Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey discusses the role & function of tendons in the body, traditional rehabilitation approaches to treating tendinopathy, as well as a new procedure called TENEX for tendinopathy management.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog.

If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

LINDSEY HUGHEYMorning PT on ICE Daily Show. How's it going? Welcome to Clinical Tuesday. I am Dr. Lindsey Hugey and I will be your host today and we're going to chat all things TENEX and TENEX care specifically for our tendons. So I'll chat with you a little bit about what it is, what the procedure proposes to do and kind of what we're seeing in regards to its effects So the title officially today is, does TENEX get a 10 for tendinopathy care? So let's dive right in. And I do want to say, spoiler alert, it does not get a 10 for tendinopathy treatment. So first, before we dive into what is TENEX, Let's just chat about in general what tendons need to heal as a little reminder to kind of set the stage. And if you've been to our extremity management course, this will just really be a review. TENDON FUNCTION But our tendons in their most basic function, they connect muscle to bone. They are to act like a spring and they are to be mechanoresponsive, right? To take on load, transmit force up and down and across. they are responsible for speed and acceleration, they need to take on compression and friction. As soon as we spike loads quickly or dramatically deload activity, we will see changes in capacity of not only that tendon, for better or for worse, but also in the structures they're attached to. So consider the muscle, local muscle, and then that bone. So not just the tendon will either gain and be challenged by spikes in load and or will reduce, right, if you dramatically deload. So come to our course if you want to, extremity management, want to learn even more about that, but that's kind of tendon basics. For those that have treated tendinopathy and are in the outpatient space, folks that do a lot of repetitive action or athletes often get tendinopathy at some point in their life. And this results in pain. It can result in sickening and swelling at that tendon, but really it's decreased performance, whether it's in their job that they need to do and or their sport participation. And a lot of folks think this is just going to go away on its own. And they'll try conservative measures, whether it's they've looked it up on Dr. Google or they've consulted their doc. And I want to set the stage of what's really being told for conservative management of our attendants. It's rest, it is NSAIDs, injections, surgery, PRP, stem cell, shockwave therapy, and then physical therapy is on there as well, but we know there's a lot of treatment variation in our profession in regards to building the capacity of that tendon. WHAT IS TENEX? Now on this list for conservative management is TENEX. So I kind of want to set the stage. We now know what kind of tendon function, what will challenge a tendon, and now we know what is really recommended for tendinopathy care. We tend to see, because of this treatment variation as well, right, from rests to anti-inflammatories to surgery and physical therapy, somewhere in between, we see people, and then some folks just not getting care at all, going on to chronicity. telling their docs that, you know, this is hanging on for more than three to six months. I'm not getting better. My performance is lessening. I'm having difficulty at work. And so TENEX was developed. And so we're gonna dive into the treatment. Is this helpful for tendinopathy? So TENEX , T-E-N-E-X, for those listening, is prescribed for those recalcitrant cases that aren't responding from that list we just reviewed. What it was developed in Lake Forest, California by TENEX Health System in collaboration with Mayo Clinic. And what it is, is it's ultrasound guided percutaneous needle tenotomy. It's a mouthful. And what they do is they use a needle, a small incision is made with this specialized device called TENEX, the device is inserted, it delivers ultrasonic energy to the damaged tendon tissue, and it emulsifies that damaged tissue into a soft liquid form, and then that's removed through the same incision. Basically, using oscillations in high frequency to debride and aspirate the diseased tendon, all guided under ultrasound image. The rationale for TENEX, is that it is minimally invasive for those that have been struggling for three to six months to even a year. It's minimally invasive as stated, but they're not going to have a ton of a recovery period. They'll get back to their activities. There is like a very wide variation here, but they'll say anywhere from three weeks to 12 weeks. The goal and kind of the underlying theory of why does TENEX work is that it is stimulating the body's natural healing process. And ultimately that helps restore tendon function. That's what the kind of the proposition is. And then they keep selling that it's minimally invasive and it's shorter recovery than like your typical surgeries that they'll do for tendinopathies. with the cell, they usually will sell the shorter time of two to three weeks back to your sport, back to work without any issue. DOES TENEX WORK? And so what are patients saying about this? So patients, when we look at systematic review level studies, and there's more than a handful of these, we are seeing these patients reporting reduced pain, reporting improved function, returning to their sport, And what's interesting is they're seeing even at a year-end, three-year mark, these patients still reporting improvement in combination with these TENEX procedures. And so we kind of have to take a pause about our biases because here at ICE, you know, and if you've been to our course, we really believe load is our love language for tendon care. And that's really the only way to remodel that tendon is high tensile loads. And so what should we be thinking and advising our patients on, knowing that this procedure exists, it's existed since 2010, knowing that even in the last five years, we've gained some systematic review studies in various areas of rotator cuff, Achilles tendinopathy, gluteal tendinopathy, our lateral elbow tendinopathies, all of these areas are showing evidence of improved pain and function. But there's a lot of unknowns, right? So like, what do we tell our patients? Because they're going to ask, especially if they're kind of looking for that quick fix, and maybe they just started out of care with you as well. Well, I think we have to be honest that we don't actually know a lot of long term data. in combination with physical therapy. So you'll see that often after this procedure, they are recommended physical therapy. So what we don't know is the differentiator yet. Is it physical therapy that is actually helping or is it that TENEX? In addition, that bias that I told you about that I want to share is that you still have to restore capacity to surrounding tissue. So even if you clear out this like dead tissue right this tissue that is specific or excuse me that's been linked to possibly being painful for this patient you still have to lay down new fibers in that tendon, you still have to challenge the local muscle, you still have to help that bone health and so all that doesn't go away. My bias here is going to be that physical therapy when done very well should prevent this TENEX from ever having to happen because we should be able to right away respect that irritability of the patient dampen their pain symptoms right whether they have some degenerative tendon on board or not we might not know but if you respect irritability and then gradually load that person load that local tendon load that local muscle challenge the chain and then as that goes well then start to add in some energy storage where the patient has to take on compression and friction and spring-like movements, we don't have to get to these invasive procedures. But it's that variation in our practice and the things that are just readily recommended on the internet and from docs, which is RESS and NSAIDs and getting stem cells or PRP, these like quick fixes, quick fixes that never really address the underlying problem. So while TENEX, I think there are some promising results and we really have to acknowledge that. I'm going to give it a 5 out of 10 because we do see in those people that are getting TENEX that they have improved pain and function consistently. Only giving it a 5 because We have an opportunity here that TENEX is not the answer, right? We see folks on the other side of that TENEX. It's not TENEX giving the 10 out of 10 pain free, right? Or 10 out of 10 function. It is really in that conjunction of getting the tendon capacity back up. So thank you for kind of going on this little journey with me about TENEX. It's been a question that's been popping up on weekends, you know, what do we think about TENEX and what do we tell our patients? What I'm going to say overall in concluding this is that those suffering from chronic tendinopathy, they may have their mind set that this is what they want to do. Know that you can partner with them. before that and after. Like you are going to be a part of their care no matter what to build up that capacity. You can educate in that way and let them know and I can attach them if you're interested that there are systematic reviews showing promise with this. know that as Dr. Justin Dunaway says, beliefs and expectations are the foundations on which outcomes are built. So if the patient believes TENEX is going to help, it is going to help with pain and function. If they believe physical therapy is going to help, it's going to help. And if in conjunction together, they believe it's going to help, it's going to help. So we really have to have a biopsychosocial approach to this too, not just the facts about the procedure and what TENEX is resulting in on a systematic review level. What really matters is what does the patient believe that's going to help and what's going to get their tendon ultimately more healthy. SUMMARY I appreciate you joining me to chat a little bit about something that's a little outside of the scope of our normal weekend. And if you want to learn more about the tendon continuum, the complex pathophysiology that's happening, we take a deep dive over an hour long lecture on day two of our course that dives into all the latest literature on tendinopathy. our upcoming opportunities to do that and join us. We have two, August 24th and 25th. I'll be in Bismarck, North Dakota, and Cody will be in Greenville, South Carolina. We would love you to join one of us, right opposite ends of the spectrum. And then the next opportunity will be September 14th, 15th in Denver, Colorado. So join us on the road if you can. Thanks for chatting with me a little bit about 10X today. Have a happy Tuesday, everyone.

OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.