Original Research

Caregiver Awareness of Safe Pitching

Recommendations in Youth Fastpitch
Softball Pitchers
Sravya Kamarajugadda,* BS, Jack Italiano,† DO, MaryBeth Horodyski,‡ EdD, ATC, LAT,
Jason L. Zaremski,§ MD, Marissa Pazik,‡ MS, LAT, ATC, CSCS, Giorgio Zeppieri,k PT, SCS,
Kevin W. Farmer,‡ MD, Stephanie Brombacher-O’Connell,‡ PA-C, Bryan Prine,‡ MD, CAQSM,
and Michael Seth Smith,‡{ MD, CAQSM, PharmD
Investigation performed at the University of Florida, Gainesville, Florida, USA

Background: Although fastpitch softball participation continues to rise, there is a lack of established pitch count guidelines,
potentially putting young female athletes at risk of overuse injuries. In addition to coaches, caregivers’ ability to recognize and
employ safe pitching guidelines plays an important role in athlete safety.
Purpose/Hypothesis: The purpose of this study was to assess caregivers’ knowledge of their child’s pitching practices and their
familiarity with softball pitching recommendations. We hypothesized that caregivers would be unaware of safe pitching recom-
mendations in youth fastpitch softball.
Study Design: Cross-sectional study.
Methods: A 30-question survey was distributed to caregivers of youth fastpitch softball pitchers in age groups 10U (ie, 10 years),
12U, 14U, 16U, and 18U. The survey included questions on the demographic characteristics of caregivers and athletes, caregivers’
knowledge of safe pitching recommendations, and athletes’ pitching background and throwing habits. Comparisons of responses
between the age groups were conducted using the chi-square test, Fisher exact test, or 1-way analysis of variance, as appropriate.
Results: A total of 115 caregivers completed the survey. Of the respondents, 84% were between 31 and 50 years, and 81.7% had
a degree beyond high school. Only 28.1% of caregivers reported participating in youth sports. When asked to estimate the number
of pitches they considered a safe amount during a single outing, 28.7% of caregivers (n ¼ 33) did not provide a limit, 4.3% (n ¼ 5)
stated no limit was needed, 32.2% (n ¼ 37) suggested 25 to 80 pitches, 21.7% (n ¼ 25) suggested 81 to 100 pitches, 12.2%
(n ¼ 14) suggested 100 to 150 pitches, and 0.9% (n ¼ 1) suggested that >150 pitches were acceptable. These data emphasized
that only 14.8% of the caregivers were aware of any pitching guidelines. However, 93% of caregivers acknowledged that they
would adhere to recommendations if guidelines were made available.
Conclusion: The study findings demonstrated that a majority of caregivers are unaware of current youth fastpitch softball pitching
recommendations.
Keywords: caregivers; fastpitch softball; overuse injuries; pitching guidelines

Fastpitch softball is one of the most popular sports among Over the past 6 years, according to the National Electronic
female athletes in the United States, having grown from Injury Surveillance System, US emergency departments
203,569 participants in the 1988-1989 season to 362,038 have seen an 11.7% increase in softball-related injuries in
in the 2018-2019 season.27,29 Additionally, approximately athletes 7 years of age.8 In a study by Shanley et al,38 50%
300,000 participants between the ages of 4 and 16 years of the injuries sustained by pitchers were directly influ-
participate in fastpitch softball in over 25 countries.25 With enced by pitching. Hill et al22 reported that of the 180 col-
increased participation and competitiveness of the sport, legiate softball pitchers surveyed during the 2001-2022
increased injury prevalence is a necessary consideration. season, 92 had chronic/overuse injuries, 53 of which
Multiple epidemiologic studies have reported the incidence involved the upper extremity; more specifically, 33 of the
of injuries in youth and high school softball pitchers.38,40 reported overuse injuries involved the shoulder. Oliver
et al32 found that of the 51 high school softball pitchers
The Orthopaedic Journal of Sports Medicine, 11(5), 23259671231169947
observed between 2005 and 2006 and 2016 and 2017,
DOI: 10.1177/23259671231169947 60.8% indicated an overuse injury to the shoulder and/or
ª The Author(s) 2023 elbow. Additionally, Smith et al40 determined that pitching

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1
2 Kamarajugadda et al The Orthopaedic Journal of Sports Medicine

injuries were twice as likely to last longer than 2 weeks Although there are data relating to caregiver awareness
compared with nonpitching injuries. While multiple studies of pitch count regulations and injury prevalence in base-
have demonstrated a predominance in shoulder-related ball, there is a paucity of similar research in fastpitch
softball injuries to pitchers,24,36,38,40 it is worth noting that softball.2,9,14,23,44 Thus, the purpose of this study was to
injuries occur at a higher incidence to the lower extremities assess caregiver knowledge of their child’s pitching prac-
in nonpitching activities, such as contact with an opposing tices and their familiarity with softball pitching recom-
player, contact with the ground, noncontact (nonthrowing mendations. We hypothesized that caregivers would be
activity), hit by a batted ball, contact with a fixed base, or unaware of safe pitching recommendations in youth
hit by a thrown pitch.26 However, given the increased risk fastpitch softball.
of injury and longer duration of injury in pitchers versus
position players, overuse injuries related to pitching are a
concern. METHODS
General safe sports recommendations include limiting
months per year and hours per week of participation, avoid- This cross-sectional study was determined to be exempt
ing participation in multiple same sports leagues simulta- from institutional review board approval. A 30-question
neously, and limiting sport specialization.7,45,47 To reduce survey was distributed to consenting caregivers of youth
stress on skeletally immature pitchers and the injury risk fastpitch softball pitchers throughout North Central Flor-
in pitchers, youth baseball leagues adhere to pitch counts ida. The survey was modified for caregivers of softball
with mandatory rest days.35 Although there are no concrete players from a survey previously developed at our institu-
pitch count guidelines, the Sports Trauma and Overuse tion for caregivers of baseball players.36 Surveys were dis-
Prevention (STOP) Sports Injuries campaign—created by tributed during practices and games at regional softball
the National Council of Youth Sports and the AOSSM—has fields as well as during locally sponsored national softball
published a set of recommendations for fastpitch softball.41 pitching camps. Additionally, outside of Gainesville, Flor-
These recommendations are not based on data collected for ida, we enlisted the assistance of Triple Crown Sports, Ris-
youth fastpitch softball but rather mimic the current guide- ing Stars, Florida Amateur Softball Association, and
lines for youth baseball.15,40 The STOP Sports Injuries private instructors to help administer and distribute an
fastpitch softball recommendations include avoiding pitch- anonymous online survey. Thus, a sample of convenience
ing >2 or 3 consecutive days based on age group, limiting was drawn from the population close to our institution. All
pitch counts by age, avoiding year-round pitching, and surveys submitted were included in the study. Missing data
avoiding multileague participation.2 were coded as “missing” to enable the use of all surveys and
Studies have demonstrated that the windmill pitch prevent the loss of valuable data from incomplete surveys.
results in higher forces on the shoulder compared with the A copy of the survey is available as Supplemental Material.
elbow, putting softball pitchers at a higher risk of shoulder The survey included sections on athlete characteristics
injuries than elbow injuries, whereas baseball pitchers as well as those of the primary caregiver completing the
suffer a similar percentage of both.3,10,20,24,31,34,37,38 Wer- survey—including the level of sport played, coaching back-
ner et al42 reported that softball pitchers can pitch upward ground, the highest level of education, sex, and age group.
of 1500 pitches over the course of a 3-day tournament, Caregivers were categorized into age groups of 18-30,
nearly 4 times the amount recommended.42 Furthermore, 31-40, 41-50, 51-60, and >60 years; and athletes were cat-
as compared with baseball, softball teams generally carry egorized according to the Florida US Specialty Sports Asso-
fewer pitchers on their roster, resulting in more innings ciation age guidelines—10U (ie, 10 years and under), 12U,
pitched per pitcher.4,30 In the Hill et al22 study, almost 14U, 16U, and 18U.18 The caregivers also answered ques-
75% of the 180 collegiate softball players reported an tions related to their knowledge of safe pitching guidelines,
injury during the 2001-2002 season. The most common the athlete’s pitching characteristics, the type and volume
mechanism of pitcher injury is overuse.22,32 The lack of of pitches thrown, and their recall of any upper extremity
pitching regulations in fastpitch softball is of great con- pain or injuries from pitching potentially being related to
cern and places athletes at potentially increased suscepti- excessive pitching above the STOP Sports Injuries
bility to overuse injury. recommendations.41

{
Address correspondence to Michael Seth Smith, MD, CAQSM, PharmD, Department of Orthopaedic Surgery & Sports Medicine, University of Florida,
3450 Hull Road, Gainesville, FL 32607, USA (email: [email protected]).
*College of Medicine, University of Florida, Gainesville, Florida, USA.
†
Department of Community Health & Family Medicine, University of Florida, Gainesville, Florida, USA.
‡
Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, Florida, USA.
§
Department of Physical Medicine and Rehabilitation, University of Florida, Gainesville, Florida, USA.
k
Department of Rehabilitation, University of Florida, Gainesville, Florida, USA.
Final revision submitted December 13, 2022; accepted January 24, 2023.
One or more of the authors has declared the following potential conflict of interest or source of funding: K.W.F. has received education payments from
Arthrex and CGG Medical; consulting fees from Arthrex, Exactech, and Flexion Therapeutics; nonconsulting fees from Arthrex, Arthrosurface, Baudax Bio,
and CGG Medical; honoraria from Baudax Bio; and hospitality payments from Rotation Medical. AOSSM checks author disclosures against the Open
Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Ethical approval for this study was waived by the University of Florida (reference No. IRB201500306).
The Orthopaedic Journal of Sports Medicine Caregiver Awareness in Youth Fastpitch Softball 3

The caregivers of youth softball pitchers were asked to outing to prevent injury. When provided various ranges of
complete and return the survey. As various methods of dis- acceptable pitch counts, 33 of the caregivers (28.7%) did not
tribution were employed and as participants who received provide a limit, 5 (4.3%) stated no limit was needed, 37
the survey were not required to submit the survey, the (32.2%) stated 25 to 80 pitches, 25 (21.7%) stated 81 to
response rate was not measured. The results of each survey 100 pitches, 14 (12.2%) stated 100 to 150 pitches, and 1
were placed into a deidentified database using the Research caregiver (0.9%) stated that >150 pitches were acceptable.
Electronic Data Capture (REDCap).21 Partially completed Approximately 39% of the U12 through U18 caregivers (31
surveys were included in the REDCap data set using only of 80) estimated their child threw more pitches per game
the questions completed. than the STOP Sports Injuries recommendation.
Descriptive statistical analyses were performed in IBM Table 1 summarizes the pitching characteristics of
SPSS Statistics for Windows, Version 28.0 (IBM Corp). the athletes as provided by the caregivers, overall and
Continuous measures were summarized as means and stratified by age group. There was a significant differ-
standard deviations, and categorical measures were sum- ence between age groups for months played per year
marized as numbers and percentages. Cross-tabulations (P < .001). Overall, 59 of the 115 caregivers (51.3%) dis-
were used to provide counts and percentages of the key closed that their child participated in >1 softball league
variables from the survey by assigned softball age groups. at a time. According to responses, 12.3% of athletes (n ¼
The Pearson chi-square test, Fisher exact test, or one-way 14) pitched in 1 game per week, 45.6% (n ¼ 52) pitched in
analysis of variance was performed as appropriate to eval- 2 games per week, and 41.2% (n ¼ 47) pitched in 3 games
uate any differences between age groups for survey ques- per week. In addition, 11.3% of caregivers reported that
tions with discrete responses, with P < .05 considered their athlete participated above the recommended 2 to 3
statistically significant. consecutive days for pitching. Furthermore, 98 caregivers
(85.2%) reported that their child pitched 7 months per
year, with 57.4% reporting their child pitched 10 to 12
RESULTS months per year.
Upper extremity pain after pitching occurred in 57.4% of
A total of 115 surveys were collected from caregivers of athletes as reported by their caregivers. The anatomical
youth fastpitch softball pitchers and used for analysis in structures where the pain was reported to have occurred
this study. Caregivers’ age groups were as follows: 18- after pitching included the shoulder (n ¼ 38), upper arm
30 years (n ¼ 4 [3.5%]), 31-40 years (n ¼ 37 [32.2%]), 41- (n ¼ 16), and elbow (n ¼ 13) with 33%, 13.9%, and 11.3%,
50 years (n ¼ 59 [51.3%]), 51-60 years (n ¼ 11 [9.6%]), and respectively. Of those suffering arm pain, 21.7% sought
>60 years (n ¼ 3 [2.6%]), with a significant difference in age evaluation by a medical professional.
among the groups (P < .05). In the study, 50.4% of care-
givers identified themselves as the athlete’s mother. Over-
all, 81.7% of the caregivers had an associate’s, bachelor’s, or DISCUSSION
advanced college degree. Only 28.1% of the caregivers par-
ticipated in youth sports. Of the respondents who partici- In our study, a survey was distributed to caregivers of
pated in youth sports, 50% played baseball and 11.5% youth fastpitch softball pitchers to assess their knowledge
participated in softball. Additionally, 70.4% of the care- of current safe pitching recommendations. A majority of
givers coached a youth sport and 13% reported coaching caregivers were between the ages of 31 and 50 years, with
at the high school level. Caregivers identified the age of half identifying as the athlete’s mother. Used as a proxy
their athletes, ranging from 7 to 18 years. The mean age measure of socioeconomic status, over 75% of caregivers
of the athletes was 12.8 ± 2.3 years. When asked about held a degree above the high school level. While approxi-
positions played and off-season sport participation, 94.8% mately only a quarter of caregivers had participated in a
(n ¼ 109) of caregivers indicated their athlete played youth sport, about three-quarters of caregivers have
another position in addition to pitcher, while 46.1% (n ¼ coached a youth sport. Also, <15% of caregivers reported
53) of caregivers reported their athlete participated in sport awareness of the current youth fastpitch softball recom-
during the off-season, 75.5% of which were in upper- mendations, yet over 90% recorded that they would adhere
extremity dominant sports. to evidence-based guidelines if established. When asked
Caregivers demonstrated a low knowledge level, with about their child’s pitching habits—including the number
only 14.8% reporting an awareness of youth softball pitch- of pitches per game, consecutive days pitched, games
ing recommendations. However, 93% acknowledged that pitched per week, months playing in per year, and simul-
they would adhere to universal guidelines if established. taneous leagues played in—many caregivers estimated
With respect to who counted game pitches, caregivers were that their athlete pitched above the current STOP Sports
able to select >1 response and reported that they (28.7%), Injuries recommendations, which can vary per age group
their spouse (20.0%), and/or the coach (53.9%) counted the from 50 to 100 pitches per game.41 More than half of the
pitches. Yet, 26.1% of the caregivers reported that they did caregivers reported that their athlete suffered upper
not know whether there was a designated person assigned extremity pain from pitching, with nearly a quarter of those
to track in-game pitch counts. requiring medical attention. This causes concern that ath-
Caregivers were asked to estimate the number of pitches letes are incurring additional load, leading to an increased
that they considered would be a safe amount in a single risk of overuse injuries.
4 Kamarajugadda et al The Orthopaedic Journal of Sports Medicine

TABLE 1
Caregiver Responses to Survey Questions on Athlete Pitching Characteristics,
Overall and by Age Group (N ¼ 115 Responses)a

Age Group

Total 10U 12U 14U 16U 18U P

Concurrent leagues played

1 56 16 12 14 10 4
2 52 5 17 9 11 10
3 6 1 2 2 1 0
4 1 0 0 1 0 0
Total 115 22 31 26 22 14 .233
Games played per week
1 14 7 4 2 1 0
2 52 10 12 15 8 7
3 26 4 7 5 5 5
4 13 0 4 2 7 0
5 5 1 2 0 0 2
6 4 0 2 2 0 0
Mean ± SD 2.61 ± 1.187 2.00 ± .976 2.81 ± 1.376 2.58 ± 1.238 2.86 ± .964 2.79 ± 1.051 .093
Total 114b 22 31 26 21 14
Consecutive days pitched
<3 67 17 18 18 10 4
3 35 5 11 5 8 6
>3 13 0 2 3 4 4
Total 115 22 31 26 22 14 .057
Months played per year
<3 2 0 2 0 0 0
4-5 15 8 2 3 1 1
7-9 32 10 9 9 3 11
10-12 66 4 18 14 18 12
Total 115 22 31 26 22 14 < .001
a
Data are reported as No. of survey responses. The bolded P value indicates a statistically significant difference among age groups
(P < .05).
b
One survey did not include a response and was not included in the analysis for this question.

Over the past decade, youth sports leagues have started to allowing >150 pitches per outing. However, if safe pitch-
to revolutionize their approach to sports participation by ing guidelines for softball were readily available, 93% of the
emphasizing participant safety. Injury prevention research caregivers in our study would use guidelines to keep their
done in baseball has established safe pitching guidelines, athletes safe. This leads us to believe that with universally
including a reduction in pitch counts with ensuing manda- accepted regulations and pitch counts, caregivers could
tory rest days, as well as limiting pitch types by age.16-19 play an integral role in protecting youth softball pitchers
These concepts are targeted to reduce the stress on skele- to reduce the risk of overuse injuries. Currently, there are
tally immature pitchers and reduce injury risk in pitchers. no restrictions established in US Softball, the National Fed-
Athlete injury prevention is structured around a multidis- eration of State High School Associations, or the National
ciplinary approach involving coaches, caregivers, medical Collegiate Athletic Association.28 The Little League Soft-
staff, and athletes.1,13 Unfortunately, the current knowl- ball organization has published regulations for pitching
edge of the injury or safe sports recommendations among availability, and the STOP Sports Injuries campaign has
coaches and caregivers is generally not adequate to assist released pitching recommendations for youth softball, yet
in injury prevention.7,33,36,45 Equally as concerning is that, there is still no restriction on pitch counts, as pitching reg-
in fastpitch softball, there is a paucity of universally estab- ulations vary widely among age groups.25,41
lished safe pitching guidelines. The combined lack of uni- The prevalence of studies involving other sports guided
versal guidelines and caregiver knowledge may contribute our research team to assess caregivers’ understanding of
to overuse injuries in softball pitchers. safe sports recommendations. To our knowledge, this is the
With respect to caregiver knowledge of pitch counts in first study to survey caregivers of youth fastpitch softball
fastpitch softball, 85.2% of caregivers surveyed in our study athletes to assess their knowledge of pitching guidelines
were not aware of youth softball pitching recommenda- and how they may relate to athlete safety. The caregiver
tions. Additionally, when asked to estimate what they plays a significant role in the development and health of
thought was an appropriate pitch count in youth softball, young athletes. However, studies regarding caregiver
caregiver responses varied between needing no pitch count understanding of injuries and preventative techniques for
The Orthopaedic Journal of Sports Medicine Caregiver Awareness in Youth Fastpitch Softball 5

softball pitchers are scarce. A study by Reintgen et al36 Limitations

determined that 83% of surveyed youth baseball caregivers
were unaware of the existence of safe pitching guidelines. Some limitations in this study are inherent in survey
Bell et al7 assessed parental knowledge of sports safety for research. Recall responses are associated with reporting
athletes participating in soccer, basketball, and volleyball errors. First, the population studied was a sample of conve-
tournaments. They discovered that approximately 80% of nience and illustrates only the small specific geographic
those surveyed did not know safe sports recommendations region of North Central Florida. As this type of sampling is
related to the duration of training or league participation. often used for pilot testing, the research team recognizes the
In our study, it was clear that the caregivers were not limitations of the presented data. The warm climate in Flor-
aware of the safe sports recommendations for fastpitch soft- ida allows athletes to play softball and other sports year-
ball, as 51.3% of them noted that their child participated in round. Therefore, the experiences of athletes in this region
>1 softball league at a time and they pitched in 1 (12.2%), 2 may not be representative of other regions of the country.
(45.2%), or >3 (41.7%) games per week. Additionally, 57.4% Surveys were diffusely distributed to caregivers at practices,
of caregivers reported that their athlete played softball 10 games, and camps through social media and by word of
to 12 months a year. mouth, with minimal oversight, resulting in no exact method
The greatest risk factors for shoulder and elbow pain in to evaluate the survey response rate. Furthermore, our sur-
baseball pitchers have been strongly correlated with the vol- vey did not include any identification data, and therefore we
ume of pitching performed, including pitches per game, inn- were unable to evaluate whether duplicate surveys were com-
ings per season, and months pitched per year.16 Yang et al43 pleted. We noted variable response rates on a few of the ques-
studied high school softball pitchers and noted that pitchers tions that could reflect caregivers’ unwillingness to disclose
averaged 12 ± 5.7 games per season and up to 89 ± 25 pitches their lack of knowledge. Although respondents were required
per game. In addition, weekend tournaments played to identify their relationship to the athlete, we did not inquire
throughout the year may extend to an additional 1.5 games as to whether the caregiver responding was the caregiver
per day, with a mean of 62 pitches per game.39 Furthermore, most involved with the athlete’s sports participation, which
pitchers exhibit a reduction in shoulder strength in addition
could have led to inaccurate reporting of data and decreased
to shoulder and hip fatigue after a single game pitched and do
awareness of guidelines.
not fully recover by the following day.12,39,43 However, the
information provided by the caregivers in our study does not
account for practices, bullpen sessions, warm-up pitches, Future Considerations
pitching camps, or throws made while an athlete is not pitch-
ing, as approximately 95% of our athletes play other posi- A primary area of research should include accurate pitch
tions. Zaremski et al46 studied unaccounted pitch volume in counts for fastpitch softball pitchers during games and
high school baseball players and determined that 42.4% of all practices. Tracking the injuries of these pitchers would
pitches thrown were not accounted for in traditional pitch allow for the assessment of whether increased pitch count
count guidelines and regulations. Like baseball players, it is associated with an increased injury rate in youth
is possible that fastpitch softball players do not have an ade- fastpitch softball players. Future studies could gather
quate amount of time to recover from the repetitive stresses responses from caregivers across the country in different
placed on their upper extremities, thus increasing their risk climates, diversifying the geographic data and making con-
of overuse injuries. clusions more generalizable. Additionally, future studies
Overuse injuries are one of the most common injuries seen could evaluate whether interventions—such as educational
throughout fastpitch softball.4,12,24,36-38,40 Common patholo- materials or seminars—would improve caregivers’ aware-
gies documented are proximal biceps tendonitis, stress frac- ness of safe pitching recommendations.
tures, and ulnar neuritis.5,11,37 Accumulation of high pitch
counts from pitching consecutive days increases a pitcher’s
susceptibility to fatigue, a natural process that occurs in
CONCLUSION
direct response to repetitive activities and in direct correla-
tion with overuse, which can also cause significant break- Our study demonstrates that a majority of caregivers were
downs of proper pitching mechanics.6,12,17,19,31,39,47 In the generally unaware of youth fastpitch softball pitching
present study, over a quarter of the caregivers reported that recommendations. With no universal regulations, there is
their child pitched more consecutive days than recom- increased importance on caregiver awareness of safe pitch-
mended by the STOP Sports Injuries guidelines. Addition- ing recommendations to help reduce the risk of overuse
ally, of the athletes who played other sports during the injuries in fastpitch softball pitchers.
off-season, over 75% played an upper extremity–taxing
sport, such as volleyball, basketball, swimming, or tennis.
Such data lead us to believe that youth fastpitch softball
pitchers are not getting adequate rest and recovery between
Supplemental material for this article is available at
outings or between softball seasons. Thus, developing uni-
https://journals.sagepub.com/doi/full/10.1177/23
versal pitching guidelines and encouraging caregivers and
259671231169947#supplementary-materials.
coaches to adhere to guidelines will keep fastpitch softball
pitchers safer and healthier.
6 Kamarajugadda et al The Orthopaedic Journal of Sports Medicine

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