Sport-Specific Considerations in ACL Reconstruction: Diagnostic Evaluation and Graft Selection

Knee biomechanical demands vary across different sports due to sport- and position-specific patterns of muscle recruitment. To return to performance, athletes must adequately restore knee kinematics to regain control over the same sport mechanics that led to the initial anterior cruciate ligament (ACL) injury. ACL graft selection should therefore minimize donor site morbidity and support sport-specific demands. This study aims to address the available evidence and guide surgical graft choice in athletes. A literature search of PubMed, MEDLINE, Scopus, and Web of Science (up to September 2025) assessed BPTB, hamstring, and quadriceps tendon autografts. Outcomes included revision, graft survival, return to sport, time to return, PROMs, anterior knee pain, donor site morbidity, and prognostic factors (age, sex). Sports were classified as pivoting, contact/collision, or endurance/non-pivoting. The results were synthesized narratively. In <i>pivoting</i> and <i>cutting sports</i>, bone-patellar tendon-bone (BPTB) autografts offer high survival rates but are associated with a high incidence of anterior knee pain, which is a substantial drawback in kneeling or flexion-intensive sports. Hamstring tendon (HT) grafts carry higher revision rates in female and younger patients, though they have low donor site morbidity that does not appear to affect long-term athletic performance. Quadriceps tendon (QT) grafts are emerging as a promising option for pivoting athletes. However, conflicting results indicate that the revision risk is comparable to that of HT grafts and possible long-standing extensor mechanism weakness. <i>Contact</i> and <i>collision sports</i> demonstrate similar trends, but kneeling and contact injuries are more common in this group. Thus, while prioritizing powerful hamstring strength, anterior knee pain symptoms should still be carefully considered. The diameter of the HT autograft should exceed 7.5 mm to ensure comparable revision outcomes with BPTB. QT grafts remain a limited-evidence attractive option. <i>Endurance</i> and <i>non-pivoting</i> athletes require fewer pivoting mechanics but rely heavily on muscle symmetry and repetitive motion. BPTB grafts are less suitable in this category due to alterations in sprint mechanics, muscle asymmetry, and repetitive patellofemoral joint loading. HT grafts provide favorable rates of return to sport, whereas evidence regarding QT graft use in non-pivoting athletes remains limited.