1. Confirming the Diagnosis of Lateral Epicondylitis

To confirm a diagnosis of lateral epicondylitis (tennis elbow), which is inflammation of the tendons that join the forearm muscles on the outside of the elbow, you would perform a combination of physical examination maneuvers:

• Palpation:
  • Lateral Epicondyle Tenderness: The most classic sign is localized tenderness to palpation directly over the lateral epicondyle (the bony prominence on the outside of the elbow). The pain should be reproducible with firm pressure.
  • Extensor Muscle Mass Tenderness: Palpate along the common extensor tendon origin, just distal to the epicondyle, and along the extensor muscle belly in the forearm. Pain here would further support the diagnosis.
• Resisted Wrist Extension Test (Cozen’s Test):
  • Instruct the patient to make a fist, pronate their forearm (palm down), and radially deviate their wrist (turn thumb away from body).
  • Place your hand on the dorsal (back) aspect of their wrist and ask them to extend their wrist against your resistance.
  • Pain over the lateral epicondyle indicates a positive test.
• Resisted Middle Finger Extension Test (Maudsley’s Test):
  • Stabilize the patient’s forearm.
  • Ask the patient to extend their middle finger against your resistance while the rest of their fingers are relaxed.
  • Pain over the lateral epicondyle suggests involvement of the extensor digitorum communis, which is often affected in lateral epicondylitis.
• 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 their wrist, and extend their elbow.
  • Pain over the lateral epicondyle indicates a positive test.
• Range of Motion (ROM): Assess the active and passive range of motion of the elbow and wrist. While ROM is typically preserved in lateral epicondylitis, pain may limit the end range of motion, especially with resisted movements.
• Neurovascular Assessment: Rule out nerve entrapment (e.g., radial nerve) or other neurological issues by assessing sensation, motor strength, and reflexes in the affected extremity. While less common, nerve compression can mimic elbow pain.
• Grip Strength: Assess grip strength, as it is often weakened in patients with lateral epicondylitis due to pain.

Based on a positive finding in several of these tests, especially the resisted movements and localized tenderness, the diagnosis of lateral epicondylitis can be strongly suspected. Imaging studies like X-rays are typically not needed for diagnosis unless there’s a suspicion of fracture, arthritis, or other bony pathology. Ultrasound or MRI might be used in chronic cases or if the diagnosis is unclear, but they are not usually necessary for an initial diagnosis.

2. Most Likely Explanation for the Daughter’s Concern

The daughter’s immediate response without consulting her father, and her increasing distress, are highly indicative of a fear related to the legal and employment status of her father and potentially other family members.

Here’s a breakdown of the likely reasons:

• Fear of Deportation/Legal Repercussions: If the father is an undocumented worker, reporting a work-related injury could lead to his employer discovering his immigration status. This could result in his termination, and more severely, deportation for him and potentially other undocumented family members.
• Fear of Job Loss: Even if not deported, reporting a work injury could lead to his employer firing him to avoid dealing with workers’ compensation claims or legal issues related to employing undocumented workers. Given that “several members of the family are working with the same local construction company,” this threat extends to their livelihoods as well.
• Loss of Income and Financial Hardship: Losing their jobs would immediately impact the family’s ability to earn income, leading to severe financial distress, inability to pay rent, buy food, or meet other basic needs. This is a very real and immediate threat for families in this situation.
• Lack of Workers’ Compensation Eligibility: Undocumented workers are often not eligible for workers’ compensation benefits, or employers may try to deny claims based on their status. The daughter may be aware that reporting it as a work injury would likely lead to no benefits and only negative consequences.
• Distrust of Authorities/Systems: Undocumented individuals often have a deep-seated distrust of official systems (government, legal, even healthcare when it intersects with official reporting) due to fears of exposure and punitive action.
• Protecting her Father/Family: As a 13-year-old, she is acting as a protector of her father and family. Her quick response is an attempt to deflect attention from the true nature of the injury’s origin (work-related) to protect them from perceived threats. She is taking on a significant burden and responsibility.

The daughter’s fabricated story about it being an “old injury” is a common coping mechanism in such situations, attempting to dissociate the injury from the current employment to avoid triggering potential negative consequences.

3. Other Assessments to Perform

Beyond visual inspection and the specific tests for lateral epicondylitis, here are other crucial assessments to perform:

• Neurovascular Assessment of the Entire Arm and Hand:
  • Sensory Exam: Test light touch, sharp/dull discrimination in all dermatomes of the arm and hand (C5-T1) to rule out nerve compression or neuropathy that could mimic or contribute to the pain.
  • Motor Strength: Assess strength in all major muscle groups of the shoulder, arm, and hand (e.g., biceps, triceps, wrist flexors/extensors, grip strength, finger abduction/adduction) to identify any weakness or muscle imbalances.
  • Reflexes: Biceps (C5), Brachioradialis (C6), Triceps (C7) reflexes to assess nerve root integrity.
  • Circulation: Check capillary refill, skin temperature, and pulses (radial, ulnar) to ensure adequate blood flow.
• Cervical Spine Examination:
  • Pain radiating from the neck can sometimes mimic elbow pain. Assess cervical range of motion (flexion, extension, rotation, lateral bending).
  • Perform Spurling’s maneuver (cervical compression with head rotation) to check for cervical radiculopathy.
  • Palpate the cervical spine for tenderness.
• Shoulder Examination:
  • Assess active and passive range of motion of the shoulder, as shoulder pathology can sometimes refer pain to the elbow.
  • Perform rotator cuff strength tests (empty can test, external rotation strength).
  • Palpate the shoulder for tenderness.
• Elbow Range of Motion: Actively and passively assess flexion, extension, pronation, and supination of the elbow. Note any limitations or pain with movement.
• Forearm Palpation: Palpate the entire forearm, including the flexor muscle mass, to rule out other sources of pain like medial epicondylitis or muscle strain.
• Functional Assessment: Ask about activities that worsen the pain and how the pain impacts his daily life and work (e.g., lifting, gripping tools, carrying objects). This provides a baseline for evaluating treatment effectiveness.
• Pain Assessment: Use a pain scale (e.g., 0-10 numerical scale) to quantify pain intensity. Ask about the character, onset, duration, and aggravating/alleviating factors of the pain.
• Review of Systems: Briefly ask about any other systemic symptoms (e.g., fever, night sweats, weight loss, joint swelling in other areas) to rule out systemic inflammatory conditions or infections, although less likely for an isolated elbow pain.