A woman aged 48 years presented to her primary care physician's office in August 2009 with a several-day history of weakness, paresthesia, and pain bilaterally in her hands. She reported that the pain seemed to develop over a period of a few days and was currently a dull ache that could not be localized to any particular area. She stated that the pain seemed to worsen while handling objects but was not otherwise related to activity. She noted that the paresthesia appeared to be diffuse in nature and not localized to any one finger. She reported no trauma to the affected area, either recently or in her distant past, and she noted no chronic repetitive motions.
The patient's medical history and family history were both significant for hypothyroidism and hypercholesterolemia. Medications used by the patient at the time of presentation were Synthroid (levothyroxine sodium) and simvastatin.
Physical examination revealed the patient to be well-nourished with no signs of physical deformity, trauma, or acute distress. Her vital signs included a body temperature of 97.3 °F (36.3 °C), a blood pressure of 120/84 mm Hg, a pulse of 64 beats per minute, and a respiratory rate of 20 breaths per minute. Results of cardiovascular and pulmonary examinations were within normal limits and without any pertinent findings. Musculoskeletal examination revealed diffusely tender forearms, bilaterally, with 5/5 muscle strength in flexion and extension of the wrist, in grip, in adduction and abduction of the digits, and in opposition of the digits. Radial pulses were measured at 2/4 bilaterally with normal character, rhythm, and rate.
No paresthesia was noted in any dermatome. Ranges of motion were within normal limits in the wrist, elbow, and digits. De Quervain test yielded positive results bilaterally. Both Phalen test and Tinel test had negative results bilaterally. Physical examination and medical history findings for the patient are shown in
Figure 2.
Laboratory tests at a hospital several days before presentation revealed a thyroid-stimulating hormone level of 1.07 mIU per milliliter (normal, 0.5-3 mIU/mL) and a fasting plasma glucose level of 85 mg per deciliter (normal, <110 mg/dL). Previous chemistry panel results showed the following levels: chloride, 109 mEq per liter (normal, 98-107 mEq/L); sodium, 143 mEq/L (normal, 136-145 mEq/L); and potassium, 4.4 mEq/L (normal, 3.5-5.3 mEq/L).
Further history of the patient was obtained from her husband, who revealed that the patient had received a new cellular telephone with a keypad within the previous month. Since then, she had been texting (ie, sending text messages to) her son on a regular basis. After additional questioning, it was discovered that during the past month the patient had sent more than 250 text messages to various family members and friends on her cellular telephone.
A diagnosis of de Quervain tenosynovitis caused by excessive texting was made. The patient was given a prescription for naproxen, a nonsteroidal anti-inflammatory drug, to be taken with food at a dosage of 500 mg twice daily. She was also advised to wear cock-up wrist splints at night and to perform only minimal texting with her cell phone during the next month. Finally, she was told that if the pain persisted, a referral for corticosteroid injections in the wrist would be required.
Three weeks after initiation of treatment, the patient returned to the office with no symptoms. She reported that she had minimized her texting since the previous visit. Repeat physical examination revealed no parasthesia in any dermatome—nor any decreased ranges of motion. De Quervain test results were negative. It was determined at this time that the patient had recovered from her episode of tenosynovitis.