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National Football League Wide Receivers and Running Backs Have Decreased Production Following ACL Reconstruction: An Evaluation of Fantasy Football Performance as an Outcome Measure

Open AccessPublished:December 10, 2021DOI:https://doi.org/10.1016/j.asmr.2021.09.021

      Purpose

      To use fantasy football points as a simple measure alongside on-field statistics to compare performance in National Football League (NFL) offensive skill position players before and after anterior cruciate ligament (ACL) reconstruction.

      Methods

      A retrospective review of all NFL quarterbacks (QB), running backs (RB), wide receivers (WR), and tight ends (TE) who sustained an isolated, unilateral ACL injury from 1988 to 2017 was conducted. Data were collected from public data sources, team releases, NFL injury reports, press releases, and other Internet resources. For each player, a matched control with similar demographics was identified. Their in-game performance post-ACL reconstruction was analyzed using fantasy football points as an outcome measure.

      Results

      A total of 13 QBs, 30 RBs, and 29 WRs who underwent ACL reconstruction from 1988 to 2017 and who met inclusion criteria were retrospectively identified and reviewed. Of the 13 quarterbacks included in the study, there was no statistically significant difference in fantasy football points between the pre- and post-ACL reconstruction groups, as well as post-ACL and matched control groups. There was a statistically significant decrease in career fantasy football performance of running backs post-ACL reconstruction compared with matched control groups (129.6 vs 553.6; P < .0001). There was also a statistically significant decrease in per game fantasy football points post-ACL reconstruction (4.4 vs 11.2; P < .0001). Lastly, WRs also demonstrated a decrease in career fantasy football performance post-ACL reconstruction compared with matched controls (145.3 vs 460.9; P = .002). In addition, they also had a decrease in per game fantasy football performance (5.0 vs 7.7; P = .042).

      Conclusions

      Quarterbacks did not have a statistically significant decrease in performance following ACL reconstruction based on fantasy football performance. Conversely, both running backs and wide receivers had decreased per game and career performance post-ACL reconstruction based on their fantasy football statistics. Furthermore, RBs had the largest decline in production each season over a 3-year period following ACLR compared to QBs and WRs, respectively.

      Level of Evidence

      Level III, case-control study.

      Introduction

      Anterior cruciate ligament (ACL) injury is a common and devastating injury, particularly in contact sports like American football.
      • Schrock J.B.
      • Carver T.J.
      • Kraeutler M.J.
      • McCarty E.C.
      Evolving treatment patterns of NFL players by orthopaedic team physicians over the past decade, 2008-2016.
      • Carey J.L.
      • Huffman G.R.
      • Parekh S.G.
      • Sennett B.J.
      Outcomes of anterior cruciate ligament injuries to running backs and wide receivers in the National Football League.
      • Brophy R.H.
      • Lyman S.
      • Chehab E.L.
      • Barnes R.P.
      • Rodeo S.A.
      • Warren R.F.
      Predictive value of prior injury on career in professional American football is affected by player position.
      • Brophy R.H.
      • Gill C.S.
      • Lyman S.
      • Barnes R.P.
      • Rodeo S.A.
      • Warren R.F.
      Effect of anterior cruciate ligament reconstruction and meniscectomy on length of career in National Football League athletes.
      • Kluczynski M.A.
      • Kelly W.H.
      • Lashomb W.M.
      • Bisson L.J.
      A systematic review of the orthopaedic literature involving National Football League players.

      Rothenberg P, Grau L, Kaplan L, Baraga MG. Knee injuries in American football: An epidemiological review. Am J Orthop (Belle Mead NJ) 45:368-373. http://www.ncbi.nlm.nih.gov/pubmed/27737282.

      As a result, understanding the impact of anterior cruciate ligament reconstruction (ACLR) in American football athletes is crucial to counseling patients after this injury and improving outcomes. Results of previous studies suggest that ACLR leads to a significant decrease in level of performance and career longevity among National Football League (NFL) athletes.
      • Mai H.T.
      • Alvarez A.P.
      • Freshman R.D.
      • et al.
      The NFL orthopaedic surgery outcomes database (NO-SOD).
      ,
      • Burgess C.J.
      • Stapleton E.
      • Choy K.
      • Iturriaga C.
      • Cohn R.M.
      Decreased performance and return to play following anterior cruciate ligament reconstruction in National Football League wide receivers.
      Among NFL players, offensive skill position players have been shown to possess the highest risk of ACL injury.
      • Dodson C.C.
      • Secrist E.S.
      • Bhat S.B.
      • Woods D.P.
      • Deluca P.F.
      Anterior cruciate ligament injuries in National Football League athletes from 2010 to 2013.
      Additionally, many parameters and outcome measures have been used for evaluating performance after ACLR in this population, some of which include games played, games started, in-game statistics, and multiple efficiency ratios used to condense a player’s stats into individual numbers.
      • Carey J.L.
      • Huffman G.R.
      • Parekh S.G.
      • Sennett B.J.
      Outcomes of anterior cruciate ligament injuries to running backs and wide receivers in the National Football League.
      ,
      • Mai H.T.
      • Alvarez A.P.
      • Freshman R.D.
      • et al.
      The NFL orthopaedic surgery outcomes database (NO-SOD).
      ,
      • Cinque M.E.
      • Hannon C.P.
      • Bohl D.D.
      • et al.
      Return to sport and performance after anterior cruciate ligament reconstruction in National Football League linemen.
      • Erickson B.J.
      • Harris J.D.
      • Heninger J.R.
      • et al.
      Performance and return-to-sport after ACL reconstruction in NFL quarterbacks.
      • Read C.R.
      • Aune K.T.
      • Cain E.L.
      • Fleisig G.S.
      Return to play and decreased performance after anterior cruciate ligament reconstruction in National Football League defensive players.
      Despite many studies investigating this topic, a universal consensus to best compare a player’s performance following ACLR remains an area of debate.
      Fantasy sports is a game in which participants assemble virtual teams of real players in a professional sport and compete on the basis of the statistical performance of those players in actual games. It is estimated that ∼60 million people in North America participate in fantasy sports annually, making fantasy football performance a generalizable metric of on-field performance.
      FSGA
      Fantasy Sports & Gaming Association - Industry Demographics.
      Fantasy football points are a single numerical value used to assess a players’ performance. Each offensive player accumulates points based on their on-field statistics. Therefore, we believe that these fantasy football points are a generalizable way to concisely evaluate performance in NFL players, including pre- and post-ACLR. This metric is likely to be more readily understood by patients compared to the traditionally used patient-reported outcome measures.
      The purpose of this study is to use fantasy football points as a simple measure alongside on-field statistics to compare performance in NFL offensive skill position players pre- and post-ACLR. We hypothesize that the statistical performance based on fantasy football points of NFL offensive players will decrease after undergoing ACLR.

      Methods

      A retrospective review of all NFL quarterbacks (QB), running backs (RB), wide receivers (WR), and tight ends (TE), who sustained an isolated, unilateral ACL injury from 1988 to 2017 was conducted using public injury data, from team releases, NFL injury reports, press releases, and other internet resources.
      • Brophy R.H.
      • Gill C.S.
      • Lyman S.
      • Barnes R.P.
      • Rodeo S.A.
      • Warren R.F.
      Effect of anterior cruciate ligament reconstruction and meniscectomy on length of career in National Football League athletes.
      ,
      • Kluczynski M.A.
      • Kelly W.H.
      • Lashomb W.M.
      • Bisson L.J.
      A systematic review of the orthopaedic literature involving National Football League players.
      ,
      • Burgess C.J.
      • Stapleton E.
      • Choy K.
      • Iturriaga C.
      • Cohn R.M.
      Decreased performance and return to play following anterior cruciate ligament reconstruction in National Football League wide receivers.
      • Dodson C.C.
      • Secrist E.S.
      • Bhat S.B.
      • Woods D.P.
      • Deluca P.F.
      Anterior cruciate ligament injuries in National Football League athletes from 2010 to 2013.
      • Cinque M.E.
      • Hannon C.P.
      • Bohl D.D.
      • et al.
      Return to sport and performance after anterior cruciate ligament reconstruction in National Football League linemen.
      • Erickson B.J.
      • Harris J.D.
      • Heninger J.R.
      • et al.
      Performance and return-to-sport after ACL reconstruction in NFL quarterbacks.
      These data are available to the public; therefore, this study did not require approval from our institutional review board (IRB). Players who played at least three regular-season NFL games prior to their injury and at least three regular season NFL games after their injury were included in this analysis. Players with a prior ACL injury, concomitant ligamentous/meniscal injuries in the ipsilateral knee, or other reported concurrent injuries regardless of location were excluded from our analysis. Although regarded as an offensive skill position, tight ends were excluded from this study due to a small number of subjects for analysis.
      Demographic data, such as age, body mass index (BMI; kg/m2), date of injury (DOI), date of return to play (RTP), and NFL experience were collected. Performance variables pertaining to regular-season play for the three-position groups both prior and after the injury year were also collected. For QBs, the performance variables collected included games played, starts, completions, pass attempts, passing yards, touchdowns thrown, interceptions, rush attempts, rushing yards, and rush touchdowns. For RBs, the performance variables collected included games played, starts, rushing attempts, rushing yards, rushing touchdowns, receptions, receiving yards, receiving touchdowns, and time to return. For WRs, the performance variables collected included games played, starts, targets, receptions, catch percentage, receiving yards per reception, total receiving yards, touchdowns, yards per target, and time to return. These values were then converted to fantasy football points using the standard Entertainment and Sports Programming Network (ESPN) fantasy point system
      ESPN
      Fantasy Football Scoring.
      through the use of unbiased in-game statistics available on STATS.com and Pro-Football-Reference.com (Fig 1). Official NFL personnel collect all on-field statistics live, which are then reviewed and edited post-game to ensure the correct statistics are logged for each participating player. No underestimation or overestimation of fantasy points is possible, as they are solely dependent on the in-game statistics and performance of the player.
      Each QB, WR, and RB in the ACL injury cohort was matched to a player without a documented history of an ACL injury (control). Matching was based on the following parameters in decreasing order of importance: prior NFL seasons played, individual (non-average) performance statistics prior to index year, and BMI.
      • Brophy R.H.
      • Gill C.S.
      • Lyman S.
      • Barnes R.P.
      • Rodeo S.A.
      • Warren R.F.
      Effect of anterior cruciate ligament reconstruction and meniscectomy on length of career in National Football League athletes.
      ,
      • Kluczynski M.A.
      • Kelly W.H.
      • Lashomb W.M.
      • Bisson L.J.
      A systematic review of the orthopaedic literature involving National Football League players.
      ,
      • Mai H.T.
      • Alvarez A.P.
      • Freshman R.D.
      • et al.
      The NFL orthopaedic surgery outcomes database (NO-SOD).
      • Burgess C.J.
      • Stapleton E.
      • Choy K.
      • Iturriaga C.
      • Cohn R.M.
      Decreased performance and return to play following anterior cruciate ligament reconstruction in National Football League wide receivers.
      • Dodson C.C.
      • Secrist E.S.
      • Bhat S.B.
      • Woods D.P.
      • Deluca P.F.
      Anterior cruciate ligament injuries in National Football League athletes from 2010 to 2013.
      • Cinque M.E.
      • Hannon C.P.
      • Bohl D.D.
      • et al.
      Return to sport and performance after anterior cruciate ligament reconstruction in National Football League linemen.
      Index year was defined as a certain time point for each control that was analogous to the time at which an ACL injury occurred in the injury cohort. For example, if a player suffered an ACL injury 2 years into his NFL career, the index year for the control would be two years into the control athlete’s career. The same demographic and performance variables were collected for both cohorts, and mean performance over time was calculated.
      Mean performance values preinjury and preindex year were compared for each position group as were the postinjury and postindex year mean performance values. Preinjury and postinjury mean performance values were compared for each position group in both cohorts. Lastly, mean performance values were compared between both cohorts for each of the first three seasons following injury or index year for each position group, respectively.

      Statistical Analysis

      All data were organized and collected on Excel software (Microsoft Corporation, Richmond, WA). Continuous variables were evaluated and represented as means ± SD. Independent-sample, two-sided t-tests were used to test for significant differences. All statistical analyses and calculations were performed using SPSS v25 (IBM Corporation, Armonk, New York). A P value of less than .05 was used to determine the statistical significance of a finding. In addition, a post hoc power analysis was performed using G∗Power (version 3.1.9.7) to ensure adequate statistical power (≥80%) was achieved to fully elucidate significant findings.

      Results

      A total of 13 QBs, 30 RBs, and 29 WRs were identified as having an isolated, unilateral ACL tear between 1988 and 2017, having previously played at least three regular-season NFL games prior to their injury and went on to play at least three regular-season NFL games following their injury. A post hoc power analysis confirmed that all findings were sufficiently powered to show actual statistical differences between the cohorts.

      Quarterbacks

      QBs within the injury cohort had similar demographics when compared to controls. There was no significant difference in QB performance between the injury cohort and controls prior to ACL injury or index year (Table 1). Following ACLR, QBs showed no statistically significant change in fantasy points or in performance variables except for NFL experience (P = .016) (Table 2). While QBs showed decreased on-field performance and fantasy football points in the index year post-ACLR, there were no significant differences in any performance variables between the QBs in the injury cohort following ACLR (Table 3). No performance variable was statistically different between the two groups in the 2nd and 3rd seasons, respectively (Table 4).
      Table 1QB Pre-ACL Reconstruction in Cases Versus Preindex Year in Controls
      CaseControlP Value
      Age27.23 ± 2.3925.46 ± 2.96.11
      BMI27.36 ± 1.4127.42 ± 1.34.92
      NFL Experience3.19 ± 2.713.19 ± 2.711.0
      Games Played35.69 ± 45.2039.54 ± 34.24.81
      Games Played per seasons8.49 ± 4.9311.90 ± 3.54.054
      Starts30.92 ± 38.1334.69 ± 27.63.78
      Completions597.61 ± 789.77641.54 ± 541.77.87
      Attempts987.69 ± 1276.981,110.07 ± 906.07.78
      Passing yards6,873.31 ± 9,072.087,404.08 ± 6,422.46.87
      Touchdowns46.62 ± 65.4843.46 ± 40.58.88
      Interceptions27.15 ± 31.4235.54 ± 26.62.47
      Rush attempts92.85 ± 137.4799.08 ± 101.52.90
      Rushing yards352.92 ± 738.95367.54 ± 738.95.95
      Rushing touchdowns3.15 ± 6.543.23 ± 4.28.97
      Fantasy points passing yards274.93 ± 362.88296.16 ± 256.90.87
      Fantasy points passing TD186.46 ± 261.93173.85 ± 162.34.88
      Fantasy points interceptions (Negative)54.31 ± 62.8471.08 ± 53.24.47
      Fantasy points rushing yards35.29 ± 73.9036.75 ± 45.57.95
      Fantasy points rushing TD18.92 ± 39.2619.38 ± 25.71.97
      Total fantasy points461.30 ± 645.93455.07 ± 415.32.98
      ACL, anterior cruciate ligament; BMI, body mass index; NFL, National Football League; QB, quarterback; TD, touchdowns.
      Table 2QB Pre-ACL Reconstruction Versus Post-ACL Reconstruction in Cases
      BeforeAfterP Value
      NFL experience3.19 ± 2.716.23 ± 3.27.016
      Games played35.69 ± 45.2058.00 ± 47.68.23
      Games played per seasons8.49 ± 4.938.30 ± 3.74.91
      Starts30.92 ± 38.1342.69 ± 54.41.53
      Completions597.62 ± 789.77940.38 ± 1,223.36.40
      Attempts987.69± 1,276.981,526.08 ± 1,922.55.41
      Passing yards6,873.31 ± 9,072.0811,191.46 ± 14,671.23.38
      Touchdowns46.62 ± 65.4868.08 ± 99.72.52
      Interceptions27.15 ± 31.4240.46 ± 45.10.39
      Rush attempts92.85 ± 137.4787.00 ± 101.46.90
      Rushing yards352.92 ± 738.95205.15 ± 289.19.51
      Rushing touchdowns3.15 ± 6.542.54 ± 4.14.78
      Fantasy points passing Yards274.93 ± 362.88447.66 ± 586.85.38
      Fantasy points passing TD186.46 ± 261.93272.31 ± 398.86.52
      Fantasy points interceptions (Negative)54.31 ± 62.8480.92 ± 90.21.39
      Fantasy points rushing yards35.29 ± 73.9020.51 ± 28.92.51
      Fantasy points rushing TD18.92 ± 39.2615.23 ± 24.81.78
      Total fantasy points461.30 ± 645.93674.79 ± 949.23.51
      Bold value is statistically significant P < .05.
      NFL, National Football League; TD, touchdowns.
      Table 3QB Post-ACL reconstruction in Cases Versus Postindex Year in Controls
      After-ACLPost-Index YearP Value
      NFL Experience6.23 ± 3.278.54 ± 5.15.19
      Games Played58.00 ± 47.6895.69 ± 77.96.15
      Games Played per seasons8.30 ± 3.749.29 ± 4.54.55
      Starts42.69 ± 54.4187.15 ± 79.58.11
      Completions940.38 ± 1,223.361,718.77 ± 1,623.89.18
      Attempts1,526.08 ± 1,922.552,910.77 ± 2,700.94.15
      Passing Yards11,191.46 ± 14,671.2320,002.54 ± 19,129.84.20
      Touchdowns68.08 ± 99.7211,792 ± 121.07.26
      Interceptions40.46 ± 45.1092.15 ± 87.62.071
      Rush Attempts87.00 ± 101.46166.15 ± 289.19.085
      Rushing Yards205.15 ± 289.19476.85 ± 413.40.064
      Rushing Touchdowns2.54 ± 4.144.62 ± 4.00.20
      Fantasy Points Passing Yards447.66 ± 586.85800.10 ± 765.19.20
      Fantasy Points Passing TD272.31 ± 398.86471.69 ± 484.28.26
      Fantasy Points Interceptions (Negative)80.92 ± 90.21184.31 ± 175.24.071
      Fantasy Points Rushing Yards20.52 ± 28.9247.68 ± 41.34.064
      Fantasy points rushing TD15.23 ± 24.8227.69 ± 23.82.20
      Total fantasy points674.79 ± 949.231,162.86 ± 1,116.13.24
      Table 4QB Cases Versus Controls: Year One to Year Three
      CaseControlP Value
      1st Season passing yards1,406.92 ± 1,569.912,371.00 ± 1,211.06.10
      1st Passing yards FP56.28 ± 62.8094.88 ± 48.44.10
      1st Interceptions FP (negative)10.61 ± 11.0623.67 ± 18.01.038
      1st Passing TD32.92 ± 41.1250.33 ± 28.15.23
      1st Rushing yards395 ± 6.877.25 ± 6.14.22
      1st Rushing TD0.92 ± 2.254.00 ± 3.91.023
      1st Total FP83.45 ± 98.87132. ± 69.07.17
      2nd Season passing yards1,580.67 ± 1,666.762,391.42 ± 1,379.25.21
      2nd Passing yards FP63.23 ± 66.6795.66 ± 55.13.21
      2nd Interceptions FP (negative)14.17 ± 16.5522.50 ± 13.70.19
      2nd Passing TD41.33 ± 47.8658.33 ± 40.84.36
      2nd Rushing yards3.49 ± 5.667.91 ± 8.53.15
      2nd Rushing TD1.50 ± 3.732.00 ± 3.91.75
      2nd Total FP95.39 ± 108.02141.40 ± 86.35.26
      3rd Season passing yards2,006.90 ± 1,769.951,906.92 ± 1,510.96.89
      3rd Passing yards FP80.28 ± 70.8076.28 ± 60.44.89
      3rd Interceptions FP (negative)15.00 ± 10.0321.33 ± 17.21.32
      3rd Passing TD52.00 ± 52.6350.37 ± 44.39.95
      3rd Rushing yards5.94 ± 7.908.45 ± 7.98.47
      3rd Rushing TD5.40 ± 7.722.50 ± 4.01.30
      3rd Total FP128.62 ± 128.04116.56 ± 90.49.80
      Bold values are statistically significant P < .05.
      FP, fantasy points; QB, quarterback; TD, touchdowns.

      Running Backs

      RBs in the injury and control cohorts had similar demographic information. Differences in fantasy football points and on-field statistics between the two groups are listed in Table 5. Following ACLR, RBs had a significant decrease in fantasy points and all performance variables (Table 6).
      Table 5RB Pre-ACL Reconstruction in Cases Versus Preindex Year in Controls
      CaseControlP Value
      Age22.47 ± 0.8622.23 ± 1.01.34
      BMI30.09 ± 1.4830.74 ± 2.00.16
      NFL experience4.03 ± 2.614.03 ± 2.611.00
      Games played53.17 ± 39.1956.17 ± 37.77.76
      Games played per seasons12.77 ± 3.2413.70 ± 2.06.19
      Rush attempts461.73 ± 413.42837.10 ± 711.19.015
      Rush attempts per game8.49 ± 5.9614.34 ± 5.01<.0001
      Rushing yards2,025.73 ± 1,959.443,670.20 ± 3,161.64.019
      Rushing yards per attempt4.24 ± 0.594.33 ± .43.49
      Rushing yards per game36.48 ± 26.9561.51 ± 21.01<.0001
      Rushing yards per season487.05 ± 370.53845.73 ± 324.48<.0001
      Rushing touchdowns14.13 ± 15.3626.17 ± 23.55.023
      Receptions109.10 ± 128.34123.63 ± 105.99.63
      Receiving yards938.60 ± 1120.13967.13 ± 787.80.91
      Receiving touchdowns4.17 ± 7.143.17 ± 3.39.49
      Fantasy points rushing yards202.57 ± 195.94367.02 ± 316.16.019
      Fantasy points touchdowns84.80 ± 92.17157.00 ± 141.29.023
      Fantasy points receptions109.10 ± 128.34123.63 ± 105.99.63
      Fantasy points receiving yards93.71 ± 78.7896.71 ± 78.78.91
      Fantasy points receiving touchdowns25.00 ± 42.8719.00 ± 20.37.49
      Fantasy points total points515.33 ± 500.53763.37 ± 638.08.099
      Points per game8.53 ± 5.3313.31 ± 4.69.001
      Points per season113.50 ± 75.83182.28 ± 72.18.001
      Bold values are statistically significant P < .05.
      ACL, anterior cruciate ligament; BMI, body mass index; NFL, National Football League; RB, running back.
      Table 6RB Pre-ACL Reconstruction Versus Post-ACL Reconstruction in Cases
      BeforeAfterP Value
      NFL experience4.03 ± 2.611.77 ± 2.06<.0001
      Games played53.17 ± 39.1918.03 ± 27.12<.0001
      Games played per seasons12.77 ± 3.246.51 ± 5.57<.0001
      Starts21.50 ± 21.918.33 ± 17.68.013
      Rush attempts461.73 ± 413.42132.37 ± 286.55.001
      Rush attempts per game8.49 ± 5.964.08 ± 4.79.002
      Rushing yards2,025.73 ± 1,959.44553.00 ± 1,291.30.001
      Rushing yards per attempt4.24 ± 0.592.44 ± 1.84<.0001
      Rushing yards per game36.48 ± 26.9516.19 ± 20.71.002
      Rushing touchdowns14.13 ± 15.36170.54 ± 240.65.001
      Receptions109.10 ± 128.3426.43 ± 38.86.001
      Receiving yards938.60 ± 1,120.13191.67 ± 281.13.001
      Receiving touchdowns4.17 ± 7.140.83 ± 1.29.015
      Fantasy points rushing yards202.57 ± 195.9455.30 ± 129.130.001
      Fantasy points touchdowns84.80 ± 92.1723.80 ± 52.250.003
      Fantasy points receptions109.10 ± 128.3426.43 ± 38.860.001
      Fantasy points receiving yards93.71 ± 78.7819.16 ± 28.110.001
      Fantasy points receiving touchdowns25.00 ± 42.875.00 ± 7.730.015
      Fantasy points total points515.33 ± 500.53129.60 ± 242.89<0.0001
      Points per game8.53 ± 5.334.43 ± 4.730.003
      Points per season113.50 ± 75.8345.70 ± 53.29<0.0001
      Bold values are statistically significant P < .05.
      ACL, anterior cruciate ligament; NFL, National Football League; RB, running back.
      RBs had significantly worse performance and fewer fantasy points after ACLR compared to controls post-index year (Table 7). In the 1st seasons after ACLR, RBs had significantly decreased rushing yards (P < .001), receptions (P = .013), receiving yards (P = .009), touchdowns (P < .001) and total fantasy points (P < .001) compared to controls. The 2nd season after ACLR, RBs did not statistically differ compared to controls. However, during the 3rd season after ACLR, RBs had significantly decreased rushing yards (P = .006), touchdowns (P = .018), and total fantasy points (P = .032) compared with controls (Table 8).
      Table 7RB Post-ACL Reconstruction in Cases Versus Postindex Year in Controls
      After ACLPostindex YearP Value
      NFL experience1.77 ± 2.063.50 ± 1.88.001
      Games played1.77 ± 2.0644.70 ± 26.42<.0001
      Games played per seasons6.51 ± 5.5712.37 ± 3.00<.0001
      Rush attempts132.37 ± 286.55615.93 ± 447.44<.0001
      Rush attempts per game4.08 ± 4.7912.97 ± 3.93<.0001
      Rushing yards553.00 ± 1,291.302,500.43 ± 1,932.18<.0001
      Rushing yards per attempt2.44 ± 1.843.88 ± 0.46<.0001
      Rushing yards per game16.19 ± 20.7151.15 ± 18.86<.0001
      Rushing touchdowns170.54 ± 240.6517.77 ± 16.10.001
      Receptions26.43 ± 38.86101.43 ± 84.89<.0001
      Receiving yards191.67 ± 281.13789.47 ± 787.22<.0001
      Receiving touchdowns0.83 ± 1.292.77 ± 3.49.006
      Fantasy points rushing yards55.30 ± 129.13250.04 ± 193.22<.0001
      Fantasy points touchdowns23.80 ± 52.25106.60 ± 96.63<.0001
      Fantasy points receptions26.43 ± 38.86101.43 ± 94.89<.0001
      Fantasy points receiving yards19.16 ± 28.1178.95 ± 7872<.0001
      Fantasy points receiving touchdowns5.00 ± 7.7316.60 ± 20.94.006
      Fantasy points total points129.60 ± 242.89553.62 ± 446.20<.0001
      Points per game4.43 ± 4.7311.18 ± 4.89<.0001
      Points per season45.70 ± 53.29142.25 ± 74.34<.0001
      Bold values are statistically significant P < .05.
      ACL, anterior cruciate ligament; NFL, National Football League; RB, running back.
      Table 8RB Cases Versus Controls: Year One to Year Three
      CaseControlP Value
      1st season rushing28.37 ± 46.7080.04 ± 41.11<.0001
      1st reception15.00 ± 14.2328.67 ± 2150.013
      1st receiving11.29 ± 10.8222.77 ± 17.32.009
      1st TD fantasy points14.73 ± 20.9342.40 ± 29.22<.0001
      1st total fantasy points69.38 ± 84.28173.87 ± 92.42<.0001
      2nd season rushing45.00 ± 40.3272.50 ± 41.42.70
      2nd reception19.00 ± 11.4332.93 ± 23.26.068
      2nd receiving13.75 ± 7.7026.19 ± 20.21.056
      2nd TD fantasy points29.72 ± 24.1734.22 ± 27.94.57
      2nd Total FP106.47 ± 76.29159.91 ± 104.88.091
      3rd rushing22.83 ± 28.2072.16 ± 40.24.006
      3rd reception15.86 ± 22.1527.60 ± 20.62.21
      3rd receiving10.86 ± 15.4321.29 ± 16.30.15
      3rd TD fantasy points8.57 ± 10.8836.60 ± 28.27.018
      3rd Total FP58.11 ± 71.87150.14 ± 98.78.032
      Bold values are statistically significant P < .05.
      FP, fantasy points; RB, running back; TD, touchdowns.

      Wide Receivers

      WRs preinjury did not statistically differ in age, BMI, NFL experience, all performance variables, and fantasy points compared with preindex year controls (Table 9). Following ACLR, WRs had a significant decrease in NFL experience, statistical performance, and fantasy football points (Table 10).
      Table 9WR Pre-ACL Reconstruction in Cases Versus Preindex Year in Controls
      CaseControlP Value
      Age25.90 ± 3.1125.43 ± 3.20.58
      BMI26.71 ± 1.5526.61 ± 1.23.10
      NFL experience3.52 ± 3.183.52 ± 3.181.00
      Games played45.66 ± 46.6546.59 ± 45.80.94
      Games played per seasons11.62 ± 4.0911.70 ± 4.76.95
      Targets254.69 ± 354.99303.21 ± 409.52.63
      Targets per game4.18 ± 2.614.82 ± 3.02.39
      Reception150.24 ± 217.10180.21 ± 243.42.62
      Reception per game2.41 ± 1.612.79 ± 1.84.41
      Catch%52.38 ± 17.5650.37 ± 19.13.68
      Receiving2055.86 ± 3049.292,438.76 ± 3,333.74.65
      Yards per reception13.13 ± 6.3012.27 ± 5.11.57
      Rec yards per game32.21 ± 21.4837.93 ± 25.66.36
      Rec yards per season425.14 ± 320.67527.17 ± 374.50.27
      Touchdowns13.14 ± 19.3316.62 ± 22.58.53
      Yards per target7.31 ± 3.206.84 ± 2.92.56
      Fantasy points receiving yards205.59 ± 304.93243.88 ± 333.37.65
      Fantasy points touchdowns78.83 ± 116.0099.72 ± 135.47.53
      Fantasy points receptions150.24 ± 217.10180.21 ± 243.42.62
      Fantasy points total points434.66 ± 634.65523.81 ± 709.02.62
      Points per game6.87 ± 4.658.17 ± 5.56.34
      Points per season90.75 ± 69.50113.856 ± 81.56.25
      ACL, anterior cruciate ligament; BMI, body mass index; NFL, National Football League; WR, wide receiver.
      Table 10WR Pre-ACL Reconstruction Versus Post-ACL Reconstruction in Cases
      BeforeAfterP Value
      NFL experience3.52 ± 3.181.59 ± 1.38.004
      Games played45.66 ± 46.6517.59 ± 20.02.004
      Games played per seasons11.62 ± 4.097.38 ± 6.28.004
      Starts28.59 ± 40.5211.00 ± 15.28.033
      Targets254.69 ± 354.9986.38 ± 121.70.20
      Targets per game4.18 ± 2.613.01 ± 3.10.13
      Reception150.24 ± 217.1051.34 ± 74.00.24
      Reception per game2.41 ± 1.611.83 ± 2.00.23
      Catch%52.38 ± 17.5640.08 ± 29.48.059
      Receiving2,055.86 ± 3,049.29681.31 ± 983.46.025
      Yards per reception13.13 ± 6.309.73 ± 7.32.063
      Rec yards per game32.21 ± 21.4823.21 ± 24.44.14
      Rec yards per season425.14 ± 320.67287.91 ± 363.13.13
      Touchdowns13.14 ± 19.334.31 ± 6.84.024
      Yards per target7.31 ± 3.205.41 ± 3.87.047
      Fantasy points receiving yards205.59 ± 304.9368.13 ± 98.35.025
      Fantasy points touchdowns78.83 ± 116.0025.86 ± 41.01.024
      Fantasy points receptions150.24 ± 217.1051.34 ± 73.98.024
      Fantasy points total points434.66 ± 634.65145.34 ± 211.55.023
      Points per game6.87 ± 4.654.97 ± 5.30.15
      Points per season90.75 ± 69.5061.51 ± 77.64.14
      Bold values are statistically significant P < .05.
      ACL, anterior cruciate ligament; NFL, National Football League; WR, wide receiver.
      Following ACLR, WRs had significantly decreased performance compared to postindex year controls with regard to NFL experience (P < .001), number of games played (P < .001), games played per season (P = .007), targets (P < .001), targets per game (P = .036), receptions (P = .002), receiving yards (P = .002), receiving yards per game (P = .042), receiving yards per season (P = .046), touchdowns (P = .003), and fantasy points in all areas (Table 11). However, when analyzing the first three seasons post-ACLR and post-index year, there were no significant performance or fantasy point differences between WRs who underwent ACLR and the controls (Table 12).
      Table 11WR Post-ACL reconstruction in Cases Versus Postindex Year in Controls
      After ACLAfter Index YearP Value
      NFL experience1.59 ± 1.383.76 ± 2.38<.0001
      Games played17.59 ± 20.0250.21 ± 37.34<.0001
      Games played per seasons7.38 ± 6.2811.52 ± 4.82.007
      Targets86.38 ± 121.70284.62 ± 286.49.001
      Targets per game3.01 ± 3.104.64 ± 2.67.036
      Reception51.34 ± 74.00165.59 ± 172.36.002
      Reception per game1.83 ± 2.002.71 ± 1.61.070
      Catch%40.08 ± 29.4852.49 ± 19.84.065
      Receiving681.31 ± 983.462,139.76 ± 2,144.00.002
      Yards per reception9.73 ± 7.3211.86 ± 4.47.19
      Rec yards per game23.21 ± 24.4435.92 ± 21.98.042
      Rec yards per season287.91 ± 363.13471.43 ± 321.25.046
      Touchdowns4.31 ± 6.8413.55 ± 14.41.003
      Yards per target5.41 ± 3.876.86 ± 2.56.098
      Fantasy points receiving yards68.13 ± 98.35213.98 ± 214.40.002
      Fantasy points touchdowns25.86 ± 41.0181.31 ± 86.47.003
      Fantasy points receptions51.34 ± 73.98165.59 ± 172.36.002
      Fantasy points total points145.34 ± 211.55460.87 ± 466.75.002
      Points per game4.97 ± 5.307.71 ± 4.72.042
      Points per season61.51 ± 77.64101.04 ± 68.49.044
      Bold values are statistically significant P < .05.
      ACL, anterior cruciate ligament; NFL, National Football League; WR, wide receiver.
      Table 12WR Cases Versus Controls: Year One to Year Three
      CaseControlP Value
      1st reception34.55 ± 34.7039.59 ± 25.58.56
      1st receiving47.29 ± 47.2057.13 ± 38.49.45
      1st TD fantasy points18.30 ± 23.1521.52 ± 19.61.61
      1st total fantasy points100.14 ± 102.65118.23 ± 78.30.51
      2nd reception32.21 ± 32.8738.37 ± 27.13.55
      2nd receiving40.69 ± 41.5249.69 ± 36.72.50
      2nd TD fantasy points16.71 ± 16.5018.44 ± 22.75.80
      2nd Total FP89.62 ± 88.55106.51 ± 82.85.56
      3rd reception35.14 ± 20.1638.95 ± 24.15.76
      3rd receiving47.30 ± 26.4648.48 ± 30.62.92
      3rd TD fantasy points13.71 ± 13.2921.79 ± 16.64.22
      3rd Total FP96.16 ± 57.43108.33 ± 67.94.66
      FP, fantasy points; TD, touchdowns; WR. Wide receiver.

      Discussion

      The results of our study show that while QBs achieved statistically equivalent on-field performance following ACLR compared to their preinjury state, as well as the postindex year control group, RBs and WRs had a significant statistical decrease in production following ACLR compared to their preinjury state, as well as the postindex year control group, respectively. This difference can be appreciated in fantasy football point decreases seen in both the RB and WR groups on a per game basis, as well as for the duration of their career (Table 13). An ACL rupture is a major injury for any individual, but it can be potentially devastating and career-altering for many high-level NFL athletes.
      • Mai H.T.
      • Alvarez A.P.
      • Freshman R.D.
      • et al.
      The NFL orthopaedic surgery outcomes database (NO-SOD).
      Between 21% and 37% of NFL athletes who suffer an ACL injury never appear in another NFL game.
      • Carey J.L.
      • Huffman G.R.
      • Parekh S.G.
      • Sennett B.J.
      Outcomes of anterior cruciate ligament injuries to running backs and wide receivers in the National Football League.
      ,
      • Meredith S.J.
      • Rauer T.
      • Chmielewski T.L.
      • et al.
      Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group.
      Those who do RTP have been shown to perform at a lower level on average than they did before injury.
      • Carey J.L.
      • Huffman G.R.
      • Parekh S.G.
      • Sennett B.J.
      Outcomes of anterior cruciate ligament injuries to running backs and wide receivers in the National Football League.
      The physical demands imposed on NFL athletes predispose them to greater injury risk in comparison to the general population. A previous analysis of relative injury risk for each position demonstrated that certain skill position players, specifically WRs, tight ends, linebackers, RBs, and fullbacks, face a significantly greater ACL injury risk than the rest of the NFL between the 2010 and 2013 NFL seasons.
      • Dodson C.C.
      • Secrist E.S.
      • Bhat S.B.
      • Woods D.P.
      • Deluca P.F.
      Anterior cruciate ligament injuries in National Football League athletes from 2010 to 2013.
      However, despite the increased risk and consequences related to ACL injuries for these elite athletes, the utility of fantasy football points as a simple outcome measure to compare performance in NFL offensive skill position players pre- and post-ACLR remains unknown.
      Table 13Fantasy Football Points Post-ACL Reconstruction Versus Postindex Year
      Per GameCareer
      PositionPost-ACLRPostindexP ValuePost-ACLRPostindexP Value
      Quarterbacks7.7 ± 6.410.1 ± 4.0.34674.8 ± 949.21,162.9 ± 1,116.1.24
      Running Backs4.4 ± 4.711.2 ± 4.9<.0001129.6 ± 242.9553.6 ± 446.2<.0001
      Wide Receivers5.0 ± 5.37.7 ± 4.7.042145.3 ± 211.5460.9 ± 466.8.002
      Bold values are statistically significant P < .05.
      Values are expressed as means ± SD.
      Although it is not yet widely accepted in the medical community, we believe that fantasy football data are a true objective way to measure performance in high-level professional athletes following an injury. It allows comparison of quantitative measures to determine whether an athlete can truly return to the same level of on-field performance following a major injury, such as an ACL tear. Additionally, fantasy football points are a recognized metric by athletes, as well as the general population. Therefore, the advantage of this study is that it allows the average American to easily discern the impact of ACLR versus traditional patient-reported outcome measures. In addition, traditional patient-reported outcome measures may be limited in their generalizability due to a ceiling effect in high-level professional athletes. Further research is warranted to better understand whether fantasy football points are a reliable metric of postinjury performance and correlates with traditional patient-reported outcome measures.
      A recent study by Provencher et al.
      • Provencher M.T.
      • Chahla J.
      • Cinque M.E.
      • et al.
      Symptomatic focal knee chondral injuries in National Football League combine players are associated with poorer performance and less volume of play.
      investigated the presence of symptomatic focal knee chondral injuries in NFL combine players using fantasy football points as one of their outcome measures. Although their study did not evaluate ACLR, the results were similar to our findings, as RBs and WRs with previously untreated knee chondral injuries were the only offensive players with significantly lower fantasy scores when compared with position-matched controls.
      • Provencher M.T.
      • Chahla J.
      • Cinque M.E.
      • et al.
      Symptomatic focal knee chondral injuries in National Football League combine players are associated with poorer performance and less volume of play.
      QBs achieved statistically similar fantasy scores as the control group. Carey et al.
      • Carey J.L.
      • Huffman G.R.
      • Parekh S.G.
      • Sennett B.J.
      Outcomes of anterior cruciate ligament injuries to running backs and wide receivers in the National Football League.
      found that player performance in NFL RBs and WRs who sustained an ACL tear was reduced by one-third and that more than 1 in 5 players never returned to an NFL game after this injury. Contrarily, a study published in 2021 by Manoharan et al.
      • Manoharan A.
      • Barton D.
      • Khwaja A.
      • Latt L.D.
      Return to play rates in NFL wide receivers and running backs after ACL reconstruction: An updated analysis.
      found that although 61.8% of players (64.5% of RBs, 60% of WRs) returned to play at a mean of 13.6 months following ACLR, RBs had an insignificant drop in production. However, WRs who successfully returned to play demonstrated significantly decreased receiving yards, receptions per game, and receiving touchdowns per season when compared with the control group. This was validated by our findings in a prior study, which showed that WRs had a significant decrease in targets, receptions, receiving yards, and touchdowns along with playing 1.9 seasons fewer and fewer than half the number of games after undergoing ACLR compared with their postindex year-matched controls.
      • Burgess C.J.
      • Stapleton E.
      • Choy K.
      • Iturriaga C.
      • Cohn R.M.
      Decreased performance and return to play following anterior cruciate ligament reconstruction in National Football League wide receivers.
      While this study does not evaluate the percentage of players who return to competition following an ACL injury, our findings align with the aforementioned studies with regard to the decreased production of RBs and WRs following ACLR compared with their preinjury on-field production as well as postindex year players who did not suffer such an injury. Therefore, evaluating athletes’ performance by the position they play is important because of the different demands placed on athletes based on the various on-field positions. Possible factors that may have allowed return to professional play, but at a less productive level, can likely be attributed to persisting knee pain, stiffness, loss of strength, deconditioning, reduced proprioception, and fear of reinjury.
      With regard to QB play, Erickson et al.
      • Erickson B.J.
      • Harris J.D.
      • Heninger J.R.
      • et al.
      Performance and return-to-sport after ACL reconstruction in NFL quarterbacks.
      conducted a study that analyzed the performance and return-to-sport after ACLR and found that there was also no significant in-game performance difference between preinjury play and control QBs (index year) following ACLR. Other studies have also found no performance differences between QBs who have native or reconstructed ACLs.
      • Brophy R.H.
      • Lyman S.
      • Chehab E.L.
      • Barnes R.P.
      • Rodeo S.A.
      • Warren R.F.
      Predictive value of prior injury on career in professional American football is affected by player position.
      ,
      • Brophy R.H.
      • Gill C.S.
      • Lyman S.
      • Barnes R.P.
      • Rodeo S.A.
      • Warren R.F.
      Effect of anterior cruciate ligament reconstruction and meniscectomy on length of career in National Football League athletes.
      ,
      • Shah V.M.
      • Andrews J.R.
      • Fleisig G.S.
      • McMichael C.S.
      • Lemak L.J.
      Return to play after anterior cruciate ligament reconstruction in National Football League athletes.
      Our results largely coincide with this finding; however, QBs in our study who underwent ACLR recorded fewer interceptions and rushing touchdowns during their 1st season upon return-to-sport but were statistically similar 2nd and 3rd year in comparison to the index year controls. A possible reason for these findings in QBs may be due to the difference in physical demands of the position compared to the RB and WR position groups. RBs and WRs are more likely to jump, pivot, and cut over the course of live game play, which may be why these position groups saw a decline in production following ACLR. Multiple factors affect the ability to perform in an elite capacity after ACLR, including previous physical conditioning and access to optimal rehabilitation after undergoing surgery.
      • Shah V.M.
      • Andrews J.R.
      • Fleisig G.S.
      • McMichael C.S.
      • Lemak L.J.
      Return to play after anterior cruciate ligament reconstruction in National Football League athletes.
      Contrary to the present study, Keller et al.
      • Keller R.A.
      • Mehran N.
      • Austin W.
      • Marshall N.E.
      • Bastin K.
      • Moutzouros V.
      Athletic performance at the NFL scouting combine after anterior cruciate ligament reconstruction.
      suggest that high-caliber athletes who participated in the NFL scouting combine between 2010 and 2014 can achieve equivalent levels of performance with no statistically significant differences in 40-yard dash time, vertical leap, broad jump, shuttle drill, and 3-cone drill compared with matched controls. While these metrics may be similarly achieved in NFL skill position players post-ACLR compared with their pre-injury state; however, they do not necessarily translate to similar on-field production as our findings suggest.

      Limitations

      This study is not without limitations. This includes a retrospective study design, the relatively small sample size, and the use of the fantasy football points as a nonvalidated performance metric. Furthermore, it is difficult to truly identify a control group while equalizing “talent” and “skill,” which partially determine productivity and objective outcomes of these NFL athletes. Since our data were based solely on public information available on the internet, we could not account for the differing techniques for ACLR. However, multiple previous studies have cited that the vast majority of NFL players who sustain an ACL tear undergo arthroscopically assisted single-bundle bone-patellar tendon-bone reconstruction.
      • Schrock J.B.
      • Carver T.J.
      • Kraeutler M.J.
      • McCarty E.C.
      Evolving treatment patterns of NFL players by orthopaedic team physicians over the past decade, 2008-2016.
      ,
      • Erickson B.J.
      • Harris J.D.
      • Fillingham Y.A.
      • et al.
      Anterior cruciate ligament reconstruction practice patterns by NFL and NCAA Football Team physicians.
      ,
      • Bradley J.P.
      • Klimkiewicz J.J.
      • Rytel M.J.
      • Powell J.W.
      Anterior cruciate ligament injuries in the National Football League.
      Thus, regardless of the possible variables in graft choice, surgical technique, and surgeon experience, it is likely that the majority of the athletes whom we reviewed had similar ACLR techniques and graft choices. Validated outcome scores evaluating high-level sports performance are still lacking; therefore, the performance measure used in this study may not truly reflect the actual on-field impact of the player. However, an advantage of using fantasy football points as an outcome tool is the consistent follow-up since the statistical data are documented annually and widely available to the public. Another limitation of our methodology is that injured players have already played a portion of their careers, and thus, the fewer number of games played after surgery may be due to the natural process of players nearing the end of their careers and not due to inferiority of their reconstructed knees. Despite these limitations, the present study suggests that RBs and WRs have a significantly decreased performance output upon returning from ACLR in comparison to their preinjury status, as well as postindex year counterparts, who did not suffer an ACL injury.

      Conclusion

      QBs did not have a statistically significant decrease in performance following ACL reconstruction based on fantasy football performance. Conversely, both running backs and wide receivers had decreased per game and career performance post-ACL reconstruction based on their fantasy football statistics.

      Supplementary Data

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