As the NBA playoffs approach, the Oklahoma City Thunder may be forced to wonder what might have been if Kevin Durant, the reigning NBA MVP, had been with them for the entirety of the 2014-2015 season. Durant, who was sidelined for seven weeks last fall after undergoing surgery to repair a Jones fracture in his right foot, saw his season come to an official close in March due to persistent problems with the foot that required another surgical procedure. Known as much for his durability as his talent, Durant’s season never really got going this year, as he was limited to just 27 games. The concern for many fans now is whether Durant will be able to return to the player he was just a year ago and if it can happen in time for next season.

The answer to both questions is, simply, yes.

Despite the failure of his foot to cooperate with the initial plan following his original injury, medical evidence suggests that Durant's chances for a successful return next season are very high. To understand that seemingly counterintuitive notion, it helps to take a closer look at the nature of the injury itself. Durant originally suffered a Jones fracture in his right foot, a break of the fifth metatarsal, the long bone on the outer aspect of the forefoot that connects to the fifth (pinkie) toe. The other end of the fifth metatarsal (the end closest to the ankle) connects to the cuboid bone, one of the bones of the midfoot. This outer forefoot bone is subjected to a great deal of torsional stress in an athlete during pivoting, pushing off, sharp deceleration and twisting. It is also subject to impact stress with repeated running and jumping. Combining these stresses, as is routine for an NBA athlete, makes Jones fractures common in this population.

The challenge in trying to heal from a fracture in this area is that the bone does not have a particularly good blood supply, which results in a frequent failure to heal independently, even with immobilization. For this reason, surgical fixation of Jones fractures (with implantation of a screw) has become the standard of care, especially in elite athletes, who will return to high-stress activities and whose specific movements in their sport put them at an otherwise increased risk of failure. Unfortunately, even when the fracture appears healed and an athlete recovers functionally to the point of being able to return to competition, problems can recur.

An X-ray of a Jones fracture on the fifth metatarsal. Courtesy Stephania Bell

Beyond the poor blood supply that makes healing in the area difficult, other factors can contribute to a challenging recovery. Not all feet are created equal, and even with the same basic bony architecture, they can vary in terms of shape (arched or flat), alignment and rigidity, all of which can affect how they absorb load.

Other lower-extremity biomechanical factors such as poor lateral ankle stability can influence the amount of stress to which the outer foot is subjected (think of the most common sprain in basketball, rolling the outer ankle so the sole of the foot turns inward). A lateral ankle sprain not only stresses the lateral ligaments of the ankle, it forces undue loading onto the outer aspect of the forefoot at the vulnerable region of the fifth metatarsal. (It’s worth pointing out Durant did suffer a sprained ankle in mid-December, less than three weeks after his season debut.) Lateral ankle strengthening, proprioceptive (body position sense) training, orthotic inserts and footwear modification to enhance ankle support can all be components of a program designed to prevent injury recurrence.

One can go further up the chain to incorporate hip and abdominal strength training as an element of controlling foot and ankle stability. Despite those measures, it can be difficult to overcome individual anatomy and years of habitual movement patterns, particularly in season. Add in the frequency of games in the NBA, the friction variants between shoes and the playing surface, even variations in body type, and there is likely no one single factor that leads to recurrence of these injuries in NBA athletes.

Durant’s original injury was projected to keep him out for six to eight weeks; he returned in seven. While some may speculate he returned to action too soon, there is no doubt that those overseeing his care were monitoring the healing of the fracture along with Durant’s report of symptoms and his response to progressive activity. Other NBA players have returned in similar timeframes without incident (For example, Tobias Harris, who suffered the injury in high school, has not had a recurrence. Brandon Jennings, now sidelined with a torn Achilles, did have a Jones fracture in 2010 and recovered fully after surgery.)

Unfortunately, Durant began to experience discomfort in the area of his cuboid (the midfoot bone that sits just above the area of the fracture site where the screw was implanted). Given the possibility that Durant’s discomfort might be related to irritation of the screw, a second procedure was performed on Feb. 22 to remove the original screw and replace it with a variant that might be better tolerated. The Thunder stated at the time, “... because the fracture itself has continued to heal as anticipated, there was an opportunity to address irritation from the screw, and make an adjustment to a different piece of hardware within the foot to relieve the symptoms of his soreness.” The team also noted the fracture was “healing excellently by all accounts” and the hope was that Durant would be able to return this season.

An example of a Jones fracture repaired with a screw. Courtesy Stephania Bell

When Durant’s symptoms persisted despite the screw replacement, it was determined he would require a bone grafting procedure. Within their statement about Durant’s condition, the Thunder outlined the rationale for the procedure: “Several conference calls and discussions among the specialist team concluded that, while the majority of the soreness in Kevin’s foot was related to continued inflammation of the cuboid bone and would subside with rest, the evaluation process also determined that the Jones fracture of the fifth metatarsal, which had shown significant healing previously, was now demonstrating signs of regression ... To address the setback of the fracture site, a bone graft procedure would be the most proactive and recommended approach.”

On March 31, Durant’s surgery was performed by Dr. Martin O’Malley at the Hospital for Special Surgery in New York with medical personnel for the Thunder present. Procedures such as this typically require approximately 12 weeks for the bone to fully heal along with the additional time necessary to return the athlete to competitive play. The Thunder have offered a broad timeline of four to six months to return to full basketball activities, indicating they can bring Durant along gradually in his progression and still expect him to be ready for the start of next season.

So why is this latest procedure expected to be successful in healing Durant’s problematic fracture? One of the benefits of bone grafting is that it directly places cells with a healthy blood supply in an underserved area, which may, ultimately, enhance the healing potential of the bone. In an article published in the American Journal of Sports Medicine in 2011 looking at bone-grafting procedures performed on re-fractures or non-unions of the fifth metatarsal in 21 elite college and professional athletes, the success rate for return to prior level of competition was 100 percent. At over two years' follow-up, only one athlete had suffered a subsequent re-fracture (the re-fracture was sustained in a motor vehicle accident, not in sports).

For those who might be wondering why not go with the bone grafting procedure first, it’s a more invasive, more complex surgery that requires a significantly longer healing time and it simply isn’t necessary in the majority of cases. Of the many athletes who sustain a Jones fracture that is surgically repaired, only a range of 5-10 percent will go on to have persistent problems that require bone grafting.

According to Dr. Norman Waldrop, an orthopedic surgeon specializing in foot and ankle injuries at Andrews Sports Medicine who has treated numerous Jones fractures in elite athletes, the good news is that for those who do require grafting, there is rarely any further treatment required. “Over 90 percent will go on to be fully competitive and free of complications for the remainder of their playing careers,” Waldrop said. Brooklyn Nets center Brook Lopez is perhaps the most recent example of a player to undergo surgery to address a re-fracture of the fifth metatarsal. Lopez had surgery last January and has played without incident so far this season.

It is also important to point out the Jones fracture is not the same type of dreaded “big man” injury that plagued Yao Ming or Bill Walton. Their fractures were to the navicular bone, a bone in the midfoot that forms a keystone of the arch on the inner aspect of the foot. It too has a poor healing supply and fails to respond in some cases even despite surgical intervention. It is vastly different from a Jones fracture and a navicular fracture that is resistant to healing can be a career-threatening injury. It’s worth noting there are no reported cases of an NBA player’s career ending as a result of a fifth metatarsal injury.

Add to the success rate for bone grafting post-Jones fracture the fact Durant is still young (just 26 years old) and the fact he has avoided the lower-extremity joint-pounding of a full NBA season, and his outlook for next year is promising. Naturally, there are still benchmarks to target. Durant has to heal from his latest operation without a setback, and he will have much work to do on the conditioning and training side to return not only to a competitive level of fitness but also to his MVP form. Still, the medical evidence tells us there is every reason for Durant, the Thunder and his legions of fans to have confidence in his foot heading into the fall.