Advanced Tendinopathy Treatment: A Look at Percutaneous Tenotomy

Abstract

In this educational post, I will explore percutaneous tenotomy, an advanced, minimally invasive procedure. This is a major advance in treating chronic tendinopathies. We will review the latest findings from leading researchers like Dr. Brian O’Connor. These findings show how modern, evidence-based methods are revolutionizing patient care. I will discuss the two primary techniques, Tenex and TenJet. I will explain their physiological mechanisms and clinical applications for conditions such as tennis elbow, Achilles tendinopathy, and plantar fasciitis. Furthermore, I will explain how our multidisciplinary team at Injury Medical Clinic PA integrates these cutting-edge medical procedures with our foundational integrative chiropractic care. Dr. Maria Guadalupe Cardenas, MD, provides medical direction for this collaborative approach. As a result, we create comprehensive, personalized treatment plans that address both the structural and functional aspects of a patient’s health. This ensures a holistic path to recovery.

Our Collaborative Care Model: Integrating Medicine and Chiropractic

At our practice, Injury Medical Clinic PA, we have cultivated a unique and powerful healthcare environment built on the principle of integrative care. My role as a Doctor of Chiropractic, Advanced Practice Registered Nurse, and Functional Medicine Practitioner is complemented by the extensive experience and medical oversight of our Medical Director, Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is Board Certified in Internal Medicine and brings over four decades of clinical wisdom to our team. Her NPI is #1164426749, and she is licensed in Texas under #J2933.

This multidisciplinary setup lets us seamlessly blend medicine, chiropractic, functional medicine, rehabilitation, and personal injury care. When a patient presents with a complex condition like chronic tendinopathy, our collaborative process begins.

• Initial Assessment: I typically conduct the initial musculoskeletal and functional assessment, utilizing my chiropractic and diagnostic expertise.
• Medical Consultation: Dr. Cardenas provides crucial medical oversight, reviewing patient histories, ordering necessary labs or advanced imaging, and determining if a patient is a suitable candidate for medical procedures like percutaneous tenotomy.
• Integrated Treatment Plan: Together, we develop a holistic treatment strategy. While Dr. Cardenas may oversee the medical intervention, my focus remains on restoring biomechanical integrity and function through chiropractic adjustments, soft tissue therapies, and personalized rehabilitation protocols.

This model ensures that our patients receive both advanced medical interventions to address specific pathologies and comprehensive chiropractic and functional care to correct underlying dysfunctions and promote long-term healing. This patient-centered approach goes beyond treating symptoms to restore whole-body health.

Understanding Chronic Tendinopathy: Beyond “Tendinitis”

For years, chronic tendon pain was commonly called “tendinitis,” a term that implies inflammation is the primary culprit. However, modern research, particularly through microscopic analysis of damaged tendon tissue, has shifted our understanding. We now know that in most chronic cases, the issue is not inflammatory but degenerative. As a result, the condition is more accurately termed tendinosis or tendinopathy.

In a healthy tendon, collagen fibers are neatly aligned, strong, and resilient, much like a well-woven rope. In tendinopathy, this organized structure breaks down. The tissue becomes:

• Disorganized: Collagen fibers are tangled and weak.
• Hypercellular: There is an abnormal increase in tenocytes (tendon cells).
• Angiofibroblastic Hyperplasia: There is an ingrowth of abnormal blood vessels and fibroblasts.

This degenerative tissue is weak, dysfunctional, and a source of persistent pain. It does not have the capacity to heal on its own, which is why traditional conservative treatments like rest, ice, and anti-inflammatory medications often provide only temporary relief. The core problem—damaged, nonfunctional tissue—remains. Percutaneous tenotomy was designed to solve this problem.

Introducing Percutaneous Tenotomy: A Minimally Invasive Solution

As a clinician constantly seeking the most effective, evidence-based treatments for my patients, I’ve been closely following the development of procedures like percutaneous tenotomy. This advanced technique represents a paradigm shift, moving treatment from the exclusive domain of orthopedic surgeons to office-based settings accessible to primary care providers and specialists like us. As highlighted by researchers like Dr. Brian O’Connor, this FDA-approved, ultrasound-guided procedure offers a powerful tool for debriding, or removing, the diseased tissue characteristic of chronic tendinopathy.

The goal of percutaneous tenotomy is simple yet profound: to precisely remove the source of the pain—the degenerative tissue—while stimulating a renewed healing response. By eliminating the dysfunctional tissue, we create an environment where the body can lay down new, healthy collagen fibers.

Approved Indications for Percutaneous Tenotomy

The procedure has been specifically approved and proven effective for several common and notoriously difficult-to-treat conditions:

• Extensor and Flexor Tendinopathy of the Elbow: Commonly known as “tennis elbow” and “golfer’s elbow,” respectively.
• Patellar Tendinopathy: Often called “jumper’s knee.”
• Achilles Tendinopathy: Affecting the large tendon at the back of the ankle.
• Plantar Fasciopathy: The correct term for what is widely known as plantar fasciitis, a primary cause of heel pain.

The Technology Behind the Technique: Tenex and TenJet

Two leading technologies currently facilitate percutaneous tenotomy, each using a unique mechanism to achieve the same goal of tissue debridement.

Tenex: Ultrasonic Emulsification

We use the Tenex Health TX system in our practice. Its technology is based on phacoemulsification, a concept borrowed from modern cataract surgery. The process works as follows:

1. Ultrasonic Energy: The Tenex device uses a handheld instrument with a specialized 18-gauge double-lumen needle. The needle tip vibrates at a precise ultrasonic frequency.
2. Tissue Emulsification: When this vibrating tip contacts the targeted degenerative tendon tissue, it instantly emulsifies, or liquefies, it. This process is highly selective; the frequency is calibrated to break down the soft, disorganized tendinopathic tissue while leaving the surrounding healthy, elastic tendon fibers unharmed.
3. Aspiration: Simultaneously, a second lumen within the needle sheath creates a vacuum, continuously suctioning and removing the emulsified debris from the body. This is a critical step, as it clears the way for healing.

The entire procedure is performed under real-time ultrasound guidance. This allows the practitioner to watch the needle tip on a screen. As a result, they ensure that only the diseased tissue is targeted and removed. This precision is what makes the procedure both safe and highly effective.

TenJet: High-Pressure Saline Jet

The TenJet system offers an alternative mechanism. Instead of using ultrasonic energy, it employs a highly focused, high-velocity, pressurized stream of saline.

• This “water jet” acts as a surgical blade, precisely cutting away the degenerative tissue.
• Like Tenex, it simultaneously aspirates the resected tissue and excess saline, leaving a clean site for healing.

Both technologies are remarkable advancements, providing minimally invasive options that bridge the gap between failed conservative care and open surgery. My clinical experience aligns with research showing these procedures can be completed efficiently, with the actual debridement, or “cutting time,” often lasting between 30 seconds and two minutes.

The Procedure: A Step-by-Step Clinical Walkthrough

Having performed this procedure, I can walk you through what a patient experiences. Let’s use the example of treating extensor carpi radialis brevis tendinopathy (tennis elbow).

1. Preparation and Sterilization: The patient is positioned comfortably, typically lying down. I prep the treatment area (the elbow) using sterile technique. I cover the ultrasound probe with a sterile sheath to maintain a sterile field throughout the procedure.
2. Local Anesthesia: I administer a local anesthetic to numb the area completely. The patient remains awake and comfortable, feeling only pressure, not pain.
3. Ultrasound Visualization: I use the ultrasound to get a clear, real-time image of the tendon. I can precisely identify the thickened, dark, and disorganized area of tendinopathy, distinguishing it from the bright, fibrillar pattern of healthy tendon tissue.
4. Needle Insertion: Guided by the ultrasound image, I insert the Tenex needle through a tiny skin incision (so small it often doesn’t require stitches) and advance it directly to the diseased portion of the tendon.
5. Debridement: With my foot on a pedal that controls the device, I activate the ultrasonic energy. On the ultrasound screen, I can see the needle tip moving back and forth in a “windshield wiper” motion. I can also see the hypoechoic (dark) area of tendinopathy gradually being removed, which appears as a “snowstorm” effect on the monitor as the tissue is emulsified and aspirated. I continue this process until all the visibly diseased tissue is gone.
6. Completion: Once the debridement is complete, the needle is withdrawn, and a small adhesive bandage is placed over the insertion site. The entire procedure, from prep to completion, typically takes less than 20 minutes.

The patient then receives post-procedure instructions, usually including a brief rest period followed by a structured rehabilitation program to support tendon healing.

The Crucial Role of Integrative Chiropractic Care Post-Procedure

Performing the percutaneous tenotomy is only part of the process. This is where our integrative model shines. Removing the degenerative tissue resets the stage for healing, but it does not automatically correct the underlying biomechanical faults that led to the tendon overload in the first place.

This is my primary focus as a chiropractor in the post-procedure phase. My clinical observations consistently show that chronic tendinopathies link to dysfunction elsewhere in the kinetic chain.

• For Tennis Elbow: The problem is rarely isolated to the elbow. I often observe restricted mobility in the thoracic spine, poor scapular stability, or nerve entrapment in the cervical spine (neck) that alters the mechanics of the entire arm.
• For Plantar Fasciopathy: I look for pelvic imbalances, leg-length discrepancies, or restricted ankle joint mobility (talus fixation) that increases stress on the plantar fascia with every step.
• For Achilles Tendinopathy: Tight calf muscles (gastrocnemius and soleus), weak gluteal muscles, and sacroiliac joint dysfunction are common contributing factors.

Our Post-Tenotomy Chiropractic and Rehabilitation Protocol

Our post-procedure care is designed to support the new tissue as it heals and to prevent recurrence by addressing the root cause:

1. Chiropractic Adjustments: I use specific, gentle adjustments to restore proper motion to restricted joints in the spine, pelvis, and extremities. For an elbow patient, this treatment might include cervical and thoracic adjustments to improve nerve flow and upper-body mechanics. For a plantar fascia patient, this includes pelvic and foot adjustments.
2. Soft Tissue and Myofascial Release: Techniques like Active Release Technique (ART) or the Graston Technique break down scar tissue in surrounding muscles and fascia, improving flexibility and reducing abnormal pulling forces on the healing tendon.
3. Personalized Therapeutic Exercise: This is the most critical component. We don’t use a one-size-fits-all approach. The rehabilitation program is phased and progressive:
   • Phase 1 (Initial Healing): Gentle range-of-motion exercises to prevent stiffness.
   • Phase 2 (Strengthening): Introduction of eccentric exercises. This is key. Eccentric loading (lengthening a muscle while it’s contracted) has been shown in numerous studies to be the most effective stimulus for promoting strong, organized collagen formation in a healing tendon (Alfredson et al., 1998).
   • Phase 3 (Functional Integration): Incorporating movements that mimic the patient’s daily activities or sport, retraining proper movement patterns to ensure the biomechanical faults are corrected.

By integrating the advanced medical procedure of percutaneous tenotomy with foundational chiropractic and rehabilitative care, we offer a comprehensive solution. Dr. Cardenas and I work in concert to manage the pathology with the tenotomy. Meanwhile, I focus on restoring optimal function and resilience to the entire musculoskeletal system. This synergy is what leads to lasting results. It also helps our patients return to the activities they love, pain-free and stronger than before.

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Reference

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