Hurt locker rooms: The four injury risks today's young players face

Robyn Beck/AFP/Getty Images

Julius Randle has seen the replay.

The 6-foot-9, 250-pound forward drives to the basket in the fourth quarter of the Los Angeles Lakers' season opener, past Houston Rockets big man Donatas Motiejunas, jumps and passes as the defense closes in on him. At first, everything appears normal.

But then his right foot buckles, and he collapses.

His right tibia, it was later found, was broken. His first season in the NBA was over after just 14 minutes of playing time.

When Randle first saw the footage it was depressing. When he started rehab, he quit watching.

"It didn't even look like it was much for a play like that to happen," he said.

But Randle wasn't alone. Eight of the top 11 picks in the 2014 draft suffered serious injuries this past season, four of whom missed 35 or more games. Many of the injuries came early in the season.

"I was definitely weirded out by that," said Boston Celtics guard Marcus Smart, who missed 12 games because of injury after being selected sixth overall. "It was less than a month in, then somebody else went down, then the next guy, then the next guy. It was like, 'What's going on?'"

Health professionals in and around the league say it isn't happenstance.

Sports science and medicine are more advanced than ever. But long-term injuries to the incoming rookie class spiked this past season.

Players picked in the 2014 lottery missed 304 games because of injury, the highest figure recorded by Jeff Stotts, a certified athletic trainer who has cataloged the careers of more than 1,100 players dating back to the 2005-06 season. First-rounders as a whole missed 421 games, the most in the data sample.

Games missed because of injury league-wide (4,649) came in just above average (4,603) in a non-lockout year over the past decade, and down from 2013's 4,989, the high in the 10-year span. But several experts are concerned.

"It's not a fluke," said Dr. Mike Clark, a former physical therapist for the Phoenix Suns, who have what's widely considered to be the league's top training staff.

Brian St. Pierre, director of performance nutrition at Precision Nutrition, echoes the message of a quote by Jacob Riis that has long hung on the wall in the locker room of the San Antonio Spurs, with whom he has worked.

It reads: "Look at a stonecutter hammering away at his rock, perhaps a hundred times without as much as a crack showing in it. Yet at the hundred-and-first blow it will split in two, and I know it was not the last blow that did it, but all that had gone before."

As with injuries, St. Pierre said, "it's often not that 101st blow, but it was really the 100 things that came before that set everything into motion."

Many say the injuries are indicative of four key issues players face in today's NBA: poorer sleep, in part because of technology; weaker bones, in part because of low calcium and high sugar intake; an uptick in wear and tear, thanks largely to players specializing in basketball at a young age; and weaker muscles, as a result of shucking traditional weight training for more en-vogue methods.

1. Blue light special report

When Cheri Mah talks to NBA players, she'll tell them how poor sleep (or lack thereof) negatively affects on-court performance. She'll mention how chronic inadequate sleep builds "sleep debt" that must be reduced over time.

Mah, a sleep research fellow at the University of California San Francisco Human Performance Center, also brings up another issue: blue light.

It's emitted from televisions, computer screens, tablets, smartphones, and at night, it suppresses the body's attempt to produce melatonin, a hormone that helps induce sleep.

"Most of them are pretty surprised," said Mah, who said she has worked with thousands of collegiate and professional athletes since 2002. "That's really because no one has told them that before and they didn't realize it could potentially impact their sleep."

Researchers say poor sleep leads to reduced reaction time, which in turn can lead to increased injuries. The average reaction time is 250 milliseconds, but it can take three times as long if people stay awake all night, making them as impaired as if they were legally drunk, according to Dr. Charles Czeisler, the director of the Division of Sleep Medicine at Harvard Medical School who has been a consultant for several NBA teams.

In the 2011-12 lockout-shortened NBA season, when teams played at a hectic pace -- back-to-back-to-back sets and, in some cases, nine games in 12 days or 20 in 31 -- the number of one-game injury absences during the first 60 days of play increased 63 percent from the same amount of time the season prior, according to statistics compiled by the league.

Czeisler said sleep is even more vital for younger players, and thus poor sleep is more harmful. One night of lost sleep is 10 times more detrimental to those ages 18-25 than to those 60 and over, Czeisler said, because younger people's sleep is much deeper, more restorative, and the body's "drive" to sleep is more intense.

"In college, you have a schedule because you're not traveling as much, so you can go to bed at 11 or 12 every night, and now I can go to sleep at 11 one night and the next night go to bed at 3."
Doug McDermott

While Mah said NBA awareness of sleep science has relatively improved in recent years, there's now talk of "blue-light pollution," an issue that Tim DiFrancesco, the Lakers' strength and conditioning coach, said is especially concerning for young players, who are conditioned to stare at a screen at all hours.

"There's plenty of information showing that people are addicted to social media," DiFrancesco said. "They can't not scroll through their Twitter feed. They need it the same way that an alcoholic [does]; if they have a drink sitting there, they're going to have it."

"That's all we know -- that's what we've grown up with, the iPhones, the iPads, the laptops," said Doug McDermott, a Chicago Bulls forward who missed 28 games because of injury after being drafted 11th overall. "They all produce so much light.

"It's easy to say you won't be on your phone before you go to bed, but the reality of it is, all of us 19- to 23-year-old kids who are just starting your NBA career, you're probably not going to listen and you're probably going to be on your phone anyway."

Several players mentioned how difficult the transition is from college to the NBA when it comes to sleep: more games, more late nights and especially more travel.

"In college, you have a schedule because you're not traveling as much, so you can go to bed at 11 or 12 every night," McDermott said, "and now, I can go to sleep at 11 one night and the next night go to bed at 3.

"It's tough. I've learned to sleep when I can."

NBA travel impacts sleep enough, but technology often only makes it worse.

"Family is trying to talk to you about the game, people whose opinions you value are trying to talk to you about your performance - what might have happened or what didn't happen," said Orlando Magic rookie point guard Elfrid Payton, drafted 10th overall in 2014. "You've got to turn your phone off -- that's the only way, I think."

Young NBA players aren't the only ones glued to a screen late at night, of course. In a 2011 poll by the National Sleep Foundation, 95 percent of those surveyed reported that they use some type of electronics (computer, video game, cell phone, etc.) at least a few nights a week within an hour before going to bed.

Mah recommends 7-9 hours of sleep per night for adults and 8-10 for NBA players. With regards to NBA players and blue light, DiFrancesco said, "I would feel confident saying they're easily losing one to two hours of sleep per night -- and it's probably more."

A potential solution is an application called f.lux, which adjusts light on a device's display to the time of day, limiting blue light after sundown. There are also amber-lensed goggles -- known as "blue-light blockers" -- that are designed to be worn at night.

McDermott said veterans have suggested reading a book for 15-20 minutes before bed, and that he uses an app on his phone that sounds like a whirring fan.

"I try to have the same noise to sleep to every night to keep it consistent, because you're sleeping in a million different beds," he said. "You can at least have some sort of consistency if you do something like that."

Dan Pardi, a sleep researcher at Stanford University and at Leiden University in the Netherlands, preaches education most of all.

"Blue light is not the problem," Pardi said. "It's the timing of it. You want a lot of blue light during the day. You don't want it during the night, because you can start to essentially cause the brain to think, oh, it's day, even though it's night, and that will initiate a shift in all the rhythms in your body.

"That's really problematic if you have to be performing the next day as an athlete. You can basically be suffering from a form of jetlag."

2. Milk does a body good

Randle recalls his family going through a gallon of milk a week when he was growing up in Texas. He drank a large glass of it at the dinner table almost every night.

"I used to love milk," he said.

McDermott did too. It was a staple in Iowa, where he grew up.

"Milk was huge," he said. "When you think of a lot of our family dinners -- sweet corn and steaks -- you had a glass of milk to go with it."

For no particular reason, they and other rookies said, they stopped drinking milk. And at some point, so too did a nation.

Americans on average drank 37 percent less milk in 2014 than in 1970, the Washington Post reported, citing USDA data, and the dairy industry recently ditched its famed "Got Milk?" campaign for a "Milk Life" approach that casts milk as key to active lifestyles.

Americans aren't just drinking less milk; they're drinking more sugary beverages.

A 2012 report by the Harvard School of Public Health pointed out that on any given day, half the people in the U.S. consume sugary drinks; one in four get at least 200 calories from such drinks; and 5 percent get at least 567 calories -- equivalent to four cans of soda.

Dr. Cate Shanahan, the director of the Lakers PRO Nutrition Program, sees an alarming trend for athletes. "From my perspective, there's an epidemic of bone health problems in pro sports because guys are drinking soda instead of milk," Shanahan told ESPN.com in January. "They're just not getting enough calcium."

Shanahan said she has calculated that some players are only getting 25 to 30 percent of the recommended daily calcium intake. (Webmd.com recommends that adult males between 19 and 50 take 1,000 milligrams of calcium on a daily basis.)

A potential side effect, Shanahan said, is more catastrophic bone breaks in younger players, such as Indiana Pacers forward Paul George's broken leg in August and Randle's two months later. "He didn't have enough dairy in his life," Shanhan said of Randle.

Of the 304 games missed by 2014 lottery players during this past regular season, 201 were the result of bone injuries.

"What we're seeing right now is low vitamin D level [among players]," Clark said. "That sets you up for a lot of injuries. You have to find other ways to get that into your diet."

St. Pierre recommended milk -- whether cow's milk, almond milk, hemp milk or even soy milk -- because "you need vitamin D to absorb calcium, and you need fats to absorb vitamin D."

The Lakers promote dairy products, such as grass-fed cheese. Kobe Bryant drinks a bottle of low-sugar chocolate milk after games specially prepared by Whole Foods.

Still, DiFrancesco said a stigma exists with dairy not only among the general public but among NBA players specifically, one that isn't easily overcome.

"In particular with athletes, there's this idea that it'll slow me down, it's fatty," DiFrancesco said. "No matter what your excuse is, everybody has one for why they don't do dairy, and so what are you going to do if you don't have a glass of milk at dinner every night? You're going to have juice, soda, a lot more sugar?

"Not only did you take out these bone-building nutrients from having full-fat, normal dairy products on our table, which people forget at one point was standard. But now we take that out and replace it with sugar, which makes bones more brittle, weakens tendons and ligaments and increases inflammation."

St. Pierre is likewise perplexed by the stigma around dairy: "The research doesn't support the bad rap."

Like Randle, Smart also grew up in Texas and said his family went through at least a gallon of milk per week. But like Randle and others, Smart said he cut back once he got older.

"I actually got away from it and that's what hurt me a little bit with my ankle and the healing process," Smart said, referencing an injury that sidelined him early in the season. "I was really low on calcium and wasn't getting the vitamin D to help my bones.

"Milk is very important."

Randle was asked if Shanahan ever mentioned drinking more dairy products.

"She probably did,' he said. "Me being a young player, [thinking] 'I'm not going to get hurt' or whatever it is and not taking it seriously, but she probably definitely did.

"It's a learning experience if anything for me."

Randle said he's getting more calcium through the vitamins the team is giving him, but is he drinking more milk now, ever since his injury?

He smiled. "It sounds pretty good right now."

3. Too much early mileage

Smart began playing AAU basketball in third grade, and through the years he might play four AAU games per day and as many as five per day at national tournaments. And that was on top of in-season competition at school.

This was the norm for Smart and other NBA rookies, and it creates perhaps the biggest red flag that trainers and others see in young players today: a considerable amount of mileage that can lead to more injuries at an earlier age.

"The AAU is the biggest thing people around the league pinpoint as to why all these injuries are occurring," Stotts said.

It's simply a matter of wear and tear.

"I think you only have so many jumps and landings in your body before it begins to break down, and you can go down through every body part and say the same thing -- each one has a separate number," DiFrancesco said. "There's no way to go back and get those miles back, but there's ways to manage their overall workload."

Obstacles exist, DiFrancesco said, such as the age-old notion that rookies must be "broken in" once they reach the NBA.

"When I first got into the league, I got this sense that, once you get your hands on a rookie, you can just push him and push him until they drop -- literally sometimes," he said. "By design, there's many people that believe that's how you have to show them the ropes, the hard way, and just grind them to see if they're mentally tough enough to withstand what it means to be an NBA player."

Another obstacle cited by players and trainers alike is the pre-draft process, during which prospects fly around the country and go through grueling workouts for NBA teams.

"They get fast food when they get off planes, then they practice on the site of the team that's requested them, then they do a huge, massive work-up -- very intense, long duration -- then they go on to the next one the next day," DiFrancesco said. "Any one of these guys will tell you it's miserable. It's one of the hardest things they do."

Bryan Doo, the Celtics' strength and conditioning coach, compared the grueling workload that many prospects face leading up to the draft to what LeBron James endured throughout the 2015 NBA Finals, when he averaged 46 minutes a game and dictated a huge portion of the Cavs' offensive possessions.

Players can do as many as 14 workouts in 20 days leading up to the draft, Doo said, and it comes right after a season of college or overseas competition and weeks of working out to prepare for the pre-draft combine and workout.

Then comes summer league.

"I do think there's a definite correlation between how many draft workouts these guys have and some of these guys getting injured," Doo said.

Most players are familiar with grueling schedules well before.

"They're getting personal trainers as kids," said Robbie Davis, a former athletic trainer for the Clippers who left in 2003 to start his own company, GameShape Inc. "They're not going to play another sport or cross-train or resting or having a summer where they just have summer vacation. Those things aren't happening with the top athletes. You would argue that they are better - people are bigger, stronger, faster and break records, but the injuries come with it.

"It's an overtraining thing and a lack of knowledge about recovery."

Davis said more players know that it's important to stretch and warm up and cool down, and as an example he mentioned Clippers star forward Blake Griffin, whom Davis trained for about five years. "We don't train hard every day," Davis said. "That's the point. There's days when I get him and we may just stretch and just foam roll and we may just ice. There are days in his routine where we just work recovery into his routine."

Doo said he'd rather see a player who was a three-sport athlete rather than a one-sport athlete in his youth because of the wear and tear caused by the same "movement patterns," such as the effects of jumping on the hardwood.

"We definitely have a lot more mileage on us because we've played so much. Only you can tell what your body has left. You have to judge it from there."
Marcus Smart

When the topic of mileage was mentioned to several rookie players, their initial response was often a sigh. None of them denied it.

"We definitely have a lot more mileage on us because we've played so much," Smart said. "Only you can tell what your body has left. You have to judge it from there."

The opportunities are especially hard for young players to turn down as they look to establish themselves in the NBA. It's valuable experience, even though it comes at a cost.

And it's not as though one could easily tell a player to stay off the court so that, down the road, their body won't be as likely to break down. Consider what Oklahoma City Thunder star Kevin Durant said after this season about his chronically injured right foot. "I was playing outside every day in the summer for five or six years, and I look back on it and I'm like, 'Damn, maybe that's the reason I got hurt,'" he told reporters. "Would I change it? Hell no. I don't regret nothing."

A similar dilemma exists in baseball. Wrote Sam Miller in an ESPN The Magazine story this year on Tommy John surgeries: "The sport has put a time bomb in every pitcher's body, a time bomb that starts ticking when they get good -- because they get good."

"We enjoy playing the game so much," McDermott said. "That's our life. We'd rather be playing. We want to get up every day and compete. It's hard to tell a kid, 'No, take a day off.'

"I'm looking back on my AAU days and you're playing three or four games in a day and then instead of going to Whole Foods like I am now and getting food, we were going to frickin' McDonald's or Burger King and eating that stuff in between games and we were fine. It's just the way it is."

Randle shook his head when he looked back on his AAU career, which began when he was 8.

"It's crazy, because you've got guys like Andrew [Wiggins], Joel [Embiid], Jabari [Parker], Aaron Gordon -- those guys were the same guys that when I was in fifth grade playing in every tournament, whether it was in Houston or Washington DC or AAU Nationals," Randle said. "Those guys were in every single tournament that I played against. They were there at every point, putting the same amount of miles on their body."

4. A weighty issue

Basketball is changing on the court, thanks to teams like the Golden State Warriors hoisting 3-pointers at record rates and blurring the lines of positions. And there's also an evolution happening in the weight room, according to several NBA strength and conditioning coaches.

Close to two decades ago, they say, the focus was more on traditional weight training -- dumbbells and free weights and such. Today, with more of an emphasis being placed on movement, core, stability and mobility, there's been a rise in the use of resistance bands and, say, a PhysioBall.

But some around the league question if the shift toward "functional training" has been a bit too drastic, and wonder if it has also contributed to injuries.

"Sometimes, industries can overreact and sometimes get past the tried and true methods that work," DiFrancesco said, "and I think we're seeing a whiplash effect from that."

One might think that lifting weights only increases muscle mass, but strength coaches say it goes beyond that.

"It's not just about making their muscles more robust, but their actual structure -- muscles, tendons, ligaments, bones, all of it," DiFrancesco said.

"What no one is talking about is why these guys need to be stronger and muscle acts as the biggest shock absorber that we have," says Shaun Brown, a former strength coach with the Raptors and Celtics who has also worked at nine colleges. "The less muscle you have, the more trauma that goes to your joints." This disagreement in approach can lead to a problem in the weight room.

"Some strength coaches use bands and stuff because the players say they feel better with them," said Doo, who has been the Celtics' strength and conditioning coach for 13 years. "When a player feels sore, sometimes players don't like that or they won't like that or they'll fight you again. So sometimes, we'll let them do that instead of holding them accountable and making them do a one-legged squat and saying, 'You need to do this.'"

While succumbing to a player's demand in such a situation is not ideal, Doo said, "It's the lesser of two evils, so strength coaches feel better -- 'At least I got them to do something.'"

DiFrancesco echoed Doo's point.

"It's easier to get a guy to say, 'Try this band exercise' than say, 'We're going to squat heavy today,'" DiFrancesco said. "But a really, really responsible and on-the-ball coach is going to say, 'No, I know you like those candy exercises that they're fun, but we need to load these structures up because that is the only way they're going to adapt and getting stronger.'"

And it's not just the players.

"Half your coaches don't want you to work out guys heavy. Why? Because 90 percent of the people in the NBA want to keep their jobs. They kowtow to the players because the players are going to dictate who's going to stay." Bryan Doo, Celtics strength and conditioning coach

"You're fighting your coaches, too," Doo said, speaking generally and not about his situation with the Celtics. "Half your coaches don't want you to work out guys heavy. Why? Because 90 percent of the people in the NBA want to keep their jobs. They kowtow to the players because the players are going to dictate who's going to stay."

Under his regimen, Doo said players might be asked to lift heavy weights two to three days a week, which he said is a pretty average workload during an NBA season.

"You've got to keep them strong," he said, "and in the course of an 82-game season, you're going to lose muscle at some point."

Dr. Rob Newton, Foundation Professor of Exercise and Sports Science at Edith Cowan University in Perth, Western Australia, said he is dismayed by what he deemed "fashion trends" in strength and conditioning that have emerged in the past 10-15 years.

"Many athletes, coaches and strength and conditioning specialists are adopting fads and fallacies which have little or no scientific basis as they try to gain some competitive edge or demonstrate that they are doing things which are new or different," Newton, who worked as a performance consultant with the Chicago Bulls from 1994-2002, wrote in an email. "Often these novel products, training systems and philosophies are driven purely by commercial interests as individuals and companies see the enormous financial gains to be made in the multibillion-dollar elite sport business."

He also said research shows that traditional weight lifting benefits strength, tendon size and stiffness, and bone density.

"We have found in our work with elite Australian football players that many are coming into the professional competition with relatively low bone density and this is resulting in high incidence of stress fractures and catastrophic fractures," he wrote. "We believe the cause is a reduced emphasis on plyometric and maximal strength training through the developmental years. In other words, they are running too much and lifting too little, which is making them weak physically and structurally."

Newton said it also improves hormonal conditions needed for high performance.

"To draw one example, testosterone is a highly anabolic hormone which facilitates muscle and connective tissue growth," he wrote. "Testosterone is also highly promoting of tissue repair and maintenance including muscle, tendon, ligament and even bone. Extensive research demonstrates that the greatest surges in testosterone are produced as a result of heavy resistance training incorporating large muscle groups, such as squats and deadlifts. Athletes who do not undertake this type of exercise every week are compromising their body's ability to improve, resist injury and recover."

All three active NBA strength coaches pointed out that newer trends are still helpful, but there needs to be more of a healthy balance involving older methods, too. They also say more programs should be designed to fit the needs of the individual.

"People are taking cookie-cutter programs today and giving them to everybody," Doo said.

While none of the coaches say that more traditional weight training alone will save players from injuries, they do believe that it could play a helpful role.

"I absolutely think there are things in the past that people are forgetting that absolutely work," said Steve Hess, who has been the Denver Nuggets' strength and conditioning coach for two decades. "They would apply adequate load to adequate body parts and I think that helped them avoid injuries because they didn't overthink it."

As Brown said, "Get guys to f------ lift weights. I wish it was more complicated. But it really ain't as complicated as people want it to be."

Randle first thought that the injuries to so many lottery players from the 2014 class were random. That there was "something in the water."

"A lot of the plays that guys got hurt on, you look at it and some of them are not, like, violent," McDermott said. "Sometimes you get bad luck and stuff happens."

But "luck" seems too easy an answer.

"It's not mysterious," Clark said. "We have kids playing too hard, too long and specializing and we're not doing the things to help them prepare before they play or recover after they play."

Clark recommended five tips for players young and old to help prevent injuries, improve performance and increase durability: nutrition, hydration, sleep, movement preparation and movement recovery -- the latter two more or less focused on warming up and cooling down (i.e. stretching).

"When people say injuries are part of the game, yes, if you step on someone's foot and you sprained someone's ankle, there's not much you can do about that," Clark said. "But almost 80 percent of injuries are non-contact injuries. The research shows that if you do a basic general warm-up, you can reduce those injuries by 50 percent."

Davis said it would be wise for all involved to ditch any machismo, too.

"There's an old saying - people used to say, 'No pain, no gain,'" Davis said. "I always argue that one. That's not true. You don't have to hurt yourself in order to get better. And people used to say, 'You can sleep when you're dead.' That's not true either."

Magic forward Aaron Gordon recommended to the 2015-16 incoming rookie class to avoid thinking that their youth makes them invincible.

"When you're young, you feel good no matter what time of day it is," Gordon said. "AAU, you could have three games a day and you wouldn't need to stretch out. You could just go out there and roll the balls out and play.

"Now that you've got an 82-game season. You've really got to take care of your body and make sure the right muscles are firing. You learn a lot more about your body in this league."

Toward the end of an hour-long interview at the Lakers' practice facility in El Segundo, Calif., during which the aforementioned issues were discussed, Randle's view on the spate of rookie injuries appeared to change.

He was asked again about the injuries to he and other members of the 2014 rookie class. Sitting on the edge of a table outside the trainer's room, he shook his head and stared at the wall.

"It's not a fluke."