Authors:

Nuray Akkaya, MD
Beril Dogu, MD Ultrasound
Zeliha Ünlü, MD
Alparslan Bayram ÇarlN, MD
Semih Akkaya, MD
Levent Tekin, MD
Levent Özçakar, MD
ORIGINAL RESEARCH ARTICLE
Affiliations:
From the Department of Physical
Medicine and Rehabilitation,
Pamukkale University Medical School, Ultrasonographic Evaluation of the
Denizli (NA); Department of Physical
Medicine and Rehabilitation, S$ is$ li Etfal
Education and Research Hospital,
Flexor Pollicis Longus Tendon in
Istanbul (BD); Department of Physical
Medicine and Rehabilitation, Celal
Frequent Mobile Phone Texters
Bayar University Medical School,
Manisa (ZÜ); Department of Physical
Medicine and Rehabilitation, Gülhane ABSTRACT
Military Medical Academy Haydarpas$ a
Training Hospital, Istanbul (ABÇ, LT); Akkaya N, Dogu B, Ünlü Z, ÇarlN AB, Akkaya S, Tekin L, Özçakar L:
Department of Orthopaedics and Ultrasonographic evaluation of the flexor pollicis longus tendon in frequent
Traumatology, Pamukkale University
mobile phone texters. Am J Phys Med Rehabil 2015;94:444Y448.
Medical School, Denizli (SA); and
Department of Physical Medicine and Objective: The aim of this study was to assess flexor pollicis longus tendon by
Rehabilitation, Hacettepe University
Medical School, Ankara, Turkey (LÖ). using ultrasound imaging in frequent mobile phone texters.
Subjects: In total, 149 subjects, aged 18Y40 yrs, were recruited as frequent
Correspondence: mobile phone texters (n = 71) and infrequent texters (n = 78).
All correspondence and requests for
reprints should be addressed to: Methods: Demographic data and estimate frequency of texting were noted.
Levent Tekin, MD, GATA Haydarpas$ a Thumb pain during activity, range of motion for thumb joints, grip and pinch strengths,
Eğitim Hastanesi, Fiziksel TNp ve
Rehabilitasyon Kliniği, and Quick Disabilities of arm, shoulder, and hand were evaluated. Standardized
Istanbul, Turkey 34668. bilateral ultrasound evaluations were performed using a linear array probe, and tendon
area measurements were done with axial imaging at midthenar region and midproximal
Disclosures: phalangeal region with manual trace technique.
Financial disclosure statements have
been obtained, and no conflicts of Results: The groups were similar except for the mean estimate number of
interest have been reported by the messages/month (P = 0.001). Whereas grip and pinch strength values were
author or by any individuals in control
of the content of this article. significantly higher (frequent texter group, P = 0.001; infrequent texter group, grip
strength P = 0.018; pinch strengths, P = 0.001) on the texting side in both
groups, flexor pollicis longus tendons were larger (P = 0.001) and the activity pain
0894-9115/15/9406-0444
was higher (P = 0.005) on the texting sides only in the frequent texter group.
American Journal of Physical
Medicine & Rehabilitation Flexor pollicis longus thickness significantly correlated with messages/month only
Copyright * 2014 Wolters Kluwer in the frequent texter group (r = 0.592, P = 0.001).
Health, Inc. All rights reserved.
Conclusions: Flexor pollicis longus tendons seem to be thicker at the
DOI: 10.1097/PHM.0000000000000186 midthenar level in subjects who frequently use mobile phone texting. Because this
increase in thickness parallels the number of messages per day, the authors believe
that further studies are needed to elucidate whether such changes become
problematic later on in life.
Key Words: Mobile Phone, Message Texting, Flexor Pollicis Longus, Ultrasound

444 Am. J. Phys. Med. Rehabil. & Vol. 94, No. 6, June 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

T endons that are exposed to overloading with
repeated joint movements may undergo adaptation
Range of motion (flexion/extension) for the meta-
carpohalangeal and interphalangeal joints of the
dominant and nondominant thumbs was measured
and constitutional changes.1 Likewise, tendon over- with a hand goniometer and total active movement
use injuries related to recreational and occupational was recorded for each.
activities are seen frequently and have been widely Grip strength was assessed using a Jamar dy-
investigated.2 The relevant literature comprises stud- namometer (kilograms), and pinch strengths (lateral,
ies pertaining to the tendinopathies of the rotator tip-to-tip, and chuck pinch) were assessed using a
cuff, flexor/extensor tendons around the elbow, and Jamar pinch meter (pounds). The measurements were
patellar and Achilles tendons.1,3Y11 Although changes performed in a standard manner and the mean of
in the finger flexor tendons of Olympic archers have three measurements was taken.13
been assessed in a recent study,12 overuse injuries Functional assessment of the upper extremity
of the small tendons have not been studied fre- was evaluated with the Quick Disabilities of arm,
quently. Therefore, in this study, the aim was to ex- shoulder, and hand, consisting of 11 questions,
plore whether the flexor tendon of the thumb is where higher scores indicated worse function.14
affected in frequent mobile phone texters. Yet, texting
is a very common condition among young people, Ultrasonographic Evaluation
and, to the authors’ best notice, studies concerning
Standardized bilateral ultrasound evaluations
the unfavorable effects of mobile phone using has
were performed using a linear array probe while sub-
been confined mainly to radiation and brain tumors.
jects were in a sitting position and hands placed on
Herein, ultrasound (US) was used as the prompt/
the examination table in supination. Because re-
convenient method for flexor pollicis longus (FPL)
peated flexion motion of the thumb was one of the
tendon imaging.
major components of the texting style, ultrasono-
graphic evaluation of the FPL tendon was performed.
METHODS
In longitudinal view, the FPL tendon was followed
Subjects from the wrist to its distal insertion (the base of
This study was performed between January and the distal phalanx) for any tendon pathology both
March 2013 in five physical medicine and rehabilita- with static and dynamic imaging (passive flexion/
tion departments (four tertiary care university hospi- extension).15 In the presence/suspicion of tenosyno-
tals and one secondary care training hospitals). In vitis, Doppler imaging was also performed according
total, 149 subjects from the normal population, aged to European League Against Rheumatism recommen-
18Y40 yrs, were recruited, and 71 were enrolled as dations.16 Thereafter, tendon measurements were
frequent mobile phone texters (sending at least 10 done with axial imaging at midpoint between the first
messages per day for at least 3 yrs) and 78 as infre- carpometacarpal and metacarpophalangeal joints and
quent texters (sending less than 10 messages per day at midpoint between the first metacarpophalangeal
for at least 3 yrs). The texting style of cases was re- and interpahalangeal joints with manual trace tech-
peated flexion movements of the interphalangeal joint nique (Fig. 1). All acquired images were also evalu-
of the thumb. Presence of any of the following in the ated eventually by a senior physiatrist sonographer
hand/upper extremity of the subjects was taken as ex- (LÖ, with a background of 910 yrs in musculoskeletal
clusion criteria: previous fracture, nerve/vessel/tendon ultrasound).
injury, and rheumatic disease. The study protocol
was approved by the local ethical committee of one Statistical Analyses
of the centers, and written informed consent was ob- Statistical analyses were performed using SPSS
tained from each participant. 17.0 software. Descriptive statistics were used for
Age, gender, and dominant/nondominant/texting numeric demographical data, and frequency analy-
hands were recorded. Estimated number of messages sis, for categorical data. Group comparisons were
per day and duration of mobile phone use (texting) done with Student’s t and W2 tests, where appro-
were also noted. priate. Paired t test was used for comparison of the
two thumbs of the subjects. FPL area ratio was cal-
Functional Assessment culated as follows: (texting side j contralateral side) /
Thumb pain during activity was evaluated bi- contralateral side  100). Correlations between
laterally with a 10-cm visual analog scale, where FPL ratio and number of message/month for each
0 indicates no pain and 10 indicates severe pain. group were analyzed by using Pearson correlation

www.ajpmr.com Evaluation of Tendon in Texters 445

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 FIGURE 1 Ultrasonography demonstrates the longitudinal view (white arrowheads) (A) and the axial view (white
arrow) (B) of the FPL tendon at midpoint between the first carpometacarpal and metacarpophalangeal
joints.

coefficients. P values less than 0.05 were considered ratio significantly correlated with messages per month
significant. only in the frequent texter group (r = 0.592, P =
0.001). Tendon pathology during B-mode and Doppler
imaging was not detected.
RESULTS
Demographic data of the subjects (63 men, 86
women) are summarized in Table 1. The groups DISCUSSION
were similar except for the mean estimate number This study’s results suggest that repetitive thumb
of messages per month (1208.5 T 693.4 vs. 50.2 T movements may cause FPL tendon thickening in
46.4, P = 0.001). Dominant hand, texting hand side, frequent mobile phone texters and that this thick-
and occupations were similar between groups (P = ening is positively correlated with the number of
0.880). There were no limitations with regard to the messages per month.
thumb range of motions in either group. Most of the studies exploring the unfavorable
While grip and pinch strength values were sig- effects of mobile phone use have focused on the
nificantly higher on the texting side in both groups; effects of radiation on head and neck regions, and
FPL tendons were larger and the activity visual ana- the pertinent consequences are well known.17Y20
log scale was higher on the texting sides only in the On the other hand, despite the fact that texting via
frequent texter group (Tables 2 and 3). Similarly, FPL mobile phones has become widespread especially

TABLE 1 Demographics of the subjects

Frequent Texters (n = 71) Infrequent Texters (n = 78) P
Age, yrs 26.8 T 4.7 28.4 T 5.7 0.070
Body mass index, kg/m2 22.8 T 2.9 23.0 T 2.6 0.658
Smoking, pocket/yr 1.5 T 3.9 1.8 T 4.9 0.674
Estimate message/month 1208.5 T 693.4 50.2 T 46.4 0.001a
Male 31 (43.7) 32 (41.0) 0.745
Female 40 (56.3) 46 (59.0)
Right-hand dominant 68 (95.8) 72 (92.3) 0.375
Left-hand dominant 3 (4.2) 6 (7.7)
Right-hand texting 66 (93.0) 72 (92.3) 0.880
Left-hand texting 5 (7.0) 6 (7.7)
Occupation
Unemployed 2 (2.8) 2 (2.6) 0.415
Housewife 2 (2.8) 8 (10.3)
Employee 7 (9.9) 5 (6.4)
Official 24 (33.8) 28 (35.9)
Student 36 (50.7) 35 (44.8)
Data are presented as mean T SD or n (%).

446 Akkaya et al. Am. J. Phys. Med. Rehabil. & Vol. 94, No. 6, June 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 TABLE 2 Comparison of the data in the frequent texter group
Texting Side Contralateral Side P
Activity VAS 0.3 T 0.9 0.01 T 0.1 0.005a
Total active thumb motion 157.3 T 4.9 157.8 T 4.4 0.089
Lateral pinch, lb 12.9 T 5.0 12.0 T 4.9 0.001a
Chuck pinch, lb 11.8 T 4.4 11.1 T 4.3 0.001a
Tip-to-tip pinch, lb 9.6 T 4.1 8.9 T 3.9 0.001a
Grip strength, kg 30.9 T 10.7 29.4 T 10.7 0.001a
Thenar FPL area, cm2 0.087 T 0.02 0.082 T 0.02 0.001a
Phalangeal FPL area, cm2 0.085 T 0.02 0.082 T 0.03 0.242
Data are presented as mean T SD.
a
Statistically significant.
VAS indicates visual analog scale.

among young people, its possible impact on hand the absence of any tendon pathology and because the
structure/functions has not attracted much atten- upper extremity functions were indifferent, its clini-
tion. However, it may well be considered a potential cal relevance remains unclear.
overuse syndrome. Tendons, when exposed to repe- One major limitation of this study is the lack
titive overload, are capable of undergoing structural of precise comparison between the texting styles of
changes. In general, whereas enlargement may ensue the subjects. The estimate number of messages per
because of edema/inflammation in the acute phases month was taken into account; however, the length
of tendon injuries, thickening of the tendons can of the messages was not considered, which can ac-
also be seen in the long-term.21 In animal studies, tually impact the amount of overload on the FPL.
exercise-induced hypertrophy of the flexor digitorum This could have been overcome, perhaps, with the
superficialis and extensor digitorum communis ten- inclusion of time spent for daily texting as well.
dons has been reported.22 Similarly, in a recent study, To summarize, in light of this study’s first and
hypertrophy of the fourth finger flexor digitorum preliminary findings, it is implied that FPL ten-
profundus tendons has been shown on the string dons seem to be thicker at midthenar level in sub-
hands of asymptomatic Olympic archers.12 In line jects who frequently use mobile phone texting.
with these studies, this study’s results indicate a hy- Drawing attention to the fact that this increase in
pertrophy in the FPL tendons of frequent mobile thickness parallels the number of messages/day,
phone texters, to the authors’ best notice, for the first the authors believe that further studies are needed
time in the literature. Furthermore, the positive to elucidate the functional relevance of this thick-
correlation between tendon thickening and the esti- ening and its probable reflection on future struc-
mate overload is also in accordance with the hitherto tural injury. However, the use of mobile phone
literature.21 In the frequent texter group, activity pain texting still remains to be noteworthy issue among
was higher on the texting side; however, because of young people.

TABLE 3 Comparison of the data in the infrequent texter group

Texting Side Contralateral Side P
Activity VAS 0.08 T 0.4 0.01 T 0.01 0.109
Total active thumb motion 158.1 T 4.9 157.9 T 5.1 0.159
Lateral pinch, lb 12.8 T 5.5 11.9 T 5.3 0.001a
Chuck pich, lb 12.04 T 4.8 11.4 T 4.7 0.001a
Tip-to-tip pinch, lb 9.9 T 4.7 9.0 T 4.4 0.001a
Grip strength, kg 30.9 T 11.3 29.7 T 11.8 0.018a
Thenar FPL area, cm2 0.092 T 0.02 0.089 T 0.02 0.084
Phalangeal FPL area, cm2 0.084 T 0.02 0.084 T 0.02 0.881
Data are presented as mean T SD.
a
Statistically significant.
VAS indicates visual analog scale.

www.ajpmr.com Evaluation of Tendon in Texters 447

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 REFERENCES 13. Aulicino PL: Clinical examination of the hand, in:
1. Wilson JJ, Best TM: Common overuse tendon prob- Hunter M (ed): Rehabilitation of the Hand and Upper
lems: A review and recommendations for treatment. Extremity. Missouri, Mosby, 2002, pp 120Y42
Am Fam Physician 2005;72:811Y8 14. URL: http://www.dash.iwh.on.ca/system/files/translations/
2. Woodwell DA, Cherry DK: National Ambulatory Medical DASH_Turkish_2012.pdf
Care Survey: 2002 summary. Adv Data 2004;346:1Y44 15. Leuven ALB, Göttingen MK, Heidelberg KS: Upper
3. Gold RH, Seeger LL, Yao L: Imaging shoulder im- limb, hand, in: Bianchi S, Martinoli C (eds): Ultrasound
pingement. Skeletal Radiol 1993;22:555Y61 of the Musculoskeletal System. Berlin, Springer-Verlag,
2007, pp. 495Y549
4. Paavolainen P, Ahovuo J: Ultrasonography and ar-
thrography in the diagnosis of tears of the rotator 16. Backhaus M, Ohrndorf S, Kellner H, et al: Evalua-
cuff. J Bone Joint Surg Am 1994;76:335Y40 tion of a novel 7-joint ultrasound score in daily rheu-
matologic practice: A pilot project. Arthritis Rheum
5. Drakeford MK, Quinn MJ, Simpson SL, et al: A com- 2009;61:1194Y201
parative study of ultrasonography and arthrography
in the evaluation of the rotator cuff. Clin Orthop Relat 17. D’Costa H, Trueman G, Tang L, et al: Human brain
Res 1990;253:118Y22 wave activity during exposure to radiofrequency field
emissions from mobile phones. Australas Phys Eng
6. Beltran J: The use of magnetic resonance imaging about Sci Med 2003;26:162Y7
the shoulder. J Shoulder Elbow Surg 1992;1:321Y2
18. Hamblin DL, Wood AW: Effects of mobile phone emis-
7. Fritschy D, de Gautard R: Jumper’s knee and ultra- sions on human brain activity and sleep variables. Int
sonography. Am J Sports Med 1988;16:637Y40 J Radiat Biol 2002;78:659Y69
8. Khan KM, Bonar F, Desmond PM, et al: Patellar 19. Haarala C, Bergman M, Laine M, et al: Electro-
tendinosis (jumper’s knee): Findings at histopathologic magnetic field emitted by 902 MHz mobile phones
examination, US, and MR imaging. Victorian Institute of shows no effects on children’s cognitive function.
Sport Tendon Study Group. Radiology 1996;200:821Y7 Bioelectromagnetics 2005;144Y50
9. Davies SG, Baudouin CJ, King JB, et al: Ultrasound, 20. Preece AW, Goodfellow S, Wright MG, et al: Effect of
computed tomography, and magnetic resonance im- 902 MHz mobile phone transmission on cognitive
aging in patellar tendinitis. Clin Radiol 1991;43:52Y6 function in children. Bioelectromagnetics 2005;26:
10. Miller TT: Imaging of elbow disorders. Orthop Clin 138Y43
North Am 1999;30:21Y36 21. van Drongelen S, Boninger ML, Impink BG, et al:
11. Neuhold A, Stiskal M, Kainberger F, et al: Degener- Ultrasound imaging of acute biceps tendon changes
ative Achilles tendon disease: Assessment by mag- after wheelchair sports. Arch Phys Med Rehabil 2007;
netic resonance and ultrasonography. Eur J Radiol 88:381Y5
1992;14:213Y20 22. Kasashima Y, Smith RK, Birch HL, et al: Exercise-
12. Kaymak B, Özçakar L, Ertan H, et al: Sonographic induced tendon hypertrophy: Cross-sectional area
assessment of finger flexor tendons in Olympic ar- changes during growth are influenced by exercise.
chers. Turk J Phys Med Rehabil 2012;58:85Y7 Equine Vet J Suppl 2002:264Y8

448 Akkaya et al. Am. J. Phys. Med. Rehabil. & Vol. 94, No. 6, June 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.