Under the knife: Exposing America’s youth basketball crisis

A 3-YEAR-OLD BALL of energy named Noah bounds around a former live music venue one block from the beach in Santa Barbara. He’s surrounded by about a dozen top prep prospects from around the U.S., all here at P3 Applied Sports Science, a performance lab that has assessed the biomechanics of hundreds of the world’s best athletes, including about 350 NBA players over the past 11 years.

It’s the first Saturday morning in May 2017, and Noah is here with his older brother, Zion, who fears that Noah will one day be better than him, because Noah began playing basketball at 2 years old while Zion only started at 4.

For now, though, Zion Williamson is 16, and in one month will grace the cover of Slam magazine, which will state that the 6-foot-7 forward is as explosive as Russell Westbrook and can dunk like LeBron James.

At P3, basketball players are typically outfitted with 22 markers, each 12.7 millimeters in diameter and placed on a dozen specific anatomical landmarks, from their feet all the way up to their back. After warming up, they undergo a series of vertical and lateral movement tests atop two force plates installed in the floor beneath them, which record their ground reaction forces. Looking on are 10 3D motion-capture cameras, at a multitude of angles, capturing more than 5,000 data points, including joint-by-joint kinetic and kinematic information. The assessments take 15 minutes. A half hour later, a remarkably detailed biomechanical model of each athlete’s skeletal system is produced.

Today, P3 officials are eager to assess Zion, given his off-the-charts athleticism and the gravity-defying slams that have already made him an international viral sensation. But instead of taking such tests, Zion is spending his first P3 visit focusing only on recovering from another long season of club basketball that, his parents worry, has taken its toll.

In Part 1 of this two-part series, ESPN explores the dangers of youth basketball — and how the culture of perpetual competition is jeopardizing the futures of the very stars it hopes to create.

Those parents, Lee Anderson and Sharonda Sampson, stand nearby while Zion’s legs are swaddled in Normatec sleeves. As the sleeves swell with air, compressing muscles to improve blood flow, Lee and Sharonda recall their own athletic experiences. Lee played college basketball at Clemson; Sharonda ran track at Livingstone College in Salisbury, North Carolina. When they were kids, decades ago, athletes played several sports and took summers off.

Zion, however, began playing on youth basketball teams at 5 years old, competing against those twice his age, and he’s been playing on the travel circuit ever since. These days, his school season starts in October, then he rolls into summer youth basketball. “This is all he does,” Sharonda says, as she watches her son. “He doesn’t have time for anything else.”

During the summers, he’d play four games in a weekend, maybe even five or six, then train for hours every day during the week. Before they knew it, Friday would roll around and he’d be off to play in another tournament. Recently, though, Zion has been feeling the brunt. After bouncing from Las Vegas to their home in South Carolina, then back to the West Coast for events, games and training, soreness and fatigue have seeped in. The high school junior says he felt especially haggard after a recent Adidas event in California, where cramps and charley horses wracked both of his legs for an hour, a first for him.

Years ago, Sharonda might have told her son to toughen up. But as Zion’s basketball profile has risen (he just averaged 36.8 points and 13 rebounds in his junior season while leading his high school to its second straight state title), and as she and Lee have become exhausted just from attending his games (“We know if we’re wearing out, he’s wearing out,” she says), she listens more. Sharonda carries a degree in health and physical education, but she’s also studying kinesiology — the science of body movement. Today, if Zion says he’s tired, she asks him to take time off.

At the moment, Zion, still in his Normatec sleeves, is recovering from a bone bruise he suffered a month ago during an AAU game in Arkansas. It was a humid night, and the floor was wet, so Zion kept slipping, hitting his knee on the court. He awoke the next day to find it swollen. Two weeks’ rest was prescribed, but the moment, Sharonda says, provided a realization: Zion is 16, she thought to herself. He has way more basketball on the other side, way in front of him.

Zion says he gets it — sort of. “That is going to be your money-maker, your body — so we have to start taking care of it,” his parents tell him. They point to the NBA, where he aims to play for at least a decade, and where recent seasons have been dominated by discussions of rest and players sitting out. “They’re resting,” his parents say. “You should be resting, too.” But the other half of Zion wants to play.

But then, as Zion is explaining his desire to play more, Lee cuts in.

“But we’re not going to let him do it when he’s hurt,” Lee says. “We’re not going to let him do that … as parents we’re going to actually let him know, Hey, you shut that down until you get better.“

Early on, Zion’s parents felt the pull of the youth circuit, as if attendance were required and missing it meant missing out on a future in the game. But as Zion got older, his parents fielded more requests for him to appear at tournaments and events. So earlier this year, they decided to limit him to four per summer.

Here, in the high-tech sports science lab, Sharonda looks at her son — at all the promise before him. How can she get the message through? “You’re 16,” Sharonda tells him. “In 10 years, you’ll be 26. You don’t want to be worn down by the time you’re 26.”

THE ORTHOPEDIC SURGEON leans over the right knee, two dime-width incisions already sliced on each side. Now comes another, just behind and below the knee — this is where he’ll draw out a shiny tendon that looks like a fresh shoelace dipped in cream: a hamstring. There are four such tendons to choose from, and they will grow back within nine months, but the surgeon only needs two. They will be used to help replace the torn anterior cruciate ligament in the knee — an injury suffered on the football field when its owner, during a game with friends, planted his right foot and collapsed.

A fellow in training and a scrub technician stand beside Dr. Nirav Pandya as he steadily guides the scalpel and maneuvers an arthroscope — a small tube with a camera at its end — inside the knee, sending back footage onto two flat-screen monitors nearby. His 39-year-old hands move with the efficiency and certainty of someone who has performed this procedure 600 times before (which he has). The steady beep of a heart-rate monitor fills the operating room. A ventilator hums while the patient’s chest rises and falls. Outside, a grey sky spits rain on a late winter Tuesday afternoon in Walnut Creek, about 20 miles from Oakland.

Typically, a procedure to reconstruct a torn ACL might take 60 minutes for an adult, but this one is taking longer because the X-ray technician is wheeling over the machine after almost every maneuver and because each X-ray is scrutinized to make sure that nearby growth plates, which have not yet closed, are not endangered. Extra time is also taken to ensure that the meniscus, the cushion of the knee, is repaired to prevent the early onset of arthritis. These steps would not be taken on an adult who has stopped growing, but this is not an adult.

It is a 9-year-old boy.

Years ago, as a 10-year-old growing up in Chicago, Dr. Pandya had planned to follow his father, a family doctor, into medicine — in his case, specifically to become the Chicago Bulls‘ team doctor. During his residency training in Philadelphia, Pandya decided that he wanted to work with kids. And seven years ago, he moved to the Walnut Creek branch of the UCSF Benioff Children’s Hospital, which examines patients up to age 25. But one day, about five years ago, in came a new patient: an 8-year-old boy, a local basketball player who had ruptured his ACL.

“He was this kid who was basically playing four or five days a week,” Pandya recalls. “He was doing drills all the time, and he was playing and landed wrong.” His ACL popped. Pandya couldn’t believe that such an injury could happen to someone so young.

In the years that followed, Pandya says, more kids that age began to come in, and the operating rooms filled with surgical trainees who came to watch because they had never seen such injuries to kids. But, in time, it became so commonplace that soon the shock wore off — no longer did an ACL surgery to an 8-year-old raise eyebrows, nor did the constant stream of patients so young seem unusual. Five years ago, Pandya estimates that he alone would see about 1,500 pediatric sports injuries and perform maybe 150 surgeries — ACL, cartilage, shoulder injuries — in a single year; those numbers have “skyrocketed,” he says, and last year stood at 6,000 and 400, respectively. More than half of his operations are now on those under the age of 14.

Often, Pandya says, he knows exactly what he’ll find before ever making an incision, before the arthroscope reveals what’s beneath the surface. He can roll the knee in his hands, and it might feel loose, like a bunch of untethered parts. He knows he’ll see cartilage that should look paper white but is grayish — not smooth, but rough — not hard and solid, but soft and spongy. He knows he’ll see an ACL and it will it not look intact, like a new shoelace, but frayed, like it’s been through a meat grinder.

During the procedures, Pandya is focused on each step, knowing the pitfalls — avoid hitting a nerve or blood vessel, be precise when drilling through bone to create a small hole through which to thread the new tendon. On the 15-minute drive from his home in Oakland to the clinic, he mentally prepares himself. How will the kid respond? How will the parents respond? Will each side listen? Will they take the rehabilitation seriously? Will they take the proper steps and be diligent?

Sometimes, he’ll see kids who aren’t injured but are in pain, month after month. “Look, you just need to stop,” Pandya will tell the parents, “if you play 40 hours a week of basketball, you’re going to get injured.”

Time and again, though, the first question parents ask is not about the well-being of their kids, but simply, “When can my kid get back out there?” Pandya will explain the potential hazards of the surgery, including risk of infection or re-injury. He’ll show them a picture of what a healthy knee looks like for someone of their child’s age — and then show them what their kid’s knee looks like now: routinely worn to the point that it appears three decades older than it should.

But often, he says, the only time parents appear truly shocked is when they’re told how long their child will be sidelined.

Pandya sees the kids throughout their rehabilitation process. Some he’s seen for years; he reconstructed their ACL only for it to be torn again. In some cases, he has repaired their ACLs three times by their early teenage years. The parents drop the kid off for physical therapy almost every day, but the kid lives with the injury, the rehab, every single day. Sometimes, they’ll confide in Pandya.

Look, I don’t want to go back, the kids will tell him. I’m afraid of going back. I don’t enjoy it anymore. I’ve spent my past three years just rehabbing. That’s all I do. I go from one surgery to the next. I just want to be a kid.

Today, when he leaves the operating room, Dr. Pandya removes his surgical mask. He’s 5-foot-6 and lean, a former collegiate track athlete at the University of Chicago. He’s just finished his second ACL reconstruction surgery of the day; he does up to four a day now, two days a week. Earlier this morning, he reconstructed the ACL of a 12-year-old boy, a skier. The day before, another ACL, that of another 12-year-old boy, a soccer player. He heads to his office, takes a seat and resets for a minute.

“I don’t want kids in my clinic,” he says. Pandya thinks of his own children, a 7-year-old boy and a 4-year-old girl. His son loves sports, plays soccer, basketball, kickball and swims. And there may come a day when his children decide to focus on one sport, believing they need to specialize in order to stand out. Pandya knows he will then have to explain in detail what he sees at work almost every day.
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