Doctors discuss ‘radical’ surgeries for Joel Embiid that could sideline him for as much as a year

For the first time since he became the face of The Process, Joel “The Process” Embiid got benched. He didn’t play in the fourth quarter Saturday because the rest of the team was better without him. That the rest of the team included Quentin Grimes, Guerschon Yabusele, and Ricky Council IV should underscore just how badly Embiid had played.

He wasn’t injured, but he was hurting, in more ways than one. His onerous left knee was hurting, and the seven-time All-Star was hurting the team. He’s averaging 23.8 points, shooting 44.4% from the field, hitting 29.9% of his three-pointers, and pulling down 8.2 rebounds in just 19 games of arguably the worst of his nine seasons. Coach Nick Nurse couldn’t beat the depleted Nets with Embiid on the floor.

Things have gotten that ugly.

They might get much uglier soon.

» READ MORE: Is Joel Embiid injured? We’re tracking his current status and injury history.

The original plan was to let Embiid get used to playing with pain, the way Dwyane Wade did during his Hall of Fame career, regularly draining the knee and injecting it with platelet-rich plasma. Sixers doctors and experts interviewed by The Inquirer considered this the best way for Embiid to rehabilitate the injury for the long term. Once it reached a certain point of healing, resting the knee would not help it recover; it would, in fact, hurt it.

However, it has been several weeks since Embiid has gotten better. Lately he’s gotten worse. NBA sources say the big guy has become morose about his latest injury battle as a series of ominous options looms — options that could cost him the rest of this season and maybe some of the next.

The same Sixer who made “orbital bone fracture” and “navicular bone fracture” common phrases in Philadelphia sports lexicon — he’s had two of each — might soon add one of these: meniscus replacement; low-dose radiation therapy; or even the ominous-sounding osteotomy, in which doctors break a bone in the hip to realign the joint to alleviate pressure.

One source called the procedures “radical” in light of the mundane injury and surgery that brought Embiid to this point. For some reason, what should have been a routine rehab and a routine return to play has gone horribly wrong.

Doctors with whom The Inquirer spoke over the past weeks say that some of these procedures require six months to a year before an athlete can return to full action, and that any return will invariably come with long-term limitations.

No wonder Embiid didn’t want to talk about it after Saturday’s game.

During the fourth quarter Saturday, Embiid iced his knee, most recently repaired last winter after an opponent fell on it. Embiid appeared to aggravate the knee in the third quarter Saturday.

» READ MORE: Paul George’s first season in Philly has been a disaster. Should Sixers still hold out hope or shut it down?

When he reported to practice Sunday, he told team medical staff that the knee felt sore, and when they saw he had suffered swelling overnight, the team ordered a comprehensive set of new images. The new tests will not be fully digested by Embiid’s doctors until Monday evening. He was ruled out for Monday night’s game against the visiting Bulls, and team sources say he isn’t expected to play in any other game in the near future.

Embiid suggested two weeks ago that he might need more surgery on the joint, then reiterated that stance after the Sixers lost to the Celtics on Thursday: “I probably need to fix the problem and then I’ll be back at that level.”

However, a source said, until this weekend, another surgery has never been a serious option. Embiid’s recovery has been slow. It possibly was impeded by playing in the Olympics. It surely was impeded by him reporting to training camp in less than optimal shape. It also was impeded by him spraining his left foot against the Celtics on Christmas Day. This last issue gets to the heart of his planned recovery.

After getting his meniscus trimmed and then stitched back together — knee cartilage generally does not regenerate — Embiid’s best possible outcome involved letting his body adapt to the new reality of the joint. That meant playing through pain.

It was always going to be an uncomfortable and inconsistent road back, said Dr. Fotios Tjoumakaris, a sports medicine surgeon at Rothman Orthopaedics.

“I’ve had patients who went through these periods where the knee would swell, and we’d sort of manage the swelling. As they got further out from their injury or from a surgery, the knee acclimates,” Tjoumakaris said. “Our bodies are tremendous at their ability to adapt. So, you might build strength. You might recover to where the knee gets more comfortable with a little bit of fluid in it and the muscle doesn’t react so much, and the muscle can maintain strength.”

Tjoumakaris does not treat Embiid, but Sixers sources over the last month have confirmed that Tjoumakaris‘ expertise was accurate in regard to Embiid’s specific situation.

» READ MORE: The Sixers are still feeling ramifications of the failed Al Horford acquisition

Embiid’s recovery was approximately on schedule at Christmas. The foot injury cost him six games, but it likely did not exacerbate the knee issue, and it likely will not complicate matters in the future, said Dr. Selene Parekh, who also is a surgeon at Rothman, and who specializes in foot and ankle issues.

“If it’s a true foot sprain, it’s a few weeks and it’s done,” Parekh said. “If there’s any relationship back to the knee injury, did it change the mechanics and set this up to happen? Who knows?”

NBA sources say the Sixers know. Parekh also does not treat Embiid, but a Sixers source said there is no evidence that the sprain affected the knee either immediately after the sprain (he played in five of six games immediately after the injury) nor since it healed.

It seems clear that the sprain stalled the knee’s acclimation process by about six weeks.

After Embiid’s season started, things looked promising. Embiid missed the first nine games of the season between the knee problems and a suspension, but once he was cleared, he played in 13 of 24 games, which was about what Sixers doctors hoped for, which Tjoumakaris endorsed.

However, since the lingering foot sprain finally sidelined Embiid on Jan. 5, he has played in just six of 22 games.

The Sixers have lost the last five of those games.

If all of this screams “deception” on the part of the Sixers, well, that’s partly fair. They expected Embiid to report to training camp fit and nearly fully recovered, but he was not close to either, and they declined to admit this until the season was about to begin.

Since then, they’ve hoped against hope that the knee and his body would naturally become accustomed to whatever his availability and ability might be. Unfortunately, at this point, his ability has diminished to the degree that his availability is basically irrelevant.

» READ MORE: As Joel Embiid talks about surgery and the Sixers look lifeless, the schedule says to tank the season now

That said, should they abandon all hope for this season?

Should they shut down Embiid? He will be 31 next month, and they just extended a contract that now is worth almost $250 million over the next four seasons.

Should they shut down Paul George? He will be 35 next season, and he will have a contract worth $162 million over the next three seasons. George, like Embiid, has been chronically injured the last few seasons, has missed 19 of 56 games this season with various injuries, and is having his worst season since 2012-13, when he went to the first of his nine All-Star Games.

Shutting down two future Hall of Fame players with 26 games to play would give the Sixers the best chance to land a higher draft choice, but they only retain their first-round pick this season if it lands among the top six picks. Because of the NBA lottery — a system engineered to discourage tanking, thanks to the Sixers’ abuse of the system during “The Process” — even if the Sixers have one of the six worst records, they aren’t guaranteed to pick sixth or worse, and the pick would go to Oklahoma City.

At some point, the Sixers owe the Thunder a draft pick. This year might not be a bad one to let it convey. For better or worse, Embiid, George, Tyrese Maxey, and injured rookie Jared McCain will likely be the focal points of the team for at least the next three seasons.

So no, they shouldn’t tank. Not unless the results from Sunday and Monday’s exams indicate that Embiid desperately needs surgery.

If doctors determine that Embiid just needs more time to get used to his new normal, then that’s what should happen. If he is structurally sound, then he has to get used to playing more conservatively until his knee can handle more stress.

Finally, whether or not he undergoes one of the radical procedures now on the table, Embiid must accept that his days of flying into the stands for loose balls, leaping out of bounds trying to block shots, or charging down the lane for monster dunks are days gone by.