Manish S. Noticewala, MD, examines the elbow of an adolescent athlete.
Courtesy of Manish S. Noticewala, MD


Published 1/1/2019
Mark Crawford

Outcome Instrument Tracks Care in Young Throwing Athletes

OREF grant recipient develops outcome instrument to evaluate shoulder and elbow injuries in young athletes

More than 2.6 million emergency department visits annually are due to sports-related injuries in the five- to 24-year-old age group. As more young athletes play organized sports, the rate of pediatric sports injuries continues to rise.

Clinical outcome instruments specific to both this patient group and constellation of injuries are needed to objectively evaluate the effect of interventions on recovery from injuries. Currently, there are no validated instruments designed to evaluate pain, function, and performance in the upper extremities (shoulders and elbows) of pediatric overhead athletes.

“There is very little in the literature regarding how to evaluate these patients and assess the efficacy of treatments,” said Manish S. Noticewala, MD, an orthopaedic surgeon conducting sports medicine research at Columbia University Medical Center in New York City. “For example, if a 12-year-old overhead athlete comes in with elbow pain, how can you quantify his or her pain and functional limitations? How can the orthopaedic surgeon objectively determine whether the treatment intervention led to an improvement in pain and function?”

Thus, there is a strong need for a rigorously developed outcome instrument for youth overhead athletes. This is especially true for youth and adolescent baseball players, who suffer increasing numbers of shoulder and elbow injuries.

Under the mentorship of Christopher S. Ahmad, MD, Dr. Noticewala received an Orthopaedic Research and Education Foundation (OREF)/Aircast Foundation Resident Research Project Grant to develop and rigorously test the reliability, validity, and responsiveness of an instrument targeted specifically to young overhead athletes. The research project, titled “Pain, Function, and Performance Assessment in the Overhead Youth Athlete,” was carried out from July 2015 to June 2016. The resulting Youth Throwing Score (YTS) was published in the February 2017 issue of the American Journal of Sports Medicine.

“This score can potentially be utilized in both clinical practice and clinical research as an objective way to assess youth overhead athletes following injury and/or treatment,” Dr. Noticewala said.

Developed by a panel of experts

“We hypothesized that the YTS will be more reliable, valid, and responsive than other patient-derived outcome instruments administered to more normally distributed, general populations, such as the Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire or the Pediatric Outcomes Data Collection Instrument [PODCI],” Dr. Noticewala said.

Dr. Noticewala assembled a panel of experts to generate potential questions for the instrument. Participants included orthopaedic surgeons, a pediatrician, certified physical therapists, athletic trainers, and coaches. They were instructed to develop questions that were neither sport- nor joint-specific. The list was reviewed, and a preliminary questionnaire evaluating pain, function, and performance was developed. The developers then administered the questionnaire to 202 youth and adolescent baseball players to assess any issues involving readability, comprehension, interpretation, visibility, and formatting.

“We didn’t ask them to just fill out the questionnaire, but to also provide feedback about the questions,” Dr. Noticewala said. “For example, is this a question they understand? How would they change this question to make it more applicable? After receiving their feedback, we went back to the clinicians and actually reworded some of the questions and eliminated others.”

The final YTS questionnaire was administered to a group of adolescent patients along with DASH and PODCI questionnaires. Dr. Noticewala and his research team compared results of all three instruments.

Discussion and outcome

A total of 223 youth and adolescent baseball players (mean age, 14.3 years) completed the final survey. Pilot analysis showed that none of the 14 questions received a mean athlete importance rating less than three of five, and the final survey had a Flesch-Kincaid readability level of 4.1, which is appropriate for patients aged nine years and older. The athletes self-assigned their injury status. Out of a possible score of 70, the mean instrument score was 59.7 for the 148 athletes “playing without pain,” 42.0 for the 60 athletes “playing with pain,” and 40.4 for the 15 athletes “not playing due to pain.” The decision by an adolescent athlete to play with pain is not only a function of his or her pain level but also thresholds for dealing with pain, as well as perceptions regarding playing with pain, said Dr. Noticewala.

Athletes playing without pain scored significantly higher than those playing with pain and those not playing due to pain. Injured players scored an average of 9.4 points higher after treatment, and those who improved in the self-assigned pain category scored an average of 16.5 points higher.

A detailed statistical analysis showed strong internal consistency, test-retest reliability, responsiveness, and content validity, as well as moderate correlations with other validated instruments. Because all design constructs were met, the YTS was confirmed as a validated outcome measure for injury assessment of young throwers.

Mark Crawford is a contributing writer for OREF. He can be reached at © Orthopaedic Research and Education Foundation (OREF)


  1. Ahmad CS, Padaki AS, Noticewala MS, et al: The Youth Throwing Score: validating injury assessment in young baseball players. Am J Sports Med 2017;45:317-24.