Chronic tendinopathy is one of the most common reasons patients remain symptomatic after months of physical therapy, activity modification, NSAIDs, or corticosteroid injections. At Baptist Health Miami Neuroscience Institute, Raul Rosario-Concepcion, M.D., RMSK, offers a structured nonsurgical pathway for these patients, pairing focused extracorporeal shockwave therapy (F-ESWT) with ultrasound-guided percutaneous tenotomy to address tendon pain that has failed first-line care but does not yet warrant surgery.

When to Refer

Consider referral for any patient with localized tendon or fascial pain persisting beyond 3 months despite a trial of physical therapy, activity modification, and/or one prior injection, particularly when the patient wishes to avoid or delay surgical consultation.

A Stepwise Tendon Failure Pathway

Rather than offering isolated procedures, Dr. Rosario-Concepcion evaluates each referred patient with diagnostic musculoskeletal ultrasound and matches them to the least invasive option likely to succeed:

• Step 1 — F-ESWT: Noninvasive, regenerative-focused therapy for most chronic tendinopathies. Typically, the first interventional step after failed conservative care.
• Step 2 — Minimally invasive ultrasound-guided percutaneous ultrasonic tenotomy and debridement: Reserved for patients with focal degenerative tissue identified on imaging who have not responded to F-ESWT or who present with more advanced tendinosis.
• Step 3 — Surgical referral: Coordinated when minimally invasive options have been exhausted or anatomic findings warrant it from the outset.

Focused Extracorporeal Shockwave Therapy (F-ESWT)

F-ESWT delivers targeted acoustic energy to injured tissue to stimulate the body's natural healing response promoting collagen synthesis, tendon remodeling, neovascularization, cellular repair activation, and pain modulation.

• Common indications: chronic plantar fasciitis, Achilles tendinopathy, lateral and medial epicondylopathy, patellar tendinopathy, proximal hamstring tendinopathy, gluteal tendinopathy, and calcific shoulder rotator cuff tendinopathy.
• Treatment course: in-office sessions of 15–20 minutes, typically 3–5 visits spaced one week apart. No anesthesia, no activity restrictions, and patients return to work the same day.
• Coverage: F-ESWT is not currently covered by most insurers and is offered as a transparent self-pay service. Patients are informed of cost prior to scheduling.

Minimally Invasive Ultrasound-Guided Percutaneous Tenotomy and Debridement

For patients with focal degenerative tendon tissue, ultrasonic tenotomy uses targeted ultrasonic energy delivered through a small percutaneous incision to debride pathologic tissue while preserving surrounding healthy fibers. The procedure is performed under local anesthesia with real-time ultrasound guidance.

• Common indications: chronic plantar fasciitis, Achilles tendinopathy, lateral and medial epicondylopathy, patellar tendinopathy gluteal tendinopathy, and calcific shoulder rotator cuff tendinopathy.
• Recovery: most patients return to desk work within 2–3 days and to light activity within 1–2 weeks; sport-specific return is tendon-dependent and guided by structured rehabilitation. Compared to open surgery, the percutaneous approach reduces soft tissue disruption, post-procedure soreness, and time away from work.
• Coverage: Ultrasound-guided percutaneous tenotomy is typically a covered benefit under most commercial and Medicare plans when conservative care has failed and imaging supports the diagnosis. Prior authorization may be required.

Why Ultrasound Guidance Matters

Every patient referred to Dr. Rosario-Concepcion receives a diagnostic musculoskeletal ultrasound examination at the point of evaluation. Real-time imaging confirms the pathology, rules out alternative or coexisting diagnoses (partial tears, bursal pathology, neuropathy), and guides procedural precision. Dr. Rosario-Concepcion holds the Registered in Musculoskeletal Sonography (RMSK) credential and teaches advanced musculoskeletal ultrasound at national and international meetings.