Assessing Return to Performance After Surgery in National Football League Quarterbacks: A Comparative Analysis of Performance Metrics.

Background Return to play (RTP) is commonly used to assess recovery after injury but does not reflect post-injury performance quality. Return to pre-injury performance (RPIP) offers a more informative outcome, yet its application to National Football League (NFL) quarterbacks and the optimal performance metric remains unclear. This study compared commonly used quarterback performance metrics to determine whether any single measure effectively characterizes RPIP following injury requiring surgery. Methods This retrospective cohort study included NFL quarterbacks who had sustained a first injury requiring surgical intervention between 2006 and 2022, missed regular-season games, and had at least one full pre-injury season. Performance was assessed using Fantasy Football Points, ESPN Total Quarterback Rating (QBR), Passer Rating, and Passing Attempts. Pre-injury baseline was defined as each quarterback's peak single-season performance within the three years preceding injury to provide a stable estimate of individual pre-injury capacity. RPIP was calculated as (peak post-injury performance / pre-injury baseline) × 100 and expressed as a percentage, with 100% indicating complete return to pre-injury peak performance. Paired t-tests compared pre- and post-injury performance, and one-way analysis of variance (ANOVA) assessed differences in recovery magnitude across metrics. Results Seventy-three quarterbacks met inclusion criteria. Mean RPIP was approximately 94% for Fantasy Points, 107% for QBR, 97% for Passer Rating, and 91% for Passing Attempts. No statistically significant differences were observed between pre- and post-injury peak performance for any metric, with only small effect sizes across all measures (Cohen's d range: -0.19 to 0.10), suggesting minimal practical differences between pre- and post-injury performance. No statistically significant differences in recovery magnitude were detected across the performance metrics, although formal equivalence was not established. Conclusion Common quarterback performance metrics demonstrate similar overall patterns of post-injury decline and recovery. While certain metrics may offer advantages within specific subgroups, no single measure demonstrated superior overall sensitivity for assessing RPIP. These conclusions are based on the absence of statistically significant between-metric differences rather than formal equivalence testing and should be interpreted accordingly.