An orthopedic surgeon explains Joel Embiid's reported meniscus injury

Given the way the last decade has unfolded, a medical degree might have been more useful than journalism school for covering the Sixers. On Saturday afternoon, new reporting from The Athletic suggested that Joel Embiid’s latest injury is a “displaced flap” in the meniscus of his left knee.

Meniscus injuries are somewhat tricky, which is why PHLY reached out to Dr. Christopher Selgrath, an orthopedic surgeon specializing in knees and hips at 3B Jefferson Orthopedics. He discussed the potential paths forward for Embiid, why the Sixers might be weighing multiple options, and more. That interview is contained below.

Disclaimer: The views and opinions expressed in this article are those of the author and guest authors and do not reflect any official policy or position of any NBA team or a team’s athletic physicians.

What is a displaced flap of the meniscus, and what are the practical effects it has on the knee?

So first, your meniscus is like a shock absorber, a type of cartilage in your knee. It acts like a shock absorber to protect the other cartilage in your knee, which on the end of the bone is called the articular cartilage. You have the articular cartilage on the end of your bones, when that articular cartilage wears away, that’s arthritis.

To spread out the force, or dissipate the force in the knee, the meniscus is like a C-shaped ring, you have a medial meniscus on the inside and a lateral meniscus on the outside. And then when you weight bear, the idea is that the meniscus is like a shock absorber and spreads out the force or dissipates the force to protect the articular cartilage.

In his case, he tore his meniscus. So one, whatever portion of it that’s torn is not really going to work anymore. And the reason I start with that is because then one of the options is surgery, which is to go remove that flap, that tear of the meniscus.

The best analogy I give patients is that it’s sort of like a hangnail, right? You have a hangnail, a little flap. Sometimes it’s sitting exactly where it’s supposed to sit, and not going to bother you. If you push away from your nail, you pull against your nail and you irritate it, it hurts. So that’s likely what’s going on with that flap.

He could have had that for a while now, that could have been his ongoing injury. And he’s been playing through it, it’s bothering him now and then. Sometimes the flap is sitting where it’s supposed to sit, and everything’s fine. Other times, it’s flapping around in there, and it’s going to cause a lot of irritation, pain, and swelling.

Based on what you said, there seem to be multiple recovery paths. How do you determine the appropriate recovery plan? How often is surgery typically recommended?

The gold standard mainstay of treatment is non-operative. So if it was you who walked into my office, I’d say, “Hey, non-operative treatment is the way to go. Give it six weeks, do some physical therapy, try to strengthen the muscles up around your knee, and give your body a chance to calm down.” And that’s been shown to lead to a course of being symptom-free.

The meniscus doesn’t have a good blood supply for the most part. So it doesn’t necessarily heal. People will ask, “Well, am I going to heal in six weeks?” I’d typically say, well, you’re not really going to heal. You’re just not going to be symptomatic in six weeks. Right? There’s a difference there.

So that meniscal tear for the most part, once it’s torn, it’s torn. It’s not mending back together. It’s not like cutting your skin. Torn is torn. It’s just that in some patients — we know because we study it — with physical therapy given six weeks, the pain goes away and they go on living life and participating in sports and don’t have any trouble.

The next group of patients, you do the same thing because we always recommend non-operative first. That person gets better, but then they go back to sports, and two or three weeks later, they go right back to where they started from again. The knee swells up, it hurts, gives them pain. So then you start again, alright, here’s your options. We can try to wait it out again another four to six weeks, or usually at that point, most people are like, well, wait a minute, I already failed that. The next course of action would be to do surgery, do arthroscopy. Go in there and just cut out that piece of the meniscus that’s torn.

You sort of touched on it there, but if they decided in the next few days that surgery is the route to take, what does a timeline for that look like?

I’m assuming it’s non-repairable, which it most likely isn’t, I’d say there’s a 99% 98 99% chance it’s a non-repairable tear. Some tears, we can repair if it’s a very specific tear around the rim of the meniscus because there is a little bit of a blood supply there. So in a case where a meniscal tear has been shown to be repairable, you’re looking at six months of recovery, right? Six to nine months.

Moving that aside, the big question that they’re going to have and what Joel along with most patients have is, “Hey doc, I need to get back to work, or I need to get back to my sport in the next four to six weeks. And you’re telling me if I do physical therapy, and I wait this out six weeks, there is a chance that in six weeks, I’m going to be right back to where I started?” And I’m going to say yes. Then we’re going to do surgery, and roughly speaking then that’s four to six weeks of recovery.

So the big question then is where high-end athletes come in and we talk to people, they could be not only a pro but a high school or college kid, say they have a state championship you want to play in. You’re throwing the medicine aside, the medicine answer is to wait six weeks, and do physical therapy. On your boards, that’s the board answer. But a high-end athlete trying to win a championship, he might not want to potentially waste the six weeks. And now he’s taking a risk that technically he doesn’t have to take, but he’s choosing to take.

That’s where it gets a little controversial, the patient could say I don’t want to wait six weeks, I think I’m going to fail. I would tell them, I don’t have a crystal ball, the problem is we can’t identify up front who succeeds with non-operative treatment and who doesn’t. The only way you’d know is to take 100 people, throw them in physical therapy, and see that maybe 80, or 85 of them don’t need surgery. So they’re contemplating doing surgery to get him back sooner, and you might not have to do surgery.

The surgery we’re talking about here is a removal, right?

Yes. 98-99% of the time, we’re doing a menisectomy, cutting out that portion of the meniscus that’s torn.

Embiid had a previous meniscus injury that was operated on in 2017 [Editor’s note: Embiid’s surgeon at that time said in a statement this was a removal operation], and was in the same knee. If someone has had a removal surgery in the past, are there any additional risks from having another? Are you any more exposed to things like, for example, arthritis?

Great question. The answer is no because whatever portion of the meniscus he tore, let’s just say it’s 20% of the meniscus, that meniscus is no longer functional. So whether you leave that in there, and it remains symptomatic, or I do a menisectomy and cut it out, you’ve lost 20% of the function of your meniscus.

I’ve actually had it done three times myself — they went back in, cut out a percentage of it, went back in, another percentage of it. This means I have a much smaller percentage of my meniscus left, which isn’t great, but it is what it is. He tore it before, he could have lost 10, 15, 20%, now he tore it again, let’s say he’s potentially lost another 10-20%.

The problem for his future, yeah, that’s not great. The less function you have in your meniscus, if you’ve gone from 100% to a much lower percentage, that’s a risk factor for developing arthritis. Now, it might not happen for two years, three years, 10 years, 15 years, we don’t know, but it’s definitely a risk factor for developing arthritis.

And to be honest, it’s a risk factor just for your knee not feeling right. I think that’s kind of what they’re contemplating. They’re likely just weighing and saying, “Man, if we wait six weeks and this doesn’t work, he could be done.” You’d go three months or so out — let’s say you wait six weeks, he comes back, plays a week, boom, it bothers him again and swells up. He’s in pain. Now you scope him, that puts you at roughly 13 weeks from today.

On that timeline, you’re probably talking about a return in the middle of the second round.

That’s their dilemma, right? They’re probably looking at that same timeline saying alright, we go non-operative, and if that doesn’t work, he’s basically done and he’s not coming back. And then you throw in, I say six weeks, that’s just you can go back and play. But you’re likely not going to be at a pro level. It’s tough to keep your cardio up when you can’t move your leg. You can do upper body and all that, but cardiovascularly, he’s going to have trouble.

So I think that’s their big dilemma, is they wait and it doesn’t work, and then he does surgery. Good chance the season’s probably scrapped. Versus saying hey, let’s jump in and take care of it in six weeks, eight weeks on a very conservative timeline, and then they make a run at the playoffs.