What are the guidelines for performing ultrasound needle fenestration for elbow pain due to conditions like tendinitis or bursitis in a patient with potential bleeding disorders or on anticoagulant therapy?

Ultrasound-Guided Needle Fenestration for Elbow Tendinopathy

Direct Answer

Ultrasound-guided percutaneous needle fenestration is a safe and effective treatment for chronic elbow tendinosis when conservative management has failed, with 80% of patients reporting good to excellent outcomes at 28-month follow-up. 1

Patient Selection Criteria

Proceed with fenestration only after failure of 3-6 months of conservative therapy, including NSAIDs, splinting, and physical therapy. 2 The ideal candidate has:

• Chronic common extensor tendinosis (lateral epicondyle) confirmed by ultrasound showing tendinotic tissue 1
• Persistent pain and disability despite conservative treatment 1
• No contraindications to the procedure 1

Critical Caveat for Anticoagulation

The provided guidelines do not address specific protocols for patients on anticoagulant therapy or with bleeding disorders. This represents a significant gap in the available evidence. In clinical practice, you must:

• Assess bleeding risk using standard periprocedural anticoagulation protocols
• Consider holding anticoagulation if medically safe, following cardiology/hematology consultation
• Weigh the risk of bleeding complications against the benefit of the procedure, as needle fenestration involves multiple passes through tendinotic tissue 1

Ultrasound Positioning and Scanning Protocol

Patient Positioning for Elbow

Position the patient sitting with:

• Full extension of the elbow joint and supination of the lower arm for ventral/anterior scans 3
• 90-degree flexion of the elbow for dorsal/posterior scans 3
• For dorsal scans, the hand can be placed on the hip or thigh with moderate internal rotation of the humerus 3

Standard Scanning Views

Obtain these views to identify pathology:

• Anterior humeroradial longitudinal scan to visualize the humerus, radius, muscles, and articular cartilage 3
• Anterior transverse scan at the distal humeral epiphysis to assess articular cartilage and muscles 3
• Posterior transverse scan at the distal humeral epiphysis to evaluate the triceps muscle and articular cartilage 3

Fenestration Technique

The procedure involves the following steps under local anesthesia and continuous ultrasound guidance: 1

1. Advance a needle into the common extensor tendon under direct visualization 1
2. Repeatedly fenestrate the tendinotic tissue using the needle tip to create multiple perforations 1
3. Mechanically fragment any calcifications if present 1
4. Abrade the adjacent bony surface of the epicondyle apex and face 1
5. Infiltrate the fenestrated tendon with corticosteroid mixed with bupivacaine 1

Post-Procedure Protocol

Immediately after the procedure, instruct patients to:

• Perform passive stretching exercises 1
• Undergo structured physical therapy 1

Expected Outcomes

At an average 28-month follow-up, patients report: 1

• 63.6% excellent outcomes (marked improvement)
• 16.4% good outcomes (some improvement)
• 7.3% fair outcomes (minimal change)
• 12.7% poor outcomes (no improvement or worsening)

No adverse events were reported in the primary study, and 85.5% of patients stated they would refer others for the procedure. 1

Detectable Pathology on Ultrasound

Before proceeding with fenestration, confirm the diagnosis by identifying: 3

• Tendinitis/tenosynovitis/tendon tear
• Effusion/synovial proliferation
• Cartilage thinning or lesions
• Bony lesions (erosions, osteophytes, irregular bone profile)
• Periarticular lesions (crystal deposition, calcinosis)

Important Distinctions

Recognize that chronic elbow pain represents degenerative tendinopathy (tendinosis) rather than acute inflammation (tendinitis), which affects treatment approach. 2 This is why fenestration—which mechanically disrupts degenerative tissue—is effective where anti-inflammatory treatments alone may fail.

Therapeutic Ultrasound vs. Diagnostic Ultrasound

Do not confuse ultrasound-guided fenestration with therapeutic ultrasound (low-power ultrasound for physical therapy). 4 Therapeutic ultrasound for tendinitis and bursitis has been used since the 1950s 4, but evidence for its benefit in subacromial bursitis shows no significant difference compared to sham treatment. 5 Fenestration is a mechanical intervention using ultrasound for guidance, not therapy. 1

Common Pitfalls to Avoid

• Do not perform fenestration as first-line treatment—reserve it for patients who have failed conservative therapy for 3-6 months 2
• Do not proceed without addressing anticoagulation status, as the provided guidelines lack specific protocols for this scenario
• Do not confuse diagnostic ultrasound positioning (for imaging) with therapeutic positioning (for intervention)—use proper positioning for optimal needle access 3
• Do not limit treatment to corticosteroid injection alone in chronic cases—fenestration addresses the underlying degenerative tissue 1