Ultrasound guided ultrasonic tenotomy (Tenex procedure)


Tendinopathy affects a large number of athletes and non-athletes, and constitutes approximately 30% of consultations for musculoskeletal pain in the general practice setting. (104)

Tendinopathy has been well established to be less of an inflammatory response and more of a chronic degradation of the tendon (think of it as tendon failure), with pathophysiology consisting of degenerative microtearing, collagen fiber disorganization, hypercellularity, and angiofibroblastic hyperplasia of the tendon proper. (105)  Chronic tendinopathies affect approximately 10 million patients per year, requiring frequent physician visits and a large economic health burden. (106,107) Often despite months of extensive conservative treatment such as rest, activity modification, physical therapy, oral and topical medications, and orthotics and/or bracing, more advanced treatment options such as injections and surgery are sought for pain relief. Traditionally corticosteroid injections are offered as the next step in treatment approach. However, as more evidence emerges revealing potential harms of corticosteroids on soft tissues such as risk of tendon rupture, and fat pad atrophy, physicians are turning to other injectable options such as prolotherapy, autologous blood products (Platelet-rich plasma (PRP), or Bone marrow aspirate concentrate (BMAC)), or placental-derived products; needle tenotomy with or without orthobiologic injectate; and neovessel ablation. (108-117)  The hope of regenerative medicine is to restore the homeostasis of the affected tissue and if possible replace or regenerate human cells or tissues to restore normal function, through stimulation of the body’s natural intrinsic pathways. (118) While still an emerging field, regenerative medicine has touched nearly every field of medicine, and has been applied to congenital defects, chronic disease, trauma and aging. (119) 

Possible treatment options for tendinopathy provided in this clinic:

• Ultrasound guided tendon scraping (Neovessel ablation)

• Ultrasound guided ultrasonic tenotomy (Tenex procedure)

• Ultrasound guided High Volume Injection (HVI)

• Ultrasound guided orthobiologics 

Platelet-rich-plasma (PRP)

Bone marrow aspirate concentrate (BMAC)

What is ultrasound guided ultrasonic tenotomy (Tenex procedure)?

Ultrasonic tenotomy (“Tenex procedure”) involves the use of a small handset to treat tendinitis/tendinopathies about the body. It allows the simultaneous emulsification and aspiration of abnormal tendon tissue using ultrasound-guidance and presents a minimally invasive alternative to traditional surgical approaches for tendinitis.120-125  Under direct sonographic visualization , the Tenex tip (Tenex Health, Lake Forest, CA) is introduced through a small 3 mm incision and uses phacoemulsification to target, debride, and aspirate abnormal tendon tissue through a tube-within-a-tubesystem. (120,122,123,126-128) 

Dr. Pourcho had the privilege and honor to train with Dr. Smith MD as part of his fellowship at Mayo clinic (Rochester, MN) who helped develop the device. He has done over 2000 tenex procedures on various tendons, has done several national talks on the subject, has been integral in developing post-procedure guidelines, and published multiple publications. He is also part of a multi-site study funded by AMSSM to publish more on the technique for use on the Achilles tendon. 

What are the common problems this device is used to treat?

Ultrasonic tenotomy (Tenex procedure) has been used to treat common extensor tendinitis (Tennis elbow), plantar fasciitis/ plantar fasciosis, calcific tendinitis, Achilles tendinitis, patellar tendinitis, hip adductor tendinitis, gluteal tendinitis, hamstring tendinitis, and rotator cuff tendinitis.

What is the efficacy?

Previous prospective case series have shown improvement in pain, function, and ultrasound (US) appearance of the affected tissue with up to 36 months follow-up. (120,122,125) The longest series to date of 20 patients showed sustained improvement in VAS score (0 ± 0.9) and mean DASH compulsory score ( 0 ± 0.644). (125)  Additionally, there was a  reduction in thickness, hypervascularity and hypoechogenicity in the majority of the patients by 3 years. (125)  No major complications were reported in any series reported to date. (120,129-131)

What is the recovery like?

Both anecdotally and in the published literature, typically it takes about 6 weeks for the tendon or fascia itself to heal. Patients will report increased pain for about 2 weeks following procedure with return to baseline pain around 2 weeks. Then the pain will wax and wane for an additional 4 weeks as the tendon/fascia remodels. On follow-up ultrasound most patients have healed the tendon/fascia by 6 weeks. Most patients become pain free or nearly pain free between weeks 6-12, but this can vary from patient to patient. 

Some patients elect to augment (combine) this procedure with an orthobiologic with the goal of putting the tendon/fascia in the best environment to heal. 

Published prospective case series have shown improvement in pain, function, and ultrasound (US) appearance of the affected tissue with up to 36 months follow-up. (120,122,125) Patients  have shown a sustained improvement in pain scores and mean DASH compulsory score at 3 year follow-up. (125)  Additionally, there was a  reduction in thickness, hypervascularity and hypoechogenicity in the majority of the patients at 3 years. (125)  

What are the risks/complications?

The risks of any procedure involving a break in the skin include, infection, neurovascular or tendinous soft tissue injury and failure to provide relief. Ultrasound makes risk of iatrogenic injury to neurovascular structures and anatomic variants lower as the anatomic is viewed throughout the procedure. 

Is this FDA approved?

Yes, this device is FDA approved since 2012. 


Research Articles

Poster 163 Percutaneous Ultrasonic Tenotomy for Refractory Common Extensor Tendinopathy Following Failed Open Surgical Release: A Case Report.

Williams RC, Pourcho A.PM R. 2016 Sep;8(9S):S215. doi: 10.1016/j.pmrj.2016.07.204. Epub 2016 Sep 24.PMID: 27672929 

Percutaneous Ultrasonic Tenotomy for Refractory Common Extensor Tendinopathy After Failed Open Surgical Release: A Report of Two Cases.

Williams RC, Pourcho AM.PM R. 2018 Mar;10(3):313-316. doi: 10.1016/j.pmrj.2017.07.077. Epub 2017 Aug 5.PMID: 28789976

Percutaneous Ultrasonic Fasciotomy for Refractory Plantar Fasciopathy After Failure of a Partial Endoscopic Release Procedure.

Reference Publications

Watch Dr. Pourcho's talk on this procedure at 2021 Tenex Sponsored Symposium

See the full list of Dr. Pourcho's reference publications on this topic