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Not so FAST

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

I recently got a question about the value of FAST (“focused aspiration of scar tissue”), a minimally invasive surgical treatment for tendinopathies like tennis elbow or Achilles tendinitis. According to one doctor’s press release, it’s “advanced technology” — of course! — “designed to remove the source of tendon pain.” Good luck finding any other kind of information about it. There are no clinical trials of FAST. It seems to just be tendon scraping (debridement, if you want to be more formal). The mechanism is unclear, obviously speculative, and based on the rather simplistic notion that one can “remove tendon scar tissue” or “diseased tissue” from tendons to solve the problem. Bad tissue is bad! MUST CUT OUT. I also saw a number of references to “stimulating” recovery, which is quite a different idea (see Tissue Provocation Therapies in Musculoskeletal Medicine).

Giving it the benefit of the doubt: maybe it can work on some kinds of patients. Tendinopathy develops in stages, and in the degenerative later stages there might be something to scrape away, for whatever that’s worth. Or not, because degenerative tendinopathy is mostly characterized by a kind of withering of the tendon (acellularity and disorderly connective tissue), and not by anything that can be removed. And in any event “there is little capacity for reversibility of pathological changes at this stage” (Cook 2009). Many cases never get that far in the first place and wouldn’t be candidates even in principle, since they involve little or no obvious “diseased tissue” in the first place, and even if they do it’s almost certainly a symptom of tendinopathy, not the cause of it. So the whole idea of a treatment based on the removal of tendon crud is dubious.

There’s a never-ending supply of minimally invasive procedures for stubborn musculoskeletal problems, like platelet-rich plasma (PRP), which has probably reached peak hype by now. They are easy to sell, because they sound simultaneously impressive but still quite safe. They can be potent generators of false hope and drainers of wallets, and they are all highly suspect for this reason. But FAST seems more desperately in need of some proper testing than most.

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