|Position||Average % Difference PPG Change From Pre-Injury Compared to 1st Game After Injury||Average % Difference PPG Change From Pre-Injury Compared to Games 2-3 After Injury||Average % Difference PPG Change From Pre-Injury Compared to Games 4-6 After Injury|
|Position||Average Change in Snap% From Pre-Injury Compared to 1st Game After Injury||Average Change in Snap% From Pre-Injury Compared to Games 2-3 After Injury||Average Change in Snap% From Pre-Injury Compared to Games 4-6 After Injury|
Anatomy of an ACL tear
The anterior cruciate ligament (ACL) is one of the most important stabilizers of the knee.1 The ACL helps prevent hyper-extension of the knee and is often torn in such injuries. An ACL tear is a potentially devastating injury for athletes, as current research shows that only about 55-65% of athletes return to their prior level of sport after reconstruction.1 In recent NFL history, several key fantasy football players have torn their ACL.
Cause of injury
Approximately 72-78% of ACL tears in athletes are due to non-contact injuries.1,2 Most recently, this mechanism was seen during the 2022 super bowl when O’Dell Beckham Jr. re-tore his ACL while running a route.
Unfortunately, this was the second time Beckham Jr. tore the ACL in his left leg. The first was during week 7 of the season prior (also a non-contact injury). Unfortunately, the risk of re-tear for an ACL is significantly higher than one might think.
The remaining 22-28% of ACL tears occur from direct contact with the knee.1,2 Most recently, this was seen with J.K. Dobbins during the 2021 preseason. As you can see in the video, the defender’s shoulder comes into direct contact with Dobbins’ knee, causing a hyperextension injury while his foot was planted.
ACL tear surgical reconstruction procedure
There are several options for surgery after an ACL tear. Most procedures today involve reconstructing the torn ligament with a quadriceps, hamstring, or patellar tendon graft. These grafts are essentially a small portion of the tendon taken from the donor site. These grafts typically come from the athlete’s injured knee and are then placed in the same location of the torn ACL in an attempt to reconstruct the torn ligament. Unfortunately, taking a graft from the same knee that is injured can cause significant weakness in the involved muscle group, causing difficulty in rehabilitation after surgery.
Although somewhat outdated (2011) the following video provides a good general idea as to how an ACL reconstruction may be performed.
You may be asking, “why don’t they use the other knee” or “why don’t they use something man-made”? Although extremely uncommon, some individuals will use a graft from the uninvolved knee or a graft from a cadaver. However, there is an increased risk of complications with a graft from the uninvolved limb, and cadaver grafts are not as strong. In the past, there was also an attempt to use Gore-tex to repair the torn ligament. Initial results were promising; however, the long-term failure rate was significantly higher than today’s methods.
ACL tear surgical reconstruction outcomes
In the past, an ACL tear was a career-ending injury. Luckily, with advancements in modern medicine, today, we know that approximately 87.8% of NFL players will return to the same level of previous participation after an ACL reconstruction. Unfortunately, there is an approximate 13% risk of re-tear to either knee after ACL reconstruction in NFL players. The good news for fantasy football players is that offensive players and younger individuals tend to have more favorable outcomes than defensive and older individuals.3
In a more recent study (published March 2022), looking at NFL players from 2013-2018, 312 NFL players sustained an ACL injury. Only 55.8% of these players returned to play, while only 28.5% remained active in the league three years after injury. This study also showed that the positions most affected by ACL tear include running back, defensive lineman, and linebackers. Meanwhile, quarterbacks were the most likely to return to play and saw the most negligible decline in performance compared to other positions.4
ACL tear and surgical reconstruction rehab process
Immediately after surgery, the individual will begin their rehab toward a return to sport. As long as there was no other structure injured and/or repaired, the athlete should be able to start weight-bearing with crutches ASAP. In the first two weeks, the primary goal of rehab is to eliminate swelling, restore range of motion, and prevent muscle loss.
During the next 2-3 months, the athlete will primarily be working on building strength and maintaining range of motion. In this phase, the athlete cannot tolerate impact through the knee and will be held from running and most impact drills.
Finally, around 12-16 weeks after surgery, the athlete can begin running. Returning to running progresses slowly, for example, starting on a treadmill and progressing to land over time. Jameis Winston was recently shown running for the first time at the 16-week post-op mark. In this video, Winston is running on an Alter-G treadmill. This device allows the individual to run at lower body weight, thus placing less impact on the knee.
From 4-6 months, the athlete will continue to work on improving their strength and power. For example, athletes will gradually be introduced to different plyometric and agility drills such as hopping, ladder drills, hurdles, etc. Once they show good strength and ability to tolerate load on the knee, they will begin cutting and changing direction activities.
From 6-9 months, the athletes primarily work on sports and position-specific drills. As they near the nine-month mark, they may be cleared to participate in practice and eventually full contact activities. Today’s research recommends waiting to return to sport until at least nine months post-op as it has shown to decrease the risk of re-injury drastically.
|Time Line||Goals and Weight Bearing Status||Rehab|
|Post-op Weeks 1-2||Goals:|
Protect surgical site.
Weight-bearing as tolerated with crutches and knee brace.
|Restore full extension range of motion, improve flexion range of motion. Emphasize good control of the quadriceps.|
May begin glute, core, upper body exercises within limits.
|Post-op Weeks 3-6||Goals: |
Protect surgical site.
Gradually increase weight bearing.
Wean off of crutches and knee brace as tolerated.
|Ensure full range of motion, continue to control swelling, avoid excessive stress on the anterior knee. |
Continue to progress strengthening and balance exercises. May begin squats and leg press within limited range of motion.
|Post-op Weeks 6-12||Goals:|
Protect surgical site.
Full weight bearing.
Should be full weightbearing with proper gait pattern.
|Continue with previous exercises.|
Begin open chain exercises as tolerated (knee extensions). Progress to single leg exercises as able.
May begin static and dynamic stretches.
Progress balance exercises: Wobble board, standing on foam pad, single leg stance.
Deep water pool walking, cycling, possible elliptical/stair stepper.
|Post-op weeks 12-16||Goals:|
Protect surgical site.
Begin running and jumping. No cutting, limited change of direction activities.
|Once strength is equal to at least 70% of opposite limb; begin straight line running and jumping/hopping. |
Likely begin some ladder drills and eccentric control exercises.
Continue to progress core, balance, and strengthening exercises.
|Post-op 4-6 months ||Goals:|
Return to practice at 6 months.
Progress position specific strength and agility
Ensure single leg balance and strength is similar to non-injured leg.
|Continue to progress and emphasize good control of the body during all movements. |
Increase challenge of balance exercises: Wobble board while tossing ball, single leg stance on foam pad while tossing ball, add cognitive task (count backwards from 100 by 3’s while balancing)
Gradually progress agility and sport specific drills. Aim for return to limited practice by 6 months.
|Post-op 6-9 months ||Goals:|
Return to sport at 9 months.
Progress position specific movements.
|Continue progressing all exercises from previous phase.|
Pending clearance, may begin full contact practices closer toward 9 month time frame.
|Post-op Months 9-12+||Goals:|
Return to prior level of performance.
|Unrestricted training. Sprinting, jumping, cutting, plyometrics, throwing, etc.|
Athletes who have had ACL surgery
|Quarterbacks||# of Weeks From Injury to Return||PPG Prior to Injury||PPG 1st Game After Injury||PPG Games 2-3 After Injury||PPG Games 4-6 After Injury|
|Kyler Murray (2022 week 14)||N/A||16.5||N/A||N/A||N/A|
|Jameis Winston (2021 week 8)||45||17.9||21.7 (+3.8)||13.6 (-4.3)||N/A|
|Joe Burrow (2020 week 11)||42||17.5||18.6 (+1.1)||16 (-1.5)||22.1 (+4.6)|
|Jimmy Garoppolo (2018 week 3)||50||17.1||11.4 (-5.7)||17.5 (+0.4)||11.7 (-5.4)|
|Carson Wentz (2017 week 14)||41||21.6||11.2 (-10.4)||20.9 (-0.7)||21.9 (+0.3)|
|Deshaun Watson (2017 week 8)||44||26.5||11 (-15.5)||23.9 (-2.6)||19.1 (-7.4)|
|Ryan Tannehill (2017 preseason)||57||16.2||13.6 (-2.6)||21.7 (+8.1)||3.6 (-12.6)|
|Number of Players Who Have Met Their Baseline at Current or Previous Time Points||2/6 (33.3%)||4/6 (66%)||4/5 (80%)|
|Running Backs||# of Weeks From Injury to Return||PPG Prior to Injury||PPG 1st Game After Injury||PPG Games 2-3 After Injury||PPG Games 4-6 After Injury|
|Breece Hall (2022 week 7)||46||15.4||15.2 (-0.2)||N/A||N/A|
|Javonte Williams (2022 week 4)||49||8.5||7.7 (-0.8)||N/A||N/A|
|Gus Edwards (2021 preseason)||59||10.7||18.6 (+7.9)||5.2 (-5.5)||7.3 (-3.4)|
|JK Dobbins (2021 preseason)||56||16||5 (-11)||11.4 (-4.6)||N/Aψ|
|Rex Burkhead (2020 week 11)||42||7.6||1.1 (-6.5)||0.5 (-7.1)||4.1 (-3.5)|
|Tarik Cohen (2020 week 3)||N/A||7.1||N/A||N/A||N/A|
|Saquon Barkley (2020 week 2)||51||20||3.2 (-16.8)||13.2 (-6.8)||14 (-6)|
|Rashaad Penny (2019 week 14)||54||9.1||0.6 (-8.5)||1.5 (-7.6)||N/A|
|Jay Ajayi (2018 week 5)||59||11.3||1.6 (-9.7)||0.7 (-10.6)||N/A|
|Jerrick McKinnon (2018 preseason)||106||8.9||11.9 (+3)||14.5 (+5.6)||8.2 (-0.7)|
|Dalvin Cook (2017 week 4)||49||16||10.5 (-5.5)||6.7 (-9.3)||15.5 (-0.5)|
|Number of Players Who Have Met Their Baseline at Current or Previous Time Points||2/10 (20%)||2/8 (25%)||2/7 (29%)|
|Wide Receivers||# of Weeks From Injury to Return||PPG Prior to Injury||PPG in 1st Game After Injury||PPG Games 2-3 After Injury||PPG Games 4-6 After Injury|
|Wan’Dale Robinson (2022 week 11)||N/A||8.2||N/A||N/A||N/A|
|Sterling Shepard (2022 week 3)||46||12.4||0 (-12.4)||N/A||N/A|
|Jaylen Guyton (2022, week 3)||N/A||7||N/A||N/A||N/A|
|Tim Patrick (Aug 2, 2022)||N/A||N/A||N/A||N/A||N/A|
|Odell Beckham Jr. (Superbowl, 2022)||82||11.4||4.7 (-6.7)||N/A||N/A|
|Jameson Williams (Jan 10, 2022)||N/A||N/A||N/A||N/A||N/A|
|Michael Gallop (2021 week 17)||39||9.3||9.4 (+0.1)||4.6 (-4.7)||4.1 (-5.2)|
|Chris Godwin (2021 week 15)||38||15.1||5 (-10.1)μ||9.4 (-5.7)||10.3 (-4.8)|
|John Metchie III (Dec 4, 2021)||N/A||N/A||N/A||N/A||N/A|
|Robert Woods (2021 week 10)||43||14.5||1.8 (-12.7)||8.2 (-6.3)||6.7 (-7.9)|
|KJ Hamler (2021 week 3)||50||5.6||0 (-5.6)||3 (-2.6)||3.1 (-2.5)|
|Odell Beckham Jr. (2020 week 7)||48||12.4||11.2 (-0.8)||3.6 (-8.8)||4.9 (-7.5)|
|Courtland Sutton (2020 week 2)||51||9.6||1.9 (-7.7)||13.3 (+3.7)||15.7 (+6.1)|
|Preston Williams (2019 week 9)||45||9.4||5.1 (-4.3)||6.4 (-3)||10.5 (+1.1)|
|Cooper Kupp (2018 week 10)||43||15.6||8.1 (-7.5)||21.4 (+5.8)||16.1 (+0.5)|
|Will Fuller (2018 week 10)||45||11.5||7.9 (-3.6)||6.8 (-4.7)||19.1 (+7.6)|
|Eli Rodgers (2018 playoffs)||47||3.7||4 (+0.3)||5.8 (+2.1)||N/A|
|Jaelen Strong (2017 week 16)||N/A||5.2||N/A||N/A||N/A|
|Allen Robinson (2017 week 1)||52||7.1||8.1 (+1)||9.9 (+2.8)||8.4 (+1.3)|
|Julian Edelman (2017 preseason)||54||14.1||9.2 (-4.9)||13.1 (-1)||15.2 (+1.1)|
|Number of Players Who Have Met Their Baseline at Current or Previous Time Points||3/15 (20%)||5/13 (38%)||8/13 (62%)|
|Tight Ends||# of Weeks From Injury to Return||PPG Prior to Injury||PPG 1st Game After Injury||PPG Games 2-3 After Injury||PPG Games 4-6 After Injury|
|Zach Ertz (2022 week 10)||39||10.2||5.1 (-5.1)||N/A||N/A|
|Logan Thomas (2021 week 13)||40||9.3||6 (-3.3)||6.4 (-2.9)||N/Aψ|
|Robert Tonyan (2021 week 8)||45||4.5||5.1 (+0.6)||4.4 (-0.1)||9.2 (+4.7)|
|Maxx Williams (2021 week 5)||N/A||6||N/A||N/A||N/A|
|Hunter Henry (2018 preseason)||33||8.9||0 (-8.9)ρ||N/A||N/A|
|Number of Players Who Have Met Their Baseline at Current or Previous Time Points||1/4 (25%)||1/3 (33.3%)||1/1 (100%)|
Sam Webb, PT, DPT, SCS
- Boden BP, Dean GS, Feagin JA Jr, Garrett WE Jr. Mechanisms of anterior cruciate ligament injury. Orthopedics. 2000;23(6):573-578. doi:10.3928/0147-7447-20000601-15
- Ristić V, Ninković S, Harhaji V, Milankov M. Causes of anterior cruciate ligament injuries. Med Pregl. 2010;63(7-8):541-545. doi:10.2298/mpns1008541r
- Khair M, Riboh J, Solis J, et al. Return to Play Following Isolated and Combined Anterior Cruciate Ligament Reconstruction: 25+ Years of Experience Treating National Football League Athletes. Orthop J Sports Med. 2020;8(10):2325967120959004. Published 2020 Oct 22. doi:10.1177/2325967120959004
- Read CR, Aune KT, Cain EL Jr, Fleisig GS. Return to Play and Decreased Performance After Anterior Cruciate Ligament Reconstruction in National Football League Defensive Players. Am J Sports Med. 2017;45(8):1815-1821. doi:10.1177/0363546517703361