Interventional Orthopaedics Offers Minimally Invasive Care for Non-Ruptured Tendinopathies

By Dominic King, DO, and Jason Genin, DO

Cleveland Clinic’s Department of Orthopaedic Surgery is staffed by a wide variety of providers who manage patients with acute and complex musculoskeletal injuries and conditions. Our orthopaedic surgeons deliver expert care through innovative and evidence-based treatments including arthroplasty. However, we also have providers who have an interest, passion and skillset in managing non-ruptured tendinopathies. These are our “interventional orthopaedists.”

The relationship between interventional orthopaedists and orthopaedic surgeons is similar to the relationship between interventional cardiologists and cardiothoracic surgeons. Interventional orthopaedics is a minimally invasive approach to treating chronic tendinopathy, including with ultrasound-guided injections, platelet-rich plasma injections, and minimally invasive tenotomy and hydroresection (TenJet) procedures.

Introducing: Tendinopathy and Interventional Orthopaedic Center of Excellence

Interventional orthopaedist Jason Genin, DO, was recently named Director of the Tendinopathy and Interventional Orthopaedic Center of Excellence (TIO CoE) within Cleveland Clinic’s Sports Medicine Center.

This center of excellence will lead efforts in coordinating the diagnosis and management of patients with non-ruptured acute and chronic tendinopathies (Figure).

Figure. Areas of tendinopathy (common diagnoses seen in the Tendinopathy and Interventional Orthopaedics Center of Excellence).

It will provide patients and orthopaedic colleagues with:

• Musculoskeletal ultrasound-based tendinopathy classification. The TIO CoE recently completed research on the inter- and intra-rater reliability of musculoskeletal ultrasound-based features of tendinopathy.1 These classification features reliably identify inflammatory, degenerative, and inflammatory on degenerative non-ruptured tendinopathies of the common extensor tendon (Table).
• Ultrasound-guided joint and soft tissue injections. Ultrasound has been found to be effective at ensuring the accuracy and precision of joint and soft tissue injections. The ultrasound-guided procedure allows for a diagnostic and therapeutic approach to aid in medical decision-making for many providers. In addition, there is opportunity to evaluate success of various medications based on accuracy of injections.
• Ultrasound-guided minimally invasive tenotomy and hydroresection. Using an in-office, ultrasound-guided needle-based procedure, we can hydroaspirate degenerative tendinosis and calcific tendinopathies. This approach can be applied to rotator cuff calcific tendinopathy, tennis elbow, golfer’s elbow, hamstring and gluteal tendinopathy, quadriceps and patellar tendinopathy, Achilles tendinopathy and plantar fasciopathy.
• Tendon evaluation and management (TEAM) combined visits. This multidisciplinary clinic is focused on the coordination of care for the nonsurgical patient with tendinopathy. Patients receive real-time, same-day care, provided with both diagnosis and treatment recovery recommendations prior to leaving the office. Providers can use TEAM combined visits to structure best practices for the care of various tendon injuries that have otherwise been difficult to manage.

Table. Tendinopathy classification.

Next steps: validating and expanding care guidelines

Now that a two-year TEAM pilot program has ended, a dedicated group of physicians and physical therapists has begun to develop care guidelines for many nonsurgical orthopaedic conditions. With continued collaboration, further research will help expand knowledge in the fields of orthobiologics, tendinopathy, musculoskeletal ultrasound and associated outcomes. Further research to validate these guidelines and expand the library of current guidelines is underway. We also will be adding more providers to the TIO CoE, with plans to expand services throughout Cleveland Clinic’s health system.

Dr. King is a sports medicine physician in the Department of Orthopaedic Surgery as well as Manager of Orthopaedic Informatics and Director of Clinical Transformation in the Orthopaedic & Rheumatologic Institute.

Dr. Genin is a sports medicine physician in the Department of Orthopaedic Surgery as well as Director of the Tendinopathy and Interventional Orthopaedics Center of Excellence.

Reference

1. Patel V, Esfahani A, Ahmadi R, et al. Interrater and intrarater reliability of musculoskeletal ultrasonographic findings for the common extensor tendon of the elbow. Journal of Diagnostic Medical Sonography. 2021 May 12:87564793211005743.