What is ultrasound guided tendon scraping (neovessel ablation)?

Tendinopathy has been well established to be less of an inflammatory response and more of a chronic degradation of the tendon, with pathophysiology consisting of degenerative microtearing, collagen fiber disorganization, hypercellularity, and angiofibroblastic hyperplasia of the tendon proper.  Chronic tendinopathies affect approximately 10 million patients per year, requiring frequent physician visits and a large economic health burden. Often despite months of extensive conservative treatment such as rest, activity modification, physical therapy, oral and topical medications, and orthotics and/or bracing, more advanced treatment options such as injections and surgery are sought for pain relief. Traditionally corticosteroid injections are offered as the next step in treatment approach. However, as more evidence emerges revealing potential harms of corticosteroids on soft tissues such as risk of tendon rupture, and fat pad atrophy, physicians are turning to other options such as orthobiologics (PRP[AP1] , BMAC, A2M) and ultrasound guided tendon scraping. 1-4

Hakan Alfredson was the first to demonstrate that neovessel abalation “tendon scraping “technique resulted in decreased pain and improved function in patients with AT.   Good results with interval reduction in pain with both open and USG percutaneous neovessel ablation techniques for midportion AT were reported.  The same group demonstrated good long-term (2-13 years) clinical outcomes with high satisfaction rates in 241 tendons following the same technique, suggesting that neovessel ablation is a safe and effective treatment for chronic AT. 5,6

 

How is it performed?

Once a decision is made on the approach, local anesthetics are used to numb the area prior to the procedure. A small stab incision is made, to allow passing the meniscotome. Following US confirmation of correct placement, a proximal-to-distal sweeping motion is used to separate the fat pad from the tendon.  Once a separation plane is created with the needle, the meniscotome is withdrawn and a 21-gauge 50mm needle is introduced with USG through the incision. Subsequently, 20mL of sterile 0.9% normal saline is injected to hydro-dissect the fat pad away from the tendon. Following completion of the procedure the wound is closed with skin glue and steri-strips.


A) Single use dual bladed meniscotome.

B) External view of left (LT) ankle demonstrating Td placement and meniscotome insertion via a medial-to-lateral approach for neovessel ablation (tendon scraping) procedure. Note a #11 blade was used to create a stab incision for introduction of the meniscotome. In this patient the area of pathology required two incision points.

C) USG correlate of in-plane, medial-to-lateral approach showing hyperechoic meniscotome (arrowheads) between the Achilles tendon (AT) and Kager’s (K) fat pad. Note the location of the sural nerve (dotted circle) just lateral to the Achilles tendon. 

D) USG correlate of out-of-plane, medial-to-lateral approach showing hyperechoic meniscotome (arrowhead) between the AT and K for tendon scraping procedure. The meniscotome is then toggled distal-to-proximal to scrape the bottom of the tendon, separating it from Kager’s fat pad.

E) USG image of a hyperechoic needle tip (arrowhead) between the AT and K performing a high-volume injection. Notice the separation of the K from the AT as the injectate (star) is injected.

LAX- long axis, SAX- short axis, DIST- Distal, LAT- lateral

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Is it safe?

long-term (2-13 years) clinical outcomes with high satisfaction rates in 241 tendons following the same technique, suggesting that neovessel ablation is a safe and effective treatment for chronic AT. 5,6

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What is the recovery like?

When tendons are treated patients are sorer with increased pain for about 1-2 weeks. Then the pain waxes and wanes for about 2-6 weeks, with some decreased pain days intermixed with days where it is very painful. It takes about 4-6 weeks for tendons to heal and remodel on repeat imaging. 

The recovery is different for different tendons and ligaments and can vary from patient to patient. This will be reviewed at the time of consultation.

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When to consider choosing tendon scraping for your tendinopathy

Typically, chronic tendinopathy has been managed with overload reduction and rehabilitation including progressive tendon loading via eccentric exercises and more recently heavy-slow exercises, along with analgesics, anti-inflammatories, ice, manual therapy, and correction of biomechanics when appropriate. After a comprehensive evaluation with imaging to confirm diagnosis, patients recalcitrant to the above conservative measures may consider ultrasound guided neovessel ablation as an option for management of tendinopathy. 

 

Schedule an appointment for evaluation to see if this is an option for your management.

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Reference Publications

See the full list of Dr. Pourcho's reference publications on this topic

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