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The American Journal of Sports

Medicine http://ajs.sagepub.com/

The Youth Throwing Score: Validating Injury Assessment in Young Baseball Players
Christopher S. Ahmad, Ajay S. Padaki, Manish S. Noticewala, Eric C. Makhni and Charles A. Popkin
Am J Sports Med published online October 10, 2016
DOI: 10.1177/0363546516667503

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AJSM PreView, published on October 10, 2016 as doi:10.1177/0363546516667503

The Youth Throwing Score


Validating Injury Assessment in Young Baseball Players
Christopher S. Ahmad,*y MD, Ajay S. Padaki,y MD, Manish S. Noticewala,y MD,
Eric C. Makhni,z MD, MBA, and Charles A. Popkin,y MD
Investigation performed at Columbia University Medical Center, New York, New York, USA

Background: Epidemic levels of shoulder and elbow injuries have been reported recently in youth and adolescent baseball play-
ers. Despite the concerning frequency of these injuries, no instrument has been validated to assess upper extremity injury in this
patient population.
Purpose/Hypothesis: The purpose of this study was to validate an upper extremity assessment tool specifically designed for
young baseball players. We hypothesized that this tool will be both reliable and valid.
Study Design: Cohort study (diagnosis); Level of evidence, 2.
Methods: The Youth Throwing Score (YTS) was constructed by an interdisciplinary team of providers and coaches as a tool to
assess upper extremity injury in youth and adolescent baseball players (age range, 10-18 years). The psychometric properties of
the test were then determined.
Results: A total of 223 players completed the final survey. The players mean age was 14.3 6 2.7 years. Pilot analysis showed
that none of the 14 questions received a mean athlete importance rating less than 3 of 5, and the final survey read at a Flesch-
Kincaid level of 4.1, which is appropriate for patients aged 9 years and older. The players self-assigned their injury status, resulting
in a mean instrument score of 59.7 6 8.4 for the 148 players playing without pain, 42.0 6 11.5 for the 60 players playing with
pain, and 40.4 6 10.5 for the 15 players not playing due to pain. Players playing without pain scored significantly higher than
those playing with pain and those not playing due to pain (P \ .001). Psychometric analysis showed a test-retest intraclass cor-
relation coefficient of 0.90 and a Cronbach alpha intra-item reliability coefficient of 0.93, indicating excellent reliability and internal
consistency. Pearson correlation coefficients of 0.65, 0.62, and 0.31 were calculated between the YTS and the Pediatric Out-
comes Data Collection Instrument sports/physical functioning module, the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow
score, and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, respectively. Injured players scored a mean
of 9.4 points higher after treatment (P \ .001), and players who improved in their self-assigned pain categorization scored 16.5
points higher (P \ .001).
Conclusion: The YTS is the first valid and reliable instrument for assessing young baseball players upper extremity health.
Keywords: youth baseball; psychometric validation; sports medicine; throwing injuries

The sports medicine community is reporting epidemic lev- indicates that more than 100,000 baseball players aged
els of throwing injuries in youth baseball.6 One study 18 and younger report to US emergency rooms annually.12
Although this study was inclusive of all baseball-related
injuries, a growing body of literature demonstrates that
*Address correspondence to Christopher S. Ahmad, MD, Columbia young baseball players are at particular risk for shoulder
University Medical Center, 622 West 168th Street, PH-1130, New York, and elbow pain and injury. Recent studies reported that
NY 10021, USA (email: csa4@columbia.edu).
y
Columbia University Medical Center, New York, New York, USA. throwing athletes develop pain in their throwing arms as
z
Department of Orthopaedics, Rush University Medical Center, Chi- high as 30% to 70% of the time, with a predilection toward
cago, Illinois, USA. pitchers.14,15 This high injury rate has been correlated
Presented as a poster at the 42nd annual meeting of the AOSSM, Col- with a variety of factors, including overuse with pitch
orado Springs, Colorado, July 2016.
counts,13 innings pitched,6 type of pitches thrown, compet-
One or more of the authors has declared the following potential con-
flict of interest or source of funding: This study was funded in part by an
ing in multiple leagues, and year-round playing.21 In addi-
Orthopedic Research and Education Fund grant (awarded to M.S.N. and tion, fatigue and poor pitching mechanics have been
C.S.A). C.S.A. is the head physician for the New York Yankees and has an implicated in injury. Early sports specialization is also rec-
affiliation with Arthrex. ognized as a significant factor related to injury in baseball
pitchers.8,9,13,15 These injuries have a significant effect on
The American Journal of Sports Medicine, Vol. XX, No. X
DOI: 10.1177/0363546516667503 patients and families, because they result in time lost
2016 The Author(s) from playing and possibly even in permanent problems

1
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2 Ahmad et al The American Journal of Sports Medicine

with playing. Beyond participation in the sport, serious and to facilitate comprehension for both the player and
injuries requiring surgical intervention can occur, result- nonphysician administrators (parent or coach).
ing in longitudinal health sequelae and decreased quality The pilot survey was administered to 28 players aged
of life. Because of the increasing incidence and consequen- between 10 and 14 years who were recruited from local Lit-
ces of these injuries, several initiatives have been intro- tle League teams. Players were asked to complete the sur-
duced to prevent, identify, and better treat them.3,8,9 vey, comment on methods for improvement, and rate the
Validated injury assessment tools have proven extremely importance of each question as it pertained to their shoul-
valuable in their respective domains to improve the der and elbow health from 1 to 5 (with 5 being the most
research of injury prevention and treatment.1,2,5,7,16,19 important). Although the final instrument was adminis-
Unfortunately, no validated injury assessment tool exists tered to players aged 10 to 18 years, an age restriction of
that is able to evaluate the health of young baseball players. 10 to 14 years was instituted for the pilot. This was
Existing tools either focus on adult athletes1 or do not focus intended to isolate the youngest players because their com-
specifically on throwing injuries.2,19 As physicians see an prehension is likely lower than that of older players. All
increasing number of young baseball players with musculo- pilot respondents were recruited by a study author
skeletal pain in their upper extremities, a validated assess- (A.S.P.) from a single recruitment session and 100% of
ment tool developed specifically to aid in this assessment players agreed to participate. Three of the 28 players
would provide critical research and clinical utility. There- responses were excluded because of incompletion. Four
fore, the purpose of this study was to generate and validate questions from the pilot instrument were eliminated
an accurate assessment tool for upper extremity injuries in because of poor comprehension and low importance ratings
youth, adolescent, and high school throwers. The hypothesis from the pilot cohort. The eliminated questions are listed in
was that the Youth Throwing Score (YTS) will be reliable, the Appendix (available in the online version of this article
sensitive, responsive, and valid for evaluating young throw- and at http://ajsm.sagepub.com/supplemental). The questions
ing athletes. were mostly psychosocial and younger players struggled with
comprehension. The instrument was also subsequently
revised in response to player input regarding question word-
METHODS ing and question comprehension. The final instrument was
formally evaluated for reading level and was determined to
After we received institutional review board (IRB) approval, be at a Flesch-Kincaid reading level of 4.1, which is appropri-
we began designing the YTS with the goal to create an accu- ate for players aged 9 years and older.10 None of the remain-
rate and expedient patient-reported outcomes measure that ing 14 questions received a mean athlete importance rating
young baseball players could complete independently. To below 3 and the mean item importance rating was 3.7. After
generate items, an interdisciplinary care team composed the 4-item reduction, the final instrument score ranged from
of orthopaedic surgeons, physical therapists, athletic train- 14 to 70. The finalized YTS can be viewed in Figure 1.
ers, and coaches was asked to generate a variety of ques-
tions regarding injury assessment in young throwing
Recruitment
athletes. In addition, existing upper extremity assessment
tools1,16,19 used in the adult population were critically ana- Separate from the pilot cohort, the final instrument was
lyzed for potential relevance to the pediatric population. then administered to 10- to 18-year-old males who played
Little League, adolescent, and high school baseball. An
Piloting and Scoring important design decision was to only include male
patients. The different throwing biomechanics in baseball
The initial pilot of the survey questionnaire included and softball led to the conclusion that specificity would suf-
a demographics section in addition to 18 items analyzing fer if both throwing motions were included. The literature
various aspects of pain, fatigue, and psychosocial health. shows that baseball players are twice as likely to have
Players self-assigned their injury status with 3 categorical shoulder injuries requiring surgery11 and elbow injuries
selections: (1) playing without pain, (2) playing with pain, occur much more commonly in baseball players.20 The com-
or (3) not playing due to pain. The additional items had 5 bination of these factors compounded with the senior
available responses: always, often, sometimes, rarely, and authors (C.S.A., C.A.P.) experience of treating serious
never, which were scored from 1 to 5, respectively. This upper extremity injuries more frequently in baseball play-
method was selected to optimize comprehension and accu- ers led to this decision.
racy for the young target population. Orthopaedic tools To be included in the study, patients had to be 10 to 18
used by the pediatric population have shown strong com- years old, male, and either actively playing baseball or not
prehension of frequency-based Likert scales among youth, playing as a result of baseball-related injuries. Patients
with the caveat that the term moderate should be were excluded if they did not meet the aforementioned
avoided.18 Other questions assessed pain, fatigue, and psy- age criteria, were female, did not play baseball, were not
chosocial health (eg, Does your arm hurt when you currently playing as a result of nonbaseball-related inju-
throw?) and higher scores were indicative of healthier, ries, were handicapped, or were not English or Spanish
pain-free throwing arms. Items were weighted equally, speaking. The baseball players were recruited from local
and the final score of the pilot form ranged from 18 to 90. baseball leagues and 2 major baseball training centers, in
Equal weighting was selected to allow for rapid scoring addition to those seen in the orthopaedic clinic at the

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AJSM Vol. XX, No. X, XXXX Injury Assessment in Young Baseball Players 3

Name: _______________________________________ Gender: Male Female

Age: _______ City, State, Zip: _______________, _____________, ____________

Date of Birth: _______ / ______ / _______ Todays Date: _____ / _____ / ______

Part I. Please answer EACH of the following questions.


1. What is your main sport? ________________________
2. What position do you play most often? ________________________
3. What other positions do you play? ________________________
4. Have you ever had an injury to your throwing arm? Yes No
a. If so, what type of injury did you have? ________________________
b. What date (approximately) did this injury occur? ________________________
5. Have you ever had surgery on your throwing arm? Yes No
a. If so, what type of surgery did you have? ________________________
b. What date (approximately) did this injury occur? ________________________
6. What type of league(s) do you play in?
School league Out-of-school league Both types of leagues

7. Describe the pain or discomfort level you felt the last time you played your sport. Please check only one box
Playing without any arm pain or discomfort
Playing with arm pain or discomfort
Not playing due to arm pain or discomfort

Part 2. Please answer EACH of the following 14 questions. Please mark only one box for each question.
1. Does your arm hurt when you throw?
Never Rarely Sometimes Often Always
2. Does your arm hurt the day after your throw?
Never Rarely Sometimes Often Always
3. Does your arm get tired during a game or practice?
Never Rarely Sometimes Often Always
4. Does arm pain decrease your throwing accuracy?
Never Rarely Sometimes Often Always
5. Does arm pain limit how hard you can throw?
Never Rarely Sometimes Often Always
6. Does arm pain or weakness limit the number of innings you can play?
Never Rarely Sometimes Often Always
7. Does arm pain or weakness limit the number of games you can play?
Never Rarely Sometimes Often Always

Figure 1. Pilot-form of the Youth Throwing Score.

senior authors institution. Numerous leagues and centers instruments were completed without supervision or influ-
in the region where the study was conducted were con- ence from parents. Youth and adolescent baseball players
tacted directly by an author in accordance with the IRB who presented to our orthopaedic outpatient clinics were
protocol. After the study was explained, only players consecutively recruited to participate. Players recruited
from leagues in which the general managers had agreed from the clinic and players involved with determining
to participate were approached. Players and parents in test-retest reliability and criterion validity were directly
these leagues and centers were then asked to voluntarily approached and observed by an author to ensure the
participate in the study before practice sessions. The absence of parental involvement. Every player asked to

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4 Ahmad et al The American Journal of Sports Medicine

participate in these cohorts agreed to participate. How- 70) and highest possible (70 of 70) YTS scores, respectively.
ever, general recruitment was largely conducted using Together, floor and ceiling effects can be used to evaluate
a secure electronic distributor. Players were explicitly content validity. Floor and ceiling effects of less than
asked to complete the surveys independently without 30% (indicating that less than 30% of respondents scored
parental contribution. The percentage of players who the lowest and highest scores, respectively) ensured con-
agreed to participate for this cohort could not be calculated tent validity.
because of the mode of distribution. Criterion Validity. The correlation between the YTS and
The psychometric properties used to evaluate the valid- existing, validated evaluation methods was assessed using
ity of the instrument are detailed below. a cohort who completed the YTS, the Kerlan-Jobe Orthopae-
dic Clinic Shoulder and Elbow (KJOC) score,1 the Quick Dis-
Psychometric Validation abilities of the Arm, Shoulder, and Hand (QuickDASH),19 the
Disabilities of the Arm, Shoulder, and Hand (DASH) sports/
Test-Retest Reliability. Test-retest reliability indicates performing arts module, and the Pediatric Outcomes Data
the degree to which an assessment tool can reproduce the Collection Instrument (PODCI).2 This cohort consisted of
same result when administered to the same patient multi- 50 players from a single training center who completed all
ple times (barring a change to the patient). To compute 5 assessment tools in 1 recruitment session with direct super-
test-retest reliability, 41 players completed the instrument vision by an author to ensure that parental influence did not
a second time 2 to 4 weeks after the first completion. This bias the results. All 50 baseball players were recruited in this
cohort consisted of players who reported to a training cen- session and this group was selected because of its size, as sta-
ter on a weekly basis. They were selected because of their tistical analysis revealed that 50 patients were needed for
cohort size and reliable attendance to ensure the feasibility this cohort. These assessment tools were determined to be
of follow-up administration. No player reported injury most relevant to assessing pediatric overhead throwing
between iterations. This cohort size was selected in accor- health and quality of life after a thorough literature review
dance with similar studies that analyzed test-retest reli- performed by the authors. The order that the instruments
ability.4 The test-retest intraclass correlation coefficient were administered was randomized using independent
was calculated from this cohort, with a value of at least software (Qualtrics) to prevent survey fatigue from dispro-
0.85 indicating strong reliability.17 portionately biasing the latter tools. A Pearson product-
Internal Consistency. The degree to which the questions moment correlation coefficient was calculated between the
in the assessment tool measured the primary construct YTS and each instrument mentioned above.
was evaluated by determining the Cronbach alpha. All Construct Validity. Construct validity refers to the abil-
responses were included in this analysis and the Cronbach ity of an assessment tool to evaluate its overarching aim in
alpha intra-item reliability coefficient was calculated. A design. The instruments construct validity was assessed
value of at least 0.85 indicated valid internal consistency, by amalgamating the aforementioned methods. Specifi-
and a value greater than 0.95 indicated redundancy cally, the constructs established were that the score would
between questions. be accurately stratified by pain category, healthier players
Exploratory Factor Analysis. An exploratory factor anal- would score higher than injured players, and the instru-
ysis was used to assess the number of constructs (poten- ment would be responsive with high internal consistency
tially pain, short-term fatigue, longitudinal fatigue, and reliability. A nonparametric Kruskal-Wallis test was
psychosocial health, and performance) present in the instru- used to contrast the scoring mean of each pain category.
ment and the variance of each construct. The individual
variance of each construct was compared with the total var-
iance of the instrument (proportional variance). We com- Statistical Analysis
puted the range of scoring for each item and analyzed the
contribution of each item to the factor with which it was Statistical analysis was conducted using R Statistical Pro-
associated. The uniqueness of the items, regarding the pro- gramming Language (version 3.1.0; R Foundation for Sta-
portion of variance not accounted for by existing factors, tistical Computing). Test-retest reliability, Cronbach alpha
was also computed. All respondents (healthy and injured intra-item reliability, and exploratory factor analysis were
players) were included in this facet of the validation. computed as detailed above. A nonparametric Kruskal-
Responsiveness. The ability of the instrument score to Wallis test was conducted to assess scoring differences
reflect the changing health of a patient who has recovered between 2 demographic cohorts (ie, history of throwing
from an injury was assessed with responsiveness in the arm surgery and no history of throwing arm surgery). A
instrument. The 61 injured patients in this cohort were P value of .05 indicated statistical significance.
contacted upon completion of treatment, with the second
iteration taken at a mean of 142 days after the first. Com-
pletion of treatment was defined as an appropriate RESULTS
response to treatment as determined by the senior sur-
geon. The significance of scoring changes after treatment A total of 241 youth baseball players aged between 10 and 18
was evaluated with a paired Wilcoxon signed-ranks test. years completed the YTS. Eighteen players were excluded
Content Validity. Floor and ceiling effects refer to the because they were unable to complete the instrument before
number of patients that scored the lowest possible (14 of the beginning of practice, which resulted in 223 respondents

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AJSM Vol. XX, No. X, XXXX Injury Assessment in Young Baseball Players 5

(92.5%). The mean age of the players was 14.3 6 2.7 years, 70
and all participants were male. Approximately 94% (n =
60
210) of players stated that baseball was their primary sport.
Regarding injury history, 45.3% of players reported having

Youth Throwing Score


50
suffered a throwing arm injury and 6.7% of players required
surgery. More than one-third of players (37%; n = 82) stated 40
that pitcher was their primary position.
30
The scoring distribution was distinguished by pain catego-
rization. The 148 players who indicated that they were play- 20
ing without pain scored a mean of 59.7 6 8.4, the 60 players
playing with pain scored 42.0 6 11.5, and the 15 players not 10
playing due to pain scored 40.4 6 10.5. An analysis of vari-
0
ance demonstrated that the pain categories were able to Playing without pain Playing with pain Not playing due to pain
accurately stratify players playing without pain from those
players with pain, regardless of playing status (P \ .001). Figure 2. Scoring tiers for the Youth Throwing Score.
Patients playing without pain were significantly stratified
from those playing with pain (P \ .01) and players not playing
due to pain (P \ .01). However, the difference in scores
between patients playing with pain and patients not playing Responsiveness was calculated after the 61 patients
due to pain was not significant (P = .21). The scoring tiers recruited from the authors clinic completed treatment. The
are displayed in Figure 2 and the distribution of scores across injuries in this population ranged from conditions treated
pain categories is displayed in Table 1. nonoperatively, such as medial epicondylitis, to operatively
Differences in the demographic representations were treated conditions, including superior labrum anterior and
also noted when the results were stratified by pain catego- posterior (SLAP) tears. Elbow injuries included ulnar collat-
rization. For patients playing without pain, 29.3% reported eral ligament (UCL) tears, UCL strains, elbow dislocations,
a throwing injury history and 4.1% reported a surgical his- lateral epicondylitis, medial epicondylitis, osteochondritis
tory related to throwing. Of patients playing with pain, dissecans (radius, capitellum) with or without loose bodies,
71.7% reported an injury history and 11.7% of these play- pronator teres strains, Little League elbow, elbow stress frac-
ers indicated a past surgical history. Finally, of players ture not otherwise specified (NOS), and elbow pain NOS.
not playing due to pain, 100% reported an injury history Shoulder injuries included impingement, SLAP tears, insta-
and 13.3% indicated a surgical history. bility, rotator cuff inflammation, biceps inflammation, Little
Other demographics were also correlated with significant League shoulder, glenoid osteochondritis dissecans, humeral
YTS scoring differences. Players who had suffered throwing stress fracture, stress fracture NOS, and shoulder pain NOS.
arm injuries (mean score, 47.7 vs 58.8; P \ .001) and players The interventions included, but were not limited to, rest,
who had undergone throwing arm surgeries (mean score, physical therapy, injections, and surgery. The mean time
45.9 vs 54.3; P = .039) scored significantly lower on the after initial recruitment was 142 6 57 days and 41 patients
YTS than players with no such medical history. In addition, (67.2%) completed the survey a second time. The remaining
players who participated on both their school and club 20 players were lost to follow-up. The mean change in score
teams scored lower than those who only played for either was an increase of 9.4 points, a significant improvement
their school or club teams (mean score, 51.9 vs 56.6; P \ (P \ .001). The greatest change in score was found among
.001). Finally, pitchers scored significantly lower than non- patients who changed their pain status (ie, from playing
pitchers (mean score, 51.2 vs 55.1; P = .013) and players with pain to playing without pain), in which the mean
aged 15 years and older scored significantly lower than increase in score was 16.5 points (P \ .001).
players younger than 15 (mean score, 51.2 vs 57.0; P \ Pearson correlations were used to calculate the correlation
.001). Table 2 provides a summary of these comparisons between the YTS and existing instruments. Fifty players com-
and shows the influence of each demographic variable on pleted all 5 surveys (YTS, KJOC, DASH sports/performing
individual item scoring. arts module, QuickDASH, and PODCI). The highest correla-
In addition to the scoring stratification, the psychometric tions were observed with the PODCI global function module
properties of the YTS were calculated. The test-retest reli- (0.76), the PODCI pain/comfort module (0.74), and the
ability was determined by the 41 players who took the sur- DASH sports/performing arts module (0.71). All Pearson cor-
vey a second time. The YTS test-retest intraclass correlation relation coefficients are reported in Table 3.
coefficient was 0.90, and none of the 14 items scored below The content validity of the instrument was also estab-
0.70 individually. The Cronbach alpha intra-item reliability lished by analyzing the presence of ceiling and floor effects.
was calculated to be 0.93 for the instrument as a whole and No ceiling or floor effect was observed because only 7 scores
no item scored below a 0.80. An exploratory factor analysis (3.1%) equaled 70 and 1 score (0.45%) equaled 14, well
was conducted and revealed that 4 factors (identified as below the 30% marker set to ensure content validity.
pain, fatigue, fun, and performance) provided the majority All established constructs were achieved, as the instru-
of proportional variance. Item 10, which assessed the effect ment accurately differentiated players by pain category,
of pain on throwing motion, was the most unique question healthy players scored significantly higher than injured
in that it least correlated with the 4 factors. players, and the instrument was responsive, internally

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6 Ahmad et al The American Journal of Sports Medicine

TABLE 1
Youth Throwing Score by Pain Categorizationa

Pain Category No. of Players Minimum Q1 Mean Q3 Maximum SD

Playing without pain 148 37 56 59.7 65.5 70 8.4


Playing with pain 60 15 34 42 50 60 11.8
Not playing due to pain 15 14 32 40.4 47 58 10.5

a
Q, quartile.

TABLE 2
Youth Throwing Score Results by Demographic Categorization

Score by Item Number


Demographic 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Overall Score

Age, y
10-14 3.74 3.89 3.82 3.79 3.76 4.15 4.20 4.42 4.27 4.26 4.20 4.19 4.20 4.14 57.0
15-18 3.31 3.40 3.46 3.17 2.90 3.79 4.09 4.39 3.97 4.03 3.81 3.92 3.46 3.53 51.2
Primary position
Nonpitcher 3.48 3.69 3.74 3.48 3.32 4.19 4.27 4.53 4.25 4.12 4.08 4.19 3.87 3.92 55.1
Pitcher 3.49 3.50 3.38 3.37 3.17 3.49 3.90 4.17 3.83 4.13 3.82 3.78 3.62 3.56 51.2
Medical history
No injury history 3.85 3.93 3.84 3.72 3.57 4.33 4.49 4.69 4.50 4.52 4.34 4.51 4.22 4.24 58.8
Injury history 3.06 3.23 3.35 3.11 2.92 3.48 3.71 4.06 3.62 3.66 3.55 3.48 3.25 3.26 47.7
No surgical history 3.56 3.65 3.67 3.51 3.30 3.96 4.18 4.43 4.14 4.17 4.02 4.05 3.85 3.85 54.3
Surgical history 2.60 3.13 3.00 2.53 2.93 3.67 3.60 4.00 3.60 3.67 3.40 3.93 2.80 3.07 45.9
Number of leagues
1 3.67 3.98 3.70 3.66 3.66 4.14 4.20 4.55 4.24 4.32 4.18 4.28 4.07 3.99 56.6
2 3.38 3.38 3.57 3.30 3.02 3.81 4.10 4.31 4.01 4.01 3.85 3.88 3.59 3.67 51.9

consistent, and reliable. The intrinsic properties of the YTS TABLE 3


are reported in Table 4. Pearson Correlation Coefficients Between the Youth
To directly contrast the critical demographic and psy- Throwing Score and Existing Assessment Modalitiesa
chometric properties of the YTS and the KJOC, a side-by
side comparison is available in Table 5. Although both Instrument Pearson Correlation Coefficient
assessment tools evaluate the throwing arm health of base-
DASH sports/performing 0.71
ball players, the YTS was validated in a population almost arts module
10 years younger than the KJOC with a reading level KJOC score 0.62
reflective of its purpose. QuickDASH 0.31
PODCI module
Global function 0.76
Pain/comfort 0.74
DISCUSSION
Sports/physical functioning 0.65
Upper extremity 0.50
The YTS is a new instrument specifically designed for young,
Transfer and basic mobility 0.35
male overhead throwers. The initial design and revisions
Happiness 0.31
after piloting ensured that the items were relevant and easily
understood. General recruitment displayed significant scor- a
DASH, Disabilities of the Arm, Shoulder, and Hand; KJOC,
ing separation between players in the different self-assigned Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow; PODCI,
pain categories. A detailed statistical analysis showed strong Pediatric Outcomes Data Collection Instrument; QuickDASH,
internal consistency, test-retest reliability, responsiveness, Quick Disabilities of the Arm, Shoulder, and Hand.
and content validity in addition to moderate correlations
with other validated instruments. Because all design con-
structs were met, the YTS was confirmed as a validated out- not specifically designed for, or validated in, young overhead
comes measure for injury assessment of young throwers. throwers. Although the KJOC was well validated in the
Although instruments have been validated to assess the adult population, its usage to accurately assess younger
adult overhead thrower,1 the global health of a child,2 and throwers health is subject to significant limitations. The
the upper extremity of a child,19 these instruments were KJOC was validated in a population with a mean age of

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AJSM Vol. XX, No. X, XXXX Injury Assessment in Young Baseball Players 7

TABLE 4 TABLE 5
The Psychometric and Intrinsic Properties Validation Properties of the Youth Throwing
of the Youth Throwing Score Score Versus the Kerlan-Jobe Orthopaedic Clinic
Shoulder and Elbow Scorea
Property Value
Property YTS KJOC
Score, mean 6 SD
Playing without pain (n = 148) 59.7 6 8.4 Age, y 14.3 23.7c
Playing with pain (n = 60) 42.0 6 11.5 Baseball players, % 100 85.7c
Not playing due to pain (n = 15) 40.4 6 10.5 Flesch-Kincaid reading level 4.1 7.6d
Test-retest reliability Test-retest intraclass correlation coefficient 0.90 0.88c
Intraclass correlation coefficient 0.90 Mean responsiveness score increase 13.4b 8.3c
Intra-item reliability QuickDASH Pearson correlation 0.31 0.84c
Cronbach alpha intra-item coefficient 0.93 DASH Sports/Performing Arts 0.71 0.86c
Responsiveness Pearson correlation
Mean score increase 9.4
Miscellaneous a
DASH, Disabilities of the Arm, Shoulder, and Hand; KJOC,
Mean item athlete importance rating 3.7 Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow; QuickDASH,
Flesch-Kincaid reading level 4.1 Quick Disabilities of the Arm, Shoulder, and Hand; YTS, Youth
Throwing Score.
b
Scaled to the 100-point total.
23.7 years, almost a decade older than the mean age used in c
As reported in the initial validation.1
d
the YTS. In addition, because the KJOC was designed for As calculated using the published instrument.
a different population, its Flesch-Kincaid reading level dem-
onstrates that its wording is not appropriate for children
younger than 12 to 13 years. Furthermore, the KJOC uses assess pain in young baseball players upper extremities.
higher-level terminology (eg, endurance limitation and The YTS more accurately assesses upper extremity health
instability) and professional questions (eg, assessing the than similar adult tools or more global youth tools. Its
athletes relationship with [his or her] coaches, manage- strong statistical properties, including test-retest reliabil-
ment, and agents1), which likely hinder its comprehension ity, content validity, internal consistency, responsiveness,
by young throwers. In fact, the senior authors experience and criterion validity, indicate its psychometric validity.
was that the KJOC could not be filled out independently In addition, the novelty of the YTS signifies its importance
by young athletes. and the research potential in aiding providers to better
The design and construct distinctions between the YTS understand the epidemic facing young baseball players.
and the validated outcomes used in this study help to Several limitations were present in this investigation.
explain the Pearson correlation variance. Although the The dearth of validated instruments in pediatric overhead
YTS and KJOC both assess overhead throwers health, their throwers resulted in a comparison with available but
difference in target population is reflected in their moderate imprecise tools for throwers. Consequently, the comparison
correlation strength. Although the YTS possessed a strong between instruments is less absolute. In addition, as
correlation with certain PODCI modalities (eg, the pain/ a result of completion of treatment and other factors inher-
comfort and sports/physical functioning), weaker relation- ent in the pediatric population, there was significant loss of
ships were observed with happiness and basic mobility. follow-up (32.8% of patients were lost). Critically, the
However, these results were expected because the 14-item instrument was designed for independent completion by
YTS focuses on upper extremity health, whereas the 83- the pediatric patient. The removal of the parents from
item PODCI offers global assessment. In addition, although instrument completion led to higher follow-up loss because
the 11-item QuickDASH and the 4-item DASH sports/per- the pediatric patients were intrinsically less compliant in
forming arts module were both validated in children, nei- independently completing follow-up surveys. Although inde-
ther specifically assesses overhead throwing. Pain with pendent completion was important to demonstrate the val-
overhead throwing is not likely to be reflected by assessing idity of the assessment tool, future studies to further
difficulty with using a knife to cut food or carrying a explore the potential of this instrument will likely include
shopping bag or briefcase.19 Although these modalities parental involvement for more accurate injury identification
offer functional assessment of the upper extremity in chil- and greater follow-up. Importantly, no operative patients
dren, neither accurately assesses overhead throwing health. were lost to follow-up. As discussed in the Methods, to
Because of its precise design and intended scope, the ensure specificity for the overhead athlete, only male base-
YTS represents the first validated instrument to aid health ball patients were included in this study. The differing bio-
professionals in researching injuries in young overhead mechanics between overhead and underhand throwing and
throwers. Epidemic levels of shoulder and elbow injuries the increased incidence of serious, upper extremity overuse
are present in the youth baseball community, and no vali- injuries in baseball players led to this decision.
dated assessment tools before the YTS existed to assist Finally, although players not playing due to pain scored
healthcare providers with this population. The multilay- lower than those playing with pain, the separation was not
ered design and thorough validation of the YTS indicates statistically significant. Even though the players playing
that it can now be used by healthcare providers to help without pain were significantly stratified from these cohorts,

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8 Ahmad et al The American Journal of Sports Medicine

this remains a limitation of the study. Differing psychosocial 6. Fleisig GS, Andrews JR, Cutter GR, et al. Risk of serious injury for
circumstances may contribute to the lack of separation young baseball pitchers: a 10-year prospective study. Am J Sports
Med. 2011;39(2):253-257.
between these cohorts, as players with similar levels of
7. Higgins LD, Taylor MK, Park D, et al. Reliability and validity of the
pain and injury may have separate playing statuses. Some International Knee Documentation Committee (IKDC) Subjective
players may continue to play because of coaching and paren- Knee Form. Joint Bone Spine. 2007;74(6):594-599.
tal pressure, whereas others may have already sought medi- 8. Intensive training and sports specialization in young athletes. Ameri-
cal care and consequently are not playing. The absence of can Academy of Pediatrics. Committee on Sports Medicine and Fit-
a floor effect, however, indicates the potential for stratifica- ness. Pediatrics. 2000;106(1 Pt 1):154-157.
tion for injured players and further investigations must be 9. Jayanthi NA, LaBella CR, Fischer D, Pasulka J, Dugas LR. Sports-
specialized intensive training and the risk of injury in young athletes:
conducted to gain insight into these cohorts. a clinical case-control study. Am J Sports Med. 2015;43(4):794-801.
This study validates the YTS and demonstrates its 10. Kincaid JP, Fishburne RP, Rogers RL, Chissom BS. Derivation of
potential to aid the baseball community in developing strat- New Readability Formulas (Automated Readability Index, Fog Count,
egies to curb the rising epidemic of youth throwing injuries. and Flesch Reading Ease Formula) for Navy Enlisted Personnel. Mill-
Further studies analyzing the responsiveness of the instru- ington, TN: Naval Air Station Memphis; 1975. http://www.dtic.mil/
ment for individual injuries could aid providers in caring for dtic/tr/fulltext/u2/a006655.pdf. Accessed June 1, 2014.
11. Krajnik S, Fogarty KJ, Yard EE, Comstock RD. Shoulder injuries in US
these young patients, but parental involvement will be nec-
high school baseball and softball athletes, 2005-2008. Pediatrics.
essary to provide injury specificity. Epidemiologic studies 2010;125(3):497-501.
could show the instruments potential in injury prevention 12. Lawson BR, Comstock RD, Smith GA. Baseball-related injuries to
for young baseball players. The YTS accurately identifies children treated in hospital emergency departments in the United
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validated as a novel research tool. 13. Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type,
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14. Lyman S, Fleisig GS, Waterbor JW, et al. Longitudinal study of elbow
ACKNOWLEDGMENT
and shoulder pain in youth baseball pitchers. Med Sci Sports Exerc.
2001;33(11):1803-1810.
The authors thank Michael Lombardi, general manager of 15. Makhni EC, Morrow ZS, Luchetti TJ, et al. Arm pain in youth baseball
the Baseball Center, and Steve Heyward, general manager players: a survey of healthy players. Am J Sports Med. 2015;43(1):
of PBI, for their extensive assistance with recruitment for 41-46.
this study. 16. Michener LA, McClure PW, Sennett BJ. American Shoulder and
Elbow Surgeons Standardized Shoulder Assessment Form, patient
self-report section: reliability, validity, and responsiveness. J Shoul-
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