JEFFREY PENG MD
SPORTS MEDICINE & FAMILY MEDICINE
Percutaneous Needle Tenotomy
What Is Percutaneous Needle Tenotomy?
Percutaneous needle tenotomy—also known as tendon fenestration, tendon needling, or ultrasound-guided dry needling—is a minimally invasive procedure used to treat chronic tendon injuries that have not improved with conservative treatments like physical therapy, bracing, medications, or cortisone injections. The term "percutaneous" means through the skin, and "tenotomy" refers to cutting or disrupting tendon tissue. You may also see this procedure referred to by the brand name of the device used to perform it, such as Tenex, TenJet, or TendoNova Ocelot—these are all FDA-cleared tools that perform the same core procedure under ultrasound guidance.
During the procedure, an FDA-cleared powered tenotomy device is guided precisely into the damaged tendon using real-time ultrasound imaging. The device mechanically fragments and debrides the diseased tissue—breaking up scarred, degenerated collagen fibers and calcific deposits that are preventing the tendon from healing. Compared to manual needle fenestration alone, a powered device provides more consistent and efficient tissue debridement while preserving healthy surrounding tendon.
This controlled mechanical disruption serves a critical purpose: it converts a chronic, stalled tendon injury into an acute one that the body can actually repair. The needling triggers localized bleeding, fibroblast proliferation, and an influx of growth factors that jump-start collagen remodeling and tissue regeneration. In simple terms, the procedure clears out the dead tissue and gives the tendon a fresh start.
The entire procedure is performed in the clinic under local anesthesia, takes approximately 10 to 15 minutes of active treatment time, requires no incisions or stitches, and most patients walk out the same day. Dr. Peng uses an advanced, FDA-cleared powered tenotomy device to perform this procedure, delivering more consistent and efficient tissue debridement than manual needle fenestration alone.
Tendon Conditions Treated with Percutaneous Tenotomy
Percutaneous needle tenotomy is effective for a wide range of chronic tendon conditions throughout the body. Whether you are dealing with tendinitis, tendinosis, tendinopathy, or calcific tendonitis, Dr. Peng uses musculoskeletal ultrasound guidance to precisely target the damaged tissue at each location.
Rotator Cuff
Tendinopathy
Tennis Elbow (Lateral
Epicondylitis)
Gofler's Elbow (Medial Epicondylitis)
Plantar Fasciitis
Achilles
Tendinopathy
Hamstring
Tendinopathy
Gluteal Tendinopathy
Patellar Tendinopathy
Quadriceps
Tendinopathy
How Does Percutaneous Tenotomy Work?
To understand why tenotomy is effective, it helps to understand what happens inside a tendon when it becomes chronically injured.
When a tendon is overloaded repeatedly, it develops microscopic tears. In a healthy tendon, these tears heal through the body's natural inflammatory response. But when the tendon is continuously stressed or the damage accumulates over months or years, the healing process stalls. The tendon shifts from an acute inflammatory state to a chronic degenerative one—a condition called tendinosis.
In tendinosis, the tendon tissue becomes disorganized. Normal, parallel collagen fibers are replaced by dense scar tissue, mucoid degeneration, and disordered collagen. Blood flow to the area decreases. Growth factors that drive healing are absent. The tendon becomes biologically "stuck" in a state where it simply cannot repair itself, no matter how much physical therapy or rest you give it.
Percutaneous tenotomy breaks this cycle through three mechanisms:
1. Mechanical Debridement
The needle physically breaks up the scar tissue, disorganized collagen, and any calcific deposits that are blocking normal healing. Think of it as clearing out the dead wood so healthy tissue can finally regrow.
2. Controlled Inflammatory Response
The needling creates localized micro-injuries within the tendon, triggering fresh bleeding and a controlled inflammatory cascade. This sends oxygenated blood, platelets, and growth factors to an area that was previously blood-deprived—essentially tricking the body into treating a decades-old injury as a new one.
3. Collagen Remodeling
The inflammatory response stimulates fibroblast proliferation and the production of new, organized collagen fibers. Over the following weeks and months, the tendon remodels and strengthens, restoring its structural integrity and load-bearing capacity.
Barbotage for Calcific Tendinopathy
Calcific tendinopathy occurs when calcium crystals build up inside a tendon, most commonly in the rotator cuff of the shoulder but also in the hip, elbow, and knee. As the deposits harden, they irritate the surrounding tissue and trigger intense pain that can make lifting your arm or even sleeping nearly impossible.
Barbotage is a specialized form of ultrasound-guided needle tenotomy designed specifically for calcific tendinopathy. During the procedure, a needle is inserted directly into the calcium deposit under ultrasound guidance. Saline is then injected and aspirated repeatedly to fragment, dissolve, and wash out the calcium. For larger or harder deposits, the needle is used to mechanically break apart the calcification before the lavage.
The results are striking. Follow-up imaging often shows near-complete resolution of the calcium deposits, and patients typically experience significant pain relief within weeks. A network meta-analysis of 19 randomized trials with over 1,100 patients found that PRP combined with barbotage ranked highest in improving shoulder function and among the best for long-term pain relief—outperforming corticosteroid injections, shockwave therapy, and barbotage alone.
Like standard tenotomy, barbotage is performed entirely in the clinic under local anesthesia, takes less than 20 minutes, and is typically covered by insurance. It represents an excellent minimally invasive alternative to arthroscopic surgery for removing calcium deposits.
Percutaneous Tenotomy Combined with PRP
While percutaneous tenotomy alone is a powerful treatment for chronic tendinopathy, Dr. Peng's approach to treating stubborn tendon injuries often combines tenotomy with platelet-rich plasma (PRP) for enhanced healing.
Here's the logic: tenotomy clears out the damaged, non-healing tissue and creates an acute wound environment within the tendon. PRP then delivers a concentrated dose of your own growth factors—including PDGF, TGF-beta, VEGF, and EGF—directly into that freshly cleared space. The PRP amplifies the body's healing response and helps the tendon rebuild stronger, healthier tissue rather than forming more scar.
The evidence supporting this combination is compelling. In a randomized controlled trial studying partial rotator cuff tears (which behave similarly to other chronic tendinopathies), patients who received PRP after tenotomy had dramatically higher healing rates. By six months, nearly 80% showed complete tendon healing on ultrasound, compared to just 21% in the tenotomy-only group—nearly a four-fold increase in actual tissue repair, without surgery.
For tennis elbow specifically, the evidence for PRP is among the strongest in all of orthobiologics. A systematic review comparing PRP to surgical treatment found that PRP produced equivalent pain relief and functional improvement as surgery at every follow-up point out to one year—but with significantly faster recovery and lower risk.
Insurance note: Most insurance plans, including Medicare, PPOs, and HMOs, cover the ultrasound-guided tenotomy portion of the procedure. PRP is currently self-pay as most insurers have not yet approved coverage. However, tenotomy alone has strong evidence as a standalone treatment that delivers meaningful, long-term results.
What Does the Research Say About Percutaneous Tenotomy?
Percutaneous needle tenotomy is one of the most well-studied minimally invasive procedures in sports medicine. The research consistently demonstrates significant improvements in pain, function, and quality of life across multiple body regions, with minimal adverse effects.
Overall Effectiveness
A 2024 systematic review published in Sports Health evaluated all available clinical evidence on ultrasound-guided percutaneous needle tenotomy and TENEX for treating tendinopathy. The review concluded that both approaches are safe and effective treatment options, particularly for tendinopathy that has not responded to conservative management. Patients showed consistent improvements in pain scores, functional outcomes, and patient-reported quality of life measures.
Pain Relief and Durability
A meta-analysis pooling data from 35 studies and over 1,600 patients found that ultrasound-guided tenotomy led to significant and lasting pain reduction. On a standard 10-point pain scale, patients experienced an average pain reduction of 2.5 points in the short term, 2.2 points in the mid-term, and 3.6 points in the long term. Function and daily activity improved alongside pain reduction, confirming that the benefits extend beyond just symptom relief.
Long-Term Results for Tennis Elbow
One of the most compelling long-term studies followed tennis elbow patients for up to six years after percutaneous tenotomy. The researchers found that tenotomy accelerated recovery, maintained pain relief, and preserved functional gains over the entire follow-up period. Ultrasound imaging confirmed sustained tissue healing without deterioration, demonstrating that the improvements are not temporary—the tendon stays healthier.
Calcific Tendinopathy Outcomes
For calcific tendinopathy specifically, ultrasound-guided barbotage has been shown to achieve near-complete resolution of calcium deposits in the majority of cases. Studies demonstrate significant improvements in shoulder function scores and pain relief that are maintained at long-term follow-up. A 2025 network meta-analysis of 19 randomized trials confirmed that barbotage combined with PRP ranks among the most effective treatment strategies available for rotator cuff calcific tendinopathy.
Percutaneous Tenotomy vs. Surgery
For patients with chronic tendinopathy who have exhausted conservative treatments, the traditional next step has been surgical debridement. Percutaneous tenotomy offers a fundamentally different approach—one that achieves comparable outcomes with dramatically less invasiveness, risk, and downtime.
Percutaneous Tenotomy
Surgical Debridement
Setting
Clinic / office
Operating room
Anesthesia
Local only
General or regional
Incision
None (needle only)
Yes (open or arthroscopic)
Procedure Time
10-15 min (active treatment)
45-90 minutes
Return to Work
1-2 days (desk work)
1-4 weeks
Full Recovery
6-12 weeks
3-6 months
Can Add PRP
Yes
Varies
Insurance Coverage
Typically covered
Typically covered
Repeatable
Yes
Limited
Percutaneous Tenotomy vs.
Cortisone Injections
Cortisone injections remain one of the most commonly prescribed treatments for tendon pain. While they can provide short-term relief, cortisone does not address the underlying tendon degeneration and may actually hinder long-term healing.
Cortisone is an anti-inflammatory, and while tendinitis (acute tendon inflammation) may respond to it, the majority of chronic tendon conditions are actually tendinosis—a degenerative process with minimal active inflammation. The distinction between tendonitis and tendinosis is critical: tendonitis involves acute inflammation that may respond to anti-inflammatory treatment, while tendinosis involves chronic degeneration of the tendon's collagen structure that requires a regenerative approach. By suppressing what little healing response the tendon has, repeated cortisone injections can weaken the tendon over time, increase the risk of tendon rupture, and lead to progressively shorter windows of relief.
Percutaneous tenotomy takes the opposite approach. Instead of suppressing inflammation, it stimulates it in a controlled, targeted way. The goal is not to mask pain but to create the biological conditions for actual tissue repair. Research consistently shows that tenotomy produces more durable improvements than cortisone, with benefits that increase over time rather than diminishing.
What to Expect: Before, During, and After Percutaneous Tenotomy
Before the Procedure
Dr. Peng will perform a comprehensive evaluation including a musculoskeletal ultrasound to visualize the tendon damage, identify the extent of tendinosis or calcification, and determine whether you are a good candidate for tenotomy. You will be asked to avoid NSAIDs (ibuprofen, naproxen, aspirin) for at least one week before the procedure, as these medications can interfere with the healing response. If you take blood thinners, you will need to discuss stopping them with your prescribing physician.
During the Procedure
The treatment area is cleaned and numbed with local anesthetic. Under real-time ultrasound guidance, the powered tenotomy device is inserted through the skin directly into the damaged tendon. The device mechanically fragments and debrides the diseased tissue with precision, targeting the tendinopathic areas identified on ultrasound while preserving healthy tendon. You may feel pressure during the treatment, but local anesthesia keeps discomfort minimal. The active treatment time is approximately 10 to 15 minutes, with total appointment time of about 30 minutes. If PRP is being added, a small blood draw is performed beforehand and the PRP is injected immediately after the tenotomy through the same access point.
Recovery Timeline
Days 1–5: Rest the treated area. Use supportive devices (sling, brace, crutches, or CAM boot) as directed. Avoid NSAIDs and ice. Acetaminophen and heat are appropriate for discomfort. Begin gentle range-of-motion exercises.
Weeks 1–2: Progress to light mobility exercises and gentle stretching. Gradually increase weight-bearing as comfort allows.
Weeks 2–6: Begin progressive strengthening with isometrics, then isotonics, then resistance training. Avoid high-impact activities or heavy lifting. Exercise should not cause pain greater than 3 out of 10.
Weeks 6–12: Return to sport-specific exercises, full activity, and normal training as tolerated. Most patients experience meaningful improvement between weeks 2 and 4, with fuller recovery in the 6- to 12-week range.
Important: Avoid NSAIDs and ice throughout the recovery period. The success of percutaneous tenotomy depends on the body's natural inflammatory response. Anti-inflammatory medications and ice can suppress this healing process and compromise your results.
Rehabilitation Protocols
Dr. Peng provides condition-specific rehabilitation protocols for each tendon location to guide your recovery after percutaneous tenotomy. These evidence-based protocols are designed to optimize healing while safely progressing you back to full function.
Download your rehabilitation protocol:
Frequently Asked Questions
Frequently asked questions
Percutaneous Tenotomy in San Jose, Campbell & the San Francisco Bay Area
Dr. Jeffrey Peng performs ultrasound-guided percutaneous needle tenotomy at his sports medicine clinic in Campbell, California, conveniently located for patients throughout the greater San Jose metropolitan area and the San Francisco Bay Area.
Patients travel from San Jose, Cupertino, Los Gatos, Saratoga, Santa Clara, Sunnyvale, Mountain View, Milpitas, and Morgan Hill to receive percutaneous tenotomy and other advanced, minimally invasive tendon treatments. Whether you are an active adult dealing with chronic tennis elbow, a weekend athlete with persistent Achilles pain, or someone who has been told surgery is the only option for calcific tendinopathy, Dr. Peng can evaluate whether percutaneous tenotomy is right for you.
Board-certified in Sports Medicine & Family Medicine · Stanford-trained · Fellowship Faculty · 400,000+ YouTube subscribers · Campbell, CA