Treating recalcitrant tendinopathy

Combination of tenotomy and PRP injections produces significant improvement

Recently recognized as primarily a degenerative condition, tendinopathy (previously called tendinitis) is characterized by hypercellularity, vascular hyperplasia and collagen disorganization. Nonoperative treatment of tendinopathy includes:

  • Correction of biomechanical factors, kinetic chain deficits and training errors
  • Activity modifications, stretching, strengthening, endurance and proprioceptive exercises
  • Bracing, physical modalities and medications

When nonoperative interventions fail to relieve symptoms, additional treatment options that attempt to stimulate tissue regeneration can be considered. Emerging therapies include tendon fenestration (percutaneous tenotomy) and platelet-rich plasma (PRP) injections.

Tendon fenestration

During tendon fenestration, the practitioner uses ultrasound to make multiple needle passes through the injured area to stimulate tissue healing. This process disrupts tendinopathic tissue and induces bleeding. The bleeding leads to clot formation and release of growth factors.

"The goal of this treatment is to convert a chronic, nonhealing injury into an acute injury with increased healing potential," explains Jay Smith, M.D., who specializes in sports medicine and musculoskeletal ultrasound in the Department of Physical Medicine and Rehabilitation at Mayo Clinic in Rochester, Minn.

PRP injections

Another promising new treatment for refractory tendinopathy is PRP injection. Used for more than a decade to facilitate the healing of difficult wounds, PRP is rich in growth factors linked to healing.

Using ultrasound guidance, practitioners inject the PRP into the affected tendon, usually following a tendon fenestration procedure. It is theorized that when PRP is injected into an area of tendinopathy, the platelets release growth factors and stimulate a healing response. "The fenestration breaks up the abnormal tissue, and then we inject the platelets into the prepared area to promote healing," explains Dr. Smith.

PRP is created from an autologous whole-blood sample through a platelet separation process, which results in an increased platelet concentration compared with that of the original whole-blood sample.

In a recent study published in the journal PM&R, "Treatment of Chronic Tendinopathy With Ultrasound-Guided Needle Tenotomy and Platelet-Rich Plasma Injection," Mayo Clinic researchers reported that the combination of tenotomy and PRP injections produced significant improvement in many patients with long-standing tendon injuries.

The study included 34 patients with a wide range of tendon and soft tissue injuries, from tennis elbow (lateral epicondylitis) to plantar fasciitis, an inflammation on the bottom of the foot. "These disorders can be hard to treat, and patients tend to receive one therapy or the other (tenotomy vs. PRP), depending on what a doctor happens to offer. Our study was the first clinical study to investigate the combination of both treatments in injured tendons," says Dr. Smith.

Researchers found maximum benefits tended to occur within four months after the procedure. More than 70 percent of patients had better use of their tendons, and 76 percent reported improvement in pain. In addition, researchers found some indication of tendon healing, which was detected with sophisticated ultrasound imaging.

"Larger studies are still necessary to determine whether the combination is particularly helpful for certain injuries or types of tendons, but this investigation showed these therapies together are safe and effective for some people who have an ongoing tendinopathy," says Dr. Smith.

Points to remember

  • During tendon fenestration (percutaneous tenotomy), the practitioner uses ultrasound to make multiple needle passes through the injured area to stimulate tissue healing.
  • Used for more than a decade to facilitate the healing of difficult wounds, platelet-rich plasma (PRP) injections are another promising new treatment for refractory tendinopathy.
  • Mayo Clinic researchers found that more than 70 percent of patients treated with a combination of tenotomy and PRP injections had better use of their tendons, and 76 percent reported improvement in pain.