How Some Types Of Elbow Tendon Tears Can Be Healed With Less Invasive Alternatives To Surgery
Only a small percentage of Tennis Elbow and Golfer’s Elbow cases involve tendon tears – Unfortunately, when they happen – tears are the most severe form of these injuries.
Tears do come in a range of severity, from mild to severe, of course – and even different “types” of tears making it difficult for sufferers to get a clear picture of what they’re really up against.
Naturally, you’d probably prefer to avoid surgery if possible – especially if it requires going under general anesthesia! (Being “put to sleep.”)
And, the good news is, you should be able to heal and recover from certain mild-to-moderate tears without resorting to full, “open” surgery.
Past a certain size, of course, the prognosis (predicted medical outcome) of a non-surgical recovery does become doubtful.
Where exactly is that line, though? Yes, you “should” be able heal and recover from a small / ‘mild’ tear without surgery!…
But what about a moderate tear? (How deep/thick, wide or long before it’s too big?)
What if you have a ‘Longitudinal Tear’ vs. a ‘Partial Thickness’ OR a ‘Full Thickness Tear?’…
And what the heck do these medical jargon terms seen on MRIs even mean!?
Well, we’re going to decipher these terms, delve into what the prognosis for recovery is for different types and degrees of tears – As in,
“Can I heal this tear without surgery?”
We’re going to explore several minimally-invasive alternatives to surgery, and when you might need them, including Protherapy, Platelet-Rich Plasma Injections and Stem Cell Therapy.
As well as some “lessor” surgical procedures that can be performed rapidly under local anesthesia, like Tenex® and TenJet® (which may be necessary for larger tears.)
This article will help you better understand and navigate this complicated issue – even if you already have “all” the data, including an MRI and the consult of an Orthopedic Surgeon.
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Outline / Table Of Contents
(Click any of the question links below to skip down to that section.)
First, let’s get into how tearing and other tendon damage is diagnosed in the first place
How Tears Are Diagnosed And Measured
How do you know if you have significant tendon damage like a tear? How are these injuries diagnosed?
(Keeping in mind we’re talking about the tendons involved with Tennis and Golfer’s Elbow injuries, although much of what we’re covering will apply to other tendons.)
First of all, if you don’t have any objective reason to think you have a tear, don’t jump to conclusions! Why not?
Because, fortunately, the vast majority of these injuries never progress to the point of a tear – especially a moderate to severe tear – and this is even more true for Golfer’s Elbow, which is 5 times rarer to begin with.
Only 3-5% of Tennis Elbow sufferers end up having surgery, (usually because of significant tendon tears.)
Fact or Myth? You can tell you have a tear by how severe your symptoms are or how long you’ve had them.
MYTH – People do tend to assume this is true, but the ONLY way to know if you have a tear is to have a scan like an MRI.
(It may be counter intuitive but severe symptoms do not automatically mean you have a tear – or any significant damage at all. And, conversely, not all tears cause debilitating pain!)
If you’ve already had a scan you can skip this section but if you’re worried you may have a tear and you’re wondering what your next step should be, keep reading.
There are two types of scans you can get to “look” at the state of your tendon(s)
- An MRI (Magnetic Resonance Imaging) or
- A Sonogram (also known as a ‘Diagnostic Ultrasound.’)
Xrays are of no use in this case since they can’t detect changes in tendons and other ‘Soft Tissues.’
However, if there are reasons to suspect a fracture or other bony injury, like Arthrosis, then an Xray would make sense.
And, although it may seem like forever to you, if you’ve only been suffering from Golfer’s or Tennis Elbow for 6 months or less – you’re probably not going to get an MRI – for good reason.
The MRI is the “gold standard” providing the clearest image but it’s usually unnecessary early on (up to at least 6 months – if not longer.)
An MRI only becomes truly essential once most conservative treatment options have failed. (AND probably only if you’re ready to consider surgery or one of the alternative medical measures.)
I’ve already covered this question separately, so if you feel you’re reaching this point, check out my article on When Is It Time To Get An MRI?
(Which also goes into more detail about the other abnormalities that are most often seen on MRIs – besides tears – and what they mean.)
However, if you’ve been suffering from your TE or GE injury for several months or longer, and you feel you need an objective measure of your injury, there IS another option…
The Sonogram is an excellent alternative to the MRI. It doesn’t produce as clear and precise an image but it’s cheap, convenient and can be done in real time.
I’ve also covered this separately in depth (and touch on it in the MRI article.) For more, see my article on the Sonogram for Diagnosing Tennis and Golfer’s Elbow here.
The short version is that the Sonogram can serve as an excellent initial “screening tool.”
It will pick up a moderate to severe tear, in which case you can then consider an MRI to verify just how bad it is…
OR if a mild / smaller tear is seen (or none at all) there probably isn’t any need for you to get an MRI.
Why not? Because, in the case of a mild tear, you have a good chance of being able to recover without surgery and MRIs are really only necessary if you’re heading toward a “full” surgical procedure.
Three Types Of Tendon Tears
First things first: Orientation! We’re going to be talking about two different directions that the majority of tears run in.
The first tear direction we’re going to cover has to do with ‘thickness,’ which means in a perpendicular orientation, or depth.
The second is in the ‘longitudinal’ direction, otherwise known as lengthwise.
I understand this can be very confusing (and they don’t make it easy!) but try picturing a stalk of celery…
The longitudinal orientation is down the length of the stalk, and if you’ve ever cut or eaten celery, you know that the fibers run that way, and the same is true for tendons.
Imagine running a knife down the middle of the celery stalk splitting it into two long pieces – That’s one type of tear; a ‘Longitudinal Tear.’
Now, imagine cutting across the stalk sideways or perpendicular. You’re cutting across the fibers – That’s the other type of tear.
And the term ‘Thickness’ is what’s most often used to describe these tears.
I know you may be thinking, “That’s only 2 out of 3 dimensions! What about the width of the tendon?”
That’s a really good question – But the medical literature and all the MRI reports I’ve seen never seem to talk about the width – Only the length and “depth / thickness.” (!)
Type 1. Partial Thickness Tears
As the term ‘partial’ suggests, the tendon in not torn “all the way through.”
(It’s also not torn off either its connection to its muscle or to the bone it’s attached to.)
Usually, partial means less than 50% of the tendon is torn but the point at which the tear is beyond that and considered a ‘Full-Thickness Tear’ can vary depending on how the Radiologist or Orthopedist interprets it.
Once again, the term “thickness” refers to the direction of the tear. It refers to a perpendicular orientation.
(You can also think of it as in a “top-to-bottom” direction or better yet, from the surface to the deeper layers.)
Type 2. Full Thickness Tears
Also known as ‘Complete Tears’ or ‘Ruptures,’ are tears that pass through the majority of the tendon in a perpendicular orientation the same as ‘Partial Thickness Tears’
‘Full thickness’ typically more than 50% of the tendon is torn but not necessarily 100% which can be quite confusing, since “full” usually means completely!
Try to keep in mind this is a “medicalease” definition that means something different than what you expect it to mean in plain English.
Full thickness, in this case, can mean anything from 51-100% torn.
Type 3 – Intrasubstance Tears
Also known as ‘Longitudinal Tears’ and less commonly ‘Split Tears.’
These tears, run through the tendon lengthwise, just like a split.
They do not run perpendicularly down through the thickness of the tendon like Partial and Full Thickness Tears.
Apparently, these types of tendon tears are the trickiest to evaluate, in the sense that they can be less clear on MRIs and thus harder to interpret.
And especially when it comes to the prognosis, as in, “How bad is this, really – and what is my chance of recovery!?”
So, let’s get right into that…
Prognosis For Different Types Of Tendon Tears
First of all, if you’ve had an MRI, always be sure to get yourself a copy of the Radiologist’s report.
Not the actual images from the MRI but the interpretation of them by the Radiologist.
Why? It’s always a good idea to get second and third opinions and not to rely on just one – whether it’s a primary care Doctor or an Orthopedic Surgeon.
Surgeons are obviously the experts when it comes to surgical procedures – BUT they are not the top experts when it comes to the interpretation of MRI scans.
Surgeons are highly capable but Radiologists specialize in this exclusively; they train extensively in this specific skill and do nothing but look at MRIs and other scans all day long.
And once you have the MRI report they produce you can contemplate it yourself.
You only need to concern yourself with the “report of findings” and the conclusion based on those findings.
Sure, you still need to decipher it, but this article and this one specifically on MRIs should help you with the terminology.
Let’s begin with the better/more hopeful prognosis, the partial thickness tear and work our way down to the hardest and least hopeful, the full thickness tear.
‘Prognosis’ meaning the predicted or expected medical outcome for an injury or condition.
The Prognosis For Partial Thickness Tears
Partial thickness tears can run anywhere between 1% and 50% of the tendon being torn so there is already a wide range of potential recovery outcomes if you’re a Tennis or Golfer’s Elbow sufferer with one of these kinds of tears.
The percentage of tendon torn is probably the single largest factor in your prognosis, since the more tendon fibers you have remaining intact the better and stronger your tendon’s structural integrity.
Although there’s more to it then that, namely the quality, density and strength of the fibers that remain intact, because there are other tendon dysfunctions besides tears to consider.
Tendinosis, being the first of these dysfunctions, the essential problem that defines a Tennis or Golfer’s Elbow injury. More on Tendinosis
‘Tendinosis’ is the slow, chronic degenerative breakdown of the tendon, which weakens it in the first place, setting you up for a tear.
See the MRI article for more about the other tendon abnormalities seen on MRI scans.
A tendon with only a 10-20% tear with 80-90% remaining intact should be cause for an optimistic prognosis!
However, a tendon that is 40-50% torn with only half or slightly more than half remaining intact is going to pose a challenge – Especially if there is significant Tendinosis (degenerative damage) weakening the remaining, intact fibers!
(Unfortunately, there is usually NO reference to what percentage of your tendon is torn in an MRI report – only a measurement in Millimeters of the tear. More on that below in ‘The Calculation Challenge’ section)
The Prognosis For Full Thickness Tears
Full thickness tears are, once again, tears that pass through the majority of the tendon (usually more than 50%) – Just like a ‘Partial Thickness Tear’ – only worse.
Keeping in mind that in medical language “full” does not necessarily mean 100% – “Full” thickness in this case can mean anything from 51-100%
And, unfortunately, in the MRI reports I’ve seen, there hasn’t been any reference to how WIDE the tear is – (or, again, what percentage of your tendon it torn.)
(Again, thickness refers to depth but not width. Sorry for the additional confusion but I think it needs to be pointed out.)
If you have a tear that’s well past the 50% mark – let’s say 75% then things may get a little easier for you to decide, since, most would agree, that puts you over the line into “surgery land.”
Ruptures: The Most Severe Tears
The term ‘Rupture’ should mean a 90-100% tear – as in, hanging by a thread or completely ripped off the muscle or bone, which would be an absolute “slam dunk” case for surgery.
(Keeping in mind the tendon is essentially a rope-like connector between muscle and bone and it can separate from either – although with Golfer’s and Tennis Elbow a tear more often forms in the middle of the tendon or where it attaches to the bone/epicondyle.)
I’ve never seen or heard of anyone who had Tennis or Golfer’s Elbow who suffered a tendon rupture, however.
It seems to be a rare thing with these particular tendons (and much more common in tendons like the Achilles.)
The Calculation Challenge: Torn Vs. Intact Percentage
Adding to the difficulty of interpreting your own MRI results is the fact that the size of the tendon tear is often given without a percentage.
(Sometimes without even a measurement!)
Usually, you’ll see something like this in your MRI report:
“Partial thickness tear of the common extensor tendon measuring 2 millimeters”
BUT, often no measurement is provided on how thick your tendon is to compare that with!
Which leaves you wondering, “OK, but how thick is my tendon and what percentage of it is torn? I can’t calculate it without knowing that!”
(That’s what I always see when I read a client’s MRI report, anyway. I’ve never seen either a percentage given – OR the full size of the tendon along with the size of the tear for comparison.)
So, here’s a reference to a medical study on how thick the average tendon to help you make the comparison.
(NOTE: this applies only to the tendon group known as the ‘Common Extensor Tendon’ which is the tendon affected by a Tennis Elbow injury.)
The average ‘Common Extensor Tendon’ at or just down from the attachment to the Lateral Epicondyle is just under half a centimeter thick – At 4.87 Millimeters.
(4.87 mm on average in the dominant hand of both men and women. Slightly less in women on average, and slightly less in both men and women in the non-dominant arm.)
Ultrasonographic Characteristics of the Common Extensor Tendon of the Elbow in Asymptomatic Individuals | Orthop J Sports Med. 2017 May; 5(5) | PMC5431425
If you happen to be Male, we can assume an average tendon thickness of 5 Millimeters in your dominant arm.
Which would mean if your partial thickness tear is 2 Millimeters then your tear is less than half, (2/5 = 40%) which is the side you definitely want to be on!
BUT if your tear is 3 Millimeters, now we’re talking about more than half your tendon is torn (3/5 = 60%)
If you happen to be Female and your Tennis Elbow tear is in your NON-dominant arm, the average thickness is closer to 4 Millimeters, so if you have a 2 Millimeter-thick tear that’s already 50% of your tendon (if it’s of average thickness.)
The Prognosis For Intrasubstance Tears
An ‘Intrasubstance’ or ‘Longitudinal’ tear runs through the tendon lengthwise, like a split, in contrast to ‘Partial’ and ‘Full Thickness’ tears, which are perpendicular.
These types of tear are the tricky ones and they are quite common in Tennis Elbow sufferers.
(And, of course, it’s possible to have this type of tear AND the other type at the same time, although I haven’t come across this yet.)
It seems very difficult to get a clear explanation anywhere of how significant these intrasubstance tears are and what constitutes a mild, moderate or severe version of one.
As in, “How bad is this, really? – And what is my chance of recovery!?”
From my perspective, these tears seem to be less serious and have the best overall prognosis for a non-surgical recovery.
Imagine the difference between a rope that has been cut part way through, across the fibers, weakening its integrity, which would be the equivalent of a partial or full thickness tear, which we discussed earlier.
And a rope in which all or most of the individual fibers are still intact but have become separated in the middle, down the length of the rope – turning it, where it’s split, into two smaller ropes (but still attached at both ends.)
This would be the equivalent of an intrasubstance / longitudinal tear.
In the first example, the rope or tendon has less fibers that can carry the load.
In the second example the fibers have become separated down the length of the rope or tendon – but they are all still intact and attached at both ends so there are still just as many fibers carrying the load.
A major difference that still needs to be taken into consideration with tendons is that there is a certain amount of “cross linking” among the tendon fibers lengthwise that add to the strength of the tendon even though a majority of the structural integrity is along the “line of force” lengthwise through the tendon fibers.
Where Is The Line Between Needing Open Surgery – And A Less-Invasive Procedure?
No one can say for certain exactly where the line is – That, once crossed, means “You definitely need surgery!”
OR at what point you might be able to recover with a “less-invasive” procedure and avoid full, open surgery.
And there are many other factors to consider besides the size and type of your tear (and amount of other tendon damage.)
Factors such as your age, general health, level of fitness and your needs and desires for the future – If, for example…
You absolutely NEED to keep working using that arm at the level you have been…
Or you desperately WANT to keep playing tennis / golf / Pickleball as much as you always have!
Here’s my article and video where I do my best to help you answer the question of:
“When Is It Time To Consider Surgery?”
Although you may not find that as helpful IF you already know you have a significant tear at this point!
With these imperfections in mind, consider three levels of damage – One that’s on the minor side and two that are more serious:
- A minor tear that has a good change of healing without more aggressive interventions,
- A moderate tear that may need more aggressive measures – (but possibly something short of full, open surgery) such as PRP injections or a minimally-invasive ‘Tenotomy’ surgery
- A major tear that has little to no chance of healing without full, open surgery.
I’m going to suggest that the line between #1 (minor tear) and #2 (moderate tear) is when you’re facing a partial thickness tear that’s between 20-40%
If your tear is less than 20% you may have a decent chance of healing without surgery or more aggressive measures.
And the closer it is to the high side of that (20-40%) the more likely you may need to consider more aggressive medical measures that are still short of full, open surgery (more on those in a bit.)
And then there’s another line between #2 (moderate tear) and #3, (a major tear) which is when you’re facing a full thickness tear that’s around 60%
There’s little to no chance you could recover without less-invasive measures…
But there may still be some chance you could recover WITH these alternatives, like PRP (but more likely Tenex or TenJet, see below)
However, this is the point (approximately) where the odds are turning against you.
You could give one of these alternative measures a shot (especially if you feel you have the time and can afford the expense.)
At the same time, it would be wise to prepare yourself mentally for the prospect of full surgery if it doesn’t work.
(And all of this is assuming you can even get a clear determination of what percentage of your tendon is torn – rather than just a measurement in Millimeters followed by a diagnosis classification of “Partial Thickness” or “Full Thickness” tear.)
Which should be one of the key questions you ask your Orthopedist! See that section below for more.
Less-Invasive Alternatives To Open Surgery
There are several alternative, minimally-invasive procedures available for tendon tears (and severe, advanced Tendinosis.)
The advantage of most of these techniques, which are forms of ‘Tenotomy,’ is that they don’t require full, open surgery.
These procedures involve only small incisions and can be done under local anesthesia – And have much quicker recovery times.
What Is A Tenotomy Procedure?
“tenotomy is the use of a needle to make small holes in a tendon through the skin. Repeated needlesticks can break up scar tissue and cause bleeding in a tendon, prompting the inflammatory cascade and helping the body’s own cells to begin rebuilding the tendon.”
Note the references in this quote to “causing bleeding” and “prompting the inflammatory cascade” in the tendon.
See also this quote from the NIH:
“…a needle is repeatedly passed into the abnormal tendon with the goal of converting a chronic degenerative process to an acute inflammatory condition that will progress to tendon healing.”
Ultrasound-Guided Percutaneous Tenotomy | Jon A Jacobson, et al | Semin Musculoskelet Radiol. 2016 Nov;20(5):414-421.
In plain English, the goal is to forcefully traumatize the damaged “rotting” and/or torn tendon; to smack it around and kick start a new inflammatory process in the hopes of getting it to finally heal!
This idea of causing inflammation (and more trauma!) may sound like a shocking contradiction to what you’ve read or been told up to this point – Which is totally understandable!
It’s a complete reversal to what most sufferers are told early on, but it happens to be correct.
When you first learned you had Tennis or Golfer’s Elbow, weren’t you given the impression that inflammation was either the “cause” of your injury or at least a problem that you needed to “treat” and suppress?
However, inflammation is the first of three stages of healing. It’s an essential part of healing and recovery – and every Doctor, Nurse and Surgeon learns this in medical school.
The problem with most of these tendon disorders (especially when they’re really chronic, as in persistent and long-standing) has never been an “excess” of inflammation.
The central issue (the nature of the injury AND cause of the pain) in the vast majority of Tennis and Golfer’s Elbow cases is that they are stuck, stagnating in a degenerative / “failed healing” state, which is called ‘Tendinosis.’
And this degenerative process gradually weakens the tendon to the point where it’s vulnerable to tearing.
So, most the time when these tears happen, they’re not the ‘Acute’ type of tears you get with, say, a sprained ankle.
They’re what’s known as ‘Chronic’ tears because they’re gradual and progressive.
What’s needed to get your tendon out of this failed-healing degenerative state is fairly aggressive action – (Especially if your tendon has torn.)
And the following procedures use needles and needle-like tools aggressively to:
“prompt the inflammatory cascade” – To “convert a chronic degenerative process to an acute inflammatory condition”
In the hope that this will lead to tendon healing.
The two major forms of (less invasive) Tenotomy are:
- Injection treatments involving hypodermic needles, and…
- Minimally-invasive surgical techniques involving “needle-like” tools / probes
(There’s also a more invasive arthroscopic surgery form of Tenotomy that’s performed under general anesthesia, which we’ll cover later.)
Hypodermic Needle-Based Injection Treatments
If you have a mild-to-moderate tear the following injection therapies may have the potential to help you recovery without resorting to full, open surgery.
However, if you have a more serious tear, chances are your only good alternative to full, open surgery are the minimally-invasive surgical techniques, which we’ll cover after these needle treatments.
The central mechanism these procedures all have in common is the hypodermic needle puncture of your tendon.
How they differ is in what is injected (or not injected.)
(And there is an interesting argument/question about whether it matters so much what’s injected – Or whether it’s really the new trauma from the needle, which kicks starts the healing process that really matters.)
Platelet-Rich Plasma Injections (PRP)
PRP is a treatment that involves drawing your blood, centrifuging it to concentrate the platelets (which contain healing/growth factors) and then re-injecting the platelets along with some of your plasma (the clear liquid, minus the red blood cells) into your torn tendon.
This approach is becoming more and more popular and is often used in less severe cases of Tennis and Golfer’s Elbow and other tendon disorders as well as for mild-to-moderate tears.
For an in depth look into this therapy see my article on Platelet-Rich Plasma for Tennis Elbow
The downsides are that it is often expensive, (particularly in affluent urban areas in the US)…
It’s typically not covered by insurance, and it can be quite painful – during and for days after the procedure.
Prolotherapy Injection
Prolotherapy Injections, are very similar to PRP, except that instead of injecting your own platelets and plasma, an innocuous substance such as a sugar solution is used.
The goal of stimulating healing by causing new trauma through the mechanism of the needle puncture is the same.
The difference is that (in theory) the sugar or other components in the injected solution supposedly irritate the tendon and add to the effect.
All things being equal, this is a somewhat less-expensive alternative to PRP injections, although likely just as painful.
Dry Needling Therapy
Dry Needling (one form of it) involves using a hypodermic needle to “punch” holes in your tendon in much the same manner as with PRP and Prolotherapy – only without injecting anything (hence the “dry.”)
There is also another meaning to ‘Dry Needling’ that involves using Acupuncture Needles but we’re not talking about that version, since it’s unlikely to be aggressive enough.
(This is a technique that has also been used for decades on horses, which suffer a lot of tendon disorders, and is known as ‘Fenestration’ in this application.)
This treatment is also less expensive than PRP injections.
For more on these therapies see my article on Dry Needling for Tennis and Golfer’s Elbow
Stem Cell Injection Therapies
The Stem Cell Injection procedure is very similar to PRP but instead of drawing your blood first, (or, often, in addition to it) bone marrow is extracted from another part of your body (often your pelvis) in order to get a significant amount of stem cells.
This concentrated Stem Cell extract (or mixture including platelets and plasma taken from your blood) is then injected into your torn tendon.
The added benefit (in theory) being that the Stem Cells will help regenerate and heal your tendon.
(Some Stem Cells have the ability to morph and become any kind of cell – Others, like the Tenocytes and Fibroblasts found in tendons, make new Collagen to repair and regenerate tendon tissue.)
Regenexx is one example of a Stem Cell (and PRP) system that some Doctors are trained in.
Like the other injection therapies, this may be a good alternative if you have a mild-to-moderate tear but may not be enough for a larger full-thickness tear.
The downsides are that it’s even more expensive than PRP, it may only be available in major cities and, and, like PRP, it’s typically not covered by insurance (and it can be quite painful – during and for days after the procedure – especially the bone puncture site in your pelvis!)
Here’s my article with more on Stem Cell Therapy
Minimally-Invasive Surgical Techniques
Now, we come to the more advanced forms of Tenotomy that are closer to full surgery but still considered “minimally invasive.”
There are two major brands/techniques: Tenex and TenJet, both of which can be done on an outpatient setting under local anesthesia.
Both of these patented Tenotomy techniques, known as ‘Percutaneous Needle Tenotomy’ involve small incisions and pointy, needle-like instruments.
In a similar fashion to the hypodermic needle Tenotomy methods, (PRP, Stem Cell) these techniques use real-time ultrasound imaging to guide the placement of the probe.
But in contrast to the hypodermic needle techniques, these procedures have the ability to precisely REMOVE any damaged tendon tissue.
“Percutaneous Tenotomy uses ultrasound guidance to insert a needle into the scarred tendon. The needle breaks up scar tissue with ultrasound waves and suctions out the treated tissue.”
And since these procedures are considerably less invasive than for full “open” surgery, the recovery time is much shorter.
And, again, they are usually performed under local anesthetic, so there is no need to be sedated under full/general anesthesia.
The Tenex F.A.S.T. Procedure
In this video, Dr. Marc Gruner, of Point Performance, explains how Tenex works.
Tenex FAST™ (which stands for “Focused Aspiration of Scar Tissue”) is a surgical technique that only requires one small incision of less than a ¼ inch.
A needle instrument is inserted through this incision and guided directly to the damaged parts of your tendon, using real-time Sonogram Imaging (Diagnostic Ultrasound)…
The degenerated and/or torn part of the tendon is then “liquefied” using powerful, focused, high-frequency ultrasonic vibrations – and then the liquefied, damaged tissue is sucked out with the same instrument.
TenJet Tenotomy
TenJet™ is a form of ‘Tenotomy,’ which uses a jet of pressurized water instead of ultrasonic vibrations.
A pressurized, high-velocity jet of saline, acting as a cutting tool, is used to debride [remove] the diseased / torn tendon tissues
TenJet For Tenotomy, by HydroCision
Like Tenex, this technique only requires one small incision under local anesthesia in an outpatient setting.
The advantage may be that the jet of water produces no heat, unlike an ultrasonic tool (like Tenex and possibly other tools.)
Arthroscopic ‘Surgical Tenotomy’
Finally, we have the arthroscopic version of Tenotomy.
There are actually two versions but, since we’re only covering less-invasive measures here we’re going to focus on the arthroscopic version.
“Surgical Tenotomy uses either traditional open surgery methods or arthroscopic methods to remove scarred or damaged tendon tissue.”
https://www.healthgrades.com/right-care/bones-joints-and-muscles/elbow-tenotomy
Arthroscopic Needle Tenotomy is a form of surgery that involves an incision (or two) – And perhaps larger incision(s) than for the techniques mentioned earlier.
The Arthroscope allows the surgeon to see with a tiny camera which allows for more precision than all the other methods listed so far.
More precision is possible because the other forms of Tenotomy require the use of Sonogram / Diagnostic Ultrasound Imaging to “see” through your skin and other layers of tissue, using sound waves, which is less clear and precise than literally seeing your tissue from a tiny camera inside your arm.
However, Arthroscopic Surgery requires more anesthesia, probably general anesthesia, as in “putting you to sleep”
(Although it may be possible to have it done under a regional anesthesia, as in a nerve block, which would affect your whole shoulder and arm. This seems to be uncommon, though.)
This surgical procedure may still be considered “minimally invasive” but it could be said to be borderline, considering the need for more anesthesia than a simple local injection of a numbing agent, which is all that’s usually required for the other forms of Tenotomy that utilize a needle or needle-like instrument.
The advantage of ‘open surgery,’ in comparison, is that a larger incision is used and the surgeon can see the whole area very clearly, (not through a camera or a Sonogram) and do everything that’s potentially necessary.
Here is a video of a surgeon explaining the open surgical procedure for Tennis Elbow
However, according to this study, there may be no advantage to Open Surgery.
In fact, there seems to be an advantage for Arthroscopic Surgery in that it seems to result in fewer complications.
“The present study suggests that despite no superiority for each techniques regarding the pain relief, subjective function, and better rehabilitation, arthroscopic method have been associated with less complications.”
Clinical Outcomes of Open versus Arthroscopic Surgery for Lateral Epicondylitis, Evidence from a Systematic Review | Arch Bone Jt Surg. 2019 Mar; 7(2): 91–104. PMC6510924
6 Key Questions to Ask Your Orthopedist
You may be able to get some idea of the answers to these questions simply by looking at a surgeon’s website or by calling and asking the staff in advance.
For example, if the Orthopedic Surgeon’s website lists some of the minimally-invasive procedures we covered earlier, like PRP pr Tenex.
If You Haven’t Had An MRI Or Sonogram
If you haven’t had either an MRI or Sonogram / Diagnostic Ultrasound yet, a couple of good questions would be:
1. “Can you perform a Sonogram as a preliminary screening?”
The idea with this is to see if there’s any evidence of a major tear before considering an MRI.
This would give you two potential paths:
The first path would be, if evidence of a smaller tear is seen on the Sonogram / Diagnostic Ultrasound – You would have the option of considering a less-invasive treatment, like PRP…
OR a Tenex / TenJet procedure in the event that a larger tear was visible (as long as it wasn’t severe enough that full, open surgery was necessary.)
This would spare you the inconvenience (+ expense?) of an MRI, since a clearer image would NOT be needed for these less less-invasive treatments.
The second path would be if your surgeon sees evidence of a major tear, you could THEN schedule an MRI to get the clearest possible image and confirmation of the larger tear before having a more invasive form of surgery.
2. “Do you offer minimally-invasive alternatives, like PRP, Stem Cell Injections – Or Tenex / TenJet?”
This is very important to know in advance if you want to consider one of these alternatives.
If the answer is no, and you were also discouraged from the Sonogram “screening” option (question #1) and encouraged to go straight to the MRI step, keep in mind that your surgeon has no real incentive to offer you a Sonogram.
No ethical surgeon would proceed with a full, open surgery on the basis of a Sonogram alone, (only with the other minimally-invasive procedures, like PRP and Tenex)…
They do routinely use Sonograms as screening tools to see if there is enough tendon damage to warrant a Tenotomy procedure like PRP injections.
(And sometimes as a follow up a certain time period after the procedure to measure the progress, or lack thereof.)
So, if they don’t offer these alternative treatments they will have a tendency regard the additional step of a Sonogram as pointless and to want to send you straight to the MRI.
However, YOU may very much wish to avoid the hassle of an MRI if you don’t need one.
Especially if you’re open to one of these less-invasive alternatives, and don’t want to be rushed into a full, open surgical procedure that you’d prefer to avoid.
If You’ve Already Had An MRI
If you’ve already had an MRI and it shows a tear that doesn’t sound like a “slam dunk” case for full surgery (based on what you now understand)…
For example, a moderate partial-thickness tear rather than a severe full-thickness tear, consider the following questions:
3. “What’s the likelihood I can recover with one of the less-invasive alternatives instead of full surgery?”
A related question also would be about the differences in recovery times between the alternative procedure and full surgery.
4. “How often does this alternative procedure fail?”
How often does a patient have (PRP, Stem Cell, Tenex) and still ends up needing full surgery later?
5. “Could I possibly recover without any procedure at all?”
Is there enough structural integrity remaining in the intact part of my tendon that I could strengthen it and recover enough to function reasonably normally?
And if you have one of these “split” type tears (‘Intrasubstance’ / ‘Longitudinal’ Tears) then:
6. “Is surgery (or ANY procedure) really necessary for this type of tear?”
If my tendon is basically split – but still fully attached – how much does this lengthwise split actually compromise its structural integrity?
The Non-Medical Alternative Approach
What if you have a fairly small tear – Or perhaps one that’s not so small – BUT you don’t want ANY kind of surgery or medical procedure, regardless of how “minimally invasive?”
How large a tendon tear (and other damage) can you potentially recover from without resorting to any of these medical measures?
Personally, I don’t think anyone knows for sure. I don’t think there’s enough data.
Why not? Because, most of the people who end up taking the alternative, non-medical / no-surgical route are not “in the system” – Or they drop out of it, so there are no “official” medical stats (or studies) to reference on them.
Even those who do get MRIs and find they have significant tears – but decide not to have a procedure will be “unknowns” as far as the medical stats are concerned.
Chances are, their Orthopedist will never know the outcome – If they don’t return for a procedure of some kind.
Now, this is entirely my opinion, but I believe it’s possible to heal and recover from a mild – possibly moderate – Partial Thickness Tear.
The tendon would likely need to be well over 50% intact – And with minimal Tendinosis / degeneration in the remaining, intact portion if between 20-40% torn.
(The smaller the tear the more Tendinosis would be acceptable in the intact portion – Remember that Tendinosis weakens the tendon structure and allows for the tear.)
With caveats; the larger the tear, the more ifs and maybes.
The big one being that it’s not going to be easy. You’re going to need three things:
- Motivation: You must be HIGHLY motivated and willing to work hard!
- Commitment: You must work consistently for a long time without short-term expectations
- Right Techniques: You must choose the right therapy techniques and exercise protocols wisely!
The best motivation: In my experience the ideal motivation is having the goal of continuing to do something you love and are passionate about! (The desire to simply get out of pain may not be enough.)
It may be that you love your work and want to be able to continue doing it without pain or limitation – Especially if your work is your passion and not just your means of income…
I work mostly with tennis players who LIVE for tennis and will do anything to be able to continue playing – Even if it means being in some pain, as long as it doesn’t become disabling!
Commitment and consistency: Your work ethic, patience and dedication need to be top level in order to do what’s necessary.
It would likely be easier, by comparison, to start and consistently follow an exercise routine for strength and health benefits from ZERO – meaning a state of poor health and fitness.
Why? Because, at least you’ll tend to see consistent, progressive results starting fairly early in the process – maybe even after only a couple of weeks (or however long it takes to get over the initial lack of inertial and get a solid routine going.)
You can’t necessarily count on any early (or sometimes even mid-term results) when you’re trying to recover from a major tendon injury – especially with a significant tear.
You’ll probably need to invest significant time and energy upfront with no immediate gratification.
As in possibly working on it for months before you really start to feel any significant improvements!
In fact, you may need to be prepared to go through cycles where you feel worse before you start to feel better!
Which is especially likely if you’ve been doing all the wrong things up to this point that have been interfering with your body’s natural healing process.
(As in all the “common wisdom” treatments that suppress your natural and necessary inflammation response, like anti-inflammatory pills, ice and Cortisone Shots)…
The right therapy / exercise protocol: The correct therapy approach, (more on my protocol shortly, below) has to begin with a change in mindset and of strategy.
Actively encouraging healing – rather than suppressing it.
And encouraging healing has to begin with stimulating and supporting your natural inflammatory response.
The ice, pills, anti-inflammatory creams and braces need to go in the garbage.
Let’s revisit the earlier quote on Tenotomy. Do you remember the goal?
“…cause[s] bleeding in a tendon, prompting the inflammatory cascade and helping the body’s own cells to begin rebuilding the tendon.”
Meaning, “We’re going to cause new trauma to your tendon with this needle / instrument in order to kick start your healing process”
The question is simply whether this process can be accomplished with less aggressive measures?
Can you stimulate healing without resorting to having holes punched in your tendons with needles?
The Tennis Elbow Classroom Protocol
Yes, I do believe the same process of stimulating healing can be accomplished by hands-on manipulation, as in “Advanced Massage Therapy Techniques”
I believe it’s enough (in certain cases on the less-severe side) to apply pressure to your tendon and a certain kind of friction (Cross Fiber Friction)
As well as some other techniques that also focus on the muscle attached to the tendon.
Because it’s also very important to release all the built up adhesions that are restricting your muscles and increasing the static load on your tendon.
More on the specific advanced Massage Therapy techniques I recommend and teach here.
And for more detail on the overall treatment protocol, perspective and “Philosophy,” see my page on:
The Tennis Elbow Classroom Treatment Strategy
The key difference being that this doesn’t happen in one shot – or one, big sledge-hammer blow, like a medical procedure.
It has to be done regularly for a fairly long time; tap, tap, tap. (It’s a very small hammer.)
The goals remain essentially the same as with these procedures we covered earlier, to:
“Prompt the inflammatory cascade” and help your body’s cells to “begin rebuilding the tendon.”
The problem isn’t that your body is incapable of healing – Of course it can heal soft tissue damage (as in skin, muscle and tendon)…
It’s just that for reasons still not fully understood, tendons often struggle to recover from excessive stresses (including slow, gradual, long-term stresses.)
It’s almost as if the body “forgets” that there’s a problem and it needs to be reminded…
As if the workers at the construction site keep falling asleep and every so often they need to be woken up and prompted to get back to work.
And regularly applying the right pressure and friction to the tendon seems to have this effect of stimulating the tendon, increasing the metabolic activity in the area and “reawakening” the workers at the tendon “construction site!”
(Can I prove this? No. There are no real studies on Manual Therapy Techniques for treating tendons disorders. There’s no money in it.)
But the best news is that you don’t necessarily have to go to someone to have this done…
(Although you certainly can and probably should get professional help if you can find the right therapist and you can afford a lot of fairly expensive treatments.)
You can actually learn to do this yourself!
(Or, better yet, learn these techniques, work on yourself AND see a professional – The best of both worlds!)
Another critical aspect of the Tennis Elbow Classroom approach and major difference has to do with rehab exercises.
Specifically, the question of WHEN to begin them.
The conventional “wisdom” approach usually emphasizes beginning them early on – Much too early, in my opinion.
Starting to load tendons with resistance exercises too early, before enough healing has taken place in the tendon, is often a recipe for struggle and failure, from what I’ve seen in my practice and heard from my Classroom members online.
The key is that the whole process has to be a lot slower.
And the priority needs to be on stimulating tendon healing and normalizing the muscles, through Advanced Massage Techniques.
Then, once significant progress has been made, and the symptoms are considerably diminished, rehab exercises can be gradually introduced.
Once, again, this hands-on approach is not for everyone – only potentially those with milder to moderate tears. (Or no tears!)
And the minimally-invasive procedures we’ve discussed are going to end up being very helpful to certain sufferers (with larger tears.)
But if you’re in the former category and you’d like to learn more about the programs here at Tennis Elbow Classroom (including for Golfer’s Elbow) learn more by following one of the links below.
OR, perhaps you’ve already had surgery and want to take your rehab to a higher level – See below for more about my home treatment programs…
Learn To Treat And Heal Your Own Tennis Elbow Or Golfer’s Elbow At Home With This Video Program
You’ll get instant access to a complete VIDEO program designed by a professional therapist to help you take charge and break your vicious cycle of pain and frustration!…
I’ll be your personal tutor guiding you through step-by-step video lessons, where you’ll get the therapy techniques, key stretches and essential exercises you need to treat and recover from your injury at home. (Without any special equipment.)
Tennis Elbow sufferers: Learn more about the home program here
Golfer’s Elbow sufferers: Learn more about the home program here
Thanks somuch for this thorough explanation of treatment. Truly helpful!
Thank you for the feedback, Tom!
Hi there,
I have a moderate partial thickness tear of the common extensor origin of my right elbow. MRI scan measures it 5mm width and 6mm length.
I have been on light duties for over a year, had two cortisone injections and three PRP injections. It finally seems to be coming good, now is the issue of how to return to full duties as a fishmonger/knife worker.
Your article was very informative although scared me a bit. Thought you might like to hear from someone with a width and length tear. Hoping for a full recovery.
Thank you for that, Dale! Good to hear the Radiologist was very specific in your case. I like that! (I looked to see if you joined and started the Tennis Elbow program but didn’t see you in the members list – Don’t think you need it at this point?)
How can PT help to heal a tendon that is torn? Like if it’s at 50% what will pull the tendon back together ?
I don’t think Physical Therapy is going to help a tendon heal if it’s that badly torn.
I injured what I think to be the tendon during a quick martial art movement and the other day carrying milk in my one arm seemed to aggravate it again after some time with no pain. Now palm up and elbow bent seems to be weak and painful. Twisting the wrist towards palm up does hurt some. I think it’s a partial tear. Ice feels good. Any idea what I should do? I can still do things. I just feel the weakness some.
If you haven’t had a scan, you don’t know if you have a tear. Don’t assume. The degree of pain means little to nothing.
My MRI read “high grade partial tear (near complete) of the common extensor tendon. My doctor has said this is non- surgical and I will just need physical therapy. So do I need a second opinion? I’m 40y/o F that works as a paramedic so my arm is definitely needed, especially with this being my dominant arm.
What treatment did you do? I have similar issue