Another year, another 76ers rookie going down with injury – this time it was 16th pick Zhaire Smith who suffered a reported acute Jones fracture of his left foot (first reported by Shams) while attending Tim Grgurich’s legendary development camp in Las Vegas.
Sources: Philadelphia 76ers rookie Zhaire Smith has suffered a fractured left foot. Smith, the No. 16 pick in the Draft, hurt his foot on Monday in Las Vegas during a developmental camp for NBA players.
— Shams Charania (@ShamsCharania) August 7, 2018
This fracture of Zhaire Smith’s foot was confirmed by imaging (most likely on x-ray because it detects bone abnormalities whereas MRI detects soft tissue abnormalities like muscle, ligament, tendon, cartilage injuries) and underwent successful surgery on August 10th.
The Sixers are intimately familiar with foot injuries – both Joel Embiid and Ben Simmons missed their rookie seasons after suffering foot injuries. Will Zhaire Smith share the same fate?
Before I give my two cents on that, let’s explore the injury itself (it’s the journey that counts right…*scrolls to the end*):
- What a Jones fracture is
- What the surgery entails and why it’s needed
- The rehab process
- The recovery timeline
I. Zhaire Smith Jones Fracture: Who Is Jones and What does He Do?
A Jones fracture refers to an acute (immediate) fracture of the proximal fifth metatarsal diaphysis (the base of the long bone of the small toe).
Here’s a picture of the foot and bone to give you a visual reference point:
And here’s where a Jones fracture occurs:
The fracture gets its name from Sir Robert Jones, “the father of modern orthopaedics”, who was the first to describe it in 1902. Unfortunately, the term “Jones fracture” has become nebulous from years of sloppy use by medical providers, often being used as a catch-all term to describe any fractures on the outer long bone of the foot (the 5th metatarsal).
The problem with that general, lazy usage is that a difference in even millimeters can lead to significantly different prognoses, treatments, return to play timelines, and risks of re-injury.
Forget inches, it’s a game of millimeters:
Zone 1 – Styloid Avulsion (Chip) Fracture
The styloid is the part of the 5th metatarsal bone that is closest to the ankle joint. Check it out:
A styloid avulsion fracture occurs when the ankle awkwardly turns inwards (like when landing awkwardly or while running on an uneven surface) which causes two muscles (the peroneus brevis and lateral band of the plantar fascia) to forcibly pull a piece of the bone off aka avulse the bone (click here, here, or here for more info).
These fractures are one of the most common in the lower body and are considered relatively benign with not much pain associated. Surgery is rarely required, symptoms usually subside in week 3, and the timetable for return is 6 to 8 weeks on average (click here for more info).
Onto zone 2…
Zone 2 – Acute fracture of the proximal diaphysis (classic Jones fracture)
Like I said in the intro – this is the classic Jones fracture. These fractures occur farther down the bone (between the base of the small toe and shaft of the bone) and extend into the joint (click here for more info)
Deja Vu in 3,2,1…
It occurs due to an immediate (acute) cause, usually from a sudden change of direction when the heel is off the ground. These fractures are most common in basketball, football, and tennis players (click here and here for more info).
There’s immediate difficulty putting weight through the foot and swelling present. This kind of abrupt increase in pain highly suggests an acute injury. I’ve had a Jones fracture myself (on my left foot during indoor soccer) and let me tell you – it hurts like hell.
In a basketball specific study of Jones fracture surgery vs conservative treatment, 50% of the players in the latter group had not healed by 12 weeks.
There’s 2 main reasons for this risk of poor healing and non-union:
- This part of the bone is an avascular “watershed” area, meaning it has limited blood supply which is a key factor in bone growth and healing.
- This part of the bone takes on significant stress during any weight-bearing so any deficit in bone healing becomes exaggerated and can lead to the bone not growing back together (non-union).
The return to play timeline is around 8 to 12 weeks.
So that’s 2 of the 3 zones. For you math wizards out there, that means we have one more left…
Zone 3 – Stress fracture of the proximal diaphysis
This fracture is the least common of the three classifications, and the location of the fracture is very similar to zone 2 (between the base and shaft of the bone or a little farther down on the shaft):
However, the key differentiator between the acute Jones fracture and the stress fracture is the mechanism of injury. In the latter, the fracture has developed over time due to repetitive micro-trauma rather than an acute movement.
There’s usually pain for months on the outside part of the foot, especially after intense weight-bearing activities, that precedes the actual fracture. Unlike an acute Jones fracture, there’s no swelling.
Alright – so now that you know more about one bone than you ever thought humanly possible, it brings us to a key question…
What fracture classification does Zhaire Smith have?
With Zhaire Smith, we don’t know if the medical staff is using that term in the very specific way or the general way. The information we do have is that he’s been diagnosed with an acute Jones fracture, had surgery, and his timetable for return looks to be around 10 weeks.
Each piece gives us some key clues(often referred to as “drops in the bucket” in the medical world) so lets get our detective hats on and go to work.
1- An acute (immediate) mechanism of injury.
I couldn’t find any indication or report that Zhaire Smith had previous foot pain in that area (and I’d be shocked if he was able to keep it on the way way DL, especially during the lead up to the draft when NBA teams are doing all sorts of poking and prodding) which leads me to believe the fracture was caused by a sudden event rather than due to repetitive stress.
This rules out a stress fracture so now I’m debating between the avulsion fracture and classic Jones fracture…
2- Injury prevalence
An avulsion fracture and classic Jones fracture are both common injuries for basketball players (although the latter is slightly more prevalent than the former). The race is still neck and neck.
3 – Treatment and Timetable
An avulsion fracture rarely requires surgery and the timetable for return is commonly 6 to 8 weeks, whereas a classic Jones fracture is often stabilized through surgery (especially for athletes wanting to return to a high level of play) and the timetable is upwards of 10 to 12 weeks.
Detective mode disengaged. Now onto the actual surgery..
II. Zhaire Smith Jones Fracture Surgery
During the surgery, the surgeon first makes a small incision at the base of the 5th metatarsal (the long bone on the outside of your foot) and inserts a screw, using x-ray imaging to guide the procedure.
Here’s a work-safe video of the procedure:
And a side by side picture showing the inserted screw on x-ray:
The screw stabilizes the bone and brings both ends of the fracture together so they can heal appropriately.
It’s a relatively straight-forward surgery and often times is done with a local anaesthetic (meaning only the foot is numbed rather than the patient being put to sleep, which is called general anaesthesia). The patient is in and out of the hospital on the same day.
With surgery complete, Zhaire Smith has now moved onto the recovery and rehab portion of his return to play journey…
III. The Return To Play Protocol
- Weeks 1 and 2
- Foot is placed a non-weightbearing splint, crutches are used to get around
- Gentle range of motion of the ankle
- Muscle activations (quads, glutes, hamstrings)
- Weeks 3 to 6
- Sutures are removed
- Progression to weight-bearing as tolerated (from using an assistive device like a cane to no device) in a CAM boot
- Soft tissue treatment to control pain & improve mobility
- Cardio on a bike and progressing exercises for foot/ankle strength, mobility
- Introducing full body strengthening and training the proprioceptive and vestibular systems (feedback systems that inform the brain of where the body is in space)
- When appropriate, transition to a running shoe and light running (often with a protective insert to protect the base of the bone)
- Weeks 6 to 8
- Manual treatment to facilitate foot and ankle joint mobility
- Progression to functional weight-bearing exercises and activities
- Start of sport specific training
- Weeks 8 to 10+
- Progress sport-specific training intensity (agility, rapid changes, introducing jumping/landing) as appropriate
- After sport-specific functional testing goals are met, return to practice and eventually the game (often with a full-length insert that protects the rear, outer part of the foot)
Some rehab teams will use a bone stimulator device daily to try and expedite the bone healing process. However, the research supporting their use is very limited.
So that’s the return to play progression for Zhaire Smith but are there any short or long-term consequences for a surgically repaired Jones fracture?
In the short-term, Zhaire Smith will very likely have some numbness in the outer part of his foot (can take months to resolve) and some residual pain as well (especially as he gets back to weight-bearing and his training intensity increases). These are both normal.
In the medium and long-term, there are a few (albeit not likely) risks:
- Research shows a 3 to 12% chance that the bone doesn’t heal (“non-union”), even with the screw fixating it together.
- There’s a 6 to 8% chance that Zhaire Smith has some irritation from the screw and has to have it removed (although that procedure is very quick and relatively simple).
- Research shows a a 5 to 8% chance of re-fracture. On average, a re-fracture will happen about 8 months after returning to sport.
However, if on the off chance there is a complication, Zhaire Smith can still get back on track and get back to 100%. Research on NBA athletes who suffered a Jones fracture has shown no drop off in performance after coming back.
For example, back in 2014 when Kevin Durant had the same injury and surgery, he subsequently had irritation in his foot from the screw AND ended up re-fracturing it. He only played 27 games that year but has had no ill-effects since even though he’s played deep into multiple post-seasons (with high usage rates) and participated in USA summer basketball.
V. All in All
This injury – although obviously not ideal for Zhaire Smith – isn’t that big of a deal. It has a really good prognosis after surgical repair and the subsequent risks are very low.
Some of ya’ll might be thinking: “Well, Ben Simmons had the same thing but was held out the entire year!”
Fair question, but the 76ers risk/reward calculus two years ago was vastly different than what it is now. Although the city and fans were excited to see Ben play alongside Joel Embiid, the team had zero expectations and was still in the process (yeh, I said it) of becoming a winner; it didn’t make sense for the 76ers to expose Simmons to any risk.
(Maybe they should have warned him about the Kardashian curse doe 😳)
The team expectations and mindset are completely different for the 2018-19 season which changes how the team will handle players. This change was already apparent during the 2017-18 regular season when the 76ers opted to bring Markelle Fultz back when they could have easily just shut him down for the year (for more on his saga, I wrote about it here).
It’s clear, in my opinion, that the Sixers staff is now trying to balance winning and development with safety. They want to expose their young players to the NBA level of play and integrate them into the team to develop chemistry, rather than just holding them out of all games.
Does this mean that they’re going to rush Zhaire Smith back? Not at all. I just think it means they won’t be ultra ultra conservative like they were with Ben. Personally, I expect Zhaire Smith to be back around Thanksgiving (right around 12 weeks) and slowly work himself into the back-end of the rotation.
Thanks for reading and until next time.
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Disclaimer: This is not medical advice and shouldn’t be taken as such. If you’re having medical issues, reach out to a medical professional.