Long before high school basketball star Anthony Harris tore his ACL in December, his father was doing his best to prevent his son from suffering the serious knee injury.

Anthony Harris Sr. visited multiple doctors and trainers and asked what workouts were best for strengthening the knee. He had them run tests to see how vulnerable his son — a senior at Paul VI Catholic High in Fairfax City, Va., who is signed to play at the University of North Carolina next season — was to getting hurt. He built rest time into his training schedule.

“There was a lot of things we tried to do to prevent him getting injured,” Harris Sr. said.

However, the precautionary approach wasn’t able to keep Harris from tearing his ACL during a December game when a defender collided with his knee as he went up for a layup. Harris was one of three elite Washington-area basketball players to suffer the injury during a six-month span, along with Paul VI teammate and Duke commit Jeremy Roach and Azzi Fudd, a sophomore at St. John’s who was recently named girls’ national player of the year.

The injuries have prompted a question about youth basketball: Amid a demanding, year-round schedule that includes high school games, AAU tournaments and all-star competitions, are kids being asked to play too much?

“We are pushing our kids to the limit where they are playing 365, 24/7,” said John Klimkiewicz, an orthopedic surgeon specializing in sports medicine and joint replacements in the D.C. area. “As you increase the number of exposures, I don’t care. If you go down the ski slope enough, you’re going to hurt yourself. It’s kind of a little bit of a time bomb.”

Though medical experts and coaches stress that every injury is unique and stop short of connecting all ACL tears to overuse, they agree that top teenagers are being made susceptible to injuries, wear and tear, and burnout.

Families such as the Harrises are aware of the risks facing players who compete year-round, but the nature of the sport’s schedule doesn’t leave them with many alternatives. The workload question is being asked all the way up to the professional level, and many acknowledge that the typical pressures and motivational tactics that come with competitive sports don’t always make it easy for parents or the athletes to allow time for rest.

“People put stuff out like, ‘While you’re resting, so and so is in the gym.’ Or, ‘While you are doing this and resting, so and so is doing this and you’re getting left behind,’ stuff like that,” said Kesha Walton, the girls’ basketball coach at Bishop Ireton. “Maybe make a quiet time across the board, I don’t know. … Football, baseball, basketball, whatever. After the season is over, everyone sit down.”

‘No one is really listening’

Part of the problem, medical professionals say, is that early specialization in basketball or any sport can leave children more vulnerable to injury as they grow up.

Neha Raukar, a senior associate professor in the department of emergency medicine at the Mayo Clinic College of Medicine and Science in Minnesota, said early sports specialization is “an American public health disaster.” Raukar equates repetitive stress to fatiguing of the muscles, with hundreds of microtears occurring every day through strenuous activities.

She uses a paper clip to explain the process: If you bend a paper clip back and forth long enough, eventually it breaks.

ACL tears are of particular concern. They have long been a common injury, Klimkiewicz said, and girls’ basketball players are especially vulnerable. He said girls ages 15 to 25 are five to eight times more likely to tear their ACLs playing basketball than boys.

“It isn’t someone landing on you. It usually is you are coming down kind of . . . mid-stride instead of the beginning or end of the stride,” Klimkiewicz said. “The muscle shuts down, and you expose the ACL. When everything fatigues and shuts down and you are putting more stress on the ACL . . . that is when you are more likely to see it.”

Klimkiewicz said overuse over time and, in some cases, being poorly conditioned can lead to fatigue. Klimkiewicz stressed the importance of ACL prevention programs, which are mostly carried out by physicians or sports medicine doctors. However, doctors are struggling to get the program in front of young participants. Klimkiewicz said if kids start at age 14 or 15, “it is too late,” and ideally they should be introduced as young as age 6.

More research has come out about the concerning effects of sport specialization, Raukar said, and it has included recommendations for kids to rest and cross-train. But the information is failing to get beyond medical circles and out to the general population.

“No one is really listening,” Raukar said.

Fudd, — who in two high school seasons has won two All-Met Player of the Year awards, played for Team USA’s under-16 and under-17 squads and was named the 2018-19 Gatorade national player of the year — was aware of the risks of serious knee injuries before tearing the ACL and MCL (medial collateral ligament) in her right knee in mid-April. The injury occurred after she absorbed contact during a three-on-three tournament with USA Basketball.

It was the type of injury that could happen to any player in any game, but it also came after a 38-game high school schedule — the same number of games played by college national champion Baylor — that included league and state championships in addition to a run to the title game of a national tournament.

The Fudds say they have always made a concerted effort to monitor Azzi’s workload, limiting the amount of “exposure camps” and clinics she attends because they deemed it “unnecessary and doing too much.” They also had her compete in sports other than basketball when she was younger, aware of the concerns over sport specialization.

“Over the years, we have been very conscientious about doing preventive exercises and strengthening areas that are commonly know to be weaker in females,” said Tim Fudd, Azzi’s father. “Azzi has a strong foundation, and that was proven to not matter as much due to her particular situation.”

Similar to the Fudds, Harris Sr. said his son’s ACL tear appeared to be unavoidable, although he did acknowledge that fatigue could have been a factor, given that it wasn’t a “massive hit” to the knee. Regardless of the causes, however, the injuries force athletes into a significant recovery period, with ACL tears keeping athletes from the court for a minimum of nine months.

“It’s not a small problem,” Klimkiewicz said. “I say to the kids that come in [with ACL tears], ‘Listen, I’ll get you back, but you can’t do it again.’ And if you look at the incidents, they are at more risk of tearing their other [ACL] a year later.”

What can be done?

Many within the basketball community acknowledge that kids are playing too much, but few have been able to come up with solutions. In the race to land college scholarships, kids are specializing in the sport and playing it year-round at increasingly younger ages, juggling participation on middle or high school teams with playing on AAU teams and attending all-star camps.

The issue of overuse is relevant all the way up to the NBA. At an event in Washington in mid-May, Commissioner Adam Silver addressed the topic of “load management” that had sparked conversation throughout the season, after stars such as LeBron James and Kawhi Leonard sat out games to rest.

"In the modern NBA we’ve had an 82-game season for roughly 50 years,” Silver said. “And maybe it’s too many games on the players’ bodies.” He also said that if “legitimate resting of [NBA] players resulted in them being healthier in the playoffs, healthier longer, able to continue their careers longer, I think we’d be in favor of it.”

This question of “how much is too much?” tracks back to the youth level, and in 2016, USA Basketball and the NBA partnered to create a set of recommended guidelines to “enhance the playing experience for young athletes.” These included delaying single-sport specialization in basketball until age 14 or older and suggestions for the number of games kids should play in a day or week — taking into consideration practice length, rest time and sleep.

“This started with a concern not only for potential injury but burnout and mental health,” said Jay Demings, USA Basketball’s youth and sport development director. “Putting less of a focus on the competitive aspect of basketball and more (on) the fun of the sport, which is the number one reason kids play sports.”

Harris Sr. said he believes the basketball community is becoming more disposed to change. Shoe-sponsored AAU circuits have teams playing only four to five games over a three-day weekend, compared with the multiple per day young athletes would play in past years. More coaches are aware of their role in trying to manage workloads and look for fatigue in their players. Parents such as Harris are taking preventive measures.

But there is still risk any time a player steps onto the court, Tim Fudd said, no matter what precautions are taken.

“I don’t know how we could’ve prevented Azzi’s other than not be in the place at that time,” he said. “Given the physicality that occurred at the moment, any player would’ve been vulnerable to injury.”

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