Chronic Tendinopathy Recovery Insights With Regenerative Orthopedics

Unlock the benefits of regenerative orthopedics in treating chronic tendinopathy. Improve your healing journey with new insights.

Abstract

This educational post explores the advanced therapeutic technique of ultrasound-guided needle fenestration, a powerful procedure for managing chronic tendinopathies such as tennis elbow, Achilles tendinosis, and patellar tendon issues. From my perspective as an integrative practitioner, I will guide you through the “why” and “how” of this minimally invasive technique. We will delve into the underlying physiological principles, explaining how fenestration aims to convert a chronic, degenerative condition into an acute, healing one by stimulating a controlled inflammatory and regenerative response. I will discuss the latest findings from leading researchers, detailing the evidence-based methodology, the role of ultrasound guidance in ensuring precision and safety, and how this procedure is often combined with regenerative injectables like prolotherapy (dextrose) and platelet-rich plasma (PRP). Furthermore, I will explain how needle fenestration fits seamlessly into our multidisciplinary model at Injury Medical Clinic PA. This model integrates my expertise in chiropractic care, functional medicine, and advanced practice nursing with essential medical oversight from our Medical Director, Dr. Maria Guadalupe Cardenas, MD. Together, we create a comprehensive treatment plan that addresses not just the localized tendon injury but also the biomechanical dysfunctions and systemic factors contributing to it, ensuring a holistic and effective journey toward healing and recovery.

A Message from Dr. Alex Jimenez

Hello, and welcome. As a practitioner dedicated to finding the most effective and least invasive solutions for my patients, I am continually exploring advanced techniques grounded in solid scientific evidence. Today, I want to share my insights on a procedure that has become an invaluable tool in my practice for treating chronic tendon pain: ultrasound-guided needle fenestration. My extensive training across multiple disciplines—from chiropractic (DC) and advanced practice nursing (APRN, FNP-BC) to functional and integrative medicine (CFMP, IFMCP)—has instilled in me a deep appreciation for a holistic, patient-centered approach. This philosophy shapes every aspect of our practice here at Injury Medical Clinic PA in El Paso, Texas.

I believe in building bridges between different fields of medicine to deliver the best possible outcomes. This is why I am so proud of our collaborative clinical model. I work hand in hand with Dr. Maria Guadalupe Cardenas, MD, a highly respected, board-certified internist with over 40 years of experience. Dr. Cardenas serves as our Medical Director and Collaborative Physician, providing crucial medical oversight and diagnostic expertise that complements my work in chiropractic, functional medicine, and rehabilitation. Our multidisciplinary setup allows us to offer a truly integrated suite of services, including advanced procedures like needle fenestration, personal injury care, and comprehensive rehabilitation programs, all under one roof.

In this post, I will take you on an in-depth journey into the world of needle fenestration. We will move beyond a simple definition and explore the intricate physiological mechanisms that make it so effective. We will look at how modern technology, specifically musculoskeletal ultrasound, has transformed this procedure from a “blind” technique into a precise, targeted intervention. You will see how we use it to restart the body’s natural healing engine, and how it aligns perfectly with the principles of integrative and regenerative medicine. My goal is to demystify this procedure and empower you with knowledge, showing you how we leverage cutting-edge, evidence-based methods to help you overcome chronic pain and get back to living your life to the fullest.

Understanding Chronic Tendinopathy: When Healing Stalls

Before we can appreciate the elegance of needle fenestration, we must first understand the problem it is designed to solve: chronic tendinopathy. For decades, we used the term “tendinitis,” which implies inflammation (the “-itis” suffix). However, as our understanding has evolved through microscopic analysis of damaged tendon tissue, we have learned that in chronic cases, inflammation is often notably absent. Instead, what we typically see is a state of degeneration.

This condition is more accurately termed tendinosis. It is characterized by a disorganized, dysfunctional, and weakened tendon structure. Let’s break down what is happening at the cellular and structural level:

• Collagen Disarray: A healthy tendon is a marvel of biological engineering, composed of tightly packed, parallel bundles of Type I collagen fibers. This highly organized structure gives the tendon its incredible tensile strength, allowing it to transmit forces from muscle to bone efficiently. In tendinosis, this beautiful architecture is lost. The collagen fibers become thin, fragmented, and haphazardly arranged. There is also an increase in the weaker Type III collagen, which is more characteristic of early scar tissue rather than mature, strong tendon tissue.
• Cellular Changes: Fibroblasts within the tendon, called tenocytes, become abnormal. They are more rounded and less organized, and they fail to produce and maintain healthy collagen.
• Neovascularization and Neoinnervation: Researchers have observed the ingrowth of new, disorganized blood vessels (neovascularization) and accompanying nerve fibers (neoinnervation) into the damaged tendon area. While this might sound like a good thing, these new vessels are often leaky and dysfunctional. More importantly, the new nerve fibers are believed to be a primary source of the persistent, localized pain that patients with chronic tendinopathy experience.
• Biochemical Imbalance: The tendon’s biochemical environment is altered. Degenerative enzymes like matrix metalloproteinases (MMPs) increase, breaking down the collagen matrix, while their inhibitors decrease. There is also a notable lack of the pro-inflammatory and growth factors needed to kickstart a proper healing cascade.

Essentially, the tendon gets “stuck” in a failed healing cycle. The initial injury may have had an inflammatory phase, but it never successfully transitioned to the proliferation and remodeling phases of healing. The body’s repair mechanisms have shut down, leaving a weakened, painful, and dysfunctional tendon that is susceptible to further injury. This is why simply resting the tendon often fails to resolve the problem; the tissue lacks the biological signals and cellular machinery to repair itself.

This is where regenerative medicine, and specifically needle fenestration, comes into play. The core strategy is to wake up the body’s dormant healing systems.

Needle Fenestration: Rebooting the Body’s Natural Healing Cascade

Needle fenestration, also known as percutaneous needle tenotomy (PNT), is a minimally invasive procedure designed to do exactly what its name implies. “Fenestration” comes from the Latin word fenestra, meaning “window.” In this context, we use a fine needle to create multiple tiny “windows” or perforations in the diseased portion of the tendon.

It is critically important to distinguish this from simply injecting a substance. While fenestration is often performed in conjunction with an injection (which we will discuss later), the mechanical action of the needling itself is the primary therapeutic event. The fundamental goal is simple yet profound: to convert a chronic, degenerative, and stagnant condition into an acute, inflammatory, and active healing process.

Let’s explore the theory behind how this works, drawing from extensive research in the field (McShane, Nazarian, & Harwood, 2006).

The Physiological Rationale: From Degeneration to Regeneration

By repeatedly passing a needle through the tendinosis area, we intentionally create a controlled micro-injury. This act disrupts the cycle of failed healing and triggers a cascade of biological events that mimic the body’s natural response to an acute injury. Here is a step-by-step breakdown of the intended physiological response:

1. Mechanical Disruption: The first and most immediate effect is the physical breakdown of the abnormal, fibrotic, and disorganized tissue. As the needle passes through the degenerated tendon, it feels “gritty” or “tough.” As the procedure continues, clinicians often report that the tissue “softens,” indicating that the dense, dysfunctional scar tissue is being mechanically broken up. This clears the way for new, healthy tissue to form.
2. Initiating a Controlled Bleed: The needle perforations cause localized micro-bleeding within the tendon. This is not a complication; it is a desired outcome. Blood is the river of life, carrying all the essential components for healing. This small, contained hematoma is rich in platelets.
3. Triggering the Inflammatory Cascade: When platelets are activated at the injury site, they degranulate and release a powerful cocktail of growth factors and cytokines. These chemical messengers orchestrate the entire healing process. Key players include:

• • Platelet-Derived Growth Factor (PDGF): Attracts immune cells and fibroblasts to the area and stimulates cell division.
  • Transforming Growth Factor-Beta (TGF-?): A crucial regulator of collagen synthesis, encouraging fibroblasts to produce new, healthy Type I collagen.
  • Vascular Endothelial Growth Factor (VEGF): Promotes the formation of new, healthy blood vessels (angiogenesis) to supply the healing tissue with oxygen and nutrients.
  • Fibroblast Growth Factor (FGF): Stimulates the proliferation of tenocytes, the cells responsible for building the tendon matrix.

• Recruitment of Healing Cells: These growth factors act as a “911 call” to the body’s repair crews. They attract macrophages (which clean up cellular debris and dead tissue), fibroblasts, and tenocytes to the site of injury. This influx of cells marks the beginning of the proliferative phase of healing.
• Stimulating Proliferation and Remodeling: Over the following weeks and months, the recruited fibroblasts and tenocytes get to work. They begin to lay down a new extracellular matrix, primarily composed of the strong, organized Type I collagen. This new tissue then undergoes a lengthy remodeling phase, where it gradually matures, aligns along the lines of stress, and regains its tensile strength. This is where integrative chiropractic care becomes indispensable, as controlled loading and specific rehabilitation exercises are essential to guide this remodeling process correctly.

In essence, needle fenestration is a biological “reset button.” We are telling the body, “You missed a spot. Let’s go back and heal this area properly this time.” We provide the initial mechanical and biological stimulus, and then we guide the body’s powerful, innate healing intelligence to complete the job.

The Indispensable Role of Ultrasound Guidance

In the past, similar procedures were performed “blind,” meaning the practitioner relied solely on anatomical landmarks to guide the needle. This approach was fraught with uncertainty and risk. The advent of high-resolution musculoskeletal (MSK) ultrasound has revolutionized needle fenestration, elevating it to a new standard of care (Jacobson, 2013).

At Injury Medical Clinic PA, we perform every fenestration procedure under direct, real-time ultrasound guidance. This is non-negotiable for ensuring safety, precision, and efficacy. Here’s why it is so critical:

1. Precise Diagnosis and Target Identification

Ultrasound allows us to see the pathology with incredible clarity before the needle ever touches the skin. A healthy tendon appears on the ultrasound screen as a bright (hyperechoic), fibrillar structure with tightly packed, parallel fibers. In contrast, an area of tendinosis typically presents as:

• Hypoechoic: Darker or black on the screen, indicating disorganized, edematous, or degenerated tissue.
• Thickened: The tendon is often visibly swollen compared to the healthy portion or the contralateral side.
• Loss of Fibrillar Pattern: The clean, parallel lines of the collagen fibers are lost and replaced by a chaotic, muddled appearance.
• Doppler Signal: Using Power Doppler ultrasound, we can often detect the neovascularization (the ingrowth of new blood vessels) mentioned earlier, which correlates with the area of pain.

This detailed imaging allows me to map out the exact three-dimensional extent of the tendinopathy. I know precisely where the disease begins and ends, which is the exact area I need to target with the needle.

2. Enhancing Safety and Avoiding Critical Structures

Tendons are surrounded by vital structures: nerves, major blood vessels, and joint capsules. Performing a blind procedure, especially in anatomically complex areas like the elbow, ankle, or shoulder, carries a significant risk of inadvertently damaging these structures.

Ultrasound provides a live, dynamic road map. I can visualize the entire path of my needle from the moment it enters the skin to the moment it reaches the target. I can see its relationship to nearby nerves (like the radial nerve near the lateral elbow) and arteries, allowing me to navigate around them with millimeter precision. This dramatically increases safety and minimizes patient discomfort and potential complications.

3. Ensuring Comprehensive Treatment of the Pathological Tissue

The goal of fenestration is to treat the entire area of tendinosis. Ultrasound allows me to ensure this is accomplished. I can guide the needle tip systematically throughout the hypoechoic region. I can see if I have covered the area from top to bottom (superficial to deep) and from side to side (medial to lateral).

• In-Plane Approach: Typically, I use an “in-plane” technique, where the needle is inserted along the long axis of the ultrasound transducer. This allows me to see the entire shaft and tip of the needle at all times, ensuring I am at the correct depth.
• Multi-Planar Assessment: After treating the tendon in its long axis, I can turn the transducer 90 degrees to view the tendon in its short axis (cross-section). This allows me to confirm that I have treated the full medial-to-lateral extent of the pathology and make any necessary adjustments.

This real-time feedback is invaluable. It removes the guesswork and ensures that the therapeutic stimulus is delivered exactly where it is needed most.

4. Observing Real-Time Tissue Response

As I perform the fenestration, I can watch the tissue’s response on the ultrasound screen. I can see the needle disrupting the degenerated tissue. I can often observe subtle changes in the tendon’s echotexture as the procedure progresses. This visual feedback, combined with the tactile sensation of the needle passing through the tissue (the “softening” effect), helps me determine when the treatment is complete. Research and clinical experience suggest that the procedure can be terminated when the entire area of tendinosis has been thoroughly treated and feels soft during needle advancement (Krey, T., & T. Krey, 2021).

The Fenestration Procedure: A Step-by-Step Walkthrough

To give you a clearer picture, let me walk you through what a patient experiences when they come to our clinic for a needle fenestration procedure, for example, to treat lateral epicondylosis, commonly known as tennis elbow. This condition involves tendinosis of the common extensor tendon, particularly the extensor carpi radialis brevis (ECRB) tendon.

Step 1: Pre-Procedure Assessment and Informed Consent

The journey begins with a thorough evaluation, including a detailed history, physical examination, and a diagnostic ultrasound scan to confirm the diagnosis and pinpoint the area of tendinosis. I discuss the findings with the patient, explain the fenestration procedure in detail, outline the potential benefits and risks, and answer all of their questions. We also discuss the post-procedure care plan, which is crucial for a successful outcome.

Step 2: Patient Positioning and Sterile Preparation

The patient is positioned comfortably, typically sitting or lying down, to allow optimal access to the elbow. The area is then meticulously cleaned with an antiseptic solution such as chlorhexidine or Betadine to create a sterile field and minimize infection risk. I place a sterile drape over the area and use a sterile probe cover and sterile gel for the ultrasound transducer.

Step 3: Local Anesthesia

Patient comfort is a top priority. I use a very fine-gauge needle (e.g., a 27-gauge) to administer a local anesthetic, typically 1% lidocaine without epinephrine, to numb the skin and the path the treatment needle will take. I carefully inject the anesthetic into the subcutaneous tissue above the tendon. Still, I try to avoid injecting it directly into the tendon itself, as some studies suggest that local anesthetics can have a temporary toxic effect on tenocytes. The goal is to make the procedure as comfortable as possible while preserving the integrity of the target tissue. We often use a vapocoolant spray on the skin just before the initial needle insertion, which provides a brief but intense cooling sensation that distracts from the prick of the needle.

Step 4: The Fenestration Technique

Once the area is numb, the main procedure begins.

1. Needle Selection: I typically select a 22-gauge or 25-gauge needle, which is robust enough to penetrate the tough, degenerated tendon tissue without bending.
2. Ultrasound-Guided Insertion: Using the in-plane, long-axis approach I described earlier, I introduce the needle through the anesthetized skin. I watch the ultrasound screen intently to track the hyperechoic (bright) needle as it advances through the subcutaneous tissue.
3. Entering the Target Zone: I carefully guide the needle tip until it enters the hypoechoic, diseased portion of the ECRB tendon. The visual contrast between the bright needle and the dark, pathological tendon is usually very clear.
4. Systematic Perforation: Now, the core of the procedure begins. I start to systematically “pepper” the tendinosis area. This involves a repetitive motion of advancing the needle a short distance, partially withdrawing it, and then re-advancing it at a slightly different angle or depth. The goal is to make numerous passes—often between 15 and 50, depending on the size of the lesion—throughout the entire pathological zone. I methodically work my way from deep to superficial and from one side to the other, ensuring complete coverage.
5. Tactile and Visual Feedback: Throughout this process, I pay close attention to both the feel of the needle (tactile feedback) and the image on the ultrasound screen. Initially, the tissue feels dense and resistant. As I continue the fenestration, this resistance typically lessens, a sign that the fibrotic adhesions are being broken down.
6. Cross-Sectional Check: Once I feel I have adequately covered the area in the long axis, I will often rotate the ultrasound transducer 90 degrees into a short-axis view to confirm that the treatment has spanned the full width of the tendinosis.

Step 5: Combining with a Regenerative Injectate (Optional but Common)

While fenestration is a powerful standalone procedure, its effects can often be enhanced by combining it with a regenerative injection. The perforations created by the needle serve as perfect channels to deliver a healing substance directly into the core of the damaged tissue. This is a common practice in my clinic, guided by the principles of functional and regenerative medicine.

Two of the most common injectates we use are:

• Prolotherapy (Dextrose): This is a cornerstone of regenerative injection therapy. We inject a hypertonic dextrose solution (a type of sugar), typically at a concentration of 15% to 25%. This hyperosmolar solution acts as a mild irritant. It is thought to cause cellular dehydration, which in turn triggers a localized inflammatory and healing response, much like the needling itself. The dextrose provides an additional, powerful chemical signal that recruits growth factors and stimulates tissue repair (Reeves, K. D., & Topol, G. A., 2011). It is safe, effective, and has been used for decades to treat ligament and tendon laxity and pain. When combined with fenestration, it provides a “one-two punch” of mechanical and chemical stimulation.
• Platelet-Rich Plasma (PRP): For more severe or stubborn cases of tendinopathy, we may opt for PRP. This involves drawing a small amount of the patient’s blood, centrifuging it to separate the components, and extracting a small volume of plasma highly concentrated with platelets (often 5-10 times the concentration of normal blood). This platelet concentrate, a powerhouse of the growth factors we are trying to stimulate, is then injected into the fenestrated area. This essentially supercharges the healing response by delivering an overwhelming dose of the body’s own regenerative signals directly to the site of injury (Mishra & Pavelko, 2006).

After completing the fenestration, I inject the chosen proliferant (dextrose or PRP) throughout the treated area, using the ultrasound to ensure it is distributed evenly within the tendinosis.

Step 6: Post-Procedure Care and Rehabilitation

The procedure itself is only the beginning of the healing journey. What happens next is just as important.

• Immediate Post-Care: We apply a simple bandage to the injection site. I advise patients to avoid anti-inflammatory medications (like ibuprofen, naproxen, or high-dose aspirin) for at least a week, and preferably longer. The inflammatory response we have just worked so hard to create is essential for healing, and we do not want to blunt it with medications. Mild discomfort can be managed with acetaminophen (Tylenol), ice (used sparingly), and relative rest for the first few days.
• The Crucial Role of Rehabilitation: This is where our integrative model truly shines. After a short period of rest (2-3 days), we begin a carefully structured rehabilitation program. This is not just generic physical therapy; it is a highly specific plan designed to work in synergy with the biological healing process we have initiated. This is where my expertise as a chiropractor and my team’s rehabilitation skills come into play. The program typically involves:

• • Gentle Range of Motion: To prevent stiffness.
  • Progressive Eccentric Loading: One of the most evidence-based therapeutic exercises for tendinopathy. Eccentric exercises involve lengthening the muscle-tendon unit while it is under tension (e.g., slowly lowering a weight). This specific type of loading has been shown to stimulate collagen production and promote proper fiber alignment, effectively remodeling the new tissue into a strong, functional tendon (Alfredson, Pietilä, Jonsson, & Lorentzon, 1998).
  • Chiropractic Adjustments: We assess and address any related biomechanical dysfunctions. For tennis elbow, this might involve examining and adjusting the wrist, shoulder, and even the cervical and thoracic spine. A misaligned kinetic chain can create abnormal stress on the elbow, and if this underlying cause is not corrected, the tendinopathy is likely to recur.
  • Functional Medicine Assessment: We look at the bigger picture. Is there a systemic issue contributing to poor tissue healing? We might investigate nutritional deficiencies (e.g., Vitamin C, zinc, protein), systemic inflammation, or metabolic issues like insulin resistance, all of which can impair the body’s ability to repair itself.

This comprehensive, multifaceted approach ensures that we are not just treating the painful spot on the tendon. We treat the entire patient, addressing the local pathology, biomechanical contributing factors, and systemic environment to create the optimal conditions for full, lasting recovery.

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The Power of Integration: The Injury Medical Clinic PA Model

The success of a procedure like needle fenestration is magnified when it is part of a cohesive, integrated treatment plan. This is the core philosophy of our practice at Injury Medical Clinic PA, built on the collaborative synergy between myself and our Medical Director, Dr. Maria Cardenas.

A Multidisciplinary Team

• Alex Jimenez (DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST): My role is multifaceted. As a Doctor of Chiropractic, I focus on musculoskeletal biomechanics, identifying and correcting structural imbalances that often underlie chronic injuries. As a board-certified Family Nurse Practitioner (FNP-BC), I am qualified to perform advanced procedures like ultrasound-guided injections and manage the patient’s overall care. My certifications in Functional and Integrative Medicine (CFMP, IFMCP) allow me to dig deeper into the systemic and metabolic factors that influence health and healing.
• Maria Guadalupe Cardenas (MD, Board Certified Internal Medicine): Dr. Cardenas brings the invaluable perspective of an experienced internist. She provides essential medical oversight for our entire practice. Her role includes reviewing complex cases, clearing patients for procedures, managing coexisting medical conditions (like diabetes or hypertension) that could affect treatment, and providing a diagnostic safety net. This collaborative relationship ensures we practice to the highest standard of care, blending the best of conventional and integrative medicine.

How Our Integrated Approach Benefits the Patient

Let’s return to our patient with tennis elbow. Here is how our integrated model works for them:

1. Comprehensive Diagnosis: The patient receives a dual-layered diagnostic workup. I perform a detailed musculoskeletal and biomechanical exam, including diagnostic ultrasound. At the same time, Dr. Cardenas reviews their overall medical history and any relevant lab work to rule out systemic conditions (like rheumatoid arthritis or other autoimmune diseases) that can mimic or contribute to tendinopathy.
2. Targeted Intervention: Based on this comprehensive diagnosis, I perform the ultrasound-guided needle fenestration, often with prolotherapy, to directly address the localized tendon pathology. Dr. Cardenas medically supervises this intervention to ensure it aligns with the patient’s overall health status.
3. Biomechanical Correction: Simultaneously, I begin chiropractic care. I assess the patient’s entire upper kinetic chain—wrist, elbow, shoulder, and spine. I might use specific chiropractic adjustments to restore proper joint mechanics in the wrist or cervical spine, which can reduce aberrant forces traveling down the arm to the elbow. Soft tissue techniques like Active Release Technique (ART) or Graston Technique might be used on the forearm muscles to release tension and improve flexibility.
4. Structured Rehabilitation: Our rehabilitation team guides the patient through a progressive exercise program, with a strong emphasis on the eccentric loading protocols that are critical for tendon remodeling. The program is tailored to the individual and progresses as their healing tissue gains strength.
5. Functional Medicine Support: If the patient’s healing is slow or if they have other chronic health issues, I may initiate a functional medicine workup. This could involve advanced testing to look for nutritional deficiencies, food sensitivities, gut dysbiosis, or hormonal imbalances. We might then recommend specific dietary changes, targeted nutritional supplements (like Vitamin C, collagen peptides, or anti-inflammatory botanicals), and lifestyle modifications to optimize their systemic healing environment.

This model departs from the fragmented, siloed approach to healthcare. Instead of a patient seeing a chiropractor for adjustments, a physiatrist for an injection, and a physical therapist for exercises—with little to no communication between them—we provide all of these services under one collaborative roof. This ensures every part of the treatment plan works synergistically toward the common goal of restoring function and eliminating pain for good.

Conclusion: A Modern, Evidence-Based Path to Healing

Ultrasound-guided needle fenestration represents a significant advancement in treating chronic, degenerative tendinopathies. It is a perfect example of how modern technology and a deeper understanding of physiology can be harnessed to create a minimally invasive yet powerful therapeutic intervention. By leveraging the body’s own innate healing mechanisms, we can effectively “reboot” a stalled healing process and guide the tissue back to health.

However, the procedure’s true power is unlocked when it is integrated into a comprehensive, patient-centered model of care. The combination of precise, ultrasound-guided intervention, expert biomechanical correction through chiropractic care, targeted rehabilitation, and a functional medicine approach to systemic health creates a powerful synergy.

At Injury Medical Clinic PA, our unique collaborative structure, with the crucial medical oversight of Dr. Maria Cardenas, allows us to offer this sophisticated level of integrated care. We are committed to using modern, evidence-based research methods to provide our patients with the most advanced and effective treatments available. We don’t just chase symptoms; we seek to understand and correct the root causes of dysfunction, empowering our patients on their journey to lasting health and vitality.

If you have been struggling with chronic tendon pain and have found that traditional methods have failed you, I encourage you to explore the potential of this integrative approach. It may be the key to finally breaking the cycle of pain and getting you back to the activities you love.

References

• Alfredson, H., Pietilä, T., Jonsson, P., & Lorentzon, R. (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. The American Journal of Sports Medicine, 26(3), 360–366. https://doi.org/10.1177/03635465980260030301
• Jacobson, J. A. (2013). Fundamentals of musculoskeletal ultrasound (2nd ed.). Elsevier Saunders.
• Krey, T., & T. Krey. (2021). Needle Tenotomy and Fenestration. In Atlas of Ultrasound-Guided Musculoskeletal Injections (pp. 13-17). Springer, Cham. https://doi.org/10.1007/978-3-030-52393-9_3
• McShane, J. M., Nazarian, L. N., & Harwood, M. I. (2006). Sonographically guided percutaneous needle tenotomy for treatment of chronic tendinosis. Journal of Ultrasound in Medicine, 25(10), 1281–1289. https://doi.org/10.7863/jum.2006.25.10.1281
• Mishra, A., & Pavelko, T. (2006). Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. The American Journal of Sports Medicine, 34(11), 1774–1778. https://doi.org/10.1177/0363546506288850
• Reeves, K. D., & Topol, G. A. (2011). Prolotherapy for the treatment of chronic musculoskeletal pain. In Pain Medicine (pp. 1437-1450). Elsevier.

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