Case Study on Diagnosing and Treating Lateral Epicondylitis

In this case study, a 41-year-old man presents symptoms of severe elbow pain radiating into the forearm. The patient is not good at English, and his 13-year-old daughter acts as his translator. The daughter says that her father has been taking Tylenol, but the pain is getting worse and preventing him from working. The patient works in construction, and he is probably an undocumented worker. 

Diagnosing Lateral Epicondylitis

An x-ray exam, magnetic resonance imaging (MRI), and electromyography (EMG) are the three strategies I would employ to confirm whether the 41-year-old patient has lateral epicondylitis. An x-ray exam would be important in analyzing the patient’s elbow and forearm joints and determining whether the patient has arthritis. As Ikemoto et al. (2020) mentioned, an x-ray is often performed in patients presenting symptoms of lateral epicondylitis to exclude other orthopedic joint conditions. In this case study, the patient’s occupation is a risk factor for arthritis because he could have suffered an injury in the past. Considering that the patient’s daughter mentioned that the pain started before her father started working at the construction company, an x-ray is important in eliminating the possibility of arthritis caused by a physical injury.

An MRI is another important exam as it allows one to analyze the patient’s elbow tendons and determine the severity of the damage. According to Cha et al. (2019), this test can be used to determine whether a patient is suffering from a common extensor tendon (CET), Radial collateral ligament (RCL), and lateral ulnar collateral ligament (LCL). The study found that patients with a history of chronic pain in the elbow region are likely to have a complete tear of the point of attachment (proximal part) of the extensor tendon, suggesting a severe injury. Also, the test is more likely to reveal a cortical irregularity or subcortical bone marrow edema along the lateral epicondyle. In this case study, the patient has a long history of severe pain in the elbow region, suggesting he could be suffering from RCL and LCL. An MRI is necessary for determining whether these symptoms are present in the patient’s arm.

An EMG is another diagnosis I would utilize to determine whether the patient is suffering from a nerve problem that could be causing the pain. Since lateral epicondylitis is characterized by pain when moving the affected part or while performing grip activities, the two requires isometric contraction of the wrist extensor muscles. In Huang and Kim’s (2020) study, the researchers found that analyzing the EMG activities of these muscles during grip activities can be used to determine whether the pain is originating from these muscles based on the relationship between maximal isometric contraction force and grip strength or pain experienced by the patient. Therefore, this diagnosis is important in determining whether the patient has any muscle or nerve problems. 

Causes of Distress when Interacting with the Patient and her Daughter

The daughter was becoming more distressed because she was revealing a lot of personal information about her father’s social and economic status. Based on the information provided by the daughter during the initial contact, it was revealed that the patient was probably an undocumented worker. The daughter was becoming concerned that revealing this kind of information could pose a problem to the patient because the care provider could ask for more information about the initial cause of the pain. For example, suppose the initial cause of the pain was an injury that occurred in the patient’s home country; this information could create a problem for the patient, especially if he does not have health insurance and his employer refuses to pay for the hospital bill. Also, she could be afraid that the healthcare facility will report them to the immigration department.  

Assessing Erythema Signs Found on the Patient’s Skin

Diffuse reflectance spectroscopy (DRS) and hyperspectral imaging (HSI) are the two technological alternatives I would employ to evaluate erythema. According to Bennardo et al. (2021), erythema is an early indicator of tissue injury characterized by skin redness. It is mainly caused by an injury, an inflammation-causing condition, or exposure to high heat. Based on the patient’s occupation, there are high chances that the erythema is caused by a physical injury or exposure to heat. The visual assessment (VA) revealed no evidence of overlying skin lesions, scars, or deformities. Based on this assessment, there are high chances that the patient has erythema ab igne, which is caused by repeated or prolonged exposure to heat (Prohic et al., 2021). The patient’s occupation could have exposed him to heat that caused the erythema.  

DRS and HSI assessments are used to determine the concentration of oxyhemoglobin and deoxyhemoglobin concentrations in patients presenting signs of erythema. Results from these assessments reveal an increasing oxyhemoglobin concentration and unchanging deoxyhemoglobin concentration, which causes the perceived skin appearance (Abdlaty et al., 2019). Suppose these results are found in this patient; it implies that the veins in the affected region are unable to pump blood back to the heart. As a result, the blood pools in the affected region, causing a reddish skin color appearance. This assessment is useful in determining the severity of the erythema. 

Treating Lateral Epicondylitis

Lateral epicondylitis is treated using self-care strategies, anti-inflammatory medications, and splint gadgets. Self-care modalities consist of rest, physiotherapy, compression therapy, and stretching. For example, Ma and Wang (2020) use the name RICE (rest, ice, compression, and elevation) to describe how patients presenting symptoms of lateral epicondylitis can deal with the condition by ensuring that the affected region is getting enough rest, compressed using ice to reduce inflammation and sensations of pain, and stretched to improve flexibility and physical function. Physiotherapy treatment modalities, such as massage and physical exercises, aid in relaxing tense muscles and improving cardiovascular health. Lastly, an elbow splint gadget can be used to stabilize and protect the affected part (Perry et al., 2021). A splint is a rigid accessory that offers additional support and prevents more injuries through immobilization or minimal mobilization of the affected part.   

Ways of Making the Patient Feel Comfortable Staying for Treatment

The best way to convince the patient and his daughter to stay for treatment is by informing them that any information shared with me is confidential and will not be shared with a third party. Since there are high chances that the patient is an undocumented worker, he could be worried that he will be reported to the immigration department. As a care provider, my priority should be providing a hospitable environment for the patient and focusing on alleviating his illness. Assuring the patient that the information shared between him and me will be kept confidential is the best way of achieving this goal.

References

Abdlaty, R., Doerwald, L., Hayward, J., & Fang, Q. (2019). Radiation-therapy-induced erythema: comparison of spectroscopic diffuse reflectance measurements and visual assessment. In Medical Imaging 2019: Image Perception, Observer Performance, and Technology Assessment (Vol. 10952, pp. 106-114). SPIE. https://doi.org/10.1117/12.2506306

Bennardo, L., Passante, M., Cameli, N., Cristaudo, A., Patruno, C., Nisticò, S. P., & Silvestri, M. (2021). Skin Manifestations after Ionizing Radiation Exposure: A Systematic Review. Bioengineering, 8(11), 153. https://doi.org/10.3390/bioengineering8110153

Cha, Y. K., Kim, S. J., Park, N. H., Kim, J. Y., Kim, J. H., & Park, J. Y. (2019). Magnetic resonance imaging of patients with lateral epicondylitis: Relationship between pain and severity of imaging features in elbow joints. Acta Orthopaedica et Traumatologica Turcica, 53(5), 366-371. https://doi.org/10.1016/j.aott.2019.04.006

Huang, T. Z., & Kim, S. Y. (2020). Effect of diamond taping applied to the elbow joint on wrist extensor muscle activity in healthy subjects. Physical Therapy Korea, 27(2), 118-125. https://doi.org/10.12674/ptk.2020.27.2.118

Ikemoto, R. Y., Almeida, L. H. O., Motta, G. G. B., Kim, A. S. M., Lial, C. V. N., & Claros, J. J. (2020). Comparative Study between Scales: Subjective Elbow Value and Patient-rated Tennis Elbow Evaluation Applied to Patients Affected by Lateral Epicondylitis. Revista Brasileira de Ortopedia, 55, 564-569. https://doi.org/10.1055/s-0039-3402465

Ma, K. L., & Wang, H. Q. (2020). Management of lateral epicondylitis: a narrative literature review. Pain Research and Management, 2020. https://doi.org/10.1155/2020/6965381

Perry, D. C., Gibson, P., Roland, D., & Messahel, S. (2021). What level of immobilization is necessary for the treatment of torus (buckle) fractures of the distal radius in children? The Bio-Medical Journal, 372. https://doi.org/10.1136/bmj.m4862

Prohic, A., Poparic, S., Cemerlic, A., & Kapetanovic, A. (2021). Erythema Ab Igne with Histological Features of Keratosis Lichenoides Chronica. Case Reports in Dermatology, 13(1), 184-189. https://doi.org/10.1159/000515259