Madison girls’ basketball players Kelly Koshuta and Megan Henshaw and Georgetown Day’s Zoe Beard-Fails have all torn their anterior cruciate ligaments. The three girls share their experiences dealing with and trying to recover from their injuries. (James Sherrill for Synthesis/Koubaroulis LLC./ The Washington Post) (James Sherrill for Synthesis/Koubaroulis LLC./The Washington Post)

The soundtrack of recent Washington area girls’ basketball seasons has not been tweets of whistles, squeaks of sneakers or roars of crowds. It’s been the popping of knee ligaments and the clang of crutches tapping aluminum courtside chairs as injured players plop into seats on the bench.

Young female athletes are two to eight times more likely than young males to tear their anterior cruciate ligaments, according to the American Orthopaedic Society for Sports Medicine. Area girls’ basketball players are doing their part to validate a statistic that one local orthopaedic surgeon considers “a national epidemic.”

Take the Virginia AAA Liberty District, just an eight-school sliver of the more than 200 high schools in the Washington area. Madison’s top two scorers from last season, sophomore Kelly Koshuta and senior Megan Henshaw, tore their ACLs last summer and have not played this season. McLean’s Elena Karakozoff, Fairfax’s Kylie Murphree and Stone Bridge’s Caitlyn Canyon this season all returned from ACL injuries, or, in Murphree’s case, a torn meniscus.

The rash of ACL tears underscores the continued severity of the problem in young female athletes and also raises questions about whether the athletes and their parents and coaches are doing enough to prevent such injuries.

There are drills and exercises designed to make ACLs less susceptible to tearing and to retrain muscles to perform in a way that make tears less likely. But these programs are not widely used in area school systems. About 70 percent of ACL tears result from no contact, according to the American Orthopaedic Society for Sports Medicine, and many of those could be avoided with smarter training, doctors conclude.

“Clinically, there is a need for sport specific injury prevention programs at the high school level,” the American College of Sports Medicine noted in an October report that capped a six-year study of high school knee injuries at 100 randomly selected high schools.

The knowledge gap

Players who tear their ACLs tend to be ACL experts — but only after they sustain the injury and undergo surgery and a demanding six-month rehabilitation that can cost tens of thousands of dollars. Otherwise, there is a general lack of awareness about the ACL, which connects the front top of the tibia to the back bottom of the femur.

“I had no idea what an ACL was,” said Madison’s Koshuta, who tore an ACL last summer while going up for a layup in an AAU game, about two weeks after teammate Henshaw tore hers at an AAU event in Chicago.

“I thought I had the strongest knees,” said Koshuta, a 6-foot-2 forward who averaged 19.5 points last year as a freshman. “I had no information on [ACLs], and then once it happened I was like, wow, so many people have had this happen to them.”

“I have never really heard, ‘Make sure your knees are okay,’ ” Henshaw said. “No one has ever told me that. It’s like arms and legs, but not knees.”

A coach could field one of the strongest girls’ teams in the area with all the players affected by ACL and similar knee injuries in the past year. Besides the Madison duo, there’s Zoe Beard-Fails, a University of Colorado signee, at Georgetown Day. Ciaira Lee and Carolyn Cosey started on Wise’s Maryland 4A runner-up team last year. Fairfax’s Murphee has eight Division I scholarship offers. Glenelg’s leading scorer, Emily Russo, tore her ACL in December. Weeks later, teammate Sam Heisig returned from an ACL injury.

Freedom-Woodbridge’s Jessica Harris has averaged 24.3 points since she came back from her torn ACL. Traonna Thomas is the leading scorer for Oakland Mills. No. 18 Stonewall Jackson’s Danielle Burns, out all season, has committed to Fordham. Hannah Hayes, of No. 14 Potomac (Va.), would have been her team’s best outside shooter and floor leader.

St. John’s guard Lindsay Allen has signed to play college basketball at Notre Dame. (The Washington Post)

Top-ranked Paul VI Catholic lost starting center Kasey Curtis, a William & Mary recruit, to an ACL tear in recent weeks.

And the problem is just as prevalent in the local college ranks where Maryland has already lost two key players — sophomore point guard Brene Moseley and junior shooting guard Laurin Mincy — for the season.

A perilous injury

In general, you’re better off breaking your leg than tearing your ACL, an injury that Northern Virginia orthopaedic surgeon Chris Annunziata considers a national epidemic for young female athletes. He has performed an estimated 750 ACL surgeries, about 60 percent on females.

The knee is considered the most complex joint in the human body, and why girls sustain ACL injuries at such a higher rate than boys is complex as well. Running, pivoting, cutting, jumping, twisting, turning, landing, stopping. All can cause an ACL to pop out of alignment.

The reasons are not conclusive why it happens more to girls. Most doctors agree that body structure could play a part. Girls have wider hips and a smaller notch that the ligament goes through to connect to the femur, which means there is less room for movement. Females are also more likely than boys to land straight-kneed instead of crouched, increasing pressure on the joints.

Another theory is that estrogen can make tendons more relaxed and more susceptible to tears. Specializing in one sport and overuse also can play a part.

Georgetown Day’s Beard-Fails is learning that recovering from a torn ACL can be a lingering task. After averaging 25 points per game as a sophomore, the 6-foot-2 post player got hurt five games into last season and also sat out the first three games this season. She returned for the fourth, then sat out four more. She came back this month but is not playing at the level at which she played before the injury and admits she pushed herself too hard too soon.

“Yeah, you can work on your body. But mentally? That’s one of the biggest struggles of this injury,” Beard-Fails said. “You say your knee’s fine, but a lot of times you have to make sure you’re mentally there because that can hurt you just as much as not being ready physically.”

Injuries close to home

Girls’ proclivity to knee injuries has been quantified locally. Fairfax County schools tracked ACL ruptures among its more than 27,000 high school athletes. Other than football, during the 2011-12 school year, the three leading sports for complete ACL tears were girls’ lacrosse, girls’ soccer and girls’ basketball.

In Prince William County, from the 2011 fall season through the 2012 fall season, girls sustained 22 ACL injuries, including seven in basketball. Of the 16 boys who injured their ACLs, 12 came on the football field.

For almost a decade, Fairfax County schools have made ACL injury prevention materials available to coaches in all sports, but it is unclear how many are using the program. “Honestly, I don’t believe that many,” said Jon Almquist, the athletic training coordinator for Fairfax County schools.

The exercises can enhance or replace a team’s normal warmup period but also require close monitoring, at least initially, from coaches versed in the procedures or athletic trainers, to make sure they are done with the proper technique to prevent, and not cause, injury.

A report published this month in the Journal of the American Academy of Orthopaedic Surgeons concluded that “neuromuscular intervention protocols have been shown to reduce the rate of injury in girls and women.”

“The recognition is slowly coming,” said Kathy Ayers, the Annandale certified athletic trainer who helps oversee the ACL injury prevention program in Fairfax County. “I think a lot of coaches feel very pressed for practice time and it’s very difficult to give up 15 or 20 minutes of practice. The coaches who have really embraced it are from teams that have been affected by [ACL injuries].”

Anne Arundel County high schools this year will emphasize female ACL injury prevention at their meeting for spring sports coaches. They will implement a pilot program this spring studying ACL injuries in girls’ lacrosse players.

Howard County has implemented a pilot program at Wilde Lake and is considering ACL prevention strategies used by the Japanese national soccer teams.

Other large school districts in the Washington area — the District, Prince George’s County, Montgomery County and Loudoun County — have not made female ACL injuries a point of emphasis, athletics supervisors from those areas say.

Almquist would like to take Fairfax County’s efforts one step further by implementing ACL injury prevention programs in elementary school physical education classes.

“The key,” Almquist said, “is to get them early.”