A 41-year-old male patient presents at the community walk-in clinic with complaints of severe elbow pain radiating into the forearm. His 13-year-old daughter is serving as a translator because her father is unable to speak English and understands only a few words in English. The daughter explains that he has been taking Tylenol to manage pain, but the pain is getting worse and is keeping him from working. You ask the daughter to describe the type of work her father does, and you notice she is hesitant to respond, first checking with her father. He responds, and she translates that he works in construction. Based on the response and the apparent concern, you suspect that the patient may be an undocumented worker. Further conversation reveals that several members of the family are working with the same local construction company.
- You suspect the pain reported as coming from the elbow and radiating down the forearm is caused by repetitive motions, perhaps indicating lateral epicondylitis. What can you do to confirm this diagnosis?
- While performing the physical examination, you ask the patient, through his daughter, if he has reported this injury to his employer, because the injury is most likely work-related. The daughter responded without consulting her father that this is an old injury that happened before he started working at his current place of employment. You could tell that she was becoming more distressed. What is the most likely explanation for her concern?
- Visual inspection reveals erythema around the affected area with no evidence of overlying skin lesions, scars, or deformities. What other assessments should you perform?
- How is lateral epicondylitis treated?
- When discussing possible treatment approaches, you notice that the patient is very worried and seems to suggest to his daughter that they should leave. The daughter begins trying to explain why they have to leave right away. What would you tell the patient and his daughter to help them feel comfortable staying for treatment?
Full Answer Section
- Cozen's Test: Stabilize the elbow with one hand. With the other hand, palpate the lateral epicondyle. Ask the patient to make a fist, pronate the forearm, and radially deviate and extend the wrist. Then, resist this motion. Pain at the lateral epicondyle is a positive sign.
It's important to differentiate lateral epicondylitis from other conditions that can cause elbow pain, such as radial tunnel syndrome, cervical radiculopathy, or arthritis.
2. Explanation for the Daughter's Concern
The daughter's distress and quick denial of a work-related injury, without consulting her father, strongly suggest fear of repercussions related to their undocumented status and employment.
Here's a more detailed explanation:
- Fear of Job Loss: Reporting a work-related injury, especially for an undocumented worker, could lead to job loss for the father and potentially other family members working for the same company. Employers might be hesitant to keep undocumented workers who have sustained injuries, due to potential workers' compensation claims, legal issues, or simply to avoid drawing attention to their hiring practices.
- Fear of Deportation/Legal Issues: There's a significant fear that reporting a work injury could expose their undocumented status to authorities, leading to deportation proceedings for the father and potentially the entire family. They may view any official interaction, even for a medical claim, as a risk.
- Lack of Workers' Compensation Coverage: Undocumented workers often do not have access to or are not aware of their rights regarding workers' compensation. They may believe that reporting an injury would not result in any benefits and would only lead to negative consequences.
- Employer Coercion/Threats: It's possible the construction company has explicitly or implicitly threatened employees against reporting injuries, especially if they are undocumented.
- Cultural/Trust Factors: There might be a general distrust of official systems or a cultural tendency to avoid drawing attention to oneself, particularly when in a vulnerable situation.
The daughter's immediate response indicates a pre-existing understanding of the risks involved and a desire to protect her father and family.
3. Other Assessments to Perform (Beyond Visual Inspection)
Given the visual inspection revealed erythema (redness) but no other obvious signs, here are other crucial assessments:
- Palpation:
- Lateral Epicondyle: As mentioned above, pinpoint tenderness is key.
- Other Elbow Structures: Palpate the medial epicondyle (to rule out medial epicondylitis), olecranon (for bursitis), radial head (for fracture/subluxation), and triceps tendon.
- Forearm Musculature: Palpate the extensor muscle belly for tenderness or trigger points.
- Range of Motion (ROM):
- Elbow: Assess flexion, extension, pronation, and supination. While lateral epicondylitis typically doesn't restrict elbow ROM, it's important to rule out other joint issues.
- Wrist: Assess flexion, extension, radial deviation, and ulnar deviation. Pain with resisted wrist extension is characteristic.
- Neurological Examination:
- Sensory: Test sensation in the distribution of the radial, median, and ulnar nerves in the forearm and hand to rule out nerve entrapment (e.g., radial tunnel syndrome).
- Motor: Assess strength of wrist and finger extensors, and other muscles innervated by the radial nerve.
- Reflexes: Biceps and triceps reflexes.
- Vascular Assessment: Check radial and ulnar pulses, and capillary refill, though less likely to be directly impacted by lateral epicondylitis unless there's significant swelling.
- Functional Assessment: Ask the patient (through his daughter) about specific movements or activities that exacerbate the pain, particularly those related to his work. This helps correlate findings with his daily activities.
4. Treatment of Lateral Epicondylitis
Treatment for lateral epicondylitis is typically conservative and aims to reduce pain, inflammation, and promote healing.
Conservative Management (First-Line):
- Rest and Activity Modification: This is paramount. The patient needs to avoid or modify activities that aggravate the pain, especially repetitive gripping, wrist extension, and pronation/supination. This might involve adjusting work tasks or using ergonomic tools.
- Pain Management:
- NSAIDs (Nonsteroidal Anti-inflammatory Drugs): Oral NSAIDs (e.g., ibuprofen, naproxen) or topical NSAID creams can help reduce pain and inflammation.
- Ice/Cold Packs: Apply ice to the affected area for 15-20 minutes several times a day, especially after aggravating activities.
- Physical Therapy/Rehabilitation:
- Stretching: Gentle stretching of the wrist extensor muscles.
- Strengthening Exercises: Gradual strengthening of the wrist extensors, initially with eccentric exercises (where the muscle lengthens while contracting), then progressing to concentric exercises. This helps remodel the tendon.
- Eccentric Training: A key component, focusing on controlled lowering of the wrist from an extended position.
- Massage: Deep tissue massage or friction massage to the extensor tendon can be helpful.
- Ultrasound or Phonophoresis: May be used to reduce inflammation and promote healing, though evidence is mixed.
- Bracing/Counterforce Brace: An elbow brace or a counterforce strap worn just below the elbow can help by dispersing the forces away from the lateral epicondyle and reducing strain on the extensor tendons.
- Corticosteroid Injections: While offering short-term pain relief, repeated injections are generally discouraged due to potential long-term tendon weakening and recurrence. They may be considered for severe, debilitating pain that doesn't respond to other conservative measures.