Percutaneous Needle Tenotomy for Tendinopathy: Promising Evidence, but Are We Getting Ahead of Ourselves? | Find Your Stride | Edinburgh Podiatrist

Introduction

Chronic tendinopathy remains one of the greatest frustrations in sports medicine. Whether it's a runner battling mid-portion Achilles tendinopathy, a footballer with patellar tendinopathy, or a recreational athlete unable to shake chronic plantar heel pain, treatment often becomes a lengthy journey of progressive loading, patience and occasionally frustration.

A recent systematic review by Maag et al. (2024) examined whether ultrasound-guided Percutaneous Needle Tenotomy (PNT) and TENEX ultrasonic tenotomy provide an effective minimally invasive option for patients who fail conservative treatment. The conclusions appear encouraging, but how convincing is the evidence?

Percutaneous Needle Tenotomy (PNT) deliberately creates controlled microtrauma within degenerative tendon tissue.

What is Percutaneous Needle Tenotomy for Tendinopathy?

Unlike corticosteroid injections, which primarily aim to suppress inflammation, PNT deliberately creates controlled microtrauma within degenerative tendon tissue. The goal is to restart the healing cascade by stimulating vascularity and collagen remodelling. TENEX builds upon this concept using ultrasonic energy to simultaneously fragment and aspirate degenerated tendon tissue under ultrasound guidance. The biological rationale is attractive. The clinical evidence is less straightforward.

What Did the Review Find?

The authors identified 20 studies involving multiple anatomical regions including:

• Achilles tendon

• Plantar fascia

• Patellar tendon

• Gluteal tendons

• Lateral and medial elbow

• Hamstring

• Iliotibial band

• Rotator cuff

  
  

Across almost every study:

• Pain scores improved.

• Functional outcome measures improved.

• Patient satisfaction was generally high.

• Serious complications were uncommon.

  
  

For podiatrists, the most relevant findings involved:

Achilles Tendinopathy

Patients reported substantial reductions in pain alongside improved Lower Extremity Functional Scale (LEFS) scores at one year.

Plantar Fascia

Although technically plantar fasciopathy rather than tendinopathy, outcomes following TENEX were similarly encouraging, with large reductions in pain and improved function. These are attractive findings for clinicians managing patients who have exhausted exercise therapy, footwear modification and orthotic interventions.

The Good

The review deserves credit for several strengths. The authors followed PRISMA guidelines and prospectively registered the protocol through PROSPERO, reducing reporting bias. Multiple databases were searched and study quality was assessed using recognised methodological criteria. Importantly, they did not simply report pain scores but also included validated functional outcome measures such as:

• DASH

• LEFS

• SF-12

• Harris Hip Score

• Oxford Elbow Score

  
  

These outcomes better reflect meaningful clinical improvement than pain alone.

Where the Evidence Starts to Weaken

Unfortunately, the quality of the underlying evidence limits the strength of the conclusions.

Most included studies were:

• retrospective case series

• observational cohorts

• small sample studies

  
  

Only two randomised controlled trials were identified. Many studies lacked control groups entirely. Without comparison to exercise therapy alone, sham procedures or natural recovery, it becomes difficult to determine whether the procedure itself produced the improvement.

Tendinopathy often improves gradually over time, particularly when patients simultaneously modify activity and undertake rehabilitation. How much of the reported success belongs to the needle? We still don't know.

Achilles Tendinopathy: A Podiatry Perspective

From a sports podiatry viewpoint, Achilles tendinopathy deserves particular scrutiny.

Only two studies investigated Achilles outcomes. Considering Achilles tendinopathy is one of the most common running injuries, this represents surprisingly little evidence upon which to base widespread adoption. Even more concerning is the absence of studies comparing TENEX directly against contemporary loading programmes. Current evidence consistently supports heavy slow resistance and progressive tendon loading as first-line management.

The review cannot tell us whether TENEX is superior or merely equivalent to a well-delivered rehabilitation programme. For clinicians, this is an important distinction.

What About Running Performance?

Athletes rarely ask: "Will my MRI improve?" Instead they ask:

• When can I run?

• Will I return to previous performance?

• Will recurrence decrease?

  
  

Unfortunately, these questions remain unanswered. Very few studies evaluated:

• return-to-running timelines

• return-to-sport rates

• performance metrics

• running biomechanics

• tendon mechanical properties

  
  

Pain reduction alone should never be interpreted as restoration of athletic capacity.

Plantar Fasciopathy: Encouraging but Not Definitive

TENEX appears promising for chronic plantar fasciopathy. However, the review combines several anatomical regions and often reports pooled results. This makes it difficult to determine precisely how effective the procedure is specifically for plantar fascia pathology.

Given that plantar fasciopathy frequently responds to progressive loading, footwear optimisation, orthoses and calf strengthening, invasive procedures should probably remain reserved for genuinely recalcitrant cases.

The Missing Piece: Rehabilitation

Perhaps the biggest omission throughout the literature is rehabilitation. Many papers inadequately describe:

• loading progression

• return-to-running criteria

• strengthening protocols

• rehabilitation compliance

  
  

This is remarkable because rehabilitation is arguably the intervention most likely to influence long-term outcomes. Needling may stimulate healing. Loading directs it. Without structured rehabilitation, the biological stimulus may never translate into improved tissue capacity.

Clinical Take-Home Messages

For clinicians:

• TENEX and PNT appear relatively safe.

• They may have a role after prolonged failure of conservative care.

• Current evidence does not justify replacing progressive loading programmes.

• Patient selection is likely to determine success more than the procedure itself.

  
  

For runners; don't view needle tenotomy as a shortcut. Successful outcomes still require:

• progressive strengthening

• load management

• patience

• return-to-running progression

  
  

The procedure should complement rehabilitation—not replace it.

Our Verdict

This systematic review provides cautious optimism rather than definitive answers. The biological rationale for PNT and TENEX is compelling, and early clinical outcomes are encouraging across several tendinopathies. However, enthusiasm should be tempered by the relatively low quality of the underlying evidence. For sports podiatrists, the evidence is strongest for considering these procedures only after comprehensive conservative management has failed. Future research needs to move beyond pain scores and focus on what athletes actually care about:

• returning to running

• restoring tendon capacity

• improving performance

• preventing recurrence

  
  

Until then, progressive loading remains the cornerstone of evidence-based tendinopathy management.

Clinical Take-Home Points

• TENEX and PNT appear safe with relatively low complication rates.

• Most patients report improvements in pain and function following treatment.

• Evidence is strongest for elbow tendinopathy but remains limited for Achilles tendinopathy.

• Progressive tendon loading remains the gold standard for first-line management.

• Rehabilitation protocols were poorly described across most studies.

• There is little evidence regarding return-to-running or athletic performance.

• High-quality randomised controlled trials comparing TENEX with exercise therapy are urgently needed.

  
  

Bottom Line

Percutaneous needle tenotomy and TENEX are promising additions to the treatment pathway for stubborn tendinopathies, particularly when conservative management has failed. For sports podiatrists working with runners, however, the current evidence is not yet strong enough to justify widespread adoption as a routine intervention. The future research priorities are clear: well-designed randomised trials, standardised rehabilitation protocols, and meaningful athletic outcomes such as return to running, tendon capacity and recurrence rates.

Until then, the best results will continue to come from combining sound clinical reasoning, progressive loading, biomechanical assessment and careful patient selection, not from the needle alone.

Find Your Stride!

Citation

Maag L, Linder S, Mitchkash M, Farley T, Lamar D, Fisher N, Burnham B. Effectiveness of Percutaneous Needle Tenotomy for Tendinopathies: A Systematic Review. Sports Health. 2024;17(4):835–841. doi:10.1177/19417381241275659