Joel Embiid’s Back Injury

Arguably the biggest news story in the Kansas City metro of late is the injury that has sidelined KU’s stud big man Joel Embiid.  KU fans are literally freaking out.  We are continually asked by KU fans about the injury, how long he’ll be out, what the rehab is like, and if he’ll be ready for the NCAA Basketball Tournament.  People have called to ask us to opine about it, so maybe this entry will help.  It is important to note that we don’t know the extent of his stress fracture or if it spans more than one vertebral segment.  The good news for him is that the treatment for stress fracture is non-operative with excellent results, with asymptomatic return to full activity in 70-80% of cases, especially in sports that don’t require excessive extension and/or rotation of the spine (Blanda et al, 1993, Congeni et al, 1997, Bell et al, 1998, Doubousset 1997, Pizzutillo & Hummer 1989, Steiner & Micheli).

 What is a stress fracture?

A stress fracture in the spine is typically a defect in the pars articularis or the “pedicle” of the vertebrae (see figure below).  It’s a narrow part of the vertebrae that is susceptible to injury.  The overall incidence in elite athletes is about 7-8% (Stanitske et al, Oper Tech Sports Med 2006), but is overwhelmingly more common in gymnastics, weightlifting, wrestling, and American football.  Female gymnasts have been reported to be at 4x higher risk than males.

What causes a stress fracture in the back?

Most stress fractures are caused from repeated extension (backward bending) and rotation.  That’s why it’s so common in sports like gymnastics, wrestling, weightlifting, and football due to those movements being performed repeatedly.  It’s also common in soccer because one foot is typically planted while the other is kicking, which causes asymmetrical torque along the spine.  In Joel Embiid’s case, his injury is likely a combination of the repetitive pounding from running and jumping as well as the fact that he is so tall – his lever arms are longer than someone who is shorter.   There may be a component of what is known as a “fatigue fracture” in that the bone is just losing the battle against the stresses he has to sustain.  Oddly enough, stress fractures in the back aren’t nearly as common in male basketball players as they are in the 5^th metatarsal of the foot or the tibia.

What are the symptoms?

Truthfully, pain is the biggest one.  There may be some local tenderness and resulting muscle tightness, but for the most part, it just hurts to do things.  Even bending over to put on socks or tie a shoe can be painful.  Some people may argue for him to “suck it up, it’s tournament time,” but that’s incredibly short-sighted and selfish.  This can be a debilitating injury and he has a bright future ahead of him.  Only he knows how bad it is and how much he can tolerate.

How long does it take stress fractures to heal?

Well, this is a difficult question because the main thing someone battling a stress fracture needs is rest.  Most studies that follow stress fractures of the spine long-term are evaluated about a year after injury (Michielsen et al, Eur Spine J 2001).  That said, most fractures heal in 4-8 weeks.  In an ideal world, Joel would just rest until the X-ray showed adequate healing and he could go back to playing.  However, this is about the worst time of year possible for a basketball player of his caliber for that caliber of a program to have a stress fracture.  There’s an old adage in sports medicine that no one gets better during the season.  You manage during the season and heal after.  His injury is definitely one of these cases.

What’s the rehab like for a stress fracture?

Modified rest is the key here.  So, it doesn’t mean that he’s just lounging on couch.  It just means that running up and down the court is not in his best interest.  If he was rehabbing with us at SSOR, here’s what we would do.  If he was in the off-season, our approach would be a little different, but if he walked in our doors today, here’s what we would do:

1. Maintain his cardio.  We would either do the stationary bike, arm bike, elliptical, or deep water running depending on what he could tolerate to keep him in as good as shape as possible.  The key is non-impact.
2. Get in the pool!  The pool is a fantastic tool for rehab.  It will “unload” his spine and still allow exercise to occur so he can get as strong as possible without the strain on his bone and soft tissues.
3. Stretch and do soft tissue work to needed areas.  Without evaluating him, we don’t know what’s tight or what’s tender, but this is critical to help reduce pain and increased mechanical holding of muscle.
4. Make sure his hips and thoracic spine are in good shape. A healthy lumbar spine requires mobile, stable hips and a mobile thoracic spine.  Otherwise, the lumbar spine has to work harder and get beat up more.  This can be addressed in more detail in the off-season, but any restrictions should be addressed and will at least help a little.
5.  Core stability exercises as tolerated.  Doing endless crunches or medicine ball tosses will not help him right now.  He needs to be make sure he can breathe and stabilize his spine correctly first, then keep his spine stable while moving his arms and legs.  We would start in supine, then move to quadruped, then tall and ½ kneeling, and eventually standing.  There’s a host of exercises we can do where his back isn’t moving but his extremities are.  Numerous studies have shown increased core muscle activity with movement of the extremities alone, and several studies have shown the benefit of therapeutic exercise for stress fractures (Lindgren et al, Arch Phys Med Rehabil 1993, Nelson et al, Orthopedics 1995, O’Sullican et al, Spine 1997, Sinaki et al, Arch Phys Med Rehabil 1989, Spratt et al, Spine 1993).

Things like heat, ice, or ultrasound may take the edge off but are doing nothing for his healing.  In more superficial stress fractures like in the 5^th metatarsal in the foot or the tibia, bone stimulators may help but in this case because of the depth of the injury, they are not likely to help (although we wouldn’t be surprised if they are using one – in urgent cases like this, it’s not uncommon for a sports medicine staff the throw the kitchen sink at an injury!).  We’re sure he’s on painkillers already.  Hopefully, he’s not doing too much with anti-inflammatories as research has shown recently they can actually delay bone healing.

So will he play or not?

Without knowing the details, it’s extraordinarily tough to speculate on this.  If we were to bet, we’ll see him for sure in this tournament.  It may not be the 1st round or even the 2nd round, but if KU makes it to the Sweet 16, we should see him on the court.  Hopefully, they won’t need him until then.  If he does play in the early rounds, expect marginal minutes to see how he handles it for one, and two, to get him back in game shape.  Don’t freak out KU fans if they pull him – sometimes it’s just to keep him fresh and prevent him from regressing.
We hope Joel Embiid has a healthy, speedy recovery because he’s a vital part of KU’s team and their success (or potential lack thereof!) in the tournament.  At this time of year, you want everyone operating on “all cylinders” so the best of the best are left at the end.  Good luck Joel, and get healthy!