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.
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?
Mills Test (Passive Stretching): Palpate the lateral epicondyle. Passively pronate the patient's forearm, flex their wrist, and extend the elbow. Pain at the lateral epicondyle indicates a positive test.
2. Explanation for the Daughter's Distress
The daughter's distress and immediate, unsolicited denial that the injury is work-related ("this is an old injury") are most likely due to fear of employer reprisal and deportation.
Fear of Job Loss: Reporting a work-related injury could lead to the father (and potentially other family members working at the same company) being fired, as employers may wish to avoid worker's compensation claims or the scrutiny of labor laws.
Fear of Deportation/Legal Risk: As an undocumented worker, the father is acutely vulnerable. Discussing a work injury, particularly with an external authority figure (like a healthcare provider who documents the event), may be perceived as a risk of being reported to immigration or labor authorities.
Role Reversal and Protection: The daughter is under immense pressure. She is acting as the primary communicator, but her priority is now shifting from a translator to a protector of her father's and family's livelihood and safety. She is trying to manage the threat she perceives from the question itself.
3. Other Assessments to Perform
Beyond the provocative tests to confirm lateral epicondylitis, you should perform a complete focused musculoskeletal and neurovascular examination to rule out other causes and establish baseline function.
Range of Motion (ROM): Assess active and passive ROM of the elbow and wrist, noting any pain, stiffness, or mechanical block. Lateral epicondylitis typically has full ROM.
Strength Testing: Test the strength of the wrist extensors and supinators against resistance, as the condition involves these tendons. Also, check the grip strength of the affected hand (which is typically diminished).
Neurological Assessment: Test sensory function (light touch, sharp/dull discrimination) along the distribution of the radial, median, and ulnar nerves to rule out nerve compression or entrapment (e.g., radial nerve entrapment, which can mimic elbow pain). Check deep tendon reflexes (biceps and brachioradialis).
Sample Answer
This patient scenario involves a clinical assessment of a suspected work-related injury and navigating the complex psychosocial and legal challenges faced by undocumented workers, particularly concerning confidentiality and employer disclosure.
1. Confirming the Diagnosis of Lateral Epicondylitis
Lateral epicondylitis (tennis elbow) is a clinical diagnosis confirmed primarily through a physical exam and specific provocative maneuvers.
To confirm the diagnosis, you would perform the following:
Palpation: Check for tenderness directly over the lateral epicondyle of the elbow (the bony prominence on the outside of the elbow).
Cozen's Test (Resisted Wrist Extension): Ask the patient to pronate their forearm, make a fist, and extend their wrist. Apply gentle pressure to the dorsal aspect of the wrist, trying to force it into flexion. A sharp pain at the lateral epicondyle indicates a positive test.
Maudsley's Test (Resisted Middle Finger Extension): Ask the patient to extend their third (middle) finger against resistance. Pain at the lateral epicondyle indicates a positive test, as the extensor digitorum muscle originates there.