Percutaneous Tenotomy for Chronic Tendinopathy Approaches

Percutaneous Tenotomy for Chronic Tendinopathy

As an advanced practice provider with a deep commitment to integrative and functional medicine, I am constantly exploring the latest evidence-based treatments to help my patients overcome chronic pain and regain function. My goal is to bridge gaps between medical disciplines, bringing together the best of chiropractic, functional medicine, and conventional medical care to create comprehensive, patient-centered solutions.

Today, I want to share exciting developments in treating chronic tendinopathy, drawing on the pioneering work of leading researchers like Dr. Brian O’Connor. Specifically, we’ll explore an innovative, minimally invasive procedure known as percutaneous tenotomy, a technique that is transforming how we manage conditions like tennis elbow, plantar fasciitis, and Achilles tendinopathy.

I will discuss how this procedure works, its applications, and how we integrate it into a broader, multidisciplinary care model at Injury Medical Clinic. This model combines my expertise in chiropractic and functional medicine with the invaluable medical oversight of Dr. Maria Guadalupe Cardenas, MD, our clinic’s Medical Director.

Our Collaborative Care Model: Integrating Disciplines for Optimal Outcomes

At Injury Medical Clinic, we have cultivated a unique, multidisciplinary environment designed to provide the most effective and comprehensive care possible. A cornerstone of our practice is the collaborative relationship between me and Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is a highly respected, board-certified internist with over 40 years of experience. As our Medical Director and Collaborative Physician, she provides essential medical oversight to ensure our treatment plans are safe, effective, and grounded in sound medical principles. Her NPI is #1164426749, and her Texas MD License is #J2933.

This partnership allows us to offer a truly integrative approach. While I focus on the biomechanical and neuromusculoskeletal aspects of health through chiropractic adjustments, functional movement, and rehabilitation, Dr. Cardenas provides the medical framework. This synergy is particularly vital when we incorporate advanced procedures like percutaneous tenotomy. Together, we manage patient care from diagnosis and treatment planning to post-procedure rehabilitation, ensuring we address all aspects of a patient’s health. Our services include:

• Chiropractic Care: Focused on restoring spinal alignment, improving nervous system function, and correcting biomechanical imbalances.
• Medical Oversight: Led by Dr. Cardenas to ensure patient safety and appropriate medical management.
• Functional Medicine: Investigating the root causes of dysfunction, from metabolic issues to nutritional deficiencies.
• Personal Injury and Rehabilitation: Specialized programs for recovery from accidents and injuries.
• Advanced Regenerative Procedures: Incorporating cutting-edge, evidence-based treatments for chronic conditions.

Understanding Chronic Tendinopathy: When Rest and Ice Aren’t Enough

Many of my patients come to me frustrated after months or even years of battling chronic tendon pain. They’ve tried rest, ice, anti-inflammatory medications, and traditional physical therapy, yet the pain persists. This is because chronic tendinopathy is not simply an issue of inflammation; it’s a degenerative process.

The condition, more accurately termed tendinosis, involves the breakdown of the collagen fibers that make up the tendon. Over time, the tissue becomes disorganized, weak, and filled with dysfunctional, scar-like material. This pathological tissue lacks a healthy blood supply, which severely limits its ability to heal on its own. This is why passive treatments often fail. To achieve lasting relief, we must actively remove the diseased tissue and stimulate a new, robust healing response. That’s where percutaneous tenotomy comes in.

Percutaneous Tenotomy: A Minimally Invasive Solution for Chronic Tendon Pain

Percutaneous tenotomy is a revolutionary, FDA-approved procedure that uses ultrasound guidance to precisely target and remove damaged tendon tissue. The term “percutaneous” means “through the skin,” highlighting its minimally invasive nature. Unlike traditional open surgery, which requires large incisions and lengthy recovery times, this procedure is performed through a tiny entry point, often in an office setting.

As Dr. O’Connor shows in his research, this technique allows providers to “debride,” or clean out, the specific area of tendinopathy with incredible accuracy. This is a significant advance, especially for primary care and specialty clinics like ours, as it provides a powerful tool to address the root cause of chronic tendon pain without resorting to major surgery.

Current approved indications for percutaneous tenotomy include:

• Extensor Carpi Radialis Brevis Tendinopathy (Tennis Elbow)
• Flexor Tendinopathy (Golfer’s Elbow)
• Patellar Tendinopathy (Jumper’s Knee)
• Achilles Tendinopathy
• Plantar Fasciopathy (Plantar Fasciitis)

The Technology Behind the Technique: Tenex and TenJet

Two primary systems perform percutaneous tenotomy, both designed to remove pathologic tissue while preserving healthy structures.

1. Tenex Health TX™: This system is based on phacoemulsification, the same technology used in modern cataract surgery.
   • It utilizes a specialized handpiece with an 18-gauge double-lumen needle.
   • The needle tip vibrates at an ultrasonic frequency, emulsifying (liquefying) the targeted degenerative tissue.
   • At the same time, a second lumen within the needle suctions the emulsified debris away, leaving the healthy tendon intact.
   • The entire process is performed under real-time ultrasound guidance, allowing for unparalleled precision. The provider can see the needle tip and the diseased tissue on the screen, ensuring only the damaged area is treated.
2. TenJet™: This system offers an alternative method for tissue removal.
   • It uses a high-velocity, pressurized stream of saline to create a “cutting” effect.
   • This powerful water jet essentially dissects and removes the diseased tissue, which is then aspirated away through the same instrument.
   • Like Tenex, TenJet is also performed under ultrasound guidance to ensure targeted and safe debridement.

In our practice, we have found the Tenex system to be exceptionally effective. A foot pedal controls the procedure, allowing precise, hands-on control while you visualize the anatomy on the ultrasound monitor.

The Percutaneous Tenotomy Procedure: A Step-by-Step Look

Let’s walk through what a patient can expect during a percutaneous tenotomy procedure for tennis elbow, a very common application.

1. Preparation and Sterilization: The procedure is conducted under strict sterile conditions. The treatment area is cleaned, and a local anesthetic is administered to numb the skin and the tissue surrounding the tendon. The ultrasound probe itself is covered in a sterile sheath.
2. Ultrasound Visualization: Using high-resolution ultrasound, I identify the exact location of the tendinopathy. The diseased tissue often appears darker (hypoechoic), thickened, and disorganized on the ultrasound image, sometimes with tiny calcifications.
3. Needle Insertion: A tiny incision is made, just large enough for the Tenex needle. Using the ultrasound image, the needle is advanced directly to the degenerative tissue. We typically use an “in-plane” approach, meaning we can see the entire length of the needle on the screen as it moves toward the target.
4. Debridement: Once the needle is in position, the device is activated. The ultrasonic energy is applied, and the provider gently moves the needle tip back and forth through the diseased tissue. As Dr. O’Connor notes, this motion is similar to dry needling or a fenestration procedure, but with the added benefit of removing the debrided tissue at the same time. The entire “cutting time” is remarkably short, typically lasting between 30 seconds and two minutes. Patients may hear the device, but they should not feel pain because of the local anesthetic.
5. Completion: After debridement, the needle is removed, and a small adhesive bandage is placed over the tiny incision. No stitches are required.

The Role of Integrative Chiropractic Care in Recovery

The procedure itself is only the beginning of the healing journey. Removing the diseased tissue creates an opportunity for the body to heal correctly, but it needs the right support. This is where our integrative model shines. My clinical observations consistently show that a structured post-procedure rehabilitation program is crucial for optimal outcomes.

Our post-tenotomy protocol is multifaceted and personalized, integrating chiropractic principles to restore function and prevent recurrence.

• Initial Healing Phase (First 1-2 weeks): The focus is on protecting the healing tissue. We may recommend a brief period of modified activity. The body initiates an acute inflammatory healing response, which is a positive and necessary step. This is the body sending growth factors, stem cells, and blood supply to the area to build new, healthy collagen.
• Restoring Mobility and Biomechanics: As a chiropractor, my primary goal is to ensure the joints and surrounding tissues are moving correctly. For tennis elbow, I would assess and adjust the wrist, elbow, shoulder, and even the cervical and thoracic spine. Misalignments in these areas can create abnormal loading patterns on the elbow, contributing to the initial injury. Correcting them is essential for long-term success.
• Soft Tissue Mobilization: We use techniques like Graston Technique® or Active Release Technique (ART®) on the surrounding muscles to break down adhesions, improve blood flow, and reduce muscular tension that may be pulling on the newly repaired tendon.
• Eccentric Loading Program: Research has conclusively shown that eccentric exercises are paramount for tendon remodeling. These exercises involve lengthening the muscle-tendon unit under load. For tennis elbow, this would involve slowly lowering a light weight. This controlled stress stimulates the fibroblasts (tendon cells) to lay down new, strong, and properly aligned collagen fibers.
• Functional and Nutritional Support: As a Certified Functional Medicine Practitioner, I also look at systemic factors. We may recommend nutritional strategies to support collagen synthesis, such as adequate protein intake and supplementation with Vitamin C, zinc, and other cofactors. Managing systemic inflammation through diet can also create a better healing environment.

Conclusion

By combining the precision of percutaneous tenotomy with the holistic, biomechanical approach of chiropractic care and the oversight of internal medicine, we can guide the body through a complete and robust healing process. We are not just removing the pain; we are restoring function, rebuilding tissue, and resolving the underlying issues that led to the problem in the first place. This is the future of musculoskeletal care—integrated, evidence-based, and profoundly effective.

References

O’Connor, B. (Presenter). (n.d.). Advanced Techniques: Percutaneous Tenotomy [Video].