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What's New For Tendonitis? How About This... A Revolutionary Minimally Invasive Procedure That May Prevent The Need For Surgery!

Mar 30, 2008
Tendonitis refers to a condition where there is inflammation of a tendon or group of tendons. Tendons are the "ropes" that connect muscles to bones. Tendons can become irritated as a result of repetitive motion or trauma. What occurs is "overuse" which causes microtrauma or injury to the tendon. The fibers that make up the tendon begin to break down. This process is often accompanied by inflammation, particularly if there is underlying arthritis.

Tendons can also be inflamed where they insert into bone. Tendons are subject to irritation because they cross joints. When joints are used, so are tendons.

While repetitive motion is the usual culprit that leads to tendonitis, aging is also a factor.

Since tendons are ubiquitous - present at every joint in the body- tendonitis is a common malady. It most often occurs in the shoulder, elbow, wrist, hip, knee, and ankle.

The traditional approach to managing tendonitis has been to use non-steroidal anti-inflammatory drugs (NSAIDS) supplemented by rest, physical therapy, assistive devices such as splints, and corticosteroid injections.

In severe case, open surgical procedures are performed

Fortunately, there is a relatively new option that appears to be having surprisingly good results.

Since tendonitis is due to inflammation, the old thinking has been that reducing inflammation is the best approach. As a result, anti-inflammatory drugs, steroid injections, and so forth have been the mainstays of the "old school" of treatment.

Unfortunately, inflammation is also the body's attempt to heal the damage to the tendon. The problem is that inflammation is not always accompanied by the increased blood flow required to bring new nutrients to the area to help with the healing processes.

So, new techniques have been devised to actually try to temporarily increase blood flow through carefully and selectively injuring the tendon at the area of concern, and then stimulating the body's normal healing mechanisms to spring into action. While this seems paradoxical, it works.

The first part of this process involves the use of ultrasound guided percutaneous tenotomy (UGPT). Ultrasound is employed to diagnose the problem and then to guide the insertion of a needle to selectively injure the tendon at the site where tissue repair needs to occur.

The second part of the process is to inject a small amount of platelet rich plasma. Platelets are small blood cells that are rich in various growth factors. These growth factors stimulate the growth and proliferation of new tissue. In essence, the platelet rich plasma helps regenerate new tendon fibers.

The procedure goes like this...

When the patient arrives at the clinic, the physician sits down and explains the procedure including risks and benefits.

The patients, if they agree to proceed, are taken to the laboratory and approximately 20 cc's of blood is drawn and then spun in a special centrifuge. After the specimen is spun, the layer containing platelets is drawn off using a special syringe.

The patient is first positioned in a comfortable manner.

The area of tendon pathology is then identified using diagnostic ultrasound. Often other problems that aggravate tendonitis such as bone spurs and arthritis will also be demonstrated.

After informed consent is obtained, the area is sterilely prepared and anesthetized with a local anesthetic. A special needle of suitable gauge and length is inserted through the anesthetized skin and soft tissue and advanced to the tendon at the site of injury. Bone spurs, if present are gently chiseled away using the needle. Using carefully placed movements, multiple small holes are then placed in the tendon.

Since local anesthetic has been administered previously, a minimal amount of discomfort is experienced.

After the needling procedure, a small amount of platelet rich plasma (also called "autologous tissue grafting material") is slowly injected into the area.

The needle is then removed and a simple bandage is placed over the needle hole.

Post-procedure care consists of absolute rest for three days followed by modified rest for another four days, then slow and careful resumption of activity.

Analgesics such as tramadol (Ultram) or Darvocet may be used. However, anti-inflammatory drugs and immunosuppressive drugs should be held for approximately a week before and a week after the treatment.

Ultrasound guided percutaneous tenomy and autologous tissue grafting often prevents the need to perform an open surgical procedure. This outpatient procedure is done using only local anesthetic.

A course of physical therapy may be initiated after the period of rest with the goals of improving function, decreasing pain, and increasing strength.

In some cases, a second course may be required. However, the long term results are extraordinary with very few patients requiring open surgery.

So who is a candidate for this procedure? Any patient with a history of chronic tendonitis that hasn't responded to other measures is a good candidate. This includes people with arthritis who also have tendonitis (sometimes the distinction is not always easy to make and the arthritis pain may actually be tendon-related pain). Patients with tendon rupture are not good candidates.

In another article I will discuss the use of platelet rich plasma.

For more information on tenotomy and platelet rich plasma, contact the Arthritis and Osteoporosis Center of Maryland at (301) 694-5800.
About the Author
Nathan Wei, MD FACP FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine. For more info: Arthritis Treatment
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