Evidence for Ultrasound Guided Needle Tenotomy
A) Hyperechoic tendon suggests tendinopathy
B) Calcifications at the tendon insertion
C) Lack of new blood vessel formation
D) Hypoechoic fluid collection within the subcutaneous tissue above the tendon
Achilles tendinopathy is another area in which ultrasonic tenotomy has been used as a treatment modality. A study in the Journal of the American Institute of Ultrasound in Medicine evaluated complications following an ultrasonic tenotomy for patients with insertional achilles tendinopathy. Side effects seen were superficial wound infection, hematoma, scarring, DVT, and recurrence of pain (6). They did find that performing an ultrasound tenotomy verse an open achilles debridement saved the institution $18,000 (6). Based on a review of the data for Achilles tendinopathy and percutaneous tentomy, there is a lack of evidence regarding long term outcomes with the procedure (10).
Further evidence looking at the use of the Tenex device for chronic elbow tendinopathy was published in the Journal of Shoulder and Elbow Surgery. The study looked at the treatment of both medial and lateral epicondylitis with the Tenex 1 system (7). They found that preprocedure VAS scores averaged to 6.4 and following the procedure at 12 months the VAS score was 0.7 (7).
Another common treatment for epicondylitis is Platelet Rich Plasma injections. As a result, a study was performed that compared a group of patients with epicondylitis and randomized them to receive either a PRP injection for epicondylitis or a Tenex procedure (9). PRP injections deliver growth factor to the tendon to stimulate angiogenesis and tendon remodeling (10). The study found that both PRP and tenotomy had statistically significant improvements in their pain scores post procedure (9). Since both procedures led to improvement in pain, it is up to the physician to choose which to use. In a patient who cannot afford the out-of-pocket price of PRP, a tenotomy may be preferred since most procedures are covered by insurance after a prior authorization. A recent review in Sports Health found five studies looking at the value of percutaneous ultrasound tenotomy for epicondylitis and found that the procedure led to significant improvements in VAS and DASH subscores (10).
Correct Answer is B calcifications at the tendon insertion. Tendinopathy on ultrasound can be seen with hypoechoicity within the tendon, calcifications within the tendon origin, neovascularization, and tendon thickening.
Seng, Chusheng, et al. “Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Sustainability and Sonographic Progression at 3 Years.” The American Journal of Sports Medicine, vol. 44, no. 2, Feb. 2016, pp. 504–10. PubMed,
- Altahawi, Faysal, et al. “Percutaneous Ultrasonic Tenotomy with the TX-1 Device versus Surgical Tenotomy for the Treatment of Common Extensor Tendinosis.” Skeletal Radiology, vol. 50, no. 1, Jan. 2021, pp. 115–24. PubMed, doi:10.1007/s00256-020-03540-7.
- Peck, Evan, et al. “Advanced Ultrasound-Guided Interventions for Tendinopathy.” Physical Medicine and Rehabilitation Clinics of North America, vol. 27, no. 3, Aug. 2016, pp. 733–48. PubMed, doi:10.1016/j.pmr.2016.04.008.
- Erickson, Jacob L., and Andrew R. Jagim. “Ultrasonic Tenotomy and Debridement for Calcific Tendinopathy of the Shoulder: A Pilot Case Series.” Journal of Primary Care & Community Health, vol. 11, Oct. 2020. PubMed Central, doi:10.1177/2150132720964665.
- Baker, Champ L., and J. Ryan Mahoney. “Ultrasound-Guided Percutaneous Tenotomy for Gluteal Tendinopathy.” Orthopaedic Journal of Sports Medicine, vol. 8, no. 3, Mar. 2020, p. 2325967120907868. PubMed, doi:10.1177/2325967120907868.
- Nanos, Katherine N., and Gerard A. Malanga. “Treatment of Patellar Tendinopathy Refractory to Surgical Management Using Percutaneous Ultrasonic Tenotomy and Platelet-Rich Plasma Injection: A Case Presentation.” PM & R: The Journal of Injury, Function, and Rehabilitation, vol. 7, no. 12, Dec. 2015, pp. 1300–05. PubMed, doi:10.1016/j.pmrj.2015.06.439.
- Chimenti, Ruth L., et al. “Percutaneous Ultrasonic Tenotomy Reduces Insertional Achilles Tendinopathy Pain With High Patient Satisfaction and a Low Complication Rate.” Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound in Medicine, vol. 38, no. 6, June 2019, pp. 1629–35. PubMed, doi:10.1002/jum.14835.
- Baria, Michael R., et al. “Percutaneous Ultrasonic Tenotomy Effectively Debrides Tendons of the Extensor Mechanism of the Knee: A Technical Note.” The Knee, vol. 27, no. 3, June 2020, pp. 649–55. PubMed, doi:10.1016/j.knee.2020.04.010.
- Barnes, Darryl E., et al. “Percutaneous Ultrasonic Tenotomy for Chronic Elbow Tendinosis: A Prospective Study.” Journal of Shoulder and Elbow Surgery, vol. 24, no. 1, Jan. 2015, pp. 67–73. PubMed, doi:10.1016/j.jse.2014.07.017
- Boden, Allison L., et al. “Platelet-Rich Plasma versus Tenex in the Treatment of Medial and Lateral Epicondylitis.” Journal of Shoulder and Elbow Surgery, vol. 28, no. 1, Jan. 2019, pp. 112–19. PubMed, doi:10.1016/j.jse.2018.08.032.
- Seng, Chusheng, et al. “Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Sustainability and Sonographic Progression at 3 Years.” The American Journal of Sports Medicine, vol. 44, no. 2, Feb. 2016, pp. 504–10. PubMed, doi:10.1177/0363546515612758.
- Vajapey, Sravya, et al. “Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies: A Systematic Review.” Sports Health, Nov. 2020, p. 1941738120951764. PubMed, doi:10.1177/1941738120951764.