This blog post delves into cutting-edge approaches for treating tendon injuries, with a specific focus on percutaneous ultrasound-guided tenotomy. Tendon injuries typically stem from tensile overload triggered by sudden events, intense training regimes, or repetitive movements. When a tendon is subjected to an unexpected surge in load, the body initiates a reactive tendinopathy response to heal the tendon, often resulting in discomfort and swelling.
However, if these excessive loads persist without sufficient time for repair, tendons may succumb to disrepair or degenerative tendinopathy. In degenerative tendinopathy, regions of abnormal collagen develop within an otherwise healthy tendon, leading to a loss of tensile strength. These regions are typically devoid of pain and inflammatory cells, posing challenges for effective healing. Meanwhile, the remaining healthier tendon sections may experience ongoing stress, triggering ongoing reactive pain responses.
As you’re aware, the healing process hinges on an initial inflammatory phase, followed by regeneration and, ultimately, remodelling. Consequently, degenerative tendinosis lacks the necessary inflammatory component crucial for proper healing.
Initial Management
The initial treatment for tendinopathy involves conservative measures such as eccentric or isometric physiotherapy. I advise my patients that resting the area entirely will cause stiffness and lack of tendon repair, while continued overuse perpetuates or worsens the tendon injury cycle. Controlled loading of the tendon to low intensity is the sweet spot. However, in my practice, I advise against the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the initial phase to avoid interference with the required inflammatory response.
Non-surgical Therapy Options
In cases where conservative management fails, percutaneous treatments offer alternatives to surgery. Although corticosteroid injections have been commonly used for rapid pain relief for many decades, concerns have been raised in recent years regarding risks such as tenocyte death and tendon rupture, particularly in chronic conditions like tendinosis. Thus, the standard of care is now moving towards safer therapies that have a slower onset of action and longer duration of benefit, such as hyaluronic acid, prolotherapy, platelet-rich plasma, and tenotomy.
What is Tenotomy?
Tenotomy, also known as needle fenestration, involves repeatedly passing a needle into the segment of the abnormal tendon to disrupt areas of the degenerative tendon and to induce acute inflammation and promote healing. Ultrasound guidance ensures precise targeting of the abnormal tendinosis location, and a new term has been recently proposed calling this procedure Percutaneous Ultrasound-Guided Needle Tenotomy (PUNT).
Evidence for Tenotomy
A 2023 Meta-analysis of percutaneous ultrasound-guided needle tenotomy reviewed 35 studies, with 1674 participants (and their 1876 tendons). Ultrasound-guided tenotomy was effective in most patients in many areas, including:
• Supraspinatus tendon
• Elbow common flexor and extensor tendons
• Biceps brachii and triceps brachii tendons
• Gluteal, hamstring, adductor, and tensor fascia lata tendons
• Patellar and Achilles tendons
• Plantar fascia
Following tenotomy, pain and function scores have been observed to improve both in the short term (within 3 months) and in the long term (over 9 months, with some studies showing benefits for more than 2 years). Compared to other injection treatments such as PRP or corticosteroids, tenotomy has demonstrated similar results in most studies in terms of pain reduction and functional improvement. Out of the 1876 procedures, there was only one reported case of ruptured patellar tendon six weeks following the procedure. Minor side effects of pain, inflammation, hypersensitivity, and superficial skin infection were rare.
Comparison to Acupuncture
You may have noticed that tenotomy is similar to dry needling or acupuncture. I agree that tenotomy and these techniques share some procedural similarities and decades of evidence in the Western medical literature. However, as a medical doctor who is also a certificant of the Canadian Academy of Medical Acupuncture, I would like to point out four key differences. Firstly, tenotomy uses ultrasound for increased safety and accuracy, ensuring that the needle passes through the degenerative portion of the tendon and avoids other vital structures like ligaments, vessels, and nerves. Secondly, local anesthetics such as lidocaine can be added to the procedure to reduce pain. Thirdly, the needle used in tenotomy is thicker, bevelled, and hollow (0.65 to 1.2mm), as compared to the solid non-bevelled acupuncture needle (0.25 to 0.4mm), which may increase the “dose” of the treatment. Lastly, tenotomy is a short office-based procedure and does not use additional energy modalities like electrostimulation or piezoelectric twisting of the fascia. Tenotomy offers a distinct advantage in terms of safety and accuracy, with procedural pain management quite beneficial for patient tolerability, in my experience.
Conclusion/Executive Summary:
This blog post explored modern treatments for tendon injuries, mainly focusing on percutaneous ultrasound-guided tenotomy. Tendon issues often stem from overuse or acute events, leading to sometimes areas of collagen breakdown known as degenerative tendinosis. These areas of the tendon lack the necessary inflammatory response for proper healing. Tenotomy induces acute inflammation through needle fenestration, promoting the inflammatory response required for repair and remodelling. Evidence shows its effectiveness across various tendon sites, with short- and long-term improvements in pain and function. Compared to injections, tenotomy provides similar benefits in RCTs with minimal complications and is an option for patients wishing to avoid medication side effects. Please feel free to contact me to discuss a musculoskeletal case you may have, or send me a referral to assist you in managing tendon problems in your patients.
Resources:
1. European Radiology (2023) 33:7303–7320).
2. Semin Musculoskelet Radiol 2016;20:414–421.
3. JISPRM 6(3):p 77-82, September 2023.
4. Skeletal Radiology Volume 52, pages 875–888, (2023)
This blog from Arthur Musculoskeletal Health is a series of free online medical education posts dedicated to providing online primary care education for physicians, nurse practitioners, physician assistants, residents, and medical students. This blog is not intended to be medical advice for patients; please see your legally qualified medical practioner for your medical condition(s). The information provided is for general and informational purposes only and is not meant to diagnose, treat, or prevent any medical condition. The post information is stated in an individual capacity, and not as a part of my duties at my hospital or academic institutions.