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In September, three days after Nick Bosa suffered a torn ACL in his right knee, San Francisco 49ers head coach Kyle Shanahan was asked about the All-Pro pass rusher’s injury history. Bosa tore the same ACL when he was a senior in high school in 2015. Would a second tear in the same knee be a factor in his recovery and eventual return to play? Shanahan said he thought there was “zero worry or correlation” between the injuries because Bosa’s second ACL tear was “clean,” meaning there was no damage to his meniscus or other ligaments. “When it’s clean and you go through the rehab,” Shanahan said, “it’s usually brand new after that.” Advertisement Article continues below this ad Wrong. A second ACL surgery on the same knee, what orthopedic surgeons commonly refer to as “revision ACL reconstruction,” produces longer recoveries and less certain outcomes. Dr. Prem Ramkumar, an orthopedic knee and hip surgeon who consults for the X Games and Long Beach State athletics, termed an ACL revision a “very big deal” and a “different beast.” Dr. Nirav Pandya, professor of orthopedic surgery at UCSF, said the trauma Bosa’s right knee has suffered means it will be “asking a lot” for the 2022 Defensive Player of the Year to flash his pre-injury form next month, or perhaps, this season. If Bosa plays in the regular-season opener on Sept. 10, it will be 354 days since he was injured. Advertisement Article continues below this ad “We always say, ‘Nine to 12 months for ACL surgery,’” Pandya said. “But if you really look at when people get back to normal after a second ACL surgery on the same knee, it’s like 12 to 18 months. And the reason why it takes longer is that the knee just doesn’t respond as well to increased load. It’ll definitely take more time just simply by the nature of it. Even as good as we’ve gotten at this surgery, it’s still a large hit to a knee.” Both surgeons detailed the challenges of returning from an ACL revision after they were contacted to discuss the tendinitis that has kept Bosa out of practice since Aug. 3. Bosa returned to rehab work on a side field for the first time Sunday. Shanahan said on Aug. 11 that Bosa’s inflammation was a “normal thing.” The coach said members of the team’s medical staff had said 90% of 49ers players who had undergone ACL surgeries had dealt with tendinitis in their recovery. Ramkumar said it’s “totally reasonable” to have tendinitis about 11 months after ACL surgery. The inflammation develops in the area where tissue was removed to create the ACL graft. “For example, if the patellar tendon graft was used, you’re taking a strip of the patient’s patellar tendon and you’re putting it inside their knee,” said Ramkumar, who works at MemorialCare Long Beach Medical Center. “They now have less patellar tendon, and they’re more likely to have anterior knee pain or patellar tendinitis.” Before Bosa was sidelined, he told Sports Illustrated that last year’s surgery had also addressed “chronic” quadriceps tendinitis that had developed from the first ACL repair on his right knee. Pandya noted it would be more problematic if Bosa’s current tendinitis isn’t related to his most recent ACL surgery, which Shanahan suggested it was. Advertisement Article continues below this ad “He’s had quad tendinitis since he was in high school and it’s been this lingering, ongoing problem,” Pandya said. “The issue that you get worried about long-term tendinitis is that that can eventually lead to degeneration of a tendon. It’s more prone to kind of have chronic issues or even tear.” Pandya said even a routine lower-body issue comes with a heightened concern given Bosa’s injury history. Bosa also tore his left ACL in 2020 and had core muscle surgery in 2018. That is, if Bosa’s twice-repaired right knee has less ability to normally absorb force, his body might have fewer places to redistribute the load. “From a 10,000-foot view perspective, any physical ailment that affects his lower extremities is going to be a concern for him,” Pandya said. “You do worry a little bit: Is even this little bit of tendinitis going to mess up the balance for him, given how much he’s been injured?”