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].