What challenges will Nick Bosa face coming back from ACL injury?

The San Francisco 49ers’ defense was missing a finisher for most of the 2020 season. Defensive lineman Nick Bosa tore his ACL early in the Week 2 win over the New York Jets and missed the final 16 games, leaving a major void in the defense.

Bosa has been putting in work to get back into the lineup and be ready for the opening game of the 2021 campaign. He shared a video on Instagram showing his progress (h/t OurSF49ers_):

Although the Niners had a top-10 defense without Bosa, his absence was felt all over the field. Arik Armstead’s numbers came down without Bosa lined up close to him and San Francisco finished with 18 fewer sacks than a year prior. Bosa’s presence in the trenches benefits every aspect of the defense.

The 23-year-old was dominant in 2019, racking up 80 total pressures, with 47 tackles, 9 sacks and 25 QB hits and won the NFL Defensive Rookie of the Year Award. Pro Football Focus graded him as the fourth-highest rookie edge rusher over the past decade.

The data isn’t too encouraging when looking at Pro Bowl-level defensive players who return from ACL injuries. A 2017 study done by The American Journal of Sports Medicine says star-level players see a dip in their performance when they return to the field.

On the defensive side of the ball, just published research by the Aune and the American Sports Medicine Institute, the injury research think tank started by Dr James Andrews, indicates that 72% of NFL defensive players return to play at least one game after an ACL injury. But behind that relatively optimistic stat, the news isn’t good for those players on the margins. Average NFL players that tore an ACL saw their performance drop to below average. In time, performance might very well return to normal, but since the NFL is a produce-now league, those players often never return to play or last only for a short period of time before getting cut or released.

Generally, those who successfully returned were above-average NFL players before their injury but relatively average after their return. In other words, after an ACL surgery, a Pro Bowl level defensive player regresses to the performance level of an average player and an average player drops below the NFL standard.

Bosa is still very young and built differently than other NFL players. We saw Von Miller of the Denver Broncos come back stronger after he tore his ACL in 2013. Miller averaged 0.12 more sacks per game after the injury.

San Francisco is hopeful that Bosa will be healthy and ready to go for Week 1 of the 2021 season. I caught up with Dr. Rajpal Brar, DPT of 3cbperformance.com and asked about any challenges Bosa could face next season after a long layoff.

Q: What is the ideal among of recovery time for an athlete coming off a torn ACL?

Dr. Brar: Ideally it would be roughly 18 months but that is never going to happen when it comes to professional athletes. So, you can grasp the difference between ideally and reality. Realistically, a year is going to be enough time for him.

The research shows that anything that’s below nine months isn’t ideal. The injury risk is six times higher if the recovery period is less than nine months. That period of time should be the low threshold in terms of recovery. Research also shows there’s deficits from 18 to 24 months out after injury and that’s inherent. When I’m looking at what to expect from a player, I’m really looking not at the first season back, I’m looking at that second season.

Q: Bosa suffered a core muscle injury during his final season at Ohio State, so he has missed most of two of the last three seasons. He’s only 23, but how much of a worry is it that he gets injured again?

Dr. Brar: The re-injury risk overall is roughly 3 percent, but for the ACL itself, there might be some compensatory injury risk just because he’s been out for a long time and he hasn’t really maintained his normal levels of fitness, so that’s always a concern.

For him it’s gonna be extended by any time where he hasn’t been playing football, because it’s hard to replicate that off the field. That’s always a concern, but typically with athletes, a nine-month mark is a good metric to kind of balance the risk/reward of a player coming back. Of course with Bosa being younger, you might have a little bit more resilience and less wear-and-tear on his body, which helps. Now, the concern becomes, if he has that core injury which kept him out for a long time now he has an ACL injury. If he picks up another major injury, then are you looking at a player who’s who might just have to adjust his playing style or whatever else. Does he have a penchant for picking up more injuries? Only time will tell, but given what we have seen from him, he should be in good shape.

Q: Bosa was one of the best in the game in 2019. Will he be able to play at the same level a year after suffering such a serious injury?

Dr. Brar: I’d be remissed to say that he will be at that level right away. There’s always an acclimation process to get back to that level and that’s typically why I look at the second season following the injury. That is where I’m looking for the player get back to their prior level of performance before to the injury. That doesn’t mean he won’t be effective this season, he’s just so good. But, he might be dealing with some deficits from that injury, whether they’re physical, or whether they’re mental. There is a lot of research now showing that some of the last things to get over when coming back after ACL injuries, is getting over that fear of re-injury, or that fear of movement.

Q: ACL injuries happen all the time in the NFL, but medical advances have made the recovery process a lot easier. The surgery techniques used 20 years ago are a lot different than they are now. Why should we expect Bosa not to suffer long-term effects from the injury?

Dr. Brar: I mean, it’s so much less of an impact. Surgeries have gotten better, rehab has gotten much better as well. It’s far less of an issue than it used to be, so I certainly expect him to get back to his prior level of performance barring any other injuries that may happen. Like I said, I think he will be very good next season, but 2022 is when he should be able to take his game to another level.

Just getting Bosa back on the field will be a huge-plus for the 49ers. The hope is that the team will get at least some production from Dee Ford, who also missed basically all of last season. The Niners would also love to see Javon Kinlaw take a step in his development to help alleviate some of the pressure off Bosa.

Either way, it’s an exciting sight for The Faithful to see Bosa getting ready for the 2021 campaign.