A 41-year-old construction worker presents with debilitating right elbow pain radiating to the forearm, which significantly affects his ability

Discussion 1

Module 5 Discussion

A 41-year-old construction worker presents with debilitating right elbow pain radiating to the forearm, which significantly affects his ability to work. His communication is facilitated by his 13-year-old daughter, introducing the concerns of language barriers and potential undocumented status. Based on his history of repetitive motion work in construction, epicondylitis of the lateral epicondyle, also referred to as tennis elbow, is highly suspected. The plan of diagnosis, evaluation of the family system, performing a directed physical exam, taking into account evidence-based treatments, and trustfully establishing rapport with the patient are key to effective assessment and management.

Confirming the Diagnosis

To confirm lateral epicondylitis, it is essential to perform the Cozen's test and the Mills' test. While performing the Cozen's test, the clinician should stabilize the patient's elbow at 90° flexion, ask him to clench his fist, pronate the forearm, and radially deviate against resistance to wrist extension. Chen et al. (2023) observe that pain at the lateral epicondyle confirms the diagnosis. Under the Mill's test, the forearm is passively pronated, the wrist maximally flexed, and the elbow extended by the nurse practitioner. Reproduction of pain at the lateral epicondyle seals the diagnosis. Imaging is not typically necessary, although it is reasonable when there is suspicion of bony fragments or fractures. Ultrasound and MRIs can be reserved for atypical presentation or refractory cases.

Understanding the Daughter’s Concern

The daughter’s distress and hesitancy likely stem from fear of jeopardizing her father’s employment and immigration status. Bretschneider et al. (2021) argue that undocumented workers may be wary of the repercussions of reporting a worker-related injury, as it can trigger an employer's retaliation, job loss, deportation, and legal consequences. She may believe that disclosing the true origin of the injury could lead to questioning by authorities or employer surveillance. Upon recognition of this, the practitioner should reassure them that worker protection laws, including the right to medical evaluation without immigration checks, apply, and that medical confidentiality secures their information.

Further Physical Assessments

Beyond provocative tests for epicondylitis, it is essential to assess the full range of motion of the wrist and elbow, considering any loss of extension or flexion strength. The practitioner should perform resisted wrist supination and valgus stress testing on the elbow to rule out lateral collateral ligament injury. Paired with that, the practitioner should also evaluate cervical radiculopathy by assessing neck range of motion and performing Spurling’s maneuver, as C6-C7 pathology can mimic forearm pain. Karabinov and Georgiev (2021) recommend inspecting for signs of compartment syndrome, such as changes in skin color, temperature, and capillary refill, and palpating the forearm compartments for tenseness. Finally, screening for distal neurovascular compromise should include checking the radial pulse, capillary refill in the hand, and light touch sensation over the dorsal hand as part of the assessment.

Treatment of Lateral Epicondylitis

Management interventions begin with activity modification and ergonomic counseling to reduce repetitive wrist extension and forearm supination. Alongside a brief period of relative rest with minimal aggravating tasks, applying a counterforce brace just distal to the lateral epicondyle helps offload the extensor tendons. A progressive physical therapy program should stress eccentric wrist-extension exercises, forearm stretching, and forearm supinator strengthening.

Chen et al. (2023) stress that nonsteroidal anti-inflammatory drugs (NSAIDs) can be used for short-term pain relief, and if symptoms persist beyond six weeks, the practitioner should consider a corticosteroid injection at the site of maximal tenderness. Nevertheless, the patient should be counseled on the risk of tendon weakening with repeated injections. For refractory cases, extracorporeal shockwave therapy or platelet-rich plasma (PRP) injections may be explored, although evidence is mixed. Surgical referral for lateral epicondyle debridement is reserved for chronic, disabling symptoms unresponsive to conservative measures after six to twelve months.

Communicating to Encourage Staying

When the patient and daughter express a desire to leave immediately, the practitioner should validate their concerns by acknowledging how intimidating medical visits can feel, particularly with language barriers and immigration worries. The practitioner should explain that proper management will restore his capacity to work and support the family, alleviating a more severe injury that could force him out of work for longer. It is also advisable for the practitioner to offer to arrange a professional medical interpreter instead of relying on his daughter, guaranteeing clear communication, and alleviating her distress.

According to Bretschneider et al. (2021), confidentiality is a key concern, and in line with this, the practitioner can provide reassurance to the patient that the clinic will not inquire about their immigration status and that all medical information is protected. Outlining a concise care plan with minimal disruption to his work schedule, for instance, scheduling therapy sessions early in the morning or late in the day, and if needed, providing documentation that facilitates short-term work modifications.

Conclusion

Confirming lateral epicondylitis through specific provocative tests, comprehending the family's immigration-related fears, and conducting a comprehensive physical assessment lay the foundation for targeted care. A conservative treatment regimen, comprised of activity modification, bracing, NSAIDs, and structured rehabilitation, helps address tendon pathology while clear, empathetic communication and assurance of confidentiality help the patient and daughter feel secure. By optimizing clinical management and building trust, the practitioner empowers the patient to complete therapy, return to work safely, and maintain his family's overall well-being.

Discussion 2

The  41-year-old Patient Evaluation and Management Plan

Confirming the Diagnosis of Lateral Epicondylitis

The confirmation of lateral epicondylitis diagnosis requires the healthcare practitioner to perform physical examination procedures. Palpations of the lateral epicondyle are the most significant ones as it is expected to cause pain at the origin of the extensor tendons. Additionally, the provider is to apply the Cozen test, which requires the patient to make a fist and, with the wrist extended, push back against the downward force exerted on the lateral epicondyle. With this technique, the provider is supposed to be able to induce pain. Additionally, the provider is required to assess the patient's grip strength, range of motion at the elbow and wrist, and conduct tests to extend the wrist against resistance as well as extend the middle finger against resistance. An extensive history, focusing on the repetitive nature of activities, the persistence of symptoms, and exacerbating factors, would also be effective in diagnosis.

Understanding the Daughter's Distress

The daughter may be worried about her father losing his job or permission to stay in the country. Based on the allegation of being illegal workers, the family would fear that any record of work injury may result in employer retaliation, loss of employment, and reporting to the immigration authorities. Thus, the daughter may be trying to save her father by labeling the wound pre-existing rather than work-related, even if this limits workers' compensation insurance coverage. Her suffering highlights how vulnerable undocumented workers are when forced to choose between medical care and legality.

Additional Physical Assessments

In addition to ocular erythema analysis, the healthcare provider should perform a complete musculoskeletal evaluation of the affected arm. This entails assessing the active and passive range of motion of the elbow, wrist, and shoulder to determine any limiting or compensatory movements. The physician should also palpate the medial epicondyle, olecranon, and radial head to rule out alternative sources of pain. In a neurological exam, sensation, reflexes, and motor activity testing should be performed to rule out entrapment syndromes of the nerves, such as posterior interosseous nerve compression (Trofin et al., 2024). The provider should also assess the cervical spine and shoulder, as referred pain from these areas may falsely resemble lateral epicondylitis. Lastly, evaluating functional movements that imitate the work tasks performed by the patient would help establish the trend of impairment.

Treatment of Lateral Epicondylitis

Conservative, multi-modal treatment is typical for lateral epicondylitis. Early treatment includes changing activities to avoid movement worsening, many 15–20-minute ice packs, and NSAIDs, which should not be used if contraindicated. The healthcare provider may recommend a tennis elbow strap to reduce tension in the extensor tendon during activities that involve repetitive motion. Epicondylitis physiotherapy includes eccentric strengthening, extensor stretching, and progressive restoration of functional activity (Yoon et al., 2021). If conservative medicine fails after 6 to 12 weeks, corticosteroid injections, PRP therapy, or extracorporeal shock wave therapy may be employed. Surgery may be selected in cases that cannot be handled conservatively within 6-12 months.

Addressing the Family's Concerns and Building Trust

The healthcare provider should inform the patient and their daughter that patient care is the most important priority and that they are protected by law. The provider should emphasize that medical staff do not report patients to immigration authorities and that access to medical care is a fundamental human right, regardless of an individual's legal status. He or she should also convince them that the medical record may be secret and that they can choose how to record the damage. The provider can also explain that addressing the problem early would prevent unmanageable complications that could lead to irreversible disability and the inability to work and maintain a family. The resourcing provider should inform the patient about community resources and sliding-scale options so the patient cannot decline emergency care due to cost or immigrant status.