Percutaneous Tenotomy Offers Another Option When Conservative Care Falls Short in Chronic Tendinopathy

For patients with chronic tendinopathy, treatment has often come down to two choices: continue conservative care after progress stalls or proceed to surgery. However, percutaneous tenotomy now offers an option between those extremes, providing relief for some patients with persistent symptoms.

The minimally invasive procedure uses ultrasound guidance to debride degenerative tendon tissue through a small incision, typically with local anesthesia in an ambulatory setting. By removing pathologic tissue and creating a controlled micro-injury, the procedure is intended to stimulate healing.

“When rest, ice, medication, physical therapy and other conservative treatments have stopped working, this procedure offers another option before considering open tenotomy,” says Cleveland Clinic primary care sports medicine physician Wesley Baker, DO. “It’s a middle ground that is less invasive and requires less downtime than full surgery. That’s why so many patients are drawn to it.”

A middle ground between conservative care and surgery

First-line treatment for chronic tendinopathy remains activity modification, NSAIDs when appropriate and physical therapy. Depending on the anatomic site and clinical scenario, selected patients also may benefit from corticosteroid injection or biologic treatments such as platelet-rich plasma (PRP).

Percutaneous tenotomy becomes a consideration when symptoms persist despite this nonoperative care. According to Dr. Baker, ideal candidates typically have:

• Chronic symptoms lasting months to years
• Inadequate relief after at least six weeks of physical therapy
• Inadequate relief with NSAIDs or other standard conservative measures
• Imaging evidence of tendinosis or partial tearing without a high-grade tear

Common indications include:

• Lateral epicondylitis
• Medial epicondylitis
• Rotator cuff tendinopathy
• Patellar tendinopathy
• Gluteal tendinopathy/lateral hip pain
• Achilles tendinopathy
• Plantar fasciitis

“If a patient had moderate success with physical therapy or injection, but the progress didn’t last for long, they might be a perfect candidate for percutaneous tenotomy,” Dr. Baker says. “For those who had no response to those conservative treatments, I would recommend further workup, probably with an MRI, to better understand their pathology.”

Patient selection is critical

As with many tendon procedures, success depends heavily on patient selection. Percutaneous tenotomy is generally not appropriate for acute inflammatory tendon pain, such as overuse symptoms in younger athletes.

It is also not the best option for patients with high-grade tearing (generally greater than 50%), tendon rupture or impending rupture.

“For acute conditions, I’d consider other nonoperative options first, including steroid injection or PRP,” Dr. Baker says. “Open surgery is more appropriate for patients with more substantial tearing because of the risk of progression or rupture.”

Imaging helps confirm candidacy

Imaging plays an important role in determining whether percutaneous tenotomy is likely to help. Ultrasound or MRI can confirm tendinosis, identify partial tearing and rule out higher-grade structural pathology that may warrant surgery.

That distinction is especially important in patients who have not responded at all to conservative treatment, since persistent symptoms may indicate a diagnosis other than isolated chronic tendinopathy.

Rehabilitation is part of the procedure

Percutaneous tenotomy should not be viewed as a stand-alone intervention. Dr. Baker emphasizes that post-procedure rehabilitation is essential to optimize tendon healing and functional recovery.

“Tendons heal according to the stresses we put on them,” he says. “Physical therapy can help load a healing tendon properly. Performing percutaneous tenotomy by itself without therapy would not be as effective.”

A structured rehabilitation plan should be part of the treatment strategy from the outset, with progression tailored to the tendon treated, symptom severity and baseline function.

The procedure may also be paired with PRP in selected patients.

“I often compare it to maintaining a golf course,” Dr. Baker says. “Percutaneous tenotomy is like aerating the grass, while PRP is the fertilizer. Each improves the health of the tissue, but the combination may produce a stronger effect.”

Setting expectations before the procedure

Although the procedure itself takes only minutes, patients should be counseled that the overall visit will be longer and that short-term restrictions are common. Depending on the tendon treated, patients may go home with a sling, walking boot or crutches and may need temporary activity or weightbearing restrictions.

Recovery timelines vary by anatomic site, but most patients should expect gradual improvement over weeks to months rather than immediate relief. Early follow-up is important to assess pain, wound healing, and readiness to begin or advance therapy.

Dr. Baker sees patients for follow-up at one week, one month and three months.

“By three months, patients usually know whether the procedure has been successful,” he says. “Percutaneous tenotomy is not appropriate for every patient with tendon pain. But for frustrated patients who have tried and failed conservative treatment and still want to avoid surgery, it’s a good intermediate option.”