Smith machine squats pose high risk to ACL graft integrity after the ACL reconstruction and conventional squats are a safer alternative

Purpose The purpose of this study was to evaluate the impact of squats after the anterior cruciate ligament (ACL) reconstruction on the ACL graft, considering new data on biomechanics, posterior tibial slope (PTS) and anterolateral ligament (ALL). Methods Utilising finite element analysis on the new 14‐component knee joint model, we have evaluated stresses on the knee elements separately for the knee with a native double‐bundle ACL and with a single‐bundle ACL graft for the 5° and 14° PTS variants during both conventional and Smith machine horizontal squats. Results Replacing a native ACL with a single‐bundle graft causes an overstrain on the graft compared to the intact ACL under all conditions. Stresses on the ACL, ACL graft and ALL are much higher during the Smith machine squats compared to the conventional ones. The stress on the menisci is 3.6–4.9 times higher with conventional squats. PTS at the squats' lowest point minimally affects ACL stress but impacts menisci. Conclusions The single‐bundle ACL reconstruction (ACLR) does not reproduce the biomechanics of the native ACL and increases stresses in most knee joint elements, according to the current study. Conventional squats are relatively safe for the ACL graft at their lowest point. Passing the half‐squat position is the most dangerous point. Smith machine horizontal squats produce stress on the ACL graft several times higher than its estimated breaking load and dangerous stress levels on the ALL. During the rehabilitation following ACLR, it is advisable to prioritise the conventional squats over Smith machine squats until ligamentisation is complete. Level of Evidence Level III.