High-Volume Injections for Chronic Tendinopathy

Unlocking Tendon Healing: Understanding High-Volume Injections and Integrative Care

Abstract

Hello, I’m Dr. Alex Jimenez. In this educational post, we will explore a powerful and advanced technique for treating chronic tendinopathy: the high-volume injection (HVI), also known as brisement. Drawing on the latest research and insights from leading experts like Dr. Fran O’Connor, we will journey into the physiological mechanisms behind this procedure. This is particularly relevant for conditions like Achilles tendinopathy. I will explain what brisement is, how it differs from other treatments, and the step-by-step process of its application under ultrasound guidance.

We will also discuss the crucial role of integrative chiropractic care within a multidisciplinary framework. This post shows how our team at Injury Medical Clinic combines my expertise in chiropractic and functional medicine with the medical oversight of our Medical Director, Dr. Maria Guadalupe Cardenas, MD, to provide comprehensive, effective patient care. Moreover, it aims to provide a clear, in-depth understanding of how we use modern, evidence-based methods to address the root causes of tendon pain and promote lasting healing.

A New Frontier in Treating Chronic Tendinopathy

As a practitioner dedicated to finding the most effective, evidence-based solutions for my patients, I am constantly exploring advancements in musculoskeletal medicine. One of the most promising techniques I’ve incorporated into my practice is an advanced procedure known as brisement, or high-volume injection (HVI). This technique also represents a significant shift in how we think about and treat chronic, stubborn tendinopathies. It is especially used for cases that have not responded to conventional therapies.

At our practice, Injury Medical Clinic, we pride ourselves on a multidisciplinary, integrative approach. Our collaborative model makes this possible. I, Dr. Alex Jimenez, work alongside our distinguished Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD, who is Board Certified in Internal Medicine and brings over four decades of experience to our team. Her medical oversight (NPI #1164426749, Texas MD License #J2933) is integral to our ability to offer a broad spectrum of care—from personal injury rehabilitation and functional medicine to advanced procedures like the ones we’ll discuss today. Therefore, this synergy lets us blend the best of chiropractic care, medical expertise, and rehabilitative science. As a result, we create personalized, highly effective treatment plans.

Drawing from the pioneering work of researchers like Dr. Fran O’Connor, we can see how modern diagnostic tools and innovative treatments are changing patient outcomes. Let’s explore the details of high-volume injections. We’ll also see how this procedure can significantly improve chronic tendon pain.

What is Brisement, or High-Volume Injection?

To truly grasp the innovation of brisement, we must first distinguish it from more familiar tendon treatments. Many people have heard of procedures like fenestration or tenotomy. In these, a needle is used to intentionally create micro-tears directly within the damaged tendon tissue. The goal is to stimulate a localized inflammatory response. Ultimately, the body’s natural healing cascade is triggered to repair degenerated tendon fibers.

Brisement, however, operates on an entirely different principle. A high-volume injection focuses not on the tendon itself but on the surrounding soft tissues. Specifically, the procedure targets the space directly adjacent to the tendon. For example, the area targeted is the space between the Achilles tendon and the underlying fat pad (Kager’s fat pad) or the paratenon (the sheath surrounding the tendon).

The “Why” Behind the Procedure: Targeting Neovessels and Nerves

So, why focus on the space around the tendon? Groundbreaking research has revealed that in chronic tendinopathy, the body attempts to heal the injured area by growing a chaotic network of new, fragile blood vessels (neovascularization) and accompanying nerve fibers (neoinnervation). These are often referred to as “tenuous neovessels and neo-nerves.”

While this might sound like a good thing—more blood flow should mean more healing—these new structures are problematic.

• The Nerves: The new nerve endings are highly sensitive and are a primary source of the persistent, nagging pain associated with chronic tendinopathy.
• The Vessels: These new blood vessels are abnormal and leaky. They don’t contribute effectively to healing and instead perpetuate a cycle of low-grade inflammation and tissue irritation.
• Adhesions: This neovascularization often leads to adhesions, or scar tissue, that can bind the tendon to surrounding structures. This “tethering” restricts the tendon’s normal, smooth gliding motion, causing friction, irritation, and further pain with every movement.

Brisement is designed to address this exact problem. The term itself, derived from French, means “breaking” or “disruption.” The procedure uses the force of a large volume of fluid to mechanically break up and disrupt these problematic neovessels, neo-nerves, and adhesions. It’s essentially a form of hydrostatic decompression.

The Brisement Procedure: A Step-by-Step Explanation

The high-volume injection procedure is a precise, minimally invasive technique performed under real-time ultrasound guidance. This is crucial. It allows the practitioner to visualize the needle, the tendon, and the surrounding tissues with pinpoint accuracy. Furthermore, it ensures the fluid is delivered to the exact target location.

Let’s walk through the process, as demonstrated by experts in the field, for a patient with Achilles tendinopathy.

1. Patient Positioning and Preparation: The patient is positioned comfortably, typically lying face down to provide optimal access to the Achilles tendon. The area is then meticulously cleaned and prepped with an antiseptic solution to ensure sterility.
2. Ultrasound Examination: Using a high-frequency linear ultrasound probe, I carefully examine the Achilles tendon in both the long axis (viewing the tendon lengthwise) and short axis (viewing a cross-section). This initial scan allows me to identify the specific area of tendinopathy—which often appears as a thickened, disorganized, and sometimes hypoechoic (darker) region within the tendon—and map the exact location of adhesions and neovascularization at the tendon-fat pad interface.
3. Local Anesthesia: A very fine-gauge needle (e.g., 25- or 27-gauge) is used to inject a small amount of local anesthetic, such as lidocaine, into the skin and subcutaneous tissues. This numbs the entry point, ensuring the patient’s comfort during the main procedure.
4. The High-Volume Injection: Once the skin is anesthetized, a slightly larger needle (e.g., a 21- or 22-gauge) is guided under ultrasound visualization to the precise space between the anterior border of the Achilles tendon and the adjacent tissues (like Kager’s fat pad).
5. Hydrodissection and Decompression: The injectate, typically a combination of a local anesthetic (like lidocaine for its pain-relieving properties) and a large volume of sterile normal saline, is then slowly and carefully injected. The literature describes a wide range of volumes, anywhere from 5 to 100 cubic centimeters (cc’s), depending on the specific case and the practitioner’s judgment. As the fluid enters the space, we can see it in real time on the ultrasound screen. The fluid acts as a hydraulic tool, physically peeling the tendon away from the tethered fat pad. This action achieves several critical goals simultaneously:
   • It mechanically disrupts the delicate neovessels and neo-nerves, effectively “pruning” away the source of chronic pain and irritation.
   • It breaks down adhesions, freeing the tendon and restoring its ability to glide smoothly.
   • The large volume of fluid literally flushes out inflammatory chemicals and metabolic waste products that have accumulated in the area.
   • It creates a physical space between the tendon and surrounding tissues, reducing friction and pressure.

The procedure is performed to the patient’s tolerance and until visible separation of the tissue planes is achieved. Throughout the process, I am in constant communication with the patient, monitoring their comfort and the tissue’s response. While the procedure is generally safe, it’s important to be mindful of the potential risks. These include tendon rupture or compartment syndrome, especially when using substantial volumes. This is where experience and precise ultrasound guidance become paramount.

Integrating Chiropractic Care for Comprehensive Tendon Rehabilitation

The high-volume injection is a powerful intervention. However, it is not a standalone cure. It is a tool that effectively “resets” the local environment and creates an optimal window for true healing and rehabilitation. This is where our integrative model at Injury Medical Clinic truly shines.

As a Doctor of Chiropractic with extensive training in functional medicine and rehabilitation, I see the body as an interconnected system. The dysfunction in the Achilles tendon is not just a localized problem. Often, it is linked to biomechanical imbalances throughout the entire lower kinetic chain—from the foot and ankle up through the knee, hip, and even the lumbar spine.

Following a brisement procedure, our integrated rehabilitation protocol begins. This crucial phase addresses the root causes of the tendinopathy. Additionally, it helps prevent recurrence.

• Chiropractic Adjustments: We assess and correct any misalignments in the spine and extremities. For example, a subluxation in the lumbar spine can alter nerve function to the leg muscles, leading to dysfunctional movement patterns. Similarly, poor foot mechanics (like overpronation) or restricted ankle joint mobility can place excessive strain on the Achilles tendon. Gentle, specific chiropractic adjustments can restore proper joint function, improve nerve flow, and balance the biomechanical forces acting on the tendon.
• Soft Tissue Mobilization: We use techniques like Graston, Active Release Technique (ART), and therapeutic massage to treat any remaining fascial restrictions and scar tissue in the calf muscles (gastrocnemius and soleus) and surrounding tissues. This improves muscle flexibility and reduces tension on the Achilles tendon.
• Eccentric Loading Exercises: This is the cornerstone of tendon rehabilitation. Once the initial pain and inflammation are under control, we introduce a carefully progressed program of eccentric exercises. These are exercises where the muscle lengthens under tension (e.g., slowly lowering your heel off a step). Research overwhelmingly supports eccentric loading as the most effective way to stimulate collagen synthesis and remodel the tendon fibers into a strong, organized, and functional structure. The brisement procedure creates the ideal pain-free window to begin this critical phase of rehabilitation effectively.
• Functional Medicine and Nutritional Support: We also look at the bigger picture. Chronic inflammation can be systemic. Using a functional medicine approach, we may assess for nutritional deficiencies, food sensitivities, or metabolic imbalances that could be hindering the body’s ability to heal. We provide targeted nutritional counseling and supplementation (e.g., Vitamin C, zinc, collagen peptides, and anti-inflammatory herbs) to support tissue repair from the inside out.

This comprehensive approach, guided by Dr. Cardenas’s medical expertise, ensures we are not just treating the symptom (the painful tendon) but also correcting the underlying biomechanical and physiological dysfunctions that caused the injury in the first place. This is the key to achieving long-term resolution and preventing recurrence.

The Future of Tendon Care

Procedures like brisement, or high-volume injection, guided by advanced imaging, represent the future of musculoskeletal medicine. They allow us to move beyond simply managing symptoms. Instead, we target the specific pathological processes driving chronic conditions. When we combine this advanced intervention with a holistic, integrative framework that includes chiropractic care, targeted rehabilitation, and functional medicine, we can offer our patients a truly comprehensive and powerful path to recovery.

I am passionate about bringing these leading-edge, evidence-based findings to my patients here in El Paso. By continuing to learn from pioneers in the field and working collaboratively with esteemed medical professionals like Dr. Cardenas, we can provide care that addresses the whole person, helping them not just heal from injury but achieve a new level of health and function.

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References

• Chan, O., & O’Connor, P. (2007). Patellar tendinopathy: a new perspective. Ultrasound in Medicine & Biology, 33(4), 521-531.
• Maffulli, N., Spiezia, F., & Longo, U. G. (2013). High-volume image-guided injection for recalcitrant patellar tendinopathy. Journal of Orthopaedics and Traumatology, 14(2), 101-105.
• Morton, S., Williams, S., Valle, X., & de-la-Fuente, C. (2017). High-volume injection in recalcitrant midportion Achilles tendinopathy in a prospective cohort. Journal of Sports Sciences, 35(15), 1500-1506.