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April 25, 2023

Orthopedic surgeon explains timeline, risks, and treatment for Joel Embiid's knee injury

How will Joel Embiid and the Sixers navigate the star center's LCL sprain? Dr. Christopher Selgrath from Nazareth Hospital offers some insight.

What do you do when Joel Embiid has another injury in the playoffs, is in doubt to be available for round two vs. the Celtics or Hawks, and you don't have a medical degree or trust WebMD enough to write an article? You call an expert who actually knows what they're talking about.

It was reported earlier this week that Embiid has an LCL sprain in his knee. On Tuesday afternoon, PhillyVoice spoke to Dr. Christopher Selgrath, the Chief of Orthopedics at Nazareth Hospital and an orthopedic surgeon at Nazareth Orthopedics. We discussed the LCL's importance to the knee, the recovery process, how the series schedule could impact his health, and more. Our conversation follows 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.

Explain to me what the LCL's role is in the knee.

Your knee has four major ligaments, one of which is the lateral collateral ligament. That's on the outside part of the knee, and that prevents the knee from gapping open if a force was applied on the inside part of the knee. The other major ligaments are the medial collateral ligaments and the two cruciate ligaments [anterior cruciate ligament and posterior cruciate ligament]. So the LCL is one of those four major ligaments that provides stability to the knee.

What are the types/grades of sprains and how does a recovery timeline change based on the grade?

It could be mild. We usually grade them one through three. One would be a mild sprain, up into a two, followed by a three which would be a complete disruption of the actual ligament. 

If we look at a physical exam, think of a ligament like silly putty. It stretches out a little bit, so we can test that on a physical exam to see if there's a little laxity there. That's one way to determine the grade and say if this is a mild problem, a moderate problem, or a severe problem. Then when you get the MRI, you can look for different hints and criteria. Is there fluid – they probably saw fluid around the lateral collateral ligament, and that's where they would come up with, we think he sprained his LCL. And then you could determine, an MRI is the test to see if it's completely torn. 

If it's a mild sprain, you can be better as quickly as maybe 10-14 days. If it's a really bad sprain going into that Grade 2, you're looking at four weeks of some irritability, and then if it's a Grade 3, you're looking at over 6-12 weeks probably. 

How do you go about taking what you know and turning that into a plan/timeline? 

The big question is, one, how much instability he has and what that MRI looks like, but then he obviously wants to play, and people want him to play, but you're doing two things. 

One, the ligament's already injured, so it's already a little compromised. You don't want to turn a Grade 1 sprain that if you didn't do anything – arguably if it wasn't the playoffs, he wouldn't play. You don't want to turn that into a Grade 2 or 3 sprain. Because then if it's a Grade 3 sprain, he completely tears everything, now you're looking at long-term not only recovery, three or four or possibly five months, and you might need reconstructive surgery. They're walking a fine line when it comes to allowing him to play and in what capacity. 

Now, they have maybe a week maybe more given the Boston series, so that'll help, he'll have had one week of healing. And then you're left with probably reevaluating him. You could use a brace, braces are hit or miss. Sometimes they're useful, sometimes they're cumbersome, and sometimes they're maybe more trouble than they're worth. But you could argue to maybe use a brace and that can give him some external stability to try to make up for the internal laxity and compromise of that ligament. You deflect some of the force away from that ligament. 

What is the typical recovery process/treatment for an LCL sprain? 

We're much better at functional recovery, we've learned from our mistakes that we don't like to immobilize people if we don't have to. We want, you know, ligaments are dynamic. A lot of times in the past we would immobilize you in extension, your knee's straight, and that just tightens up the ligament, because when you bend your knee your ligament stretches out a little bit.

So we've learned that we're much better off leaving you [in position] to move the knee and protect you. If it hurts to walk on it, then use crutches, if it doesn't hurt to walk on it, you don't use crutches. And then just using a common sense approach of being careful, whether it's stepping off of a curb, going up and down steps, we don't want you to reinjure, tweak, twist, or turn it to cause some increased compromise.

The true treatment would be increasing his dynamic stabilizers of the knee, which are the muscles. If you can get those muscles pretty tuned up, which they probably already are because it's mid-end season, you'd want to keep those muscles strong. They're there to help to support the knee, they're called the dynamic stabilizers, versus that ligament is called a static stabilizer. You can't really work on the ligament outside of maybe some ultrasounds, stuff like that, to try to get some penetrating anti-inflammatory effect. 

Otherwise, you're just letting your body heal and it's an incredible healing machine. It's just that it takes a little time, and it could heal as quickly as a week or two, but it could drag out maybe three to four weeks.

The Sixers essentially have two different series scenarios in front of them. They could start sooner (Saturday, the 29th) while having a longer break between Games 2 and 3, or they could start later (Monday, May 1st) with the consequence being they play every other day for most of the series. Do you think one of those outcomes is better from a medical perspective, or do they stack up the same?

It's a good question. I think scenario one's pretty good in that I think you could argue, you're gonna have to decide do you hold him out maybe a game or two with the hopes that you maybe split? And then you have him back at let's say 90 percent, versus getting him back early at 60 percent. And that's sort of the challenge there – do we let the athlete back knowing he's 60-70 percent when it comes to a performance level, and then you're left with not just performance, but we're worried about reinjury, or something bad happens.

You're kind of looking at that and saying, hey, I think you're probably going to be about 60-70 percent, and I think there's a 50 percent chance you might tweak your knee. Well then if we hold you out two games, which is in this case maybe 5-6 more days because of that scenario, now maybe your performance will be 90 percent, and I only think you have maybe a 5-10 percent chance you're going to reinjure your knee. That's what you're sort of playing around with.

There's no crystal ball, but that's what's in everyone's head. What's his performance going to be, and what's the likelihood he's really going to really hurt his knee? There's no great answer to that outside of taking it day by day, keep examining him, and see how he feels. 

A patient's pain is a great indicator of how they're doing compared to re-MRIs and stuff like that. It's really if in 3-4 days you re-examine him and he's got no tenderness around the LCL, there's still arguably a little laxity but his pain is completely gone. That's a great prognostic indicator that he's really healing, and it's healing pretty quick so you can be a little bit more aggressive with that. But it's one of those things where if it still hurts and you see him still limping around wincing, it's not a great idea to let him play, right? 

What are the biggest risks associated with playing through an LCL sprain? 

One, you're going to make this Grade 1 sprain into a Grade 3 sprain. And again, your knee is a four-ligament system. You've got this one ligament's compromised, not only could you make this ligament worse, you could hurt one of the other ligaments because they're all trying to help out and there's not as much stability to the knee. 

Or, you could tear the meniscus, again because of the lack of stability to the knee. 

So you're really going through everything from making this one LCL injury a real bad injury to compromising the other ligaments in your knee, and the third thing would be to tear your meniscus in your knee. 

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