Tenex Procedure: Everything You Need to Know

The Tenex procedure is a minimally invasive, trademarked procedure used to treat chronic pain associated with tendinitis (tendon inflammation). The minimally invasive technique can reduce tendon pain by breaking down and removing damaged tissues with high-frequency ultrasound energy.

Also known as percutaneous ultrasonic tenotomy and percutaneous ultrasonic fasciotomy, the Tenex procedure is commonly used to treat tendinitis of the elbow, hip, knee, shoulder, and ankle, as well as plantar fasciitis foot pain. The Tenex procedure may, in some cases, be a reasonable alternative to conventional tendon surgery when conservative therapies fail to provide relief.

What Is the Tenex Procedure?

The Tenex procedure was developed by California-based Tenex Health in the mid-2010s to relieve chronic pain associated with tendinitis. It is a minimally invasive procedure performed on an outpatient basis under local anesthesia.

The Tenex procedure is typically performed as a single treatment. It involves making multiple tiny incisions through which a needle-like ultrasound transducer is inserted into or near a joint space to break up and remove damaged tissues. Most procedures can be performed within 20 minutes without the need for stitches.

Contraindications

Although there are no absolute contraindications for the Tenex procedure, it may be deferred if there is a local skin infection due to the risk of cellulitis. The procedure should also be avoided if there are significant changes in a joint resulting in joint instability or recurrent dislocation, both of which indicate the need for more invasive treatment.

The Tenex procedure is neither used to replace first-line conservative treatments nor use as a stopgap measure when conventional surgery is clearly indicated (such as for a ruptured tendon).

Possible Risks

There are few notable side effects associated with the Tenex procedure. Other than mild bleeding and short-term pain, redness, and swelling at the treatment area, the Tenex procedure is considered safe with a low risk of infection.

On rare occasions, nerve damage has been reported, but the risk is low (less than 1%) due to the absence of nerve fibers within tendon tissues.

Purpose of the Tenex Procedure

The Tenex procedure is used to relieve refractory (treatment-resistant) pain associated with chronic tendinitis. Whenever a tendon is injured, it will usually repair itself by rebuilding the collagen matrix and undergoing a process called remodeling in which the damaged cells and tissues are replaced "as new."

But, in some cases, this doesn't happen, and the collagen matrix will not only form abnormally, but the tendon itself will start to degenerate as the cells become displaced by fats, calcium, and other substances. These structural changes can cause inflammation, calcification (hardening), and the weakening of tendon tissues, contributing to the onset of pain.

The Tenex procedure is commonly used to treat tendon pain caused by long-standing sports injuries, repetitive motion injuries, and progressive weight-bearing injuries of the tendons and joints. These include:

• Achilles tendonitis
• Lateral epicondylitis ("tennis elbow")
• Medial epicondylitis ("golfer's elbow")
• Patellar tendinitis ("jumper's knee")
• Plantar fasciitis
• Proximal biceps tendinitis
• Rotator cuff impingement ("swimmer’s shoulder")
• Rotator cuff tendinitis

Preoperative Evaluation

The Tenex procedure may be considered when conservative therapies fail to provide relief. These may include nonsteroidal pain relievers, splints/braces, foot orthotics, physical therapy, eccentric joint exercises, therapeutic ultrasound, cortisone injections, extracorporeal shock wave therapy, and platelet-rich plasma (PRP) injections.

Prior to scheduling the procedure, you would undergo a preoperative evaluation by a specialist trained in the technique. This may include a rheumatologist (a specialist in diseases of the joints and muscles), an orthopedist (who specializes in musculoskeletal disorders), or a podiatrist (who specializes in the ankle and foot).

This evaluation would involve a physical exam, a review of your medical history, and, most importantly, the imaging of the joint—using an X-ray, computed tomography (CT) scan, or magnetic resonance imaging (MRI)—to determine the location and extent of the degenerated tissue.

The examination is meant to confirm that the Tenex procedure is the appropriate treatment option. The imaging studies also help map the general treatment area.

How to Prepare

Although the Tenex procedure is fast and minimally invasive, there are still things you need to do before undergoing the procedure. The healthcare provider trained in the technology will walk you through the steps, including what to expect during recovery.

Location

The Tenex procedure can be performed in a hospital, clinic, specialized surgical center, or a healthcare provider's office. The procedure room is comprised of an operating chair or table and the patented Tenex Health TX system.

The placement of the needle is directed by a separate musculoskeletal (MSK) ultrasound, which produces live images of the tendon on a video monitor.

What to Wear

Wear something comfortable that you can change into and out of easily if needed. Leave jewelry and any valuables at home. You will be provided a gown and possibly head cap to change into.

Food and Drink

There are no food and drink restrictions for the Tenex procedure.

Medications

As a general rule, nonsteroidal anti-inflammatory drugs (NSAIDs) are stopped at least one week before and after any percutaneous joint procedure to reduce the risk of bleeding. The restriction applies whether the procedure is ultrasonic or employs some other form of energy, such as heat or electricity.

This includes such common over-the-counter and prescriptions NSAIDs as:

• Advil (ibuprofen)
• Aleve (naproxen)
• Aspirin (acetylsalicylic acid)
• Celebrex (celecoxib)
• Voltaren (diclofenac)

In the interim, chronic pain can be controlled with Tylenol (acetaminophen) (which is not an NSAID) or regular ice application.

What to Bring

You will need to bring your driver's license or another form of government photo ID for registration. Also, bring your insurance card and an approved form of payment if copayment or coinsurance costs are required upfront.

Even though the Tenex procedure involves only local anesthesia, it is still a good idea to bring someone with you to drive you home. Depending on the joint treated, you may experience pain and a significant restriction of movement that may impair your ability to drive safely.

When in doubt, it is best to play it safe and organize for a friend, family member, or car service to drive you home.

What to Expect on the Day of the Procedure

Upon arrival, you will check-in and be asked to complete the necessary forms, including a medical history sheet and a consent form stating that you understand the aims and risks of the procedure.

Before the Procedure

Upon completion of registration, you are escorted to the procedure room, where your weight, height, and vital signs (temperature, blood pressure, heart rate) are taken and recorded by a nurse. A hospital gown will be provided to change into if needed.

Unlike tendon surgery, the Tenex procedure doesn't involve intravenous anesthesia or sedatives of any sort. This negates the need for an anesthesiologist, as well as an IV line, pulse oximeter, and other equipment typically used in surgery.

The Tenex procedure can be performed by a healthcare provider trained in the technique, usually with the accompaniment of a single nurse or medical technician.

During the Procedure

Once prepped, you are placed on a table or chair in a position that provides direct access to the treatment site. A handheld MSK ultrasound helps map the needle insertion point on the skin, which is marked with a pen.

Next, a local anesthetic like 1% lidocaine is delivered under the skin to numb the general area. You may feel a little prick but generally little pain. When sufficient numbing has occurred, more of the local anesthetic is delivered into deeper tissues. As much as 10 to 30 cubic centimeters (cc) may be used.

After swabbing the skin with an antimicrobial wash, the healthcare provider makes a 3-millimeter (1/10th-inch) incision on the premarked location on the skin. Using the MSK ultrasound for guidance, the healthcare provider then inserts the oscillating needle at a shallow angle into the damaged tendon (which appears black on the video monitor).

Once completed, the needle is extracted, and the incision is closed with an adhesive strip.

After the Procedure

Depending on the area of treatment, the healthcare provider may decide to temporarily immobilize the joint with a brace, splint, or a walking boot. Crutches may be needed for people who have undergone treatment of the foot, ankle, knee, or hip.

You can usually go home immediately after the Tenex procedure is complete. Many people report immediate pain relief.

Recovery

Upon your return home, you will need to relax for several days, placing minimal weight on the affected joint. Pain, if any, can usually be treated with Tylenol or a cold compress.

Although excessive movements are avoided, you will need to perform gentle range of motion exercises for the first 48 hours to prevent adhesions (the sticking together of tissues). Wound care instructions will also be provided.

After a week, a routine program of eccentric exercises (in which a muscle is lengthened at the same time it is being contracted) should be included in the treatment plan to build strength and restore joint mobility. A physical therapist can help design the appropriate home-based program.

Most people are able to return to work and normal activity within a week to 10 days of the procedure. Even though the pain relief is often striking and immediate, it can take anywhere from four to 12 weeks before you regain full function of a joint and a return to unencumbered physical activity.

Follow-Up Care

You will need to schedule regular follow-up appointments with your healthcare provider to gauge your response to treatment and monitor for complications. Additional imaging studies may be ordered.

Although the Tenex procedure provides significant relief for many people, retreatment is sometimes necessary. A 2016 study published in the Journal of the American Podiatric Association found that two of 26 procedures for Achilles tendinitis required repeated treatment.

Lifestyle Adjustments

It is important to remember that the Tenex procedure relieves the pain associated with chronic tendinitis but doesn't necessarily correct the underlying cause.

Though many people who undergo the procedure may remain symptom-free for years (and possibly permanently), those who developed tendinitis due to repetitive stress or extreme sports may experience a relapse unless certain behaviors are modified.

Modifications may include the use of braces or splints in occupations that involve repetitive motions (such as a carpal tunnel brace). Athletes may require joint-specific strengthening exercises or the modification of sports techniques (such as moving from a one-handed to two-handed tennis backhand) to avoid recurrence.

By adjusting behaviors that contribute to tendinitis, you stand a far better chance of remaining pain-free over the long run.

A Word From Verywell

The Tenex procedure is a new and promising technique whose use is expanding in tandem with its growing acceptance in the treating community. Still, it can be hard to find a healthcare provider qualified in the Tenex procedure or to know who is competent in delivering effective treatment.

If exploring the Tenex procedure for the treatment of refractory pain, do not hesitate to interview the treating healthcare provider and ask about their qualifications. This includes asking how long the healthcare provider has performed the procedure, how frequently they use it in their practice, and what response rates they have achieved.

The Tenex procedure is not a one-size-fits-all solution. If used appropriately, it can deliver impressive results. But, if used solely to avoid surgery, it less likely to do anything but provide short-term relief and may end up causing you harm.