Chronic Tendinopathy Care With High-Volume Injections Benefits

Chronic Tendinopathy Care With High-Volume Injections

Abstract

Welcome to our educational series. I’m Dr. Alex Jimenez, and today, we’re exploring an advanced, evidence-based technique for managing chronic tendinopathies: brisement, also known as high-volume injection (HVI). This post will take you through the science and application of this innovative procedure. We will unpack what brisement is. We’ll also discuss how it differs from other treatments like fenestration and its physiological mechanism of action.

We’ll examine Achilles tendinopathy, where brisement has shown significant promise. I’ll explain the step-by-step process, supported by ultrasound imaging, to illustrate how we hydrostatically decompress tissues to alleviate pain and promote healing. We’ll also discuss how this procedure integrates seamlessly into our multidisciplinary model at Injury Medical Clinic. Here, chiropractic care, functional medicine, and medical oversight converge to create a comprehensive, patient-centered treatment plan for complex musculoskeletal injuries.

Our Integrative Approach to Patient Care in El Paso

At Injury Medical Clinic, we have built a unique healthcare environment founded on collaboration and a shared commitment to patient well-being. My journey and extensive training in chiropractic (DC), advanced practice nursing (APRN, FNP-BC), and functional medicine (CFMP, IFMCP) have shown me something important. In fact, the best patient outcomes often come from a fusion of different medical disciplines.

This philosophy is the cornerstone of our practice. I am honored to work alongside Dr. Maria Guadalupe Cardenas, MD, a highly respected internist with over 40 years of experience. As our Medical Director and Collaborative Physician (NPI #1164426749, Texas MD License #J2933), Dr. Cardenas provides essential medical oversight. She ensures our care is effective, safe, and aligned with the highest standards of internal medicine. Our multidisciplinary setup allows us to offer a spectrum of services. These include integrative chiropractic adjustments and functional medicine protocols. We also provide advanced medical procedures and comprehensive rehabilitation. This collaborative model is particularly crucial for personal injury cases. In these cases, complex conditions demand a multifaceted approach to diagnosis and treatment. Together, we create a synergistic plan that addresses the patient from every angle—structural, physiological, and biochemical. This plan supports true, lasting healing.

Understanding Brisement: A New Frontier in Tendon Treatment

When dealing with chronic tendon pain, particularly in conditions like Achilles tendinopathy or patellar tendinopathy (jumper’s knee), we are constantly seeking more effective, less invasive solutions. One of the most promising techniques we utilize is brisement, or high-volume injection (HVI).

To understand its value, let’s first clarify what it is not. Brisement is fundamentally different from procedures like fenestration or tenotomy, where a needle is intentionally inserted into the tendon to create micro-trauma and stimulate a healing response. Instead, brisement focuses on the space around the tendon. The primary goal is to target and disrupt the problematic network of neovessels (new, abnormal blood vessels) and neoneurogenesis (the accompanying growth of new, pain-sensing nerve fibers) that often develops in the fatty tissues adjacent to a chronically inflamed tendon. These new vessels and nerves contribute significantly to the persistent pain and dysfunction associated with tendinopathy.

The procedure involves hydrostatic decompression of the soft tissues adjacent to the tendon, such as the peritendon (the sheath-like tissue surrounding the tendon) or the adjacent fat pad, like Kager’s fat pad located anterior to the Achilles tendon. By injecting a large volume of fluid, we physically separate these adherent tissues. We also break up the neovascular and neural ingrowth and create a healthier environment for the tendon to heal.

Why Do We Use Brisement? The Rationale Behind the Technique

The reasoning for using brisement is rooted in a modern understanding of what causes chronic tendon pain. For years, the term “tendinitis” was used, implying inflammation. However, research shows that chronic tendinopathy is more of a degenerative process (tendinosis). It is characterized by disorganized collagen fibers, cellular changes, and the problematic ingrowth of new vessels and nerves from the surrounding fat pad. These neovessels and nerves create a feedback loop of pain and irritation, preventing the tendon from healing properly.

Brisement directly addresses this pathophysiology by:

• Mechanical Disruption: The sheer volume of the injected fluid physically tears and breaks apart the delicate neovessels and nerve endings that have infiltrated the area. This is a form of mechanical disruption without cutting tissue.
• Hydrostatic Decompression: The fluid separates the tendon from the adjacent fat pad, relieving mechanical pressure and shearing forces that can exacerbate the condition during movement.
• Washing Out Pain Mediators: The saline solution helps to dilute and “wash out” biochemical irritants and inflammatory mediators that have accumulated in the area, further reducing pain signaling.
• Anesthetic Effect: Including an anesthetic like lidocaine provides immediate pain relief and can help “reboot” local nerve signaling pathways.

By accomplishing these goals, we create an environment where the tendon is no longer constantly irritated. This allows the body’s natural healing processes to take over more effectively.

The Brisement Procedure: A Step-by-Step Clinical Walkthrough

Performing a high-volume injection is a precise, ultrasound-guided procedure that demands a thorough understanding of anatomy. Let’s walk through the process for an Achilles tendinopathy patient, one of the most common and well-researched applications.

1. Patient Positioning and Preparation:
   • The patient is positioned comfortably, typically lying prone (face down) with their feet hanging off the edge of the treatment table. This position provides excellent access to the Achilles tendon and keeps it relaxed.
   • The area is meticulously cleaned and sterilized using an antiseptic solution. We then drape the area to maintain a sterile field, which is critical for any injection-based procedure to prevent infection.
2. Ultrasound Assessment:
   • Before introducing any needle, I use a high-frequency linear ultrasound probe to perform a detailed diagnostic scan. I examine the Achilles tendon in both long-axis (along its length) and short-axis (cross-section) views.
   • This initial scan allows me to identify the precise location of the tendinopathy, which often appears as a thickened, hypoechoic (darker) area within the tendon. Critically, I also assess the interface between the anterior border of the Achilles tendon and Kager’s fat pad, looking for signs of neovascularity using color Doppler imaging.
3. Local Anesthesia:
   • Patient comfort is paramount. Using a very fine needle (typically 25 or 27-gauge), I administer a small amount of local anesthetic, like lidocaine, to numb the skin and subcutaneous tissues at the planned needle entry point. This helps keep the main procedure as comfortable as possible.
4. The High-Volume Injection:
   • Once the skin is numb, I switch to a slightly larger needle (21- or 22-gauge) suitable for delivering a larger fluid volume.
   • Under continuous ultrasound guidance, I carefully advance the needle to the target area: the fascial plane between the anterior aspect of the Achilles tendon and Kager’s fat pad. Ultrasound precision is non-negotiable here; it ensures the injectate is delivered to the correct tissue plane and, importantly, that the needle does not puncture the tendon itself.
   • I then begin to inject the brisement solution. This is typically a mixture of sterile normal saline and a local anesthetic. The volume can vary significantly based on the patient’s condition and the specific area being treated, with literature describing anywhere from 10 to 50 mL or more for the Achilles.
   • On the ultrasound screen, we can visualize this process in real-time. As the fluid is injected, you see it spread and create a distinct, anechoic (black) space, physically lifting the tendon away from the fat pad. This is hydrodissection, or hydrostatic decompression, in action. You can literally watch the adherent tissues being separated. I continue injecting until I feel a significant change in resistance or the patient reports a feeling of fullness, indicating the space has been adequately expanded.

The Role of Integrative Chiropractic Care in Recovery

The brisement procedure is a powerful tool for disrupting the pain cycle, but it is not a standalone cure. True, long-term recovery requires a comprehensive rehabilitation strategy that addresses the underlying biomechanical faults that led to the tendinopathy in the first place. This is where our integrative model, with chiropractic care at its core, becomes indispensable.

Following a high-volume injection, my focus as a chiropractor and rehabilitation specialist shifts to:

• Correcting Biomechanical Imbalances: Achilles tendinopathy is often linked to poor foot mechanics (like overpronation), ankle joint restrictions, or even misalignments in the pelvis and lumbar spine that alter the entire lower-limb kinetic chain. Through chiropractic adjustments, I work to restore proper joint mobility in the foot, ankle, sacroiliac joints, and spine. This ensures that forces are distributed correctly during walking and running, reducing abnormal strain on the Achilles tendon.
• Progressive Loading and Rehabilitation: A tendon heals best when it is subjected to a carefully managed and progressive loading program. Complete rest is often counterproductive. We design a specific exercise protocol that typically starts with isometric exercises (contractions without movement) to modulate pain, then progresses to eccentric exercises (lengthening the muscle-tendon unit under load), and finally to functional, sport-specific movements. This structured loading stimulates collagen synthesis and remodeling, helping the tendon regain its strength and resilience.
• Soft Tissue Mobilization: We use techniques like Active Release Technique (ART) or Graston Technique on the surrounding calf muscles (gastrocnemius and soleus) to release tension and adhesions, further improving ankle flexibility and reducing the load on the Achilles tendon.

This combined approach—using the brisement injection to create a window of opportunity by reducing pain and inflammation, and then leveraging that window with targeted chiropractic and rehabilitative care—is what sets our clinic apart. This approach allows us to address both symptoms and the root cause. As a result, we achieve more durable and successful outcomes for our patients.

References

• Barker-Davies, R. M., et al. (2017). Achilles tendinopathy: a systematic review of the validity of and adherence to clinical practice guidelines for diagnosis. British Journal of Sports Medicine, 51(20), 1435–1441.
• Boesen, M. P., et al. (2017). High volume injection with and without corticosteroid in chronic midportion Achilles tendinopathy. Scandinavian Journal of Medicine & Science in Sports, 27(5), 527–535.
• Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409–416.
• Maffulli, N., et al. (2008). High-volume image-guided injection for the management of chronic recalcitrant patellar tendinopathy. The American Journal of Sports Medicine, 36(6), 1162–1167.