Anatomy Of Joel Embiid

Joel Embiid is back in the news, and back in Qatar visiting the Aspetar Podiatry and Sports Clinic there.  Should we feel concern or relief?

Camaroon native Joel Embiid is up to 7′ 2″ tall, and weighs 250 pounds. When he entered the NBA, he was accurately listed as 7′ 0″.  But with many young men, he has continued to grow through the age of 20.  And so now, at age 22, he is two inches taller than his NBA listed height, two years older than his 20 year old debut, but he has yet to play in an NBA game.  He just can’t seem to get his foot in the door. Still, he has remained in touch with the team throughout the entire ordeal, and had this to share with his head coach Brett Brown before he was scheduled for his second surgery on his right foot Navicular bone.

"“I get a text from Joel a few weeks ago in the middle of the night that said: ‘Guess how tall I am.’ And so I guessed seven-foot. Two minutes later he texts back ‘You’re wrong, I’m 7’2″.’ I text back ‘How do you know this?’ He texts back ‘Doctors. I’m 7’2″ in sandals.’ And when you stand next to him, when you’re around big men you understand the difference between seven-foot and seven-two, and he is 7’2″.”"

Fortunately for Joel Embiid, the science of treating Navicular stress fractures has advanced many times over and continues to do so as global awareness turns its attention towards that little weight bearing bone of the human foot.   This fact is the focus of Dr. David T. Martin, hired on as the team’s  Director of Performance Research and Development.  This is the role Dr. Martin, vetting these new treatments while weaving them into the critical path of next steps that Joel Embiid must now follow in adhering to his road to recovery.  As many watch events play out: an unassuming year with little news which preceded the Philadelphia 76ers hiring of Dr. David Martin, which preceded Joel Embiid’s second surgery, which preceded revisiting the discipline of the player after the first surgery to exploring the new rehabilitation track for Embiid, which preceded the first trip to Aspetar, which preceded Embiid’s return to the USA which preceded Joel Embiid’s second trip to Aspetar.

Got all that?  Well yes, it is somewhat confusing.

Next: Timeline

Timeline

Perhaps the best presentation for this is to list the key dates:

DATE:                               News Item:                                                 Narrative:

2010                                  Luc Mbah A Moute finds Embiid          Luc Mbah A Moute discovers 16 year old Joel Embiid playing basketball in Yaounde Cameroon.

Nov 13, 2012                    Joel Embiid commits to Kansas           Following advise of Luc Mbah A Moute, Embiid commits to Kansas University basketball program

March 11, 2014                Joel Embiid back injury                          Joel Embiid’s season ended prematurely with a back injury – a stress fracture in his lower back.

April 9, 2014                    Joel Embiid declares for NBA draft      Joel Embiid immediately projected as 2014 NBA draft top pick.

June 21, 2014                   Joel Embiid’s first foot Surgery             Surgery was performed by Dr. Richard Ferkel, a leader in foot orthopedic surgery

October 14, 2014             Arthur Embiid dies in Africa                  Joel Embiid’s younger brother, Arthur, died in Africa.  Joel, having spent four years in America pursuing his basketball career, had not visited his brother.  Joel’s sister, Muriel, also younger than elder Joel, flew to America to accompany her brother on the trip back to Africa to attend the funeral.

June 13, 2015                   Routine CT scan revealed regression   Routine CT Scan revealed bone healing had regressed, leaving site of surgery vulnerable to re-injury. Dr. Richard Ferkel diagnosed the regression, and alerted the Philadelphia 76ers.

June 15, 2015(est)          Hinkie flies w Martin Embiid                 Due to the nature of the news, Hinkie brought consulting Dr. Martin with Embiid to visit Dr. Ferkel.

June 29, 2015                   76ers announce hire Dr. Martin            Team hiring world’s leading expert in Sports Science and Medicine. First priority: Joel Embiid.

June-July 2015                76ers consult experts for advice             Team sought medical advice of world’s leading experts in case.  Rapid consensus that 2nd surgery needed.

July 4, 2015                      Sixers determine 2nd Surgery                 Team  summarized findings of a dozen or so of world experts and present to Joel Embiid.  Joel was given opportunity to ask     questions and absorb data.  Joel wanted to talk with players, 76ers wanted to assemble the surgical team.

July 11, 2015                    Sixers announce  2nd Embiid surgery    Sixers confirm report from Keith Pompey that Joel Embiid would require second surgery, this time w/ bone graft.  Projected          surgery would occur within seven to ten days.

July 21, 2015                    Embiid seen by TMZ with John Wall     TMZ ran into Joel Embiid and John Wall, Embiid in tennis shoes. Embiid replied “playing video games”.

August 15, 2015               Sixers announce 2nd surgery sched’d     Philadelphia 76ers confirm second surgery will be performed Tuesday, August 18.

August 18, 2015               Embiid 2nd Surgery                                    Embiid second surgery performed at New York City’s Hospital for Special Surgery.  Surgeons involved in Joel Embiid’s surgery  included: Martin O’Malley, Richard Ferkel, Dufetti Fufa, Jonathan Glashow, and Christopher Dodson.

August 19, 2015               Hinkie teleconference Embiid Surgery   Hinkie fielded a teleconference on August 19, 2015 to address the concerns over the situation and layout the timeline.  A 6-8 month recovery period is cited.

Aug 2015-Mar 2016        Joel Embiid’s recovery period.                 6-8 month recovery period begins.  Three weeks of hard cast followed by three weeks of supportive cast.  Team “ALL IN” on his recovery plan.

Nov 18, 2015                     Zydrunas Ilgauskas visits Embiid            Zydrunas Ilgauskas, an NBA veteran and survivor of a navicular bone graft surgery, begins series of visits with Joel Embiid during initial rehabilitation to the injured foot.  Ilgauskas brings a player perspective of someone who had been through it all to reassure a young Joel Embiid.

Jan 3, 2016                       Embiid spotted working out on court      Embiid took part in  agility drills after the Sixers’ shoot around at Santa Monica High School on Friday. Brown said that Embiid     also worked out on the sand of a beach.

Feb. 17, 2016                     Joel Embiid 1st visit Aspetar                     As a clinical segway  from recovery to proactive rehab, Embiid visits Qatar to attend rehab boot camp at Aspetar sports clinic.

March 2, 2016                   Embiid spotted shooting before game     Embiid was spotted shooting before the Philadelphia 7ers faced off against the Charlotte Hornets

March 19, 2016                 Embiid returns for 2nd Aspetar visit        Joel Embiid returns to Aspetar Clini in Qatar, this time he is accompanied by Dr. David T. Martin and other Sixers personnel.     Visit is slated for several weeks and perhaps up to a month.

So that is where we now stand. Seems like a long time for a foot injury, doesn’t it? Well, it’s not just any ole foot injury, and it’s not just anyone, but a potentially elite NBA star.

So what is really going on here?

Next: History of the Navicular Bone

The Navicular bone and its history

In the past, most foot injuries were not fully understood, and were  simply considered a simple “car repair” .  Surgeons bolted small foot bones together as best as they could and sent the athlete back out to smash the bone once more. The horror stories of the navicular bone recovery is not a distant memory either, folks.  There has been a history of this injury in the NBA for years, and the results have been mixed:

on the disappointing side, Bill Walton played in just 259 of the possible 738 games after his injury, while 7′ 6″ Yao Ming played in 82 of his possible 258 games

while on the more positive outlook, Kevin Mchale played in 419 out of  492 games and Zydrunas Ilgauskas played in 756 out of 902 games..

In recent years,  the treatment options have improved greatly. What have doctors learned about the injury?  Well, breaking down the components, there are three areas to be addressed in the injury.

The first is the diagnosis. Due to the area, and the complexity, of the injury, the imaging of the injury requires more detailed process. A simple XRay may appear completely normal. A true diagnosis can optimally be made with an MRI, a CT scan, or a bone scan. An MRI or a CT scan will allow the fracture orientation to be identified. In addition, those studies will allow determination of whether the fracture is complete or incomplete.

The second is the injury itself. Due to the location, size, and load bearing features of the foot skeleton, the slightest misalignment of any bone or bones in repair can be devastating. The injury is either “undisplaced” or “displaced”. In an undisplaced injury, the fracture occurs without reorienting the alignment of the bones. Simply casting the foot and staying off that injured foot for the first six weeks can achieve a 90% rate of fully healing after a four month process. Sometimes in an undisplaced injury, surgery is still the best option. This assures the bones remain in alignment throughout the time required to heal the fracture.

In a displaced injury, surgery is required.  The surgeon must now reduce the fracture (set it into exact position), hold it in place with screws, and introduce a bone graft to promote healing of the bone back to full strength.

The third is the vascular system – the blood flow system. The foot is not a well nourished area of the human body in terms of the blood supply it receives. It is at the farthest point from the life giving lungs and blood pumping heart, so it tends to be the least satisfied when the body is subject to any stress.  If you’ve stood outside in the winter for long, you may have experienced a pins and needles feeling in your foot.  That’s just the body cutting blood off to the feet so that more vital organs remain warm and nourished. But that blood is imperative to heal a fractured bone.   So what is there to do…. um… wait.

The struggle facing Joel Embiid and the Sixers with this injury is ensuring that good nutrition races to the injury site, while ensuring that toxins are eliminated.   That’s sports medicine.  That’s sports science.  That’s the brainchild of Dr. David T. Martin.

So what?  Well, research on slow healing bone fractures have shown remarkable improvement with a strict regiment of diet, fluid, supplements, and where appropriate, exercise.   Diet ensures a good healthy and stress free body.  Fluids ensure good blood flow and effective kidney functions.  Supplements ensure the injured area is getting a supercharged blood stream loaded with the building blocks needed to repair the  fracture quickly.  And finally appropriate exercise ensures that the blood is flowing to nourish the site.

After an initial healing phase with a cast, Embiid’s cast was removed.  As all signs were positive , Joel has graduated from a elevated cast, to a weight bearing cast with crutches., to  pain free ambulation.  Now he is learning an exercise routine, checking his progress, and receiving clinical confirmation that the injured site is fully healed.

Next: Why Aspetar

Why Aspetar?

Well, we had investigated the Aspetar Sports Clinic upon learning of Joel Embiid’s initial visit.  This is not just a hospital, but rather an intensive clinic which boards and monitors the 24 hour cycle of each and every patient.   More intensive than the individualized treatments available in most professional sports teams, this is a full room and board boot camp, designed to be a 100% controlled environment that measures inputs, outputs, activity, healing process, stresses, and graphical trends that can be tracked and analyzed.

The science and medicine for Navicular bone treatment must first focus on the cause of the initial injury.  In any stress fracture, the bone breaks due to unnatural forces acting upon it.  “Unnatural” in this case merely describes pressure coming at the foot bone from an odd angle, or from overexertion, or from hyperextension.

After surgery, the joint is immobilized until the site is no longer tender to the touch at the top of the foot.  This can take from six weeks to as many as twelve weeks to heal.   During this time, the joint must remain immobilized and in a full hard shell cast.   After tenderness fades, the foot can be freed from its cast and can begin the slow rehabilitation process.  Initially, walking with fully supportive footwear is sufficient, augmented by reverse gravity workouts.

ALSO ON SIXER SENSE:  Aspetar Holds the Key

But the challenge with Joel Embiid’s injury is more complex than just “fix it”.  It requires the team to retrain the athlete to avoid future events of stress, which has afflicted Embiid in both his back and foot.  To do so, the Aspetar Podiatry clinic gives more than just a menu, a list of exercises, and a farewell handshake.  The treatment plan there involves intensive massages to stimulate blood flow, recording the athlete’s body positioning through exercises while monitoring both the body stress as well as vital signs.

Joel Embiid is a very tall and athletic basketball player.  Over the course of his career, he’s learned to command his body to respond to a basketball game, but seldom had training in the proper way to make his body respond.   Recall the Jedi Master Yoda’s reluctance to train Luke Skywalker?  “he is too old to begin the training.”   Well Joel Embiid is not too old, but he must unlearn improper techniques.

Right now, Joel Embiid must adhere to proper training techniques.  Training errors in terms of technique or over training should be identified and immediately corrected.   During this learning process, a podiatrist can check if there are any bio-mechanical factors such as over pronation of the foot which should be corrected with orthotic inserts in the shoes.  Tarsal coalition where the tarsal bones fuse together as well as restricted dorsi flextion of the ankle will also make the athlete more susceptible to a future navicular stress fractures.

Aspetar personnel, monitors Embiid’s jumps, stops, starts, pivots and gate.  The podiatrist reviews the data from his jumping exercises, and then directs the proper inserts to mitigate any over stress going forward.  Somewhat like getting corrective lenses to fix poor vision.  The several weeks is to run Embiid through the entire gamut of exercises in order to instill proper techniques and create the proper aids to ensure that his body mechanics optimize balance of pressure across the entirety of his feet.

Next: Weird Science

Weird Science

Sometimes I get a tad “meditechnical” when facing the issues the team is confronting with Joel Embiid’s condition.  This slide entitled weird science is for those who want to know more about the science of the treatment.   If you are not one of those types, simply hit the “next slide” and you will emerge at more basketball related conversation.

The basic path of Joel Embiid’s treatment is to engage in vigorous exercise, be monitored as to his body’s reaction to elevated exertion, and then acting to eliminate any anomalies.  But to say that the treatment at this point is entirely just made of running, jumping, massaging, and graphing the trends as they devellop is simplistic.  There exists a wide arsenal of treatments to promote more rapid and thorough recovery. Let’s examine a few of the most recent developments such as PEMFs, ESWTs and PRPs.

One such alternative method of treatment is known as Pulsed ElectroMagnetic Fields (PEMFs). They have been shown to promote rapid healing in parts of the body with limited blood flow.  This technology is widely accepted in equestrian care, as it is often used to heal similar injuries in race horses.  In this type of therapy, insulated coils of wire are place on or around the injury site.   When current is turned on, the coils become a low intensity electromagnet, stimulating the injury site.

Extracorporeal Shockwave Therapy (ESWT) is another cutting-edge treatment which shows promise to help improve healing times for stress fractures.   This type of treatment has grown popular with ballet dancers, who often suffer from foot injuries, but cannot risk long rehabiliation periods to recover in a traditional manner.  In this treatment, sound waves or low intensity ultrasound waves are focused upon the injury site.

Another area of interest is the use of Platelet Rich Plasma (PRP).   In this treatment, whole blood is taken directly from the patient where it is processed to concentrate platelets.  This platelet enriched blood is then used directly at the injury site, flooding the area with platelet enhanced blood. Although evidence suggests that PRP is safe and can promote bone formation, the strategy is designed to promote healing of the surrounding connective tissue as well.

But there continue to be pitfalls in care even as technology offers several new and effective options.  That  is why the team has elected a very conservative approach of engaging a fully intensive rehabilitation therapy at this vulnerable stage.

As I was investigating Navicular stress fracture, my research uncovered a similar type ailment to bones of the human foot, and can occur after a bone suffers stress fractures – known as bone marrow edema.  This is a relatively new medical terminology, only made possible with the advent of superior imaging equipment such as the magnetic-resonance imagery (MRI).  In essence, the bone marrow of an injured bone separates from the calcified bony shell, showing up as a white patch on the normally darker imaged bone.  That separation is considered part of a recent terminology “bone bruise” and can result in swelling of tissue inside of the bone.  That swelling appears as a gap between a bone and the bone marrow, and results in pain prolonged pain to the victim.  Since the symptoms are virtually identical to that of a patient recovering from Navicular stress fracture surgery, the only distinction is the use of advanced imagery equipment.

Once diagnosed, the bone marrow Edema can be treated with multiple infusions of 50 µg of iloprost given over six hours on five consecutive days. Iloprost is a drug used to treat the constriction of blood vessels, which prevents blood flow to an injury site.  If caught early, full recovery is expected.  That could explain the nature of the second visit, to eliminate any complications in the rehab process.

Next: When Can We Cheer?

When can we cheer?

Welcome back to the “don’t tech talk me to death” folks!  To those who braved the last slide with me, I salute you.  Now, back to the matter at hand…

To say that the most recent trip is simply a very accountable team showing extreme responsibility to their marquis player is probably the most accurate answer from what we know right now.  But that’s as mysterious as it gets.   There are many pitfalls to the rehabilitation of a tall young man in a very demanding sport trying to re-inflate a flat tire.   The team simply wants to be certain they get it as correct as possible.

Suffice it to say that Dr. David T. Martin is very focused on the first NBA player’s health for which he is responsible.  Since Martin’s arrival on this team, he has been overseeing one of the most publicly followed medical case in modern history.  As such, he is being as cautious as new parents are with their first infant.

But even after the medical team signs off on the NBA prospect, there is a matter of over two years time.  Joel Embiid stopped participating in organized basketball play on the court on March 11, 2014.  Since that time, it has been gymnasium shooting drills, rehabilitation, and mentally following the game of basketball as best as he can.

Rust is bound to happen.

But that shouldn’t translate into pessimism either.  Not with perennial optimist head coach Brett Brown on the loose:

"“We got the third pick (in the 2014 draft). I’m sitting there and Sam Hinkie said Joel Embiid has been injured and there’s a chance he will fall to three,” Brown recalled. “You step back and get a little excited. I felt what I saw was special and unique. Seeing the skill package of such a young big man, he hadn’t even played that much. Big people develop late, 28-32. Look at that time range for the development of a big man. See the competitiveness and skill package. Zoom in. I think Jerry Colangelo said it best — that’s a high-class problem. Joel coming back will be a challenge in that he hasn’t played basketball for two years. For us to expect immediate results would be naïve. I say that because inevitably there will be minute restrictions with what we expect. How they (Embiid, Noel, Okafor) co-exist is ever present. It’s the most asked question I get. And how long is it going to take? I answer it freely that way because it’s the truth. Time as it unfolds will better direct us.”"

And so, the reality is that even as he comes back to us healthy, we have no way of knowing what we get. That’s not necessarily a bad thing, as it means that the powers that be will not make any moves in the front court for now. That means Jahlil Okafor and Nerlens Noel have a new lease on life together for next season, until the team can sort out which of the pair can play better with Joel Embiid.

But this is a Joel Embiid article after all, and with that comes the mandatory youtube footage of a young man with little formal training shooting the lights out with a basketball.  So with no further adieu, let’s roll the tape!

The Philadelphia 76ers are not dependent upon the return of Joel Embiid. Certainly his arrival next season will add to the optimism, and the first time he sets foot onto the court in Philadelphia will most assuredly be standing room only. But as far as the #TrustTheProcess plan? Not dependent at all. What has happened in his off-court career is that the city of Philadelphia has fallen in love with the charismatic Cameroon. It’s just that plain and simple. And with an fan base enamored with the trials and tribulations of a young man who is now over two years of playing the game he loves, there is certainly an entire city hoping for the best for him now.  It’s not hype, although it will be interpreted as such by those unconnected to the team.

It’s simply hoping for the best for him.

Next: Ben Simmons Reportedly Hired An Agent

In the words of Brett Brown:

"“We are going to be doing something that we haven’t done yet,” coach Brett Brown said. “Like I feel like the rebuild as people know it, the severe rebuild as we have known it, those days are done. Now what that place means in a quality of wins, we don’t know. We don’t know who the team is yet. But the path and the plan will take a left turn in a more legitimate way in trying to build it in a more expedited way.” – Brown as interviewed by Keith Pompey at Philly.com"

And so, the young man and an entourage from the Philadelphia 76ers are navigating the perilous journey from recovery to an NBA basketball court.  Eventually, that journey will end up on a basketball court.  Right now,  the basketball court doesn’t hold much joy for the Sixers.  But perhaps it’s the journey of Joel Embiid that will not only bring him to his dream, but will restore the dreams to the city of Philadelphia.   At least, with a story unfolding like this one has, a happy ending only seems fitting, doesn’t it?