Podiatry Primer: A Med Student on Embiid’s Injury

June 21st, 2014 | by Dan Clayton
(Photo by Cooper Neill/Getty Images)

(Photo by Cooper Neill/Getty Images)

Special to SCH: Former Jazzbot writer Danny Hansen is a fourth-year medical student at the Arizona School of Podiatric Medicine at Midwestern University. As a specialist in the area of medicine specific to Joel Embiid’s injury, he brings his knowledge to bear in this special guest post on the medical realities of Embiid’s injury and whether the Jazz should consider drafting him.

Early Thursday, news appeared that top draft prospect Joel Embiid had a broken foot. GMs and the media were sent scrambling to gather more information. Draft boards across the league and mock drafts across the Internet were in disarray as we waited to discover which of the foot’s 26 bones was actually broken. It was later revealed that the Kansas phenom had a stress fracture of his navicular bone.

A panic then followed. The navicular bone has been known to affect the careers of Yao Ming, Bill Walton, Zydrunas Ilgauskas, and former Jazzman Curtis Borchardt. Embiid’s status has been elevated to “ultimate risk”. However, looking at his condition, how much of a risk is it really to draft Embiid? If he were to fall to the Jazz at #5, should they select him? To better answer these questions, we need to analyze his situation and condition. What is the navicular bone? How long does it take to heal? Will this be a chronic problem for him?

The Navicular and Stress Fractures

The navicular is a comma-shaped bone on the medial1 side of your midfoot. It serves as the location for various ligament and tendon attachments. It is the keystone of the medial longitudinal arch2. The blood supply for the navicular comes from branches off an artery on top of the navicular, which come together with branches off an artery on the bottom of the navicular. This pattern creates an area in the center of the bone where blood supply is poor, also known as a watershed area. Watershed areas are more prone to fracture and take longer to heal. 

Navicular stress fractures usually run in a vertical pattern, and involve the body of the navicular, or the center area of the bone.  These kinds of stress fractures in the navicular account for 15% of all stress fractures in the foot. There are 3 kinds of these stress fractures. A Type I fracture means only the upper portion of the bone is fractured and it only descends minimally into the body of the bone. Type II is like a Type I, but it does descend into the body of the bone. Both a Type I and Type II are called incomplete fractures. Finally, a Type III involves the upper portion of the bone, descends through the center of the bone, and fractures on the far side of the bone. It is called a complete fracture. 

A Type I or Type II can be treated by putting the patient in a cast and keeping them off it for 6 weeks and slowly transitioning to weight bearing and physical therapy. A Type III is most often fixed with surgery. However, as is the case with Joel Embiid and other young athletes who will be putting a lot of stress on their feet in the future, surgical repair with a screw across the fracture site is usually done in all three types.  So, Embiid’s choice to have have surgery doesn’t necessarily mean that he has a Type III fracture. It is more likely, given his status as a young professional athlete and the fact it hadn’t been picked up until recently, that surgery is done to ensure it heals properly and quickly. 

Healing Time

Average return to activity for patients treated surgically and non-surgically for a Type I fracture was 3.0 months. For a Type II, healing time was 3.6 months. And for a Type III fracture, return to activity was found to be about 6.8 months. Patients who had surgical correction were found to return to activity quicker than those who were treated conservatively3.  Other things, such as bone grafting and bone stimulation, can be done to aid in fracture repair. 

Reports surfaced after Embiid’s operation on Friday that he had 2 screws placed in his navicular and that his recovery time is 4 to 6 months. Once can speculate that perhaps Embiid had a Type II stress fracture of the navicular. This is definitely a better prognosis than a Type III. His recovery time indicates how soon he can return to activity and isn’t necessarily the time until he will play in the NBA. Any team that selects is going to be extremely patient to ensure the bone has adequate strength before allowing him to return to the court. 

Complications

Because of the unique blood supply in this part of the foot, and possible disruption of that blood supply, there is a chance of the fracture not healing. There is also the risk of the bone undergoing avascular necrosis, death of the bone due to lack of blood supply, as was the case with Curtis Borchardt. Refracturing the navicular is also a possibility. Yao Ming had numerous tiny fractures in the navicular that required multiple screws.

Studies show, however, that non-healing and avascular necrosis is more the exception than the rule. The problem with these studies, though, is that they weren’t conducted on professional athletes over 7 feet tall.  Joel Embiid, currently at 240 pounds, isn’t as heavy as those mentioned before (Yao Ming weighed 311 lbs, Zydrunas Ilgauskas 260), which means less stress on his feet. He is, however, more of a leaper than those other players, which adds its own forces to the foot and the previous fracture site. There are multiple theories as to the causes of navicular stress fractures. Some speculate anatomical variety, such as a high arched foot, or a short 1st metatarsal bone could contribute to increased stress on the navicular. Though these theories aren’t proven, you can bet teams will be assessing the biomechanical function of Embiid’s feet very carefully. 

Is He Worth the Risk at #5?

Embiid has the chance to be a very special player. Experts have said he reminded them of NBA great and two-time Finals MVP Hakeem Olajuwon. In a league void of impactful centers, he could be the best center in the league in a couple of years. There is no doubt he has the talent to be special. There is a good chance his navicular will heal correctly, quickly, and never be a problem again. However, Joel Embiid is a special case. He is an athletic 7 footer, who is light on his feet. He had a foot fracture that was found only recently. We won’t really know the extent of the injury until doctors get in there and assess the quality of the bone. We haven’t even mentioned his back troubles that kept him out for a big chunk of his season at Kansas, which is a serious risk in and of itself. 

If I have the #1 pick, as the Cavs do, there is a 0% chance that I take Embiid. In this draft, with other potential superstars in the waiting, you can’t miss with the first pick. However, with the 5th pick, once the potential superstars are off the board, I do seriously consider it. Do you take the potential superstar with health risks, or do you take somebody like Noah Vonleh, with just some all-star potential but more of a sure thing health-wise? It comes down to what kind of risk taker you are. When your team is down two with five seconds left, do you go for a three-pointer, or do you play it safe with the two to try and force overtime? What kind of risk taker is Dennis Lindsey? We’ll find out on draft night, but somebody is sure to take the risk.

- Danny Hansen, 4th Year Medical Student, Arizona School of Podiatric Medicine at Midwestern University

Dan Clayton

Dan Clayton

Dan covered Utah Jazz basketball for more than 10 years, including as a radio analyst for the team’s Spanish-language broadcasts from 2010 to 2014. He now lives and works in New York City where his hobbies include complaining about League Pass, finding good doughnut shops and dishing out assists for the Thoreau It Down team in the Word Bookstore basketball league.
Dan Clayton

18 Comments

  1. Pingback: How far will Joel Embiid slide? – ESPN | dailynewscafe.net

  2. Mac_Jazz says:

    Danny and Dan, great post. Thank you for the great info.

    I’ve had a hard time wrapping my head around this idea that Embiid had a fractured foot and didn’t know about it until his Cleveland physical. I understand the facts of the injury’s discovery are not complete, but it seems as if the doctors discovered this fracture during his physical, which I’m taking to assume that he didn’t know about it.

    If this is true, how common is it for someone to have a navicular fracture and not know about it? Is it possible that he had been working out with this fracture?! If so, could the injury really be as worrisome as some have suggested. I know nothing about foot anatomy, but on its face, it seems wild to me that Joel didn’t know he had this fracture until the Cleveland physical. (I realize this comment makes some assumptions that might not be true, e.,g., perhaps he hurt it during his workout for Cleveland. But most of the reports make it seem as if Cleveland discovered the injury, implying that Embiid didn’t know. I’d be interested to hear your take on the injury if we assume that to be the case. Thanks!)

    • Danny Hansen says:

      Great questions. These kind of fractures usually start out as a generalized top of the foot pain that becomes more localized with time. Stress fractures don’t always show up on x-rays immediately. There is usually a lag of a couple of weeks. Navicular stress fractures can have a lag on x-rays of 3 to 6 weeks. They do show up on MRI, CT, Bone Scan, and even ultrasound sooner. It is hard to say in this situation. Embiid, already answering numerous questions about his health, may have been experiencing generalized foot pain but not telling anybody, or perhaps didn’t even think it was a big deal. Teams, wanting to be thorough, probably ordered a different kind of imaging, probably an MRI, of his lower extremity, and the fracture was found on it. Depending on his activity leading up to his Cleveland workout, he may possibly have been on the fracture for a while. I also don’t know the details of how it was discovered, or the events that led up to its discovery, so I too am speculating some.

      • Mac_Jazz says:

        Thank you for the reply and the great answers. It’s crazy to think about Embiid possibly walking around with an injury that could have career-ending implications thinking it was just foot pain. It’ll be really interesting to see what happens if he’s on the board at #5.

  3. Audiris says:

    Great article!

    If Wiggins, Parker, Exum and Vonleh are all of the board when th Jazz pick at 5, they have to consider Embiid, simply because the drop off from the Top 5 players to the likes of Smart, Gordon and Randle is big nough to make the risk of drafting Embiid worthwile

    • That’s an absolute waste of a pick especially considering the depth of talent that is in this draft. You want your team to use their fifth pick on a player that is at best a “wild card” over more reliable player who can contribute right away, as it is the case in this draft? No one is worth that risk.

  4. I see Embiid going all the way to the bottom third of the first round. There is no way that a team with a high fiirst round pick, or even a mid first round would waste their pick on a player that has more red flags that a beach on hurricane season–especailly when there is so much talent in one of the deepest NBA Drafts in recent memory. I can see a team like the Heat or Spurs picking him really late in the first round as they have the patience to wait and see with this player. So don’t be surprised if his name is not mentioned until very well into the draft.

  5. ScotsJazzFanIn London says:

    There are a couple of teams that have a more than one pick in the first round that can take a chance on Embiid. I’m just not sure the Jazz should be one. The Jazz would unlikely to be able to play Embiid this year, which means another season that the team isn’t competitive, and going forward there is no guarantee that the team has an asset that will move this team up a level. Before the foot injury I would havce taken the risk on the back issues, now that there is more than one injury that could affect his career the risk I think is too high. Embiid has only been playing the game of basketball for four years and he already has these issues, thats worrying.

  6. BALLA says:

    A podiatric student is not a medical student. Very different admission and education processes.
    However, I appreciate the information, which is accurate… just not the inaccuracy of stating he is a medical student.

    • TC says:

      Translation: What he said is correct; BUT he’s not as smart as a medical student.

      BALLA: that is a dick comment. If you need to step on people to make yourself feel good then keep it to your kids and your wife (poor bastards).

  7. Ben Dowsett says:

    What an excellent piece – thank you to Danny for his insight and to Dan for doing the legwork and getting it up in short order.

    I just want to play a little devil’s advocate here, as I’m still processing the news and haven’t fully formulated my opinions as far as potentially selecting Embiid goes…but I’m just interested, do those arguing that his selection would be what preempted another “developing” season truly believe that other players potentially available at 5 would be such a large right-now improvement that this wouldn’t be the case anyway? Like, do folks believe Noah Vonleh would be such a huge upgrade on Kanter/Gobert/even Favors that this team is going to compete for the 8-seed as currently constructed? I guess I’m missing the logic here – if you think Embiid is too large a risk, period, I have no qualm with that. But I’m more than a little confused at the prevailing opinion I’ve been seeing (both elsewhere and in these comments) that the pick would be wrong because Embiid would miss time this upcoming season. I hope I’m not surprising anyone here, but barring a couple major power moves by DL (which aren’t out of the question, of course), this is not a team that will be contending for a playoff spot in the West next season.

    Again, if you believe the health risk is too high under any circumstances, I can’t fault you. But if you are only arguing against it because it “keeps the team from competing next year” when you otherwise would have considered him the top prospect in this draft, then saying you’d pass on him at 5 is foolish.

    • Clint Johnson says:

      Not necessarily. You’re assuming the Jazz select a major project like Vonleh at #5. If the Jazz were to select either Marcus Smart or Julius Randle, I think either of those players would make the team better instantly. Not playoff contenders, but notably better than last season. Add in the likelihood the team leverages some of it’s young assets to try to bring in upgraded talent, likely veteran – as Dan said on the latest podcast – and the team may well be closer to the eighth spot than another top five pick in what looks to be a much weaker draft.

      Pick #5 is a major piece in constructing next season’s team, but it is far from the only piece. What they do with it will be greatly informed by their intent in free agency and via trades.

      • Ben Dowsett says:

        Don’t disagree with any of those general points individually, but likely do just a little in terms of how such potential moves might stack the Jazz up against the rest of a West that might even get tougher from last year’s already-ridiculous standard. I don’t mind either Randle or Smart as prospects, but just am not sure one of them plus the type of veteran we can likely bring in will really move the needle enough for the Jazz to truly challenge teams like Phoenix, Dallas, Portland, and even New Orleans.

        Of course, I’m only playing percentages when I say this – a number of things could happen to prove me wrong, and I’m betting DL is working on as many of these things as possible, I just don’t find it likely. If I had Embiid as the top guy in the draft before the news and DON’T believe that he’s just too huge an injury risk under any circumstances (I’m hoping to learn more before making this determination for myself), then I’d absolutely draft him at 5 if available given Utah’s situation in my eyes.

        • Hazel says:

          Agreed, for argument’s sake let’s say we have the choice between Embiid who has the legitimate chance of being a superstar in 3-5 yrs or Vonleh/Randle who have very similar potential to the Kanter/Favors duo. If they all reach their potential then you no-question pick Embiid, if they all flop, you might as well have flopped with Embiid, if Embiid flops and the others meet that potential, then your best case scenario is three all-star level players at the same position. I say pick Embiid if these are your options. The one thing that would change my mind is if a Exum is available and he has similar potential at his position to Embiid, then let’s go that direction.

  8. Clint Johnson says:

    Excellent information! I really appreciate the primer.

  9. cw says:

    I don’t think in the Jazz’s position you don’t draft thinking about this year. I think you draft a thinking three or four years down the road. That sound’s like a reason to draft Embiid, but the history of big men with foot and knee injuries is not good. Way more failures than successes. So you have to figure that down the road somewhere a reoccurance. What if you have a team onthe verge of contending and he blows out his foot (or his back) again? It messes everything up.

    Then you factor in the chance that someone you could have drafted turns into a very valuable player or even a superstar. What if Aaron Gordon learns how to shoot the three at 37% and gets his free throws up? Basically becomes Kawhi Leonard? Or Smart becomes Derrick Rose? Those things can’t be predicted, but something like that seems more likely in this draft than in most others.

    Then that has to be weighed against the likely hood of the Jazz getting another chance at an all-star within the next 4-5 years.

    I think given the very high chance of reoccurance, and the moderately elevated chance of getting a really valuable piece in this draft, I’d pass on him. I think the fact that the league is sort of in a period of evolution in terms of analytics and what kind of game/personnel are winning and the new CBA, along with the stockpile of players the Jazz have make the chance of getting the right kind of transcendent player higher that it was in the past.

    Here’s another thing. Teams with two picks can take a chance on drafting Embiid. For instance, Favors and the 5 might be attractive to Cleveland, becasue then they would get a good player who still has upside AND Embiid. The jazz would get Wiggins. I don’t think that trade was as likley before Embiid got hurt. The same deal could be made with Milwaukee, and Philidelphia. IS that a good deal? It all depends on how good you think Wiggins (or parker or Exum) will be vrs. Favors and whatever upside he has left. There’s risk there but I think less risk than just taking Embiid.

    Alternatively, Smart, Gordon, or Randle might be just as good as Exum, Wiggins, Parker. If you go by analytics and traditional scouting, Smart is probably the player with the most potential in the draft.

  10. Aaron says:

    I am curious if the med/podiatric student has an opinion on whether the combination of the back stress fracture and foot stress fracture are possibly indicative of a more chronic condition that Embiid might be more prone to stress fractures than your average Joe.

  11. Great article! I wonder how is he now after the surgery. Oh well, he’s Philadelphia 76ers’ problem now. There are some reports/rumors that he’s not going to play this season. It’s just funny Embiid tweeted Lebron on going to Philly. Fat chance! LOL

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