The Medical Case for Saquon Barkley


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The Medical Case for Saquon Barkley

This one is a monster, so strap in.

Fantasy football can be really hard. It’s a game based on projections using indirect information coming from individuals who, although often extremely sharp, operate with very similar information available to most casual players. This is why finding an edge doesn’t always have to come from a new metric. Instead, information that already exists helps make optimal decisions.

That leads to Saquon Barkley … and the decision to steal him at ADP (roughly #7 overall). As most know by now, I have been pounding the table for Barkley since early in the off-season. However like most taeks, this isn’t bulletproof and he does not come without risk. This profile will walk through the data that exists demonstrating how Barkley can succeed followed by a totally 100% unbiased account for how he fails. Maybe it’s a little biased, but hey I’m human.

What Happened?

Barkley sustained a season ending ACL tear that included a mild MCL sprain and partial tear of the meniscus. Usually when the MCL is damaged, the meniscus is as well. This is very common. After pre-operative physical therapy, Saquon went on to have the reconstruction on October 30. The MCL did not require interventions and the meniscus damage was minimal.

What’s it Mean?

I’m so glad you asked! The average return to sport time for players coming off an ACL tear in the NFL is approximately 11-12 months. However, this number isn’t precise as it includes fringe players, the most severe types of injuries, and most importantly doesn’t account for players who are injured in the preseason and subsequently can’t technically “return” for an entire year. Clinically, most patients come back and perform between 8-10 months depending on the situation. Most surgeons won’t completely clear a player for games until at least 9 months. After 9 months, re-tears are no different than at 12 months. After 18 months, re-tears dip even further. For reference, Adrian Peterson’s historic 2012 comeback season occurred after just 8 months and 8 days which is bananas. In contrast, Jamaal Charles, in 2012, took 10 months and 30 days. When the Giants kickoff in 2021, it will have been 10 months and 13 days since Barkley’s surgery.

It’s important to understand that although this injury is a big one, ACL tears are not a death sentence. However, several objective criteria need to be met for a player to improve his odds at returning and smashing. The following criteria is based on a new study analyzing 47 NFL players over the span of 27 years. The criteria for what it meant to return to previous performance levels were:

  • Pass a battery of physical assessments aimed at challenging the knee

  • Perform position specific rehab for at least 6 weeks

  • Pass an NFL physical

  • Return to participation with a team at the same level (i.e. practice squad returns to practice squad, starter returns to starter etc.)

The article is open access for those interested in the specific methods. What the authors found was that the following variables were independent predictors of returning to previous level of performance/NFL longevity:

  • Age < 25 years old (previous performance)

  • Offensive players (performance)

  • NFL draft capital in rounds 1-4 (longevity)

Ostensibly, the younger the player, the more talented/athletic, and the higher the draft capital, the better the chances are of a smash return. The most reasonable explanation is that these players have fewer complications, more front office support, and overall supreme talent. They can progress more quickly through rehab and are least impacted by ACL injuries. This study on NCAA players supports the argument for youth aiding in ACL rehab. Every step matters in the NFL and physiologically, the younger dudes are in their physical prime.

Another important point is that any MCL and LCL damage did not impact return. Additionally, Barkley did not have PCL damage and the meniscus damage was minimal. This matters because it is implied in the study that the less complicated the injury, the smoother the return. Lastly, there’s emerging evidence that preoperative rehabilitation like Barkley underwent can help overall outcomes for these patients. It also highlights his body’s overall resiliency to continue exercising despite a ruptured ACL.

How Does he Succeed?

Why does any of this matter? Saquon checks the following boxes:

  • 24 years old (young age)

  • Offensive player (with supreme talent and opportunity)

  • Ceiling draft capital (with associated top 1% athleticism at the position and staunch front office support)

  • Minimal involvement of neighboring ligaments (previously discussed above)

  • Preoperative physical therapy

  • An entire summer to dial in strength/conditioning/football related activities

  • No real backfield competition

Historical Precedence and Fantasy Implications

Now, you might be wondering why I haven’t mentioned any fantasy finishes by RBs after ACL tears. Some, like my buddy and fellow physical therapist Dr. Chap, might even point out that “hit rates” (at least WR2 or RB2 finishes) after ACL injuries are much higher in WRs comparably. Well, since 2015 there haven’t been fantasy relevant running backs. There simply haven’t been RBs the caliber of Jordy Nelson, Julian Edelman, Allen Robinson, Cooper Kupp, and Keenan Allen to smash ADP. Instead, the following running backs make up the sample of fantasy “relevant” backs we would need to work with:

  • Darren Sproles: 34 years old, 10 missed games due to hamstring injuries the following year

  • Danny Woodhead: 31 years old, missed 8 games due to hamstring injuries the following season and subsequently retired

  • Lamar Miller: 28 years old, average talent

  • Jerick McKinnon: 26 years old, severe complications of initial injury

  • Jamaal Charles: 29 years old on his second ACL tear of a career

  • Rashaad Penny: very late season injury with continued complications and bad front office support from the beginning. A sad ending for a player who had great promise.

So who does that leave?

  • Dalvin Cook: essentially a rookie who missed five games due to injury the post-ACL year but still finished as RB16 on a FPG basis
  • Jamaal Charles (2012): an absolute efficiency monster, he finished as the RB10 on a ppg basis
  • Adrian Peterson: you know the story

Even if you disagree with everything else in this article, there’s no way around the fact that this tiny and heterogeneous sample of recent running backs in any way shape or form justifies a reason to fade Saquon in 2021. Simply put, citing that no running back has met/broken expectations after an ACL injury without dissecting the context above is just lazy analysis. Furthermore, old tropes like “Adrian Peterson is the exception to the rule” totally ignores the fact that if Saquon goes on to do something similar, we wouldn’t say the exact same thing! This needs to be assessed and analyzed as its own unique situation because it is.

Well, well, well, now who do we have left? None other than the generational (by every sense of the word) legend Peterson. Arguably the GOAT of running backs, AP was a unicorn going into the surgery and remains a unicorn nearly 10 years later. No other running back who has torn their ACL has matched AP’s athleticism, his dominance, or his draft capital. Whatsmore, no other athlete at this level has returned as lightning fast from this injury let alone dominate and become the RB1 afterward.

Enter Saquon Barkley.

Barkley narrowly edges AP out in athleticism, according to PlayerProfiler. Additionally, Saquon has two additional months to rehab compared to Peterson’s experience and is three years younger at the time of their respective injuries. Don’t think of this as a direct comparison but more so as a parallel. These two situations are quite literally unparalleled. In medicine, when randomized trials or even case control studies don’t exist to guide treatment for a rare condition, clinicians lean on case studies based on what’s been done before. Because there really isn’t a true sample that represents Barkley’s specific situation, the case study to analyze is Peterson. Does that mean Barkley will be the overall RB1 in fantasy football? I won’t go that far. However, if healthy, we’ve seen it done before by somebody with less time to rehab.

So then what reasons do exist to fade Saquon?

How Does Saquon Fail?

Soft Tissue Injuries

A very realistic avenue that Saquon could “fail” to meet his current ADP/expectation as a top running back. Since 2015, there have been 73 skill players who have torn an ACL and went on to have soft tissue complications and/or miss time the following season. Of those 73, 7 players missed time due to groin/quad/hamstring injuries. The average amount of missed time was 4.5 games. A 34-year-old Sproles and 32-year-old Woodhead accounted for 18 of those games. Overall, this could definitely put a damper on Barkley’s return. Theoretically, according to this sample, players miss time for soft tissue issues about 10% of the time.

Complications and Swelling

Like we recently saw with Rashaad Penny, complications can linger, impacting both availability and performance. Not every surgery is a success — especially if it’s complex. In that same sample of 73, another 8 missed time and were listed on the injury report with “knee” the following season at least once. Now, this average is much bigger at 9 missed games. The absolute worst case scenario is what happened to McKinnon in 2017 where he missed the entire 2018 and 2019 season. Jamaal Charles in 2016 is another player missing basically an entire season due to complications. Overall, soft tissue injuries and/or “knee” complications accounted for 21% of at least partially derailed seasons. These first two avenues of failure are what scares me the most personally.


This one is short and (not so) sweet. In our original study, that sample had a retear rate of approximately 12.8% overall. That includes re-injury of the same ACL or the opposite leg. The body doesn’t fully integrate the new graft until about 18 months, after which re-tears take a precipitous fall.

Eased In

Jordan Raanan caused quite the ruckus in early June with his article discussing Saquon’s usage in the early days of the season. I discussed it in greater detail here. He makes the point that the Giants never planned to give him a full role right away. That they want to protect their franchise running back and topped it off by emphasizing that even though Barkley “has impressed” in the process, the team won’t say where he is in the rehab protocol. The argument to use here is that despite a 55% snap rate in 2012 after his first ACL tear, Jamaal Charles saw just 42% and 27% of snaps in the first two games back. He had two more weeks to recover than Saquon. In theory, if this is the only possibility that occurs, Saquon could still match ADP, but his chances of totally smashing are much less likely.

Jason Garrett

Well, I mean…


Conducting research for this specific injury illuminated the context in which players fail. Unfortunately, fringe or bubble players fall out of the league, aging players retire after losing the war of attrition, or postoperative complications linger. There’s probably an efficiency statistic to point to in the year following ACL surgery, but the reality is that most “failures” are due to the circumstances above.

Overall, Barkley is an elite talent who had a less complicated tear and has more than enough time to rehab. Additionally, he had preoperative PT to prep for surgery, and is a younger athlete checking all the boxes to return to his previous level of performance. He doesn’t come without risk, however as 21% of skill players since 2015 have suffered soft tissue or knee complications the following season. In fact, there have been two cases in which players missed 16 and 14 games respectively. In the end, Barkley’s comparison group is a poor reflection of his specific situation and his injury/recovery merits it’s independent analysis and breakdown.

Edwin completed his Doctorate of Physical Therapy education in 2020. His expertise is in all thing’s orthopedics, injury recovery, and he has a special interest in human performance. Edwin’s vision is to push injury advice past simple video analysis and into the realm of applying data from the medical literature to help fantasy players make informed start-sit decisions.