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Getting to a specialist through an HMO, if that's what your using, can sometimes be more painful than the injury itself. An MRI is usually a "referrable" issue in todays medical processes. That referral happens after the initial doctors "coarse of healing" is deemed not working.

I don't know the specifics of your sons injury, but, I do know that with most injuries that have strain/sprain symptoms an MRI is not the "next action". Because of the costs involved with an MRI, it takes some failed healing time from the initial diagnosis to get one scheduled.

If your the parent, you think this thought process sucks. If your an HMO member trying to keep costs down, you do not want every sprain/strain that comes into the clinic fast tracked to the MRI device.

I don't mean to be ngative, what I do suggest is be persistant and play within the medical game. Start by having the initial doctor set up a timeline of recovery before he refers you to a Sports Med specialist
Last edited by rz1
I agree with rz1, if you are under an HMO, then the doc you saw can't give a referral for this injury until sufficient time/therapy has passed.

We sat out one summer with pain related to a stress fracture that wasn't viewable on X-Ray.

... And some injuries won't show up on MRI's either, they take Bone Scans. An MRI isn't a magic bullet nor is it infallible.

You will have to treat it symptomatically until the pain is gone. Once it has disappeared, then get in with a good pitching coach to see if he has a mechanical problem. If the pain re-occurs and his technique is fine, then you can probably get an MRI and go from there.
This is a good time of year for a break anyhow. Give it 3-4 weeks of complete rest. After that, slowly work on coming back up to speed. If the pain persists, then push for a sports ortho.

Elbow pain basically can come from overuse (even with good mechanics), mechanics that place undue stress on the elbow, or a traumatic injury. Figuring out which was the likely cause can help prevent recurrence. Good luck.
I am not a doctor either. However "wet" (dye injected) MRI's are used very effectively to diagnose and non-diagnose soft tissue injuries, based on recent, first hand experience. A word of caution. A wet MRI hurts. Not pleasant to go through.

With that said, if you can't get a referral that information is not useful. As stated, you are subject to the plan you are on. Check your plan to see if you actually need a referral to visit a specialist or what type.
Last edited by Dad04
Dad04,
Good first response.

I am not an xray technician, so I wouldn't even venture to guess what is the difference between an xray and an MRI, except that an MRI gives a different view or views of the area in question and into deeper tissue.

Regarding insurance, doesn't matter if you have an HMO or PPO. A good point is made that an MRI is expensive and a doctor has to justify the test.

In my experience and understanding an xray is taken first, then a plan is made by the doctor which might include rest, anti inflammatory. Then possible therapy which would include massage, elec stim and excercise to strenghten the area. If all else fails and pain still persists, the doctor might choose an MRI to see if there are any problems the xray did not pick up.

The elbow pain could be a sign that some adjustments need to be made, not necessarily a major problem. But that can't be determined until the pain goes away. The body is sending signals something is not right.

Unless you have visited a doctor who specializes in sports injuries, it's pretty hard to tell anyone what might be causing the problem, especially over the internet. When son suffered a bout with tendinitous a few years back it took 3 months (not an HMO) before the doctor decided to do an MRI, which resulted in nothing of significance. Physical therapy and a good rehab throwing program before season started, took 5 months. Fall ball was cut immediately and then in the off season they worked on teh long toss. This whole episode was the result of throwing a screwball incorrectly (which he shouldn't have been throwing at all).
This year son suffered a bit of tendinitous in his shoulder. Xray's showed nothing. He went on 2 weeks complete rest, therapy and then a rehab long toss program before he went into the bull pen to see if the shoulder was ok. It was a little bit faster process than before as he had therapy available whenever he wanted and a trainer. No MRI was needed, just rest, anti inflammatories and a good program to get back on track. This was a result of not beginning his long toss program early in aug and hitting the bull pen too early, a major cause of injury before teh season even begins.
I can't believe how many times I hear parents say they took their son to a doctor and doctor said it was nothing serious, then next day son is back playing or in the gym, or back at the cage or throwing. The slight injury never has a chance to heal, then come season all h**l breaks loose. o not let anyone tell you it even MIGHT mechanics. Elbow pain is serious and NOT normal in many cases, though there may be referred pain in the AREA. Only a doctor can diagnose that.

Follw doctor's advice, if your son does not feel that improvement is being made, you might need that other opinion.

Health South offers a variety of doctors who specialize in sports injuries. You could call to see if there is one located near you and if the pain does not subside, politely ask for a referral to one.
Last edited by TPM
I agree completely with the importance of diagnostic testing. However, part of that diagnostic testing must be to look at and understand the throwing motion of the player.

Let me give you an example of why I feel so strongly about this (and feel like I have something to contribute).

This year I had a young pitcher who, after throwing just 1 amazing inning in the first game of the year, started complaining of medial elbow pain. Being the hyper-cautious person that I am, I decided to not let him pitch again until I knew what was going on.

After playing catch with him, watching him throw a striped ball (so I could watch the spin of the ball), and understanding what seemed to bring on the problem (he thought he was throwing a fastball but seemed to be able to stall the ball out over the plate) his father and I realized that he was inadvertently throwing a slider. This was because he was supinating his wrist as he released the ball.

Now, this may admittedly be a somewhat different case since the pain came up out of nowhere and I could feel pretty confident that it could be correlated to the inning he pitched. However, I wouldn't have solved the problem by taking him to the doctor. They would have diagnosed him with an inflamed medial epicondyle, would have told him to not throw for 3 or 4 weeks, and would have left the underlying flaw in his motion untouched.

If you want to solve the problem, then you have to look at the big picture, not just the symptoms.
quote:
My point is that you should try to understand the root cause of the problem rather than spending all of your time on the treatment. All of the treatment in the world won't help if you don't understand and address the root cause of the problem.


We agree and that is true. That is different than saying an MRI can't find a soft tissue issue.

If the kid tore something, then all the corrective mechanics in the world won't fix it, either.
Last edited by Dad04
CC,
Your example may have validity and make sense. However, I think we (I) are talking about persistant pain. Most kids come to parents or coaches after it gets to a point that the pain is there, not just in throwing.
No matter what the reason, the persistant pain needs to be treated before anyone can decide what is wrong.
Last edited by TPM
Coach Chris - You are 100% correct. I agree that mechanics or overuse are often contributing factors to pain. However, the physcian is the one to determine this and if it just an inflammatory process, then hopefully that physician and parent will turn to their coach or someone they trust to help develop better techniques.
Last edited by lafmom
Where exactly did he feel the pain? Inside or outside? Was it sharp or dull?

Try this when you start throwing again.

Take a baseball and draw a green stripe around it with a Sharpie such that when he is holding the ball with a four-seam grip, the stripe runs between his index and middle fingers under his palm and back around the ball. In other words, draw the line such that it splits the ball in half.

Now play catch with him and watch the line as the ball comes toward you (and as you throw it back toward him). This takes some getting used to but is pretty cool once you learn to do it.

Also, and as an aside, this will teach you and him to really watch the ball and will make you both better hitters.

Anyway, in the ideal case what you will see is a constant vertical green line coming toward you. That means he released the ball with a vertical forearm and with pure backspin. If the line is solid but tilted, then you know that he is throwing with pure backspin but with a non-vertical arm slot. This can also be used to check a 12-6 curveball. It will look the same but the ball will be spinning with topspin and not backspin.

If you don't see any line, then you know that the ball is twisting and/or tumbling in flight. This indicates that he either twisted his wrist when releasing the ball or did not release it with uniform pressure.
Ghoti- the best advice you have received here is in 2 areas:
1] shut him down
2] try to find another doc, who specializes in sports med or who will send you to one

XRAY is for bones, MRI is for soft tissue

"MRI is the method of choice for the diagnosis of many types of injuries and conditions because of the incredible ability to tailor the exam to the particular medical question being asked. By changing exam parameters, the MRI system can cause tissues in the body to take on different appearances. This is very helpful to the radiologist (who reads the MRI) in determining if something seen is normal or not. We know that when we do "A," normal tissue will look like "B" -- if it doesn't, there might be an abnormality. MRI systems can also image flowing blood in virtually any part of the body. This allows us to perform studies that show the arterial system in the body, but not the tissue around it."

ALSO

"Why would your doctor order an MRI? Because the only way to see inside your body any better is to cut you open. MRI is ideal for:
Diagnosing multiple sclerosis (MS)
Diagnosing tumors of the pituitary gland and brain
Diagnosing infections in the brain, spine or joints
Visualizing torn ligaments in the wrist, knee and ankle
Visualizing shoulder injuries
Diagnosing tendonitis
Evaluating masses in the soft tissues of the body
Evaluating bone tumors, cysts and bulging or herniated discs in the spine
Diagnosing strokes in their earliest stages"

You can't do any of this with an X-ray. X-rays show bone issues.

Try to find a doc to refer you to a sports med doc to get an MRI. Resting is good, only if that will cure the problem. Coach Chris is correct in that you have to find the root of the problem [i.e the cause], but until you find out WHAT is wrong, you might have a hard time figuring out what caused the problem to begin with. Very few of the people on this site are certifiable experts in anything outside of baseball, and most of those are self-proclaimed Big Grin, [although many of us are certifiable, period]. Ask for advice, but be wary of email/remote diagnoses of health related issues, especially as they relate to your children.

REPEAT - find a doc who is willing to work with you, to get the MRI or at least to explain WHY you don't need one.

CAVEAT: MRI's don't always tell the whole story, although they do a great job. I had a 30% tear in my rotator cuff - X-ray showed nothing, MRI was inconclusive. After a full year of rehab and minimal results, the tear was only discovered when they cut me open.

Good luck
Just for the record, let me reiterate that I am not a doctor and never have been one (or have claimed to be). As such, I am not contradicting the advice of the people who are telling you to go see a doctor.

They are correct.

What I am is an educated parent, which is something that I suggest that the parent of every pitcher (at least) should become. The problem is that many doctors and coaches have only a minimal (or worse yet incorrect) knowledge of the impact of pitching on the body or injury mechanisms and as such often give out bad advice (e.g. what they have heard, not what the studies say). As a result, it is in your interest to learn everything that you can about the physiology of pitching.

One place to start is in the Q&A files of Dr. Mike Marshall (http://www.drmikemarshall.com). In these files he talks in depth about the physiology of pitching. Once you have done that you might want to start googling around for phrases like "little league elbow" and "reduce risk injury pitching." You will come across multiple studies that are accessible over the web and that help to explain what happens to young pitchers and why.
1) How old was your son when he first started pitching?

2) Has your son ever (intentionally) thrown a curveball or slider? If so, at what age did he start?

3) You said your son plays Feb-Aug but it looks like you first posted in Nov. Does he have pain in the off season?

4) When you talked to the first MD, did you get any kind of formal diagnosis? Can you get your hands on the notes of the person who read the X-Ray (or the X-Rays themselves)? Do you have a diagnostic code (see if one is listed on the EOB if your insurance company sent you one)? Did the MD say anything about "medial epicondylitis?"

5) Can your son throw a football without experiencing pain?

6) I would suggest that you go to the Q&A portion of Dr. Mike Marshall's web site...

http://www.drmikemarshall.com/Question-Answer2005.html

...and search for the keyword "medial epicondyle".

The bottom line is that this is something to take seriously. Ideally, your son has just irritated his medial epicondyle, which will heal itself over time (this is the same basic thing as "golfer's elbow"). However, in the worst case he could have an avulsion fracture of the medial epicondyle or a growth plate injury, both of which are very big deals.
I agree that doctors usually do a good job of determining what happened. The problem is that they are often at a loss to explain why something happened or what to do about it. Something about their training seems to give them tunnel vision and focuses them on solving the problem rather than preventing it. Of course, it might be the case that they have a perverse incentive to not fix the problem. In the same way that I don't know who will invent a gadget that will eliminate the need for shaving, but I'm pretty sure it won't be the people at Gilette, I don't know who will eliminate the need for Tommy John surgery, but I'd be willing to bet that it won't be Frank Jobe or James Andrews.

As an example I give you this study...

http://mednews.wustl.edu/tips/page/normal/6099.html

They explain that pitchers lose range of motion in their pitching elbows but don't seem interested in why or what to do about it.

The only person who even attempts to answer these deeper questions (but still not to my complete satisfaction) is Dr. Mike Marshall. To find out what he says about this subject, Google "mike marshall range motion pitching elbow".
he started at 8yr.old 2inn. and 8 thru 11 maybe 20-25 innings total.at 12 may 30 inn 13-45, 14-50,15,maybe 60.at a young age 8,9,10 his fastball looked like a slider dot in the center. worked hard to correct that he never tried to throw a curve till he was 13 and never in a game just played with a little i wouldn't let him throw it to me but i know he did. threw it some in games at 14 but not much and alittle more at 15.

we were going to a camp at vanderbilt dec 3rd so we started throwing a little early only threw about 5 days.

i didn't take him to the doctor my wife did.

he threw a football all fall and had no problem at all.

ill check dr marshall web.
"(A)t a young age 8,9,10 his fastball looked like a slider dot in the center."

This is the most telling fact, in my opinion. I would bet a non-trivial amount of money that what your son is doing is throwing an involuntary (or not) slider some of the time that he thinks/says he is throwing a fastball. Does your son's fastball seem especially wicked compared to those of others? Does it move more? Is it harder for catchers to catch? Is he a great strike-out, ground-out pitcher even though he doesn't always keep the ball down? If so, then that suggests that the ball is diving right at the end of its flight.

"(I)ll check dr marshall web."

Be warned that he is undoubtedly the most opinionated person you will ever meet. He also thinks he's smarter than everyone else. This rubs a lot of people the wrong way, but I work with programmers so it's just par for the course for me. Of course, having a PHd and a Cy Young will do that for you.
Elbow problems with pitchers-hang in there..if you and they love the sport, chances are they've been overthrown for years. As kids get older those joints etc aren't rubber anymore and problems arise whether it be from overuse, mechanical flaws etc. They stive to win the game no matter what it takes...........

Having one child now (18) that had Tommy John at 17 and hoping and praying the next one won't. It all started with a sprained elbow medial epocodolytis(sp)xrays, MRI's,nerve tests scoped, rest, ice, PT (hours and hours). What we didn't do in the beginning was stop throwing completely and letting it heal. Ligament was replaced but since no damage to the nerve it wasn't moved. This fall with college ball the nerve got involved and slipped.no nerve damage thankfully...finally after 6 weeks resting and again rehab...(for life after TJ) hopefully a lesson learned.

My advice ..rest...go see an ortho dr. who will hopefully refer you onto a sports PT and begin with exercised to strength those muscles. Purchase an exercise ball for your son...

One good thing--older sibling in now in athletic training and plans to go on into physical therapy.
quote:
pain was inside and dull he never showed discomfort on his face or with his body movement when we threw. i just ask him why he was taking some advil and he said his arm had hurt when he made some throws. thats when i shut him down and ask for some advice.


ghoti, kids will rarely tell you the true pain they might be experiencing. Number of reasons. Denial, they think it will get better, they don't know better, don't want to disappoint a parent...lots of reasons. Mine separated his growth plate pitching in a high school game when he was 15. Started to ache about a week before but ne never said anything. Pitched 4 innings before he finally told the coach the pain was too intense to continue. Even if you have to pay the cost yourself, the conscensus advice given here is the right. You are not going to find the answer on the internet. Your son deserves to be evaluated by a sports medicine orthopedist...now.
Been...I think you might have meant ob/gyn??? Eek

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