Tennis elbow is a common musculoskeletal condition affecting middle-aged patients with symptoms usually lasting from 6 months to 2 years. The vast majority of individuals will respond to conservative therapy; however, some will require surgical intervention. A new treatment system has been developed for use with ultrasound guidance in the ultrasonic microresection of tendinopathic tissue. This technology has been implemented in the TX1 Tissue Removal System and is used to treat various tendinopathies by debridement using targeted ultrasonic energy. We describe the surgical technique for the TX1 system as well as provide pain and functional outcome scores for a series of patients with recalcitrant lateral epicondylitis treated with percutaneous tenotomy with ultrasonic energy utilizing ultrasound guidance.