Managing Refractory Tendinopathy: Needle Tenotomy (Part 2)

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Managing Refractory Tendinopathy: Needle Tenotomy (Part 2)

In part two of managing refractory tendinopathy, we review the evidence behind needle tenotomy, sometimes called dry needling or needle fenestration and tendinopathies. Previously, we have reviewed the role of topical nitroglycerin.

The principle behind needle tenotomy involves repeated needling of the pathologic tendon to promote an inflammatory response [1]. The goal is to convert a chronic, degenerative tendon to an acute inflammatory condition with subsequent evolution of a healing response. The repeated fenestration leads to hemorrhage, an inflammatory response with cytokine cascade and the formation of granulation tissue. The granulation tissue is believed to strengthen the tendon.

There are several considerations to make before performing the procedure. A diagnostic ultrasound should be performed and site marked prior to beginning. Sterile technique should be followed and local anesthetic utilized. For tenotomy, most literature cites either a 20g or 22g needle for fenestration with anywhere from 20 to 50 passes. There is no clear consensus. Post procedure, the patient should avoid anti-inflammatory medications and ice. On weight bearing tendons, non-weight bearing status or immobilization should be considered. 

In general, dry needling involves the use of ultrasound guidance. Superficial tendons such as the common flexor and extensor tendon may not require ultrasound guidance to identify clinically, however ultrasound provides superior visualization of both the tendon and needle during the procedure. Overall, dry needling is thought to be safe with few contraindications. The complications described have been negligible [8]. The procedure is relatively inexpensive.

There are several studies and case reports evaluating the use of needle tenotomy. In one study, 58 patients with chronic lateral epicondylitis were treated with ultrasound guided needle tenotomy with roughly ⅔ reporting improvement in symptoms [4]. In another case series, 14 individuals received needle tenotomy on the following tendinosis: patellar (5), Achilles (4), proximal gluteus medius (1), proximal iliotibial tract (1), proximal hamstring (1), common extensor elbow (1), and proximal rectus femoris (1). VAS scores were significantly lower at 12 and 14 weeks [5]. In patients with patellar tendinitis, more than ¾ of subjects had a reduction in pain at 4 weeks [9].

Image 1.  Needle tenotomy of common extensor tendon adopted from Jacobson.

Image 1. Needle tenotomy of common extensor tendon adopted from Jacobson.

A case report of ultrasound guided dry needling of the supraspinatus tendon showed an improvement in patients symptoms and ability to return to previous level of physical activity. Notably, at 10-day follow-up, increased echogenicity was found in the previously heterogenous hypoechoic areas [3]. Additional studies have shown benefit with needle tenotomy for achilles tendon [6], common flexor tendinopathy and common extensor tendinopathy [7]

Other upper extremity tendons to consider are biceps brachii and triceps brachii tendons. In the lower extremity, additional tendons include gluteal tendons at the greater trochanter, hamstring attachment at the ischial tuberosity, adductor tendons, and tensor fascia lata if the iliotibial band. Ultimately, any tendinopathy refractory to standard treatment can be considered for needle tenotomy although there is a dearth of literature evaluating the procedure on most tendons.

Image 2 . Needle tenotomy of achilles tendon adopted from Jacobson.

Image 2. Needle tenotomy of achilles tendon adopted from Jacobson.

There are alternative approaches to standard needle tenotomy which are not well studied. One approach involves repeated fenestration with injection of some combination of normal saline, local anesthetic and corticosteroids. In patients suffering from achilles tendinopathy, this approach has been shown to reduce pain and improve function [2]. The benefit of this approach is unclear as it is combining an inflammatory response (needle tenotomy) with an anti-inflammatory response (corticosteroids). Some narratives have discussed using PRP however no published data yet supports this approach.

Conclusion

Needle tenotomy remains a safe, cheap and under-studied treatment option for refractory tendinopathies. There is decent evidence to support its use in the more common tendinopathies. Unfortunately, there are few head to head comparisons to other modalities including corticosteroid injections, PRP, other medications and/or physical therapy. Furthermore, we don’t know if certain tendons respond better than other tendons. The procedure itself varies from study to study as does the post-procedure care. More comprehensive and vigorous research is needed to better understand the role of needle tenotomy in the context of the tendinopathy landscape.

References

[1] Chaudhry, F. A. "Effectiveness of dry needling and high-volume image-guided injection in the management of chronic mid-portion Achilles tendinopathy in adult population: a literature review." European Journal of Orthopaedic Surgery & Traumatology 27.4 (2017): 441-448.

[2] Maffulli N, Spiezia F, Longo UG, Denaro V, Maffulli GD (2013) High volume image guided injections for the management of chronic tendinopathy of the main body of the Achilles tendon. Phys Ther Sport 14(3):163–167

[3] Settergren, Roy. "Treatment of supraspinatus tendinopathy with ultrasound guided dry needling." Journal of chiropractic medicine 12.1 (2013): 26-29.

[4] McShane, John M., Levon N. Nazarian, and Marc I. Harwood. "Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow." Journal of ultrasound in medicine 25.10 (2006): 1281-1289.

[5] Housner, Jeffrey A., Jon A. Jacobson, and Roberta Misko. "Sonographically guided percutaneous needle tenotomy for the treatment of chronic tendinosis." Journal of Ultrasound in Medicine 28.9 (2009): 1187-1192.

[6] Testa, V., et al. "Management of Achilles tendinopathy by ultrasound-guided percutaneous tenotomy." Medicine and science in sports and exercise 34.4 (2002): 573-580.

[7] Barnes, Darryl E., James M. Beckley, and Jay Smith. "Percutaneous ultrasonic tenotomy for chronic elbow tendinosis: a prospective study." Journal of shoulder and elbow surgery 24.1 (2015): 67-73.

[8] Jacobson, Jon A., Sung Moon Kim, and Monica Kalume Brigido. "Ultrasound-guided percutaneous tenotomy." Seminars in musculoskeletal radiology. Vol. 20. No. 05. Thieme Medical Publishers, 2016.

[9] Kanaan Y, Jacobson JA, Jamadar D, Housner J, Caoili EM. Sonographically guided patellar tendon fenestration: prognostic value of preprocedure sonographic findings. J Ultrasound Med 2013; 32 (5) 771-777