The American Journal of Sports

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

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

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4 Ahmad et al
participate in these cohorts agreed to participate. How-
ever, general recruitment was largely conducted using
a secure electronic distributor. Players were explicitly
asked to complete the surveys independently without
parental contribution. The percentage of players who
agreed to participate for this cohort could not be calculated
because of the mode of distribution.
The psychometric properties used to evaluate the valid-
ity of the instrument are detailed below.
Psychometric Validation
Test-Retest Reliability. Test-retest reliability indicates
the degree to which an assessment tool can reproduce the
same result when administered to the same patient multi-
ple times (barring a change to the patient). To compute
test-retest reliability, 41 players completed the instrument
a second time 2 to 4 weeks after the first completion. This
cohort consisted of players who reported to a training cen-
ter on a weekly basis. They were selected because of their
cohort size and reliable attendance to ensure the feasibility
of follow-up administration. No player reported injury
between iterations. This cohort size was selected in accor-
dance with similar studies that analyzed test-retest reli-
ability.4 The test-retest intraclass correlation coefficient
was calculated from this cohort, with a value of at least
0.85 indicating strong reliability.17
Internal Consistency. The degree to which the questions
in the assessment tool measured the primary construct
was evaluated by determining the Cronbach alpha. All
responses were included in this analysis and the Cronbach
alpha intra-item reliability coefficient was calculated. A
value of at least 0.85 indicated valid internal consistency,
and a value greater than 0.95 indicated redundancy
between questions.
Exploratory Factor Analysis. An exploratory factor anal-
ysis was used to assess the number of constructs (poten-
tially pain, short-term fatigue, longitudinal fatigue,
psychosocial health, and performance) present in the instru-
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-
puted the range of scoring for each item and analyzed the
contribution of each item to the factor with which it was
associated. The uniqueness of the items, regarding the pro-
portion of variance not accounted for by existing factors,
was also computed. All respondents (healthy and injured
players) were included in this facet of the validation.
Responsiveness. The ability of the instrument score to
reflect the changing health of a patient who has recovered
from an injury was assessed with responsiveness in the
instrument. The 61 injured patients in this cohort were
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
response to treatment as determined by the senior sur-
geon. The significance of scoring changes after treatment
was evaluated with a paired Wilcoxon signed-ranks test.
Content Validity. Floor and ceiling effects refer to the
number of patients that scored the lowest possible (14 of
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The American Journal of Sports Medicine
70) and highest possible (70 of 70) YTS scores, respectively.
Together, floor and ceiling effects can be used to evaluate
content validity. Floor and ceiling effects of less than
30% (indicating that less than 30% of respondents scored
the lowest and highest scores, respectively) ensured con-
tent validity.
Criterion Validity. The correlation between the YTS and
existing, validated evaluation methods was assessed using
a cohort who completed the YTS, the Kerlan-Jobe Orthopae-
dic Clinic Shoulder and Elbow (KJOC) score,1 the Quick Dis-
abilities of the Arm, Shoulder, and Hand (QuickDASH),19 the
Disabilities of the Arm, Shoulder, and Hand (DASH) sports/
performing arts module, and the Pediatric Outcomes Data
Collection Instrument (PODCI).2 This cohort consisted of
50 players from a single training center who completed all
5 assessment tools in 1 recruitment session with direct super-
vision by an author to ensure that parental influence did not
bias the results. All 50 baseball players were recruited in this
session and this group was selected because of its size, as sta-
tistical analysis revealed that 50 patients were needed for
this cohort. These assessment tools were determined to be
most relevant to assessing pediatric overhead throwing
health and quality of life after a thorough literature review
performed by the authors. The order that the instruments
were administered was randomized using independent
software (Qualtrics) to prevent survey fatigue from dispro-
portionately biasing the latter tools. A Pearson product-
moment correlation coefficient was calculated between the
YTS and each instrument mentioned above.
Construct Validity. Construct validity refers to the abil-
ity of an assessment tool to evaluate its overarching aim in
design. The instruments construct validity was assessed
by amalgamating the aforementioned methods. Specifi-
cally, the constructs established were that the score would
be accurately stratified by pain category, healthier players
would score higher than injured players, and the instru-
ment would be responsive with high internal consistency
and reliability. A nonparametric Kruskal-Wallis test was
used to contrast the scoring mean of each pain category.
Statistical Analysis
Statistical analysis was conducted using R Statistical Pro-
gramming Language (version 3.1.0; R Foundation for Sta-
tistical Computing). Test-retest reliability, Cronbach alpha
intra-item reliability, and exploratory factor analysis were
computed as detailed above. A nonparametric Kruskal-
Wallis test was conducted to assess scoring differences
between 2 demographic cohorts (ie, history of throwing
arm surgery and no history of throwing arm surgery). A
P value of .05 indicated statistical significance.
RESULTS
A total of 241 youth baseball players aged between 10 and 18
years completed the YTS. Eighteen players were excluded
because they were unable to complete the instrument before
the beginning of practice, which resulted in 223 respondents
AJSM Vol. XX, No. X, XXXX
(92.5%). The mean age of the players was 14.3 6 2.7 years,
and all participants were male. Approximately 94% (n =
210) of players stated that baseball was their primary sport.
Regarding injury history, 45.3% of players reported having
suffered a throwing arm injury and 6.7% of players required
surgery. More than one-third of players (37%; n = 82) stated
that pitcher was their primary position.
The scoring distribution was distinguished by pain catego-
rization. The 148 players who indicated that they were play-
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
playing due to pain scored 40.4 6 10.5. An analysis of vari-
ance demonstrated that the pain categories were able to
accurately stratify players playing without pain from those
players with pain, regardless of playing status (P \ .001).
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
due to pain was not significant (P = .21). The scoring tiers
are displayed in Figure 2 and the distribution of scores across
pain categories is displayed in Table 1.
Differences in the demographic representations were
also noted when the results were stratified by pain catego-
rization. For patients playing without pain, 29.3% reported
a throwing injury history and 4.1% reported a surgical his-
tory related to throwing. Of patients playing with pain,
71.7% reported an injury history and 11.7% of these play-
ers indicated a past surgical history. Finally, of players
not playing due to pain, 100% reported an injury history
and 13.3% indicated a surgical history.
Other demographics were also correlated with significant
YTS scoring differences. Players who had suffered throwing
arm injuries (mean score, 47.7 vs 58.8; P \ .001) and players
who had undergone throwing arm surgeries (mean score,
45.9 vs 54.3; P = .039) scored significantly lower on the
YTS than players with no such medical history. In addition,
players who participated on both their school and club
teams scored lower than those who only played for either
their school or club teams (mean score, 51.9 vs 56.6; P \
.001). Finally, pitchers scored significantly lower than non-
pitchers (mean score, 51.2 vs 55.1; P = .013) and players
aged 15 years and older scored significantly lower than
players younger than 15 (mean score, 51.2 vs 57.0; P \
.001). Table 2 provides a summary of these comparisons
and shows the influence of each demographic variable on
individual item scoring.
In addition to the scoring stratification, the psychometric
properties of the YTS were calculated. The test-retest reli-
ability was determined by the 41 players who took the sur-
vey a second time. The YTS test-retest intraclass correlation
coefficient was 0.90, and none of the 14 items scored below
0.70 individually. The Cronbach alpha intra-item reliability
was calculated to be 0.93 for the instrument as a whole and
no item scored below a 0.80. An exploratory factor analysis
was conducted and revealed that 4 factors (identified as
pain, fatigue, fun, and performance) provided the majority
of proportional variance. Item 10, which assessed the effect
of pain on throwing motion, was the most unique question
in that it least correlated with the 4 factors.
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Injury Assessment in Young Baseball Players 5
70
60
Youth Throwing Score
50
40
30
20
10
0
Playing without pain Playing with pain Not playing due to pain
Figure 2. Scoring tiers for the Youth Throwing Score.
Responsiveness was calculated after the 61 patients
recruited from the authors clinic completed treatment. The
injuries in this population ranged from conditions treated
nonoperatively, such as medial epicondylitis, to operatively
treated conditions, including superior labrum anterior and
posterior (SLAP) tears. Elbow injuries included ulnar collat-
eral ligament (UCL) tears, UCL strains, elbow dislocations,
lateral epicondylitis, medial epicondylitis, osteochondritis
dissecans (radius, capitellum) with or without loose bodies,
pronator teres strains, Little League elbow, elbow stress frac-
ture not otherwise specified (NOS), and elbow pain NOS.
Shoulder injuries included impingement, SLAP tears, insta-
bility, rotator cuff inflammation, biceps inflammation, Little
League shoulder, glenoid osteochondritis dissecans, humeral
stress fracture, stress fracture NOS, and shoulder pain NOS.
The interventions included, but were not limited to, rest,
physical therapy, injections, and surgery. The mean time
after initial recruitment was 142 6 57 days and 41 patients
(67.2%) completed the survey a second time. The remaining
20 players were lost to follow-up. The mean change in score
was an increase of 9.4 points, a significant improvement
(P \ .001). The greatest change in score was found among
patients who changed their pain status (ie, from playing
with pain to playing without pain), in which the mean
increase in score was 16.5 points (P \ .001).
Pearson correlations were used to calculate the correlation
between the YTS and existing instruments. Fifty players com-
pleted all 5 surveys (YTS, KJOC, DASH sports/performing
arts module, QuickDASH, and PODCI). The highest correla-
tions were observed with the PODCI global function module
(0.76), the PODCI pain/comfort module (0.74), and the
DASH sports/performing arts module (0.71). All Pearson cor-
relation coefficients are reported in Table 3.
The content validity of the instrument was also estab-
lished by analyzing the presence of ceiling and floor effects.
No ceiling or floor effect was observed because only 7 scores
(3.1%) equaled 70 and 1 score (0.45%) equaled 14, well
below the 30% marker set to ensure content validity.
All established constructs were achieved, as the instru-
ment accurately differentiated players by pain category,
healthy players scored significantly higher than injured
players, and the instrument was responsive, internally
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
TABLE 4
The Psychometric and Intrinsic Properties
of the Youth Throwing Score
Property Value
Score, mean 6 SD
Playing without pain (n = 148) 59.7 6 8.4
Playing with pain (n = 60) 42.0 6 11.5
Not playing due to pain (n = 15) 40.4 6 10.5
Test-retest reliability
Intraclass correlation coefficient 0.90
Intra-item reliability
Cronbach alpha intra-item coefficient 0.93
Responsiveness
Mean score increase 9.4
Miscellaneous
Mean item athlete importance rating 3.7
Flesch-Kincaid reading level 4.1
23.7 years, almost a decade older than the mean age used in
the YTS. In addition, because the KJOC was designed for
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
higher-level terminology (eg, endurance limitation and
instability) and professional questions (eg, assessing the
athletes relationship with [his or her] coaches, manage-
ment, and agents1), which likely hinder its comprehension
by young throwers. In fact, the senior authors experience
was that the KJOC could not be filled out independently
by young athletes.
The design and construct distinctions between the YTS
and the validated outcomes used in this study help to
explain the Pearson correlation variance. Although the
YTS and KJOC both assess overhead throwers health, their
difference in target population is reflected in their moderate
correlation strength. Although the YTS possessed a strong
correlation with certain PODCI modalities (eg, the pain/
comfort and sports/physical functioning), weaker relation-
ships were observed with happiness and basic mobility.
However, these results were expected because the 14-item
YTS focuses on upper extremity health, whereas the 83-
item PODCI offers global assessment. In addition, although
the 11-item QuickDASH and the 4-item DASH sports/per-
forming arts module were both validated in children, nei-
ther specifically assesses overhead throwing. Pain with
overhead throwing is not likely to be reflected by assessing
difficulty with using a knife to cut food or carrying a
shopping bag or briefcase.19 Although these modalities
offer functional assessment of the upper extremity in chil-
dren, neither accurately assesses overhead throwing health.
Because of its precise design and intended scope, the
YTS represents the first validated instrument to aid health
professionals in researching injuries in young overhead
throwers. Epidemic levels of shoulder and elbow injuries
are present in the youth baseball community, and no vali-
dated assessment tools before the YTS existed to assist
healthcare providers with this population. The multilay-
ered design and thorough validation of the YTS indicates
that it can now be used by healthcare providers to help
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Injury Assessment in Young Baseball Players 7
TABLE 5
Validation Properties of the Youth Throwing
Score Versus the Kerlan-Jobe Orthopaedic Clinic
Shoulder and Elbow Scorea
Property YTS KJOC
Age, y 14.3 23.7c
Baseball players, % 100 85.7c
Flesch-Kincaid reading level 4.1 7.6d
Test-retest intraclass correlation coefficient 0.90 0.88c
Mean responsiveness score increase 13.4b 8.3c
QuickDASH Pearson correlation 0.31 0.84c
DASH Sports/Performing Arts 0.71 0.86c
Pearson correlation
a
DASH, Disabilities of the Arm, Shoulder, and Hand; KJOC,
Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow; QuickDASH,
Quick Disabilities of the Arm, Shoulder, and Hand; YTS, Youth
Throwing Score.
b
Scaled to the 100-point total.
c
As reported in the initial validation.1
d
As calculated using the published instrument.
assess pain in young baseball players upper extremities.
The YTS more accurately assesses upper extremity health
than similar adult tools or more global youth tools. Its
strong statistical properties, including test-retest reliabil-
ity, content validity, internal consistency, responsiveness,
and criterion validity, indicate its psychometric validity.
In addition, the novelty of the YTS signifies its importance
and the research potential in aiding providers to better
understand the epidemic facing young baseball players.
Several limitations were present in this investigation.
The dearth of validated instruments in pediatric overhead
throwers resulted in a comparison with available but
imprecise tools for throwers. Consequently, the comparison
between instruments is less absolute. In addition, as
a result of completion of treatment and other factors inher-
ent in the pediatric population, there was significant loss of
follow-up (32.8% of patients were lost). Critically, the
instrument was designed for independent completion by
the pediatric patient. The removal of the parents from
instrument completion led to higher follow-up loss because
the pediatric patients were intrinsically less compliant in
independently completing follow-up surveys. Although inde-
pendent completion was important to demonstrate the val-
idity of the assessment tool, future studies to further
explore the potential of this instrument will likely include
parental involvement for more accurate injury identification
and greater follow-up. Importantly, no operative patients
were lost to follow-up. As discussed in the Methods, to
ensure specificity for the overhead athlete, only male base-
ball patients were included in this study. The differing bio-
mechanics between overhead and underhand throwing and
the increased incidence of serious, upper extremity overuse
injuries in baseball players led to this decision.
Finally, although players not playing due to pain scored
lower than those playing with pain, the separation was not
statistically significant. Even though the players playing
without pain were significantly stratified from these cohorts,
8 Ahmad et al
this remains a limitation of the study. Differing psychosocial
circumstances may contribute to the lack of separation
between these cohorts, as players with similar levels of
pain and injury may have separate playing statuses. Some
players may continue to play because of coaching and paren-
tal pressure, whereas others may have already sought medi-
cal care and consequently are not playing. The absence of
a floor effect, however, indicates the potential for stratifica-
tion for injured players and further investigations must be
conducted to gain insight into these cohorts.
This study validates the YTS and demonstrates its
potential to aid the baseball community in developing strat-
egies to curb the rising epidemic of youth throwing injuries.
Further studies analyzing the responsiveness of the instru-
ment for individual injuries could aid providers in caring for
these young patients, but parental involvement will be nec-
essary to provide injury specificity. Epidemiologic studies
could show the instruments potential in injury prevention
for young baseball players. The YTS accurately identifies
young players with throwing pain and has been robustly
validated as a novel research tool.
ACKNOWLEDGMENT
The authors thank Michael Lombardi, general manager of
the Baseball Center, and Steve Heyward, general manager
of PBI, for their extensive assistance with recruitment for
this study.
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