isometrics in as soon as possible.

And for those of you who are listening, trying to figure out what isometrics are. Imagine that you bend your elbow to 90 degrees. Your elbow flexed and you put your hand on top of your wrist and then you try to flex your elbow, trying to pull your wrist up, but pushing down with the opposite arm. You feel your bicep engaged, but it’s not moving. So that is an isometric where we’re kicking on the muscle, but we are not changing in length or the position is not changing. And this is one of my favorite ways to load, especially post-op or whenever people are dealing with some high sensitivity. Because it allows us a good entry point without irritating the joint or the area too much. And we can always adjust the intensity and how long we do it, the angle. There’s a lot of ways to enter without really provoking the area.

The only caveat I’m going to give here is that, if there’s a certain type of meniscus repair or some sort of other addition to the surgery, maybe it’s with a restriction for the hamstring graft because of its insertion into the medial meniscus or a meniscus repair. These are just things that we might have to depend on the surgeon and the surgery and some of the restrictions there. But in most cases, we are able to add some load of some degree immediately post-op, even if it’s just a little. Our goal is to work into the pain but not through it. That’s what’s really important here, is to find your tissue tolerance, basically, the level it can handle and recover from. So feeling productive in the loading, but not provoking the knee or making it angry. I’ve done previous podcast episodes on pain in ACL rehab and how we use feedback loops to help control this and give us data in order to adjust the next day. Check them out if you haven’t listened to them. But these are some of the frameworks that we start to use when we start to load some of these donor sites post-op. 

Now, you might be thinking I’m a couple of days out or a week out and I still can’t really get engagement in the area. That’s still okay. Everyone is going to vary on this spectrum. But you might be coming out of surgery and you’re feeling okay to add a little bit of engagement in that certain muscle in that donor site, and that’s going to be okay. That is actually going to set us up for success as long as we manage it very well. For a simple approach to post-op for our athletes I want to show you and give you the tactical framework to start with a lower level of intensity and discomfort. Don’t try to push it, just start with some sort of easy entry point. Hold the position for 15 seconds, the isometric, building up maybe to 30 to 45 seconds over multiple sets. 

For example, if you have a quad graft, we might get you in a prone knee extension type position, so on your stomach, and have your knee bent to a position that’s tolerable. And you might be kicking into a box or maybe you have a strap around the foot, and then we bend it to a certain angle, like a knee extension flat on your stomach, and you’ll lightly kick into it. That will help load your quad tendon a little bit. Patellar tendon graft, we might be seating you at 90 degrees or 60 degrees like a seated knee extension. And you might be kicking into just one of those pads or the wall. And you might be doing it at like a 10% intensity, maybe a 20% just to get some load into the quad into the patellar tendon. If you’re doing a hamstring graft, maybe it’s just heel digs on your couch or your bed. Maybe it’s on the box at varying angles. Maybe we’ll move towards a hamstring bridge where we can actually engage your hamstrings, isometrically, and bridge up. And as time goes on, you can be more and more specific with your loading.

For example, hamstring grafts can be really tricky. I remember for the longest time I would have hamstring strains. My strength wouldn’t get up to where it needed to be, especially when I was trying to do higher-end sprinting or loading my hamstrings or especially this inner range type flexion. When you imagine like heel to butt type range of motion, you could do that if you pull it there or use your hand at your ankle to pull your heel to your butt, hopefully, if you have the flexion. But to control that last little bit to get towards that end range flexion, that requires a lot of your hamstring tendon and your hamstring muscle. And so that inner range is what we’re talking about. So think about maybe that 110, 120 to 145 degrees. There is a lot responsible for that hamstring graft that was taken to assist with that. 

And a lot of times the athletes with a hamstring graft will have weakness in that range. So what we’ll do is maybe later on in the process we’ll work on that inner range strength with lift-offs, maybe with some tibial internal rotation to help bias that hamstring region and that graft area to target that donor site, more directly. But the goal is to find a tolerance you can handle and don’t pay for the next day. You want to make sure it returns back to normal baseline, ideally. And post-op, that might be a little tricky because everything feels really sharp and uncomfortable. So that’s where you just want to be very mindful, find a good entry point, and as long as you wake up the next day and you’re not overcooking it and you’re not really paying for it, then you can keep working with it, keep building it in. 

And the one thing that I always tell my athletes is this analogy we always use is -and I hope you guys who are listening if you don’t you can just run with the analogy. But if you’re cooking a steak, would you rather overcook it or undercook it? When you’re thinking about preparing for the situation, what would you rather be dealing with? An overcooked steak or an undercooked steak? An undercooked steak because you can always heat it up more to get it to the right temperature. If you overcook it, you’ve just got a well-done steak and that’s all you’re going to get. You can’t go back. But if you undercook it, you could always add a little bit more. But once you go too far, it’s burnt or it’s well done and you have to deal with it. In this case, in ACL rehab, if you go too far or do too much, you have to wait and let the knee do its job, the body does its job in order to get back to that baseline. But if you undercook it, you could always add more the next day or the next time you attack it. This is always a really good rule of thumb for a lot of our ACLers because knees can be so sensitive and we want to make sure that we don’t try to push really hard and then have to take a big step back. And this is a way to really help navigate that process.

Take care of your donor sites. You can think about it like a tendinopathy or a muscle strain. That is something that could be helpful to change our perspective on it and understand that there’s multiple moving pieces within this ACL reconstructive process versus all right, they went in and put a new ACL. But there’s a place that they took it from if it was an autograft. Just think about it from that sense so you can think about taking care of that donor site area. Find a good entry point to load it. Respect the healing process and your body, especially early post-op, and follow your specific guidance. That will do it for today, until next time, team.