Written by Tom Christ, PT, DPT, OCS, FAAOMPT
@FantasyInjuryT
An unfortunate part of football is the inevitable injury. Every season, several players seasons are lost to injury, sometimes requiring season-ending surgery. Below, I will discuss the major fantasy-relevant players who saw their seasons end early from an Anterior Collateral Ligament (ACL) injury and discuss their outlooks for 2023. As you will read, several factors play a role in the readiness to play next season. It’s important to remember that I am writing this article in March, and there are several months between now and week one. Recovery from major injury often includes several unpredictable obstacles, so we will revisit this list in the summer. For now, we will discuss the ACL injuries to monitor for 2023.
ACL Injuries
The dreaded Anterior Collateral Ligament (ACL) injury never fails to strike numerous players each year. The ACL is the primary source of passive stability in the knee, meaning that without an intact ACL, it is nearly impossible to perform high-level athletic activities. Without an intact ACL, the knee is likely to buckle with cutting, jumping, and landing tasks making it challenging to perform at peak level.
Rehab from an ACL is no breeze. ACL rehab typically takes 9-12 months, explaining why this is always a season-ending injury. The major challenges in the early phases of rehab are regaining full range of motion at the knee, regaining quad strength, and re-learning how to walk properly. As the athlete progresses through rehab, it is imperative they regain single-leg balance and proprioception. Proprioception is something I talked extensively about last season, specifically in regard to Lamar Jackson’s PCL injury. Proprioception is the body’s sense of where its limbs are in space without looking. This allows an athlete to plant their foot and cut on a dime without looking down at their foot. Another good example of proprioception is the classic sobriety test, where the police officer asks the person to close their eyes and touch their finger to their nose. One’s ability to properly touch their finger to their nose is dependent on their proprioception. Ligaments, such as the ACL, provide significant amounts of proprioceptive input to the spinal cord and brain, allowing us to subconsciously know where our limbs are in space.
The latter phases of rehab can be challenging as well for elite athletes. It takes a lot to regain elite speed, strength, agility, etc. At the NFL level, the difference between a starting running back and a practice squad player is very minute, making the last push in rehab so essential to regain one’s previous abilities fully. To be cleared to play, a series of tests must be passed, all comparing the surgical leg to the non-surgical leg. These include strength testing, balance testing, several single-leg hop tests, and the player demonstrating the ability to perform football-specific moves (route running, blitz pickups, etc.).
Every injury and subsequent recovery is unique to the individual. This is why it is impossible to perfectly predict a return to sports timelines. However, the research does identify several key factors that influence the prognosis for recovery from an ACL injury. I will go through these and apply how these factors line up with each fantasy-relevant player returning from an ACL injury this year.
Factors Influencing Recovery From ACL
Age
Age is highly influential on injuries and recovery. Anyone above 25-30 understands this; we just don’t heal as quickly anymore! Medical research often cites age 25 as the cutoff. Every year below 25 improves the prognosis for full recovery, and every year above makes a full recovery more challenging. This does not mean that a player over the age of 25 cannot make a full recovery; it is just more difficult.
Number of Tissues Involved
Number of Tissues Involved: This one is critical. Injury to additional structures other than just the ACL will prolong recovery. Let’s consider when the meniscus also needs to be repaired. With an isolated ACL tear, after surgery, there are no restrictions on weight bearing, meaning that as long as it is tolerable, the patient can put all of their weight on the surgical leg right away, there are no restrictions on weight bearing after surgery, meaning that as long as it is tolerable, the patient can put all. Additionally, with an isolated ACL tear, the patient can work toward restoring full range of motion at the knee right away, typically achieving full range by post-op weeks 3-5. When there is also a meniscus repair, they must protect the meniscus by not allowing full weight bearing until weeks 4-8. The delay in full weight bearing leads to rapid muscle atrophy (loss of size and strength), setting the athlete back several weeks.
Further, protection of the meniscus includes limiting the range of motion, often to 90° of flexion (bending) until week six post-op. When a joint is restricted from moving through its full range of motion, it becomes prone to stiffness. Stiffness can be challenging to regain fully and will impact athletic performance if full ROM is not achieved. When the PCL is also involved, the rate of regaining knee flexion is slower, again rendering one prone to stiffness. The athlete must avoid hamstring contractions for several weeks, leading to atrophy of the hamstring muscles. Adding an MCL or LCL injury similarly slows rehab quite a bit.
Time From Surgery to Week 1
Time From Surgery to Week 1: Every year, teams try to test the post-op timeline, pushing their players to play faster and faster after surgery. The medical research does not yet support this. At present, nine months is identified as the cutoff for a safe return to play. Returning in less than nine months significantly increases the risk of re-tear or the development of other injuries. Ideally, we want as much time as possible and definitely want more than nine months. It must be noted that the timeline does not start until the day of surgery, not the day of injury.
Baseline Athleticism
Baseline Athleticism: This one is not yet in the medical literature, but it makes sense. An athlete with a higher level of strength, speed, agility, and other athletic attributes before the injury, is more likely to recover enough to still be an elite athlete than someone who is less gifted athletically. Think about it, if you have 100 apples and lose 50, you start again at 50 apples. If you have 75 apples and lose 50, you start again at 25 apples. Some analysts will use combine data to distinguish who is a freak athlete, but the validity of this has not yet been confirmed in medical literature, to my knowledge. This metric is more subjective and opinion based at this time.
Now let’s break down how these factors apply to each player returning from ACL.
Kyler Murray
Age: 25: Neither positive nor negative factor.
Number of Tissues Involved: Isolated ACL tear, positive factor
Time From Surgery to Week One: 8 months 7 days, negative factor
Baseline Athleticism: Very gifted athletically, positive factor.
Javonte Williams
Age: 22, positive factor
Number of Tissues Involved: ACL and posterolateral corner (PCL + LCL + meniscus): Very much a negative factor
Time From Surgery to Week One: 48ish weeks: Positive factor
Baseline Athleticism: Very gifted athletically, positive factor
Breece Hall
Age: 21, positive factor
Number of Tissues Involved: ACL and meniscus (however unclear if the meniscus was repaired or not): Possibly a positive factor if the meniscus was not repaired. If the meniscus was repaired, this becomes a negative factor.
Time From Surgery to Week One: 46 weeks: Positive factor
Baseline Athleticism: Absolute beast! Positive factor
Sterling Shepard
Age: 30, negative factor
Number of Tissues Involved: Isolated ACL injury, positive factor
Time From Surgery to Week One: 10.5 months, neither positive nor negative factor
Baseline Athleticism: Talented but not especially gifted, negative factor
Wan’Dale Robinson
Age: 22, positive factor
Number of Tissues Involved: Isolated ACL injury, positive factor
Time From Surgery to Week One: 39 weeks, negative factor
Baseline Athleticism: Very talented but not a freak athlete: Negative factor
Odell Beckham Jr.
Age: 29, negative factor
Number of Tissues Involved: Isolated ACL injury, positive factor
Time From Surgery to Week One: 1.5 years, positive factor
Baseline Athleticism: Once was a freak athlete, many would argue he no longer is, negative factor
Tim Patrick
Age: 29, negative factor
Number of Tissues Involved: Isolated ACL injury, positive factor
Time From Surgery to Week One: >12 months: Positive factor
Baseline Athleticism: Talented but not a freak athlete: Negative factor
Jaylen Guyton
Age: 25, neither positive nor negative factor
Number of Tissues Involved: Isolated ACL injury, positive factor
Time From Surgery to Week One: 49 weeks, positive factor
Baseline Athleticism: Talented but not a freak athlete, negative factor
Zach Ertz
Age: 32, negative factor
Number of Tissues Involved: ACL and MCL, negative factor
Time From Surgery to Week One: 42 weeks, neither positive nor negative factor
Baseline Athleticism: Still talented but not a freak athlete anymore, negative factor
Conclusion
This information is helpful for fantasy football players to gauge appropriate expectations for each of these players. However, it is imperative to understand that humans are highly complex creatures, and recovery from major surgery has many paths. Some players will return from injury much faster than expected, whereas some much slower. We will continue to monitor the progress of each player’s recovery throughout the offseason and provide updated projections as OTA and camp reports become available.
Tom has been passionately playing fantasy football since he was 7 years old. Originally from Philadelphia, PA, Tom graduated from Coastal Carolina University with a B.S. in Exercise and Sports Science in 2014 and worked as a personal trainer for two years while earning his M.S. in Exercise and Sports Physiology at West Chester University of Pennsylvania in 2016. Next, he moved to Atlanta, GA, for physical therapy, earning his Doctorate of Physical Therapy at Mercer University in 2019. Over the past three years, Tom completed a physical therapy residency in orthopedics and passed his specialty examination to become a Board-Certified Orthopedic Clinical Specialist (OCS). He followed that up by enrolling in a two-year fellowship training in manual therapy which will conclude on July 1st, 2022. Tom works with a variety of patients with orthopedic conditions, including athletes from middle school to professional, of all sports, including football.