Ultrasound-Guided Longitudinal Percutaneous Tenotomy: Alternative Therapy for Tissue Damage
Sam Russo, ND, LAc
Numerous procedures using various types of needles exist for the treatment of diseased connective tissue, including acupuncture, dry needling, trigger point injection, corticosteroid injection, and prolotherapy with various substances. In the last few years, a technique has been developed called longitudinal percutaneous tenotomy (LPT). This involves placement of a hypodermic needle along the long axis of the tissue structure to stimulate tissue repair. It represents a treatment option for patients who have tissue damage, such as tears, degeneration, calcification, or other abnormalities, that is too small to be treated by conventional surgery but is not responding to conservative treatment of rest, ice, and nutritional support. In this technique, the hypodermic needle is used as a small surgical instrument to break up scar tissue or fenestrate an injured ligament or tendon. The inflammatory response results in neovascularization, migration of fibroblasts, and production of new collagen to replace the damaged tissue.
Ultrasound-guided LPT is a safe and effective procedure for treating chronic tendinosis in many areas of the body and can beperformed in the office. Ultrasonographic guidance is used to increase accuracy of the technique and to decrease the incidence of adverse events. A significant benefit is that the procedure is so minimally invasive that restoration of function is rapid, much more so than with arthroscopic surgery. The technique is performed under local anesthesia and on average takes 30 to 60 minutes to complete. Generally, posttreatment pain lasts from a few days to a few weeks depending on the extent of treatment provided, which is determined by the severity of tissue damage.
Following LPT, patients should be instructed to avoid stressing the treated area for 1 week and to perform only light stretching for the following 2 weeks, with weight restrictions for the area treated. Strengthening exercises, particularly eccentric loading, begin after 3 weeks, with gradual return to higher-level activities at 6 weeks. Symptomatic relief may not been seen until 12 weeks after the procedure and may require more than 1 treatment.
A recent study1 sought to determine the effectiveness of LPT at various locations of pathologic tendons. Fourteen tendons in 13 patients were identified as having longer than a 6-month history of clinical presentation consistent with tendinopathy that had failed treatment with physical therapy. The 14 tendons included patellar (5 patients), Achilles (4 patients), and proximal gluteus medius, proximal iliotibial tract, proximal hamstring, common extensor elbow, and proximal rectus femoris in 1 patient each. All patients were treated by sonographically guided percutaneous tenotomy using a 22-gauge needle and a local anesthetic. The mean (SEM) composite visual analog scale scores were significantly lower at 4 weeks (2.4 [0.7]) and at 12 weeks (2.2 [0.7]) compared with baseline (5.8 [0.6]) (P < .001). No complications or morbidity occurred.
Lateral epicondylosis is one of the most frequently researched conditions that are treated by LPT. In a comparison study2 of treatment with local anesthetic only vs local anesthetic plus corticosteroids, there was no significant difference between study groups, both of which improved, indicating that the technique (not the medication) is the key to healing. Another 2 studies looked at the use of this technique in the treatment of chronic tendinosis of the lateral elbow (ie, tennis elbow). In the first study,3 a total of 55 patients were treated by LPT in which the tendon was infiltrated with corticosteroids. Thirty-five (63.6%) reported excellent outcomes, 16.4% good, 7.3% fair, and 12.7% poor. A second study4 by the same research group treating 52 patients using the same procedure without corticosteroid therapy showed that sonographically guided LPT for refractory lateral elbow tendinosis is an effective procedure and that subsequent corticosteroid injection is unnecessary. Of 52 patients, 30 (57.7%) reported excellent outcomes, 18 (34.6%) good, 1 (1.9%) fair, and 3 (5.8%) poor. No adverse events were reported in either study. In another study,5 a cohort of 47 patients received LPT or open surgery for chronic tennis elbow. Patients who underwent LPT returned to work on average 3 weeks earlier and improved significantly more quickly than those who underwent an open procedure. The authors concluded that LPT is a quicker and simpler procedure and produces significantly better results than open surgery.
Longitudinal percutaneous tenotomy performed under ultrasonography guidance is a simple outpatient procedure that requires minimal follow-up care. The technique does not hinder the prospect for surgical intervention if it fails and has a low complication rate. For comparison, the complication rate can be as high as 11% for open repair of Achilles tendon.6 Longitudinal percutaneous tenotomy should be considered in the management of muscular, tendinous, and ligamentous injuries that have not responded to conservative care.
Contraindications for LPT include concurrent anticoagulant therapy. Diabetes mellitus is a relative contraindication for dextrose, which should not be added to the treatment solution for patients with diabetes. Immune dysfunction is also a relative contraindication, as treatment may result in a less than optimal healing response and may increase the risk of infection in an immune-compromised patient. In my practice, I have patients wait 3 weeks after any antibiotic treatment and 6 weeks after treatment with fluoroquinolones because of the association of this drug class with tendon rupture. Conditions that may not respond well to LPT include severe Achilles pantendinopathy and severe calcific tendinosis of any tendon.
Report of a Case
A 59-year-old female patient was seen with right lateral elbow pain in a workers’ compensation case. She had been evaluated by an upper extremity orthopedic specialist and was diagnosed as having lateral epicondylitis, which had developed as a work-related repetitive use injury. She was referred for treatment because she had failed conventional treatment, which included physical therapy and corticosteroid injections. She had persistent elbow pain to the point that she could not hold any weight in her pronated right hand. Initial ultrasonographic evaluation demonstrated an enlarged hypoechoic (darker) tendon, which indicates mucoid degeneration and loss of normal tendon fibers. In addition, there were many hyperechoic (bright) foci that resembled pieces of popcorn in the tendon, indicating scarring and calcification.
The patient was treated by LPT with platelet-rich plasma as the injectate 6 times over a 16-month period at 8- to 12-week intervals. Between treatments, she followed a nutritional medicine protocol that included the following: vitamin C (500 mg BID), manganese (4 mg BID), copper (2 mg BID), and methylsulfonylmethane (titrated to 5 mg BID). She completed eccentric loading exercises with hand weights. At a follow-up visit, she had no lifting restriction with her elbow. She persisted in having palpatory pain in a small section of the lateral epicondyle; however, she had regained 100% of her previous function.
A Safe and Effective Procedure for Treating Chronic Tendinosis
Ultrasound-guided LPT is simple, can be performed on an outpatient basis, and requires minimal follow-up care. In my experience and that reported in the literature, the procedure has a low complication rate. Ultrasonographic guidance provides an increased level of safety and accuracy that cannot be matched with blind injection procedures. I use this procedure as the therapy of choice for patients with chronic tendinosis who have failed conservative treatment.
Dr. Sam Russo, ND, LAc completed his Masters Degree in Acupuncture and Doctorate Degree in Naturopathic Medicine at Bastyr University. Dr. Russo is past president of the Vermont Association of Naturopathic Physicians and currently serves as advisor to the Office of Professional Regulation in Vermont. He is a member of the Vermont Association of Naturopathic Physicians, the American Academy of Pain Management and the American Institute of Ultrasound In Medicine and is the scientific editor for Better Nutrition Magazine.
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2. Altay T, Günal I, Oztürk H. Local injection treatment for lateral epicondylitis. Clin Orthop Relat Res. 2002;398:127-130.
3. McShane JM, Nazarian LN, Harwood MI. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow. J Ultrasound Med. 2006;25(10):1281-1289.
4. McShane JM, Shah VN, Nazarian LN. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow: is a corticosteroid necessary? J Ultrasound Med. 2008;27(8):1137-1144.
5. Dunkow PD, Jatti M, Muddu BN. A comparison of open and percutaneous techniques in the surgical treatment of tennis elbow. J Bone Joint Surg Br. 2004;86(5):701-704.
6. Testa V, Capasso G, Benazzo F, Maffulli N. Management of Achilles tendinopathy by ultrasound-guided percutaneous tenotomy. Med Sci Sports Exerc. 2002;34(4):573-580.