TENEX and Needle Tenotomy

Minimally Invasive Treatment for Chronic Tendon Pain and Degenerative Tendon Injuries

Chronic tendon pain can persist even after rest, physical therapy, medication, bracing, activity modification, or injections. In many of these cases, the problem is not ongoing short-term inflammation. Instead, the tendon may contain chronically damaged, disorganized, or degenerative tissue that is no longer progressing through a normal healing response.

TENEX and ultrasound-guided needle tenotomy are minimally invasive procedures designed to treat this type of chronic tendon dysfunction.

Both procedures target abnormal tendon tissue under direct musculoskeletal ultrasound guidance. The goal is to stimulate a new, organized healing response and improve the tendon’s ability to tolerate movement, exercise, work, and athletic activity.

TENEX uses ultrasonic energy with irrigation and aspiration to break down and remove selected damaged tissue. Needle tenotomy uses a standard medical needle to repeatedly stimulate the abnormal portion of the tendon without removing it.

These procedures can provide an intermediate treatment option between conservative care and traditional open surgery.

What Is Tendinopathy?

Tendinopathy is a chronic condition affecting a tendon—the strong connective tissue that attaches muscle to bone.

Although chronic tendon pain is often called tendinitis, many long-standing tendon conditions are not primarily inflammatory. The tissue may instead demonstrate:

• Disorganized collagen

• Tendon thickening

• Partial fiber disruption

• Reduced blood flow

• Abnormal blood-vessel formation

• Calcification

• Scar tissue

• Loss of normal tendon stiffness

• Degenerative tissue changes

• Reduced ability to tolerate mechanical loading

This chronic degeneration is sometimes described as tendinosis.

Pain may improve temporarily with rest or medication, but symptoms frequently return when the tendon is loaded again. This can create a cycle of pain, reduced activity, weakness, and repeated irritation.

TENEX and needle tenotomy are designed to interrupt this cycle by targeting the abnormal tendon tissue and stimulating a renewed healing response.

What Is Percutaneous Tenotomy?

The term percutaneous means that the procedure is performed through the skin rather than through a large surgical incision.

A tenotomy is a procedure involving a tendon. In minimally invasive sports medicine, percutaneous tenotomy generally refers to using a needle or small specialized instrument to stimulate, fragment, or remove chronically damaged tendon tissue.

The procedure is performed under musculoskeletal ultrasound guidance so the provider can:

• Identify the abnormal tendon tissue

• Visualize the treatment instrument in real time

• Avoid nearby nerves and blood vessels

• Target the damaged tissue precisely

• Limit disruption of healthier tendon fibers

• Evaluate the surrounding anatomy

Percutaneous needle tenotomy and TENEX ultrasonic tenotomy use different instruments, but both are based on the principle that chronic degenerative tendon tissue may benefit from controlled mechanical treatment.

What Is the TENEX Procedure?

TENEX is a minimally invasive form of percutaneous ultrasonic tenotomy.

The procedure uses a specialized microtip that delivers ultrasonic energy into the diseased portion of a tendon or fascia. The ultrasonic energy fragments and emulsifies selected abnormal soft tissue, while irrigation and aspiration help remove the treated tissue.

The FDA-cleared TENEX Health TX System is classified as an ultrasonic surgical aspirator and is indicated for procedures in which fragmentation, emulsification, and aspiration of soft tissue are desired, including orthopedic procedures.

The procedure is performed through a small skin opening and generally does not require the larger incision, sutures, or extensive tissue exposure associated with open tendon surgery.

How TENEX Works

TENEX treatment involves several coordinated steps.

Identifying the Damaged Tissue

Musculoskeletal ultrasound is used to locate areas of tendon thickening, degeneration, tearing, calcification, or abnormal tissue architecture.

The provider can compare healthy and unhealthy areas of the tendon and identify the safest treatment path.

Local Anesthesia

The skin and surrounding treatment area are numbed with local anesthetic. General anesthesia is typically unnecessary.

Introducing the Microtip

A small opening is created in the skin, and the TENEX microtip is advanced toward the abnormal tissue under direct ultrasound guidance.

Ultrasonic Tissue Treatment

The microtip delivers ultrasonic energy that fragments and emulsifies selected abnormal soft tissue.

Irrigation and Aspiration

The system introduces fluid while simultaneously removing fragmented tissue. This allows the provider to selectively debride the targeted area through a very small access point.

Closing and Protecting the Area

The microtip is removed, and the small opening is covered with a dressing. Sutures are often unnecessary, although the exact closure method depends on the treatment area and procedure performed.

What Is Ultrasound-Guided Needle Tenotomy?

Needle tenotomy—also called percutaneous needle tenotomy, tendon fenestration, or dry needling of the tendon—is performed using a standard medical needle.

Under ultrasound guidance, the needle is passed through the abnormal portion of the tendon multiple times in a controlled pattern.

This creates small channels within the degenerative tissue and converts a chronic, biologically inactive condition into a controlled acute healing response. The intended result is renewed bleeding, cellular recruitment, inflammatory signaling, collagen turnover, and tissue remodeling.

Unlike TENEX, conventional needle tenotomy does not use ultrasonic energy or aspiration to remove tissue.

How Needle Tenotomy Works

During ultrasound-guided needle tenotomy:

1. The injured tendon is evaluated with musculoskeletal ultrasound.

2. The skin and treatment area are sterilized.

3. Local anesthetic is administered.

4. A needle is advanced into the abnormal portion of the tendon.

5. The needle is passed through the damaged tissue in multiple directions.

6. Calcific, scarred, or degenerative areas may be mechanically disrupted.

7. The needle is removed, and a small dressing is applied.

The controlled needle passes stimulate localized bleeding and biological signaling within the abnormal tendon.

Needle tenotomy may be performed alone or combined with another regenerative medicine treatment, such as platelet-rich plasma or plasma prolotherapy.

TENEX Versus Needle Tenotomy

Both procedures are designed to treat chronic tendon or fascial disease, but they do so differently.

TENEX Ultrasonic Tenotomy

TENEX:

• Uses a specialized ultrasonic microtip

• Fragments selected abnormal tissue

• Uses irrigation and aspiration

• Physically removes a portion of the treated tissue

• Requires a small skin opening

• Is generally used for more established or focal degenerative tissue

• May be useful when ultrasound demonstrates scarred, thickened, calcific, or clearly diseased tissue

Percutaneous Needle Tenotomy

Needle tenotomy:

• Uses a standard medical needle

• Creates multiple controlled passes through the tendon

• Stimulates bleeding and a renewed healing response

• Does not aspirate or remove tissue

• Typically requires only a needle puncture

• May be appropriate for less extensive tendinopathy

• Can be combined with PRP or another orthobiologic treatment

Neither procedure is automatically superior for every patient.

The correct treatment depends on the location, tissue appearance, severity of degeneration, duration of symptoms, previous treatments, functional demands, and rehabilitation goals.

Conditions Commonly Treated With TENEX or Needle Tenotomy

These procedures may be considered for chronic tendon or fascial conditions that have not improved adequately with conservative care.

Elbow

• Lateral epicondylitis, or tennis elbow

• Medial epicondylitis, or golfer’s elbow

• Common extensor tendinopathy

• Common flexor tendinopathy

• Distal triceps tendinopathy

• Selected distal biceps tendon conditions

Shoulder

• Rotator cuff tendinopathy

• Calcific rotator cuff tendinopathy

• Selected partial tendon injuries

• Chronic biceps tendinopathy

Not every rotator cuff tear is appropriate for percutaneous tenotomy. Full-thickness tears, major retraction, muscle atrophy, instability, or advanced joint disease may require a surgical consultation.

Hip and Pelvis

• Gluteus medius tendinopathy

• Gluteus minimus tendinopathy

• Greater trochanteric pain syndrome

• Proximal hamstring tendinopathy

• Selected adductor tendon injuries

• Iliotibial band-related pathology

• Tensor fascia lata tendinopathy

Knee

• Patellar tendinopathy

• Quadriceps tendinopathy

• Jumper’s knee

• Selected iliotibial band conditions

• Chronic tendon attachment pain

Foot and Ankle

• Plantar fasciopathy

• Chronic plantar heel pain

• Achilles tendinopathy

• Insertional Achilles tendinopathy

• Peroneal tendinopathy

• Posterior tibial tendinopathy

Other Conditions

• Chronic tendon scarring

• Calcific tendon deposits

• Recalcitrant tendon pain

• Chronic myotendinous injuries

• Selected postoperative scar or tendon abnormalities

Evidence is strongest for certain conditions, particularly chronic elbow tendinopathy and plantar fascia pain. Research involving other tendon sites is promising but remains more limited and heterogeneous.

When TENEX May Be Recommended

TENEX may be considered when:

• Symptoms have persisted for several months

• Physical therapy has not produced adequate improvement

• Activity modification has not resolved the pain

• The tendon contains a focal area of degenerative tissue

• Ultrasound demonstrates thickening, tearing, calcification, or scar tissue

• The condition continues to limit work, exercise, or sports

• The patient wants to avoid or delay open surgery

• Needle tenotomy or previous injection treatments have not provided lasting improvement

• The tissue abnormality can be safely accessed under ultrasound guidance

TENEX is generally not the first treatment for a new tendon injury. Most patients should first undergo an appropriate period of diagnosis-specific conservative care.

When Needle Tenotomy May Be Recommended

Percutaneous needle tenotomy may be considered when:

• Chronic tendinopathy is present without extensive tissue damage

• The abnormal tendon can be clearly visualized on ultrasound

• Progressive strengthening has not fully resolved symptoms

• A controlled healing response is desired

• The patient is not ready for a more involved procedure

• The treatment will be combined with PRP or plasma prolotherapy

• There is a localized degenerative area that can be safely fenestrated

• Previous conservative treatment has failed

Needle tenotomy may also be used as part of a regenerative injection procedure. In this setting, the needle mechanically stimulates the tendon before PRP or another biologic product is placed into and around the damaged tissue.

Combining Needle Tenotomy With PRP

Needle tenotomy and PRP address different parts of the healing process.

Needle tenotomy provides a mechanical stimulus by creating small channels within the abnormal tendon. PRP delivers concentrated platelets, growth factors, and signaling proteins from the patient’s own blood.

When combined, the procedure is intended to:

• Disrupt chronic degenerative tissue

• Stimulate localized bleeding

• Recruit healing-related cells

• Deliver platelet-derived signaling proteins

• Support collagen synthesis

• Improve tendon remodeling

• Create a more complete regenerative response

Research has examined needle tenotomy both alone and in combination with PRP. Available evidence suggests that both approaches may improve chronic tendinopathy symptoms, although outcomes vary by tendon, PRP preparation, diagnosis, and rehabilitation protocol.

Adding PRP is not required in every case. The decision should be based on the condition, tissue quality, previous treatment, and desired biological effect.

Why Musculoskeletal Ultrasound Is Essential

TENEX and needle tenotomy should not be performed solely by estimating where the tendon is located.

Musculoskeletal ultrasound allows the provider to identify:

• Tendon thickening

• Hypoechoic degenerative tissue

• Partial tearing

• Calcification

• Scar tissue

• Abnormal blood flow

• Fascial thickening

• Fluid or bursitis

• Nearby nerves and blood vessels

• The relationship between the tendon and surrounding structures

Ultrasound also allows the provider to observe the needle or TENEX microtip throughout the procedure.

This helps ensure that treatment is concentrated within the abnormal tissue while protecting healthier tendon fibers and nearby anatomy.

TENEX and Needle Tenotomy Are Not Cortisone Injections

Corticosteroid injections are intended primarily to suppress inflammation and provide symptom relief.

TENEX and needle tenotomy have a different purpose.

These procedures attempt to alter the structure and biological behavior of chronically damaged tissue. They are not designed to numb the area temporarily or eliminate all inflammation.

In fact, a controlled inflammatory response is part of the intended healing process after tenotomy.

This is why recovery is gradual and why soreness may initially increase after the procedure.

What to Expect During the Procedure

Both TENEX and needle tenotomy are generally performed in an outpatient setting.

Before the procedure:

• The diagnosis and imaging findings are reviewed

• The tendon is examined with ultrasound

• The treatment area is marked

• The skin is cleaned and sterilized

• Local anesthetic is administered

Patients may feel pressure, movement, vibration, or mild discomfort during treatment. The area should remain adequately numb, although some sensations related to tissue manipulation may still be present.

Procedure time varies by the tissue and treatment performed. The active treatment portion is often relatively brief, but additional time is needed for preparation, ultrasound evaluation, anesthesia, dressing placement, and post-procedure instructions.

Recovery After TENEX or Needle Tenotomy

TENEX and needle tenotomy are minimally invasive, but they are still tendon procedures.

The treated tissue requires time to heal and remodel.

Recovery generally progresses through several phases.

Initial Protection

During the first several days, patients may experience:

• Soreness

• Bruising

• Mild swelling

• Stiffness

• Tenderness

• Temporary weakness

• Increased pain with use of the treated tendon

The area may require a brace, walking boot, sling, compression wrap, or other temporary support depending on the tendon treated.

Early Movement

Gentle range-of-motion exercises may begin relatively early to limit stiffness and maintain normal movement.

The timing depends on the location and severity of the tendon condition.

Progressive Loading

As initial soreness improves, controlled strengthening is introduced.

This may include:

• Isometric exercise

• Slow resistance training

• Eccentric loading

• Concentric loading

• Mobility work

• Balance and stability training

• Gradual functional activity

Return to Activity

Running, jumping, throwing, heavy lifting, and sport-specific activity are gradually reintroduced based on tendon tolerance and functional testing.

Symptoms alone should not determine readiness to return to unrestricted activity. Strength, mobility, tendon capacity, movement quality, and the demands of the activity must also be considered.

Published rehabilitation protocols after needle tenotomy and ultrasonic debridement remain inconsistent, reinforcing the need for an individualized recovery plan.

How Long Does Recovery Take?

Recovery time varies significantly by tendon and procedure.

Smaller tendon areas may recover more quickly, while larger weight-bearing tendons may require a longer period of protection and rehabilitation.

General improvement may occur over:

• Several weeks for early pain reduction

• Six to twelve weeks for meaningful functional improvement

• Three to six months for continued tendon remodeling

• Longer periods for severe, chronic, or weight-bearing tendon injuries

A comparative study of ultrasonic tenotomy and surgical tenotomy for chronic common extensor tendinosis reported meaningful symptomatic improvement developing over approximately three to six months.

These timelines are general and should not be interpreted as guaranteed recovery periods.

Potential Benefits

For appropriately selected patients, potential benefits may include:

• Minimally invasive treatment

• No large surgical incision

• Local rather than general anesthesia

• Direct ultrasound visualization

• Targeted treatment of damaged tendon tissue

• Limited disruption of surrounding healthy tissue

• Shorter initial recovery than open surgery

• Reduced tendon pain

• Improved function

• Improved tolerance of exercise and loading

• Potential ability to delay or avoid open surgery

• Ability to combine treatment with PRP or other regenerative procedures

Systematic reviews have reported improvements in pain, physical function, and quality of life after percutaneous needle tenotomy and ultrasonic tenotomy, with relatively few reported adverse effects. However, much of the available literature consists of observational studies, and outcomes vary by condition.

Risks and Limitations

TENEX and needle tenotomy are generally well tolerated, but no procedure is risk-free.

Potential risks include:

• Pain

• Bleeding

• Bruising

• Swelling

• Infection

• Skin irritation

• Nerve injury

• Blood-vessel injury

• Incomplete symptom relief

• Temporary worsening of pain

• Tendon weakening

• Progression of an existing tear

• Tendon rupture

• Scar formation

• Need for additional treatment

• Need for later surgery

TENEX-specific risks may also include device-related complications or retained device fragments, although these events appear uncommon. FDA adverse-event reports document microtip separation events in which fragments were retrieved without reported patient complications. Individual adverse-event reports cannot establish the overall frequency of a complication.

A careful ultrasound evaluation and appropriate post-procedure restrictions help reduce risk.

When These Procedures May Not Be Appropriate

TENEX or needle tenotomy may not be appropriate when there is:

• A complete tendon rupture

• Severe tendon retraction

• Advanced muscle atrophy

• Active infection

• An open wound

• Uncontrolled bleeding risk

• Certain anticoagulant-related concerns

• Severe nerve dysfunction

• A tumor or unexplained mass

• An acute fracture

• Advanced joint destruction requiring surgical evaluation

• Inability to follow post-procedure restrictions

• A tendon abnormality that cannot be safely accessed

• Pain that is not generated by the tendon

Additional MRI, X-ray, electrodiagnostic testing, or surgical evaluation may be required before treatment.

TENEX Is Not the Same as Open Surgery

Open tendon surgery generally requires a larger incision, greater tissue exposure, and surgical dissection to locate and remove damaged tissue.

TENEX performs a more limited debridement through a small access point under ultrasound guidance.

Potential advantages include:

• A smaller skin opening

• Less disruption of surrounding tissue

• Local anesthesia

• No large surgical incision

• Reduced postoperative immobilization in many cases

• Faster return to basic daily activities

However, TENEX cannot replace surgery in every situation.

Large tendon tears, complete ruptures, severe retraction, significant instability, major bone abnormalities, or advanced joint disease may require open or arthroscopic repair.

The Importance of Rehabilitation

Removing or stimulating abnormal tendon tissue does not automatically restore strength and function.

The tendon must be progressively reloaded after the procedure.

Rehabilitation helps:

• Restore tendon strength

• Improve collagen organization

• Correct weakness

• Improve joint mobility

• Normalize movement patterns

• Reduce compensatory loading

• Rebuild sport-specific capacity

• Reduce the risk of recurrence

Too little loading can leave the tendon weak and poorly conditioned. Too much loading too early can irritate the healing tissue or increase the risk of treatment failure.

The rehabilitation plan must balance protection with progressive mechanical stimulation.

A Complete Tendon Recovery Strategy

Chronic tendinopathy is often influenced by more than the damaged tissue alone.

Contributing factors may include:

• Weakness

• Restricted joint mobility

• Repetitive overload

• Poor movement mechanics

• Training errors

• Inadequate recovery

• Metabolic disease

• Nutritional deficiencies

• Hormonal factors

• Tobacco use

• Poor sleep

• Medication effects

At Arizona Sports Medicine, TENEX and needle tenotomy may be incorporated into a broader treatment plan that includes:

• Diagnostic musculoskeletal ultrasound

• MRI or X-ray review

• Physical therapy

• Progressive tendon loading

• Shockwave therapy

• Platelet-rich plasma

• Plasma prolotherapy

• Bracing

• Movement correction

• Peptide-based recovery support

• Nutrition and health optimization

• Gradual return-to-sport planning

The goal is not simply to remove or needle abnormal tissue. The goal is to improve the entire environment in which the tendon must heal and function.

Which Procedure Is Right for Me?

The appropriate treatment depends on the appearance and severity of the tendon injury.

Needle tenotomy may be appropriate when the goal is to stimulate a chronic tendon without removing tissue.

TENEX may be preferred when there is a more defined area of diseased, scarred, calcific, or degenerative tissue that may benefit from ultrasonic debridement and aspiration.

PRP may be added when a stronger platelet-derived biological stimulus is desired.

Some patients may benefit more from shockwave therapy, physical therapy, an injection procedure, or surgical evaluation rather than tenotomy.

The correct recommendation should be based on examination, diagnostic imaging, previous treatment, activity goals, and realistic expectations.

Schedule a TENEX or Needle Tenotomy Evaluation

Persistent tendon pain does not always mean that open surgery is the next step.

A comprehensive evaluation can help determine:

• Whether the pain is coming from a tendon

• Whether the tissue demonstrates chronic tendinopathy

• Whether additional imaging is required

• Whether TENEX or needle tenotomy is appropriate

• Whether PRP should be included

• Whether shockwave therapy should be attempted first

• What recovery timeline should be expected

• What rehabilitation will be required

• Whether surgical evaluation is more appropriate

Schedule an evaluation with Arizona Sports Medicine to determine the most appropriate treatment for chronic tendon pain or a degenerative tendon injury.