Breaking down Joel Embiid’s foot fracture

News broke Friday that Joel Embiid had successful surgery on a right foot fracture, and will miss 4-6 months recovering. This deals a significant blow to Embiid’s draft stock, and raises many questions about his future as an NBA player. It will certainly delay his debut, but will he be able to recover from the injury with little long-term concern? Or is this something that will bother him throughout his career? This is not the first time we’ve discussed injury with regards to Embiid, as I broke down Embiid’s back injury from this season a few weeks ago. Now, it’s time to answer some questions about a new injury for Embiid, and why this injury is far more concerning.

So we know Embiid has a stress fracture in his right foot. What bone is fractured?

Embiid has fractured one of his tarsal bones, called the navicular. The navicular is the tarsal bone that connects with the talus, which is the tarsal that forms the ankle joint, to the midfoot and metatarsals on the inside of the foot. It is considered the “keystone” that holds the main arch of the foot up, and in a high and rigid arch, the navicular receives most of the force the arch takes during activity. Over time, these stresses will cause inflammation of the bone, and that inflammation can lead to a stress fracture. The navicular is one of the most common bones to suffer a stress fracture, and it is mostly seen in track runners and basketball players.

How serious of a fracture is this?

That can depend on the site of the fracture, the fracture size, and how far along in development the fracture progresses before it is found. These fractures are tricky because they are often asymptomatic, as Embiid’s appears to have been. If the fracture is caught early, usually it will be smaller, and therefore more manageable. However, this is easier said than done, as stress fractures of the navicular rarely show up on X-Rays until 3-6 weeks after injury. By then, the injury has usually progressed to a more serious fracture. This is a huge issue, as serious fractures of the navicular can lead to avascular necrosis, which is tissue death due to lack of blood flow. The navicular’s middle has very poor blood supply, and if that is fractured, prolonging of treatment can lead to this necrosis, which leads to serious long-term health concerns. Embiid’s fracture is reportedly at this stage, and thus falls into the “very serious” category.

Does the injury require surgery?

At this stage, surgery to fixate the fracture with a screw is required, and usually is recommended to be performed as soon as possible after diagnosis. That’s why Embiid had surgery Friday, after the injury was discovered Thursday:

The screw will stabilize the fracture, and allow the fracture to form a union and heal. In the case of someone who has had multiple fractures, or has a fracture that has not healed correctly, a bone graft is used to help reform the navicular.

What is the treatment plan after surgery?

Step 1: Take a post-surgery selfie.

After surgery, the general plan involves a period of immobilization in a cast for 6-8 weeks to allow for healing, much like any other fracture. After this period, the foot and ankle experience muscle weakness and range of motion deficits, and much of the initial rehabilitation will focus on relieving restrictions in the joint, and regaining this lost muscle in the lower leg. Postural evaluation is also important, as abnormalities in the knees, hips, low back, and ankles can lead to compensation during running that could have caused the added force that caused the fracture. Embiid’s back injury is likely what falls into this category, so it will be necessary for this to be addressed. Additional consideration to shoe type, and orthotics should also be considered. In all, Embiid should be able to return to the court in about six months.

What long-term complications can result from this injury?

Reinjury is common with this type of injury, especially in basketball, where the players suffering them are quite large and logging a lot of running miles. It’s very difficult to prevent the repetitive forces going through the foot, and since many players that suffer this injury have rigid, inflexible feet, it’s difficult to completely fix this without causing problems elsewhere in the lower extremity. Size is also a problem, which is why centers seem to have particular struggles staying healthy after this type of injury. This is usually not a problem with the surgery, and is more of an issue of recurring pain and athletes rushing back. The surgeries for this type of injury have good results with runners, but the past history of centers who have had this injury is not good.

Go on……

Well, Cavs fans should know someone who made a decent comeback from this injury, as it’s the same one that plagued Zydrunas Ilgauskas early in his career. Z had extensive bone grafting performed to take the pressure off of his medial arch, and was able to have a long, relatively healthy career after that 2001 surgery. However, Yao Ming was forced to retire due to repeated stress fractures to this bone, and this is what ruined Bill Walton’s career. Brook Lopez has also had repeated fractures of this bone in his right foot, and has dealt with ankle sprains and midfoot sprains in the same foot in the interim between fractures. Isolated incidents of navicular fractures are not common; even Z, thought of as the success story of the bunch, had multiple fractures of the same bone. Centers and stress fractures are a bad, bad combination.

Why is this injury more serious than his back issue?

For one, the navicular fracture usually requires surgery followed by complete immobilization of the foot for up to two months. A spondylolysis can be treated conservatively, which cuts down on the recovery time. Also, the mechanisms of injury for the two conditions are vastly different. Spondylolysis occurs because of the repeated stress of activities involving back extension, while the navicular injury results from repeated stresses from running and walking, things the average NBA player obviously does more frequently. The risk of re-injury is also much higher with in the foot than in the back, which is why Embiid’s long-term health is more justifiably in question this time around.

Should Cleveland still consider Embiid for the number one pick?

Since the Cavs are the one team that has had success with a center with navicular fractures before, lightning could strike twice, thanks to the teams being able to follow Ilgauskas’s treatment plan. However, the risk is still high with Embiid, and with two perfectly viable forwards on the board who would fill just as many needs as Embiid, it doesn’t make sense for the Cavs to pull the trigger unless they know something the public does not. Even then, though, I’m not sure he’s worth the risk of a top-five pick. If Nerlens Noel dropped to number six as the only high-profile talent in a terrible draft because of an ACL tear, Embiid could fall a lot further than that in this loaded draft.