A sound approach to treating tendon injuries

Ultrasound-guided procedure offers an alternative to open surgery
Dec. 2, 2015

Two decades ago, John Hill, DO, a family medicine and sports medicine physician at University of Colorado Hospital, began using ultrasound for a variety of obstetrical procedures, such as amniocentesis and dilation and curettage. His skills improved, along with ultrasound technology, which steadily sharpened the resolution of images produced by sound waves.

In the early 2000s, Hill married his interests in ultrasound and sports medicine and created something of a stir in both fields. He was treating a patient’s ankle injury when he decided to try using ultrasound to see the joint damage. He was pleasantly surprised by the clarity of the images and later reported his experience with musculoskeletal ultrasound to rapt audiences of the American College of Sports Medicine and the American Medical Society of Sports Medicine.

“The technology for obstetrical ultrasound and musculoskeletal ultrasound was the same,” Hill said. “It helped me to understand normal and dysfunctional tissue and gave me a clear visual of tendon injuries and how they heal.”

The ultrasound imaging also did a better job of showing damage in the shallow structures near the skin than MRI, which is better suited to showing the core of joints, Hill said.

About two years ago, Hill found and began applying a new minimally invasive technology that uses musculoskeletal ultrasound to enable pinpoint repair of damaged tendon or joint tissue. He was the first physician in the state to use the system, developed by Lake Forest, Calif.-based Tenex Health. He has treated epicondylitis (aka tennis elbow), plantar fasciitis, and shoulder, patellar and Achilles tendon injuries. High hamstring injury repair is next on the docket, he said.

Probe and pulse

University of Colorado Hospital family and sports medicine physician John Hill, DO, uses ultrasound-guided technology to diagnose and treat a variety of tendon injuries without traditional surgery.

The Tenex procedure begins with Hill using ultrasound to find the diseased area, which typically appears darker than surrounding healthy tissue and bone. He then sterilizes the area and gives the patient a local anesthetic. Through a tiny incision, he guides the Tenex device, which is fitted with a probe that irrigates the area and delivers ultrasound pulsations that weaken the diseased tissue. By moving the tip of the device in and out gently, Hill breaks apart the damaged tissue and vacuums it out of the patient. In a matter of minutes, the procedure is finished.

After the procedure, patients generally feel uncomfortable the first night, Hill said, but instead of sharp, stabbing pain caused by the chronic damage, the discomfort is “more diffused.” In most cases, it steadily lessens over a recommended six-week recovery time, he said.

The Tenex treatment is not aimed at routine inflammation from acute injuries, which can be treated with anti-inflammatories like ibuprofen, or arthritic joint inflammation, which responds well to steroid injection, Hill said. Rather, the Tenex treatment targets damaged tissue within a tendon or ligament that causes chronic pain.

Getting to the root

small incision
In a Tenex procedure, a probe inserted through a small incision irrigates, breaks up, and removes damaged tissue. Graphic: Tenex Health.

“Degeneration of the tissue produces micro-tears that don’t heal,” Hill said. No amount of anti-inflammatory medications will make a difference in that case, he added. “I could give patients ibuprofen until they have a bleeding ulcer and it won’t fix the tendon problem.”

Traditional surgery is an option, but Hill said ultrasound guidance decreases the risk of removing healthy tissue, which would increase patients’ recovery time and procedural cost. The American Academy of Physical Medicine and Rehabilitation agrees. In a March 2014 position statement, the academy concluded that musculoskeletal ultrasound “is cost-effective and integral” to the diagnosis and treatment of patients with certain musculoskeletal conditions.

The group also noted that musculoskeletal ultrasound is less expensive than MRIs, does a better job of diagnosing injuries than “static imaging,” and allows for a greater number of minimally invasive procedures, which it said reduces the risk of complications and shortens recovery time.

While he enthusiastically endorses the Tenex procedure, Hill said it is not a panacea. A successful recovery relies on patients “moving again” after the recovery period. With activity, Hill said, the tissue not only heals, but regenerates. Damaged tendon tissue that had the consistency of a banana begins to regain the toughness of gristle, he said.

Athletic aid

Ellen Hart, 57, didn’t require encouragement to be active. She’s a Denver-based world-class runner and triathlete who has dedicated a good portion of her life to taking on physical challenges. But in 2014, pain around the patellar tendon in her right knee ground her training to a halt.

Austria Triatholon
Ellen Hart wins the Half Ironman Triathlon in Austria on Aug. 30, 2015. Hill performed a Tenex procedure on a damaged tendon around her patella that helped her prepare for this, the first of five world championships. Photo courtesy Ellen Hart.

The “low-level” pain in the knee began around February of 2014, Hart said, but she completed the Ironman Los Cabos the following month before taking time off in June when the knee didn’t get any better. In early August, however, she was back to running, biking, and swimming again at the U.S. Olympic and Sprint National Triathlon Championships in Milwaukee. She got through the Olympic portion, but a mile into the shorter Sprint, the concrete and asphalt surfaces took a heavy toll on the knee.

“I felt a sharper pain,” she said. “I finished the race limping.” The pain shut her down when she tried to work out a couple of days later.

To minimize pressure on the knee, she worked out on an AlterG anti-gravity treadmill and ran less frequently. After six weeks, she competed in the Mont-Tremblant World Championship, finishing a disappointing – for her – second. The next month, October 2014, Hart entered the 140.6-mile Kona Ironman Triathlon, thinking she wouldn’t be able to finish. Instead, she pulled off what she called a “miraculous one-off win” in the 55-59 age group, enduring sharp knee pain in addition to the usual fatigue and nausea.

“Because I didn’t expect to win, it was all the more welcome,” she said. But the satisfaction came with a price. The persistent pain forced Hart to close down for the season.

The culprit revealed

Hart sought help from UCH physical therapist Joy Anderson, PT, and orthopedic surgeon Armando Vidal, MD, both of whom believed Hart suffered from an impingement in the upper right quadrant of the knee, but couldn’t isolate it with X-ray or MRI. When physical therapy, massage, dry needling, and other therapies failed to solve the problem, they referred her to Hill, who used ultrasound to find calcifications above and to the side of the patella.

“When he saw the damaged tendon, there were tears in my eyes,” Hart said. “I felt I wasn’t a wimp who should have been able to put up with more pain.”

Hill used Tenex to clean out the damaged tissue, but the recovery wasn’t easy. Hart felt significant pain for a week, and took six weeks to get back to running. She still felt generalized pain in the repaired area, but nothing like the intense pain she had experienced before the Tenex procedure. Her ability to thrust down on the pedals when she biked and kick off walls when she swam also improved, she said.

After the Tenex, Hart still had to use the AlterG for a good portion of her training, but she was able to run outside one day a week on soft surfaces. She ran more slowly, but the decrease in pain allowed her to improve her cycling. “Overall, I felt I became a stronger triathlete,” she said.

Head of the pack

How much improved? Between Aug. 30 and Oct. 18 this year, Hart won five multisport world championships in her age group, including another Ironman in Kona. She’s already signed up for four events next season and said she’s continuing to care for her knee with platelet-rich plasma injections from Jason Glowney, MD, at CU Sports Medicine and Performance Center in Boulder.

Triathlon Chicago
Hart cycling during the International Triathlon Union championships in Chicago on Sept. 17. She won this sprint distance event, then won the Olympic distance competition two days later. Photo courtesy Ellen Hart.

“I’m grateful and lucky,” she said, crediting Hill, Vidal, and Anderson for sticking with finding an effective treatment for her injury. “I had a bad knee a year and a half ago, and now I have five world championships. I’ll take that.”

Hill said there are many other success stories like Hart’s, but added he’s used Tenex to benefit many non-athletes. “It helps with work-related injuries, like those that happen from digging ditches all day long,” he said.

As the director of the Primary Care Sports Medicine Fellowship at CU, Hill is teaching Tenex techniques to physicians who will take the skills back to their communities. But he’s not worried about competition.

“I’m training others who directly compete with me, but I still seem to have plenty of business,” he said.

About the author

Tyler Smith has been a health care writer, with a focus on hospitals, since 1996. He served as a writer and editor for the Marketing and Communications team at University of Colorado Hospital and UCHealth from 2007 to 2017. More recently, he has reported for and contributed stories to the University of Colorado School of Medicine, the Colorado School of Public Health and the Colorado Bioscience Association.