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
Radiation: Confirm the exact path of radiation into the forearm. Does it go all the way to the hand/fingers? Any numbness or tingling? (To rule out nerve impingement). *
Aggravating Factors: What specific movements or activities make the pain worse (e.g., gripping, lifting, twisting forearm, using tools, shaking hands)? *
Alleviating Factors: What makes it better (e.g., rest, Tylenol, ice)? *
Work Activities: Ask specifically about typical daily tasks in construction (e.g., hammering, screwing, lifting, carrying, using specific power tools). This helps identify repetitive stress. *
Previous Treatments: Has he ever seen a doctor for this before? What treatments were tried? Did they help? *
Other Medical Conditions: Any history of arthritis, gout, diabetes (which can affect tendon healing)? *
Hand Dominance: Is he right or left-handed? (Lateral epicondylitis often affects the dominant arm).
2. Physical Examination (Focused Musculoskeletal Assessment):
- Palpation:
- Lateral Epicondyle: Apply firm pressure directly over the lateral epicondyle (the bony prominence on the outside of the elbow). Significant tenderness here is a hallmark sign.
- Extensor Muscle Mass: Palpate the extensor muscles of the forearm just distal to the elbow for tenderness and tightness.
- Resisted Wrist Extension (Cozen's Test):
- Have the patient make a fist, pronate the forearm (palm down), and radially deviate the wrist (tilt hand towards thumb).
- Then, instruct the patient to extend the wrist against resistance from the examiner's hand.
- Positive Result: Sharp pain at the lateral epicondyle indicates lateral epicondylitis.
- Resisted Middle Finger Extension (Maudsley's Test):
- Have the patient extend their middle finger against resistance while the rest of the hand is relaxed.
- Positive Result: Pain at the lateral epicondyle. This targets the extensor digitorum communis.
- Passive Wrist Flexion with Elbow Extension (Mill's Test):
- Palpate the lateral epicondyle with one hand.
- With the other hand, passively pronate the patient's forearm, flex the wrist, and extend the elbow.