A 41-year-old male patient presents at the community walk-in clinic with complaints of severe elbow pain radiating into the forearm.

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.

Case Questions

1. 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?
2. 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?
3. Visual inspection reveals erythema around the affected area with no evidence of overlying skin lesions, scars, or deformities. What other assessments should you perform?
4. How is lateral epicondylitis treated?
5. 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?

ANSWER

Diagnosing and Addressing Lateral Epicondylitis in an Undocumented Worker: A Case Study and Approach

Confirming the diagnosis of lateral epicondylitis, commonly known as tennis elbow, is crucial in order to provide appropriate treatment and care for the patient. While the patient’s reported symptoms of severe elbow pain radiating into the forearm are consistent with this condition, further investigation is necessary to confirm the diagnosis.

Confirming diagnosis

To confirm the diagnosis, several diagnostic tests and assessments can be performed. These may include:

Medical History: Gather a detailed medical history, focusing on the onset and duration of symptoms, any previous injuries, and relevant occupational history (Buchanan, 2022). In this case, it is important to explore the patient’s work activities in construction, as repetitive motions often contribute to the development of lateral epicondylitis.

Physical Examination: Conduct a thorough physical examination of the affected area. Assess the range of motion, strength, and stability of the elbow joint. Palpate the lateral epicondyle, where tenderness and pain may be present. Perform resisted wrist extension and supination tests, as these typically elicit pain in patients with lateral epicondylitis.

Imaging Studies: X-rays may be ordered to rule out other possible causes of elbow pain, such as fractures or arthritis. However, lateral epicondylitis does not typically show any abnormalities on X-ray images (Cha et al., 2019). In some cases, an MRI may be recommended to assess the extent of soft tissue damage and rule out other potential causes.

Diagnostic Injections: If there is uncertainty regarding the diagnosis, a diagnostic injection of local anesthetic, such as lidocaine, can be administered at the origin of the extensor tendon. If the patient experiences immediate relief of pain, it strongly suggests that lateral epicondylitis is the cause.

An explanation for the patient’s daughter’s concern

Regarding the patient’s daughter’s concern and hesitance to respond when asked about the patient’s work, the most likely explanation is that the patient and his family may be undocumented workers. This apprehension may arise from fear of potential legal consequences or employment issues related to their immigration status. Undocumented workers often face challenges in accessing healthcare and may hesitate to disclose their occupational injuries or seek medical attention.

Other assessments that should be performed

Apart from the visible erythema around the affected area, other assessments that should be performed include:

Range of Motion: Evaluate the range of motion of the elbow joint, including flexion, extension, pronation, and supination. Limited range of motion may be indicative of additional joint involvement or inflammation.

Grip Strength: Assess the patient’s grip strength, as lateral epicondylitis can affect the ability to grasp objects firmly.

Neurological Examination: Conduct a neurological examination to rule out any nerve involvement or compression that may mimic or coexist with lateral epicondylitis. Assess sensory function and reflexes in the affected limb.

Treatment for lateral epicondylitis

Treatment for lateral epicondylitis focuses on relieving pain, reducing inflammation, and promoting healing. Conservative management options include:

Rest and Activity Modification: Encourage the patient to avoid activities that exacerbate symptoms and provide adequate rest to the affected arm.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs): Prescribe NSAIDs, such as ibuprofen or naproxen, to alleviate pain and reduce inflammation.

Physical Therapy: Refer the patient to a physical therapist who can provide exercises and modalities to strengthen the forearm muscles, improve flexibility, and promote healing.

Counterforce Braces or Straps: Suggest the use of counterforce braces or straps to help reduce stress on the tendon and alleviate pain during activities.

Steroid Injections: Consider corticosteroid injections if symptoms persist despite conservative measures. These injections can provide temporary relief by reducing inflammation.

Extracorporeal Shockwave Therapy (ESWT): In cases where conservative measures fail, ESWT may be recommended to stimulate tissue healing and relieve pain.

When discussing the treatment options with the patient and his daughter, it is important to address their concerns and reassure them that seeking medical care will not lead to any legal repercussions (Varkey, 2020). Emphasize the importance of early intervention and treatment to prevent further complications and promote recovery. Inform them about the rights and protections in place regarding occupational injuries, regardless of immigration status. If necessary, provide information about local resources and organizations that can assist them with legal and employment-related issues.

What would you tell the patient and his daughter to help them feel comfortable staying for treatment?

By creating a safe and supportive environment, emphasizing the importance of their well-being, and providing information about their rights and available resources, you can help alleviate their fears and encourage them to stay for treatment. Ensuring clear communication through the use of a qualified interpreter, such as the patient’s daughter, is essential to facilitate understanding and build trust.

References 

Buchanan, B. K. (2022, November 7). Tennis Elbow. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK431092/ 

Cha, Y. K., Kim, S. J., Park, N. H., Kim, J. B., Kim, J. S., & Park, J. (2019). Magnetic resonance imaging of patients with lateral epicondylitis: Relationship between pain and severity of imaging features in elbow joints. Acta Orthopaedica Et Traumatologica Turcica, 53(5), 366–371. https://doi.org/10.1016/j.aott.2019.04.006 

Varkey, B. (2020). Principles of Clinical Ethics and Their Application to Practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119