Full Answer Section

• • Pain reproduced at the lateral epicondyle suggests a positive test, as it stretches the extensor muscles.
• Grip Strength:
  • Assess the patient’s grip strength (using a dynamometer if available, or a subjective squeeze test). Patients with lateral epicondylitis often have decreased grip strength, especially with the elbow extended.
• Range of Motion (ROM):
  • Assess active and passive range of motion of the elbow, wrist, and forearm. While lateral epicondylitis doesn’t typically cause a significant loss of joint motion, pain may limit functional ROM.
• History of Aggravating Activities:
  • Ask the daughter to ask the father about activities that worsen his pain. Repetitive gripping, lifting, carrying, or twisting motions of the forearm (common in construction work) are classic aggravators.
• Onset and Duration:
  • Inquire about how long the pain has been present and if there was a specific event that triggered it (though often it’s gradual onset).
• Relieving Factors:
  • What makes the pain better? (Rest, over-the-counter pain relievers, ice).

What NOT to do: X-rays are typically not needed for the initial diagnosis of lateral epicondylitis unless there’s concern for a fracture, arthritis, or other bony pathology, as they won’t show soft tissue inflammation.

2. Explanation for the Daughter’s Concern

The daughter’s distressed reaction and quick response that the injury is “old” and happened before his current job is most likely due to fear of repercussions related to her father’s undocumented status and work-related injury reporting.

Here’s a breakdown of the probable concerns:

• Fear of Job Loss/Deportation: If the injury is officially reported as work-related, it could expose her father’s undocumented status to his employer. This could lead to immediate termination, potentially without pay or benefits, and could even trigger immigration enforcement actions, leading to deportation.
• Fear of Financial Instability: Losing his job would mean a loss of income, impacting the entire family’s financial well-being, especially since “several members of the family are working with the same local construction company.” This suggests they are heavily reliant on this income.
• Lack of Workers’ Compensation: Undocumented workers are often hesitant to report injuries because they fear they will not be eligible for workers’ compensation benefits, or that attempting to claim them will expose their status. The daughter may be trying to protect her father from this legal and financial entanglement.
• Distrust of Authorities/Systems: Undocumented individuals often have a deep-seated distrust of official systems (including healthcare and legal) due to fear of discovery and exploitation. The daughter might be trying to navigate this complex situation to protect her family.
• Protecting Her Father: As a 13-year-old, she is in a difficult position, bearing the responsibility of translation and trying to protect her father from perceived threats. Her quick, unconsulted response is a protective mechanism.
• Employer Coercion/Threats: It’s not uncommon for unscrupulous employers to implicitly or explicitly threaten undocumented workers with deportation if they report injuries or complain about working conditions. The daughter may be aware of such threats.

Her distress highlights the vulnerable position this family is in, and it’s crucial to address this sensitively.

3. Other Assessments to Perform

Given the erythema (redness) and the patient’s presentation, here are other important assessments:

• Neurovascular Examination of the Affected Limb:
  • Sensation: Assess sensation in the distribution of the radial, median, and ulnar nerves in the hand and forearm. This helps rule out nerve impingement or damage.
  • Motor Function: Test the strength of specific muscle groups in the hand and wrist (e.g., thumb opposition, finger abduction/adduction, wrist flexion).
  • Pulses: Check radial and ulnar pulses to ensure adequate circulation to the hand and forearm.
  • Capillary Refill: Assess capillary refill in the fingertips.
• Cervical Spine Examination:
  • Pain radiating down the arm can sometimes originate from the cervical spine (neck) due to nerve root compression (radiculopathy).
  • Assess cervical range of motion.
  • Perform Spurling’s test (gently extend, rotate, and laterally bend the neck towards the affected side, applying gentle axial compression) to see if it reproduces arm pain.
  • Check for dermatomal sensory changes and myotomal weakness in the upper extremity.
• Elbow Joint Stability and Range of Motion (Beyond pain-provocation tests):
  • Assess full active and passive flexion, extension, pronation, and supination of the elbow to rule out other joint issues.
  • Check for any crepitus or locking.
  • Assess for collateral ligament integrity if there’s any history of trauma or instability.
• Shoulder Examination:
  • Pain can sometimes refer from the shoulder to the elbow. Briefly assess shoulder range of motion and palpate for tenderness.
• General Musculoskeletal Screen:
  • Briefly observe the patient’s general posture and how they use their arm.
• Pain Assessment (Quantification):
  • Use a pain scale (e.g., 0-10 numerical rating scale) through the daughter to quantify the severity of the pain. Ask about its impact on daily activities and sleep.
• Functional Assessment:
  • Inquire about specific movements or tasks at work or home that are difficult or impossible due to the pain.
• Skin Integrity (Closer Look):
  • Although you noted erythema, a closer look to rule out any subtle signs of infection (e.g., warmth, streaking, drainage, fluctuance) or other skin conditions that might mimic or complicate the presentation.