High-Volume Injections for Tendinopathy Pain Relief

Abstract

Welcome to our educational post on advanced treatments for chronic tendinopathy, a condition that causes persistent pain and dysfunction in tendons throughout the body. In this discussion, I will guide you through an innovative and minimally invasive procedure known as brisement, or high-volume injection (HVI). Drawing from the latest evidence-based research and the pioneering work of leading physicians, we will explore the physiological mechanisms behind this technique.

I will explain how HVI uses hydrostatic pressure to decompress tissues, disrupts problematic neo-vessels and neo-nerves, and provides significant relief for conditions like Achilles and patellar tendinopathy. I will also explain how we at Injury Medical Clinic integrate this advanced procedure into a comprehensive, multidisciplinary care model. This model combines my expertise in chiropractic and functional medicine with the invaluable medical oversight of our Medical Director, Dr. Maria Guadalupe Cardenas, MD, to offer a holistic path toward recovery and optimal function.

Our Integrative Approach at Injury Medical Clinic

At Injury Medical Clinic, our philosophy is rooted in a collaborative, patient-centered approach. I am Dr. Alex Jimenez, and my extensive background as a Doctor of Chiropractic (DC), Advanced Practice Registered Nurse (APRN), and Board-Certified Family Nurse Practitioner (FNP-BC), along with multiple certifications in functional and lifestyle medicine, allows me to view health through a multifaceted lens. This perspective is foundational to how we treat complex musculoskeletal and systemic health issues.

A cornerstone of our practice is our multidisciplinary team structure. I am proud to work alongside Dr. Maria Guadalupe Cardenas, MD, a highly respected, board-certified Internist with over four decades of clinical experience. As our Medical Director and Collaborative Physician, Dr. Cardenas provides essential medical oversight, ensuring that all our treatment plans meet the highest standards of safety and efficacy. Her profound knowledge of internal medicine complements my focus on biomechanics, functional neurology, and metabolic health, creating a truly integrative environment. This synergy allows us to manage everything from acute personal injuries and rehabilitation to complex chronic conditions by combining chiropractic adjustments, advanced soft tissue therapies, functional medicine diagnostics, and conventional medical wisdom in one place.

Deconstructing Tendinopathy: Beyond Simple Inflammation

For years, conditions like “tennis elbow” or “jumper’s knee” were broadly labeled as “tendinitis,” implying that inflammation was the primary culprit. However, modern research has reshaped our understanding. We now know that in chronic cases, the issue is less about active inflammation and more about a degenerative process called tendinosis. This involves a breakdown of the tendon’s collagen fibers, a disorganized healing response, and the ingrowth of abnormal, fragile blood vessels and nerve endings. This process is known as neovascularization and neoinnervation.

These new vessels and nerves, which I will refer to as neo-vessels and neo-nerves, are not beneficial. They are highly sensitive and are believed to be a primary source of the persistent, nagging pain associated with chronic tendinopathy. The tendon itself becomes thickened, weakened, and less able to handle mechanical loads, leading to a cycle of pain, dysfunction, and further degeneration. Our goal in treatment is to interrupt this cycle and stimulate a more organized, effective healing response.

Introducing Brisement: A High-Volume Injection Technique

This brings us to an advanced, ultrasound-guided procedure known as brisement or high-volume injection (HVI). This technique represents a significant evolution in how we address the root cause of tendinopathy pain. It is crucial to distinguish brisement from other needle-based procedures, such as fenestration or tenotomy. In those treatments, the needle is intentionally directed into the tendon substance to create micro-trauma and stimulate a healing cascade.

In contrast, the primary target of brisement is not the tendon itself but the interface between the tendon and adjacent structures, such as the paratenon (the sheath surrounding the tendon) or a neighboring fat pad (like Kager’s fat pad behind the Achilles tendon). The core principle of brisement is hydrostatic dissection—using the physical force of a large volume of fluid to mechanically separate these tissues.

The Rationale Behind Brisement

So, why is this separation beneficial? The theory, supported by a growing body of evidence, is that this procedure achieves several key objectives simultaneously:

1. Disruption of Neo-vessels and Neo-nerves: The forceful injection of fluid into the precise plane where these pathological structures have formed shears effectively and destroys them. By eliminating these pain-generating nerves and fragile vessels, we can significantly reduce or eliminate the primary source of a patient’s discomfort.
2. Mechanical Release of Adhesions: Chronic tendinopathy often leads to adhesions—sticky, fibrous bands of tissue that “glue” the tendon to its surroundings. These adhesions restrict the tendon’s natural gliding motion, causing friction, irritation, and pain with movement. The high-volume fluid acts as a powerful tool to hydrostatically break down these adhesions and restore mobility.
3. Hydrostatic Decompression: The injected fluid creates space, decompressing the soft tissues that are juxtaposed against the tendon. This can alleviate mechanical pressure and improve the local metabolic environment, allowing for better fluid exchange and waste removal.

The injectate itself is typically a simple mixture of a local anesthetic, such as lidocaine, and a large volume of sterile normal saline. The anesthetic provides immediate pain relief and makes the procedure comfortable, while the saline provides the necessary volume to achieve the mechanical effects. The literature describes a wide range of fluid volumes, anywhere from 5 to 100 cubic centimeters (cc’s), depending on the specific tendon and the clinician’s judgment. While larger volumes are effective, proceed with caution to avoid potential complications like tendon rupture or compartment syndrome, a rare but serious condition involving excessive pressure buildup in a confined muscle compartment.

A Step-by-Step Look at the High-Volume Injection Procedure

To help you visualize this technique, I’ll walk you through the process, drawing on the excellent work demonstrated by my colleague, Dr. Knight, in his procedural videos on Achilles tendinopathy.

Step 1: Patient Positioning and Initial Scan

First, position the patient comfortably to allow optimal access to the affected tendon. For an Achilles tendon procedure, the patient typically lies face down (prone) with their foot hanging off the end of the examination table. The area is then prepped with an antiseptic solution to ensure sterility.

Using a high-frequency linear ultrasound probe, I perform a thorough diagnostic scan of the tendon in both long-axis (parallel to the tendon fibers) and short-axis (perpendicular to the fibers) views. This initial examination is critical. It allows me to pinpoint the exact location of the tendinopathy, which often appears as a thickened, hypoechoic (darker) region within the tendon. I also carefully identify the fascial plane between the anterior border of the Achilles tendon and Kager’s fat pad—our target for the injection.

Step 2: Anesthesia

Before the main procedure, I anesthetize the skin and subcutaneous tissues. Using a very fine needle (typically 25- or 27-gauge), I inject a small amount of lidocaine to numb the entry point. This ensures the patient remains comfortable throughout the process.

Step 3: Performing the High-Volume Injection

With the area anesthetized, I switch to a slightly larger needle (21- or 22-gauge) needed to deliver the high volume of fluid. The choice of needle approach—either in-plane (where the entire needle is visible on the ultrasound screen) or out-of-plane (where the needle is seen as a cross-sectional dot)—depends on the specific anatomy and physician preference.

As demonstrated in Dr. Knight’s videos, an out-of-plane approach is often used for the Achilles tendon. I guide the needle tip precisely into the space between the tendon and the fat pad, watching its position in real time on the ultrasound monitor. Once in position, I begin to inject the saline and lidocaine mixture.

On the screen, the effect is immediate and dramatic. You can see the fluid rapidly spreading, creating a dark, anechoic (black) space. This is the hydrostatic dissection in action. The fluid visibly peels the tendon away from the underlying fat pad, breaking adhesions and decompressing the area. I continue to inject to the patient’s tolerance or until I feel a significant increase in resistance, indicating that the space has been adequately filled and dissected. The fluid can be seen tracking along the fascial plane, mechanically clearing the area where the problematic neo-vessels and neo-nerves reside.

The entire process is a beautiful example of how modern imaging technology allows us to perform highly precise, minimally invasive interventions that directly target the source of pathology.

The Role of Chiropractic Care in a Post-Brisement Rehabilitation Protocol

The high-volume injection procedure is a powerful tool for alleviating pain and breaking the cycle of chronic degeneration, but it is only one part of the overall approach. True, long-lasting recovery requires a comprehensive rehabilitation program designed to address the underlying biomechanical and functional deficits that contributed to the tendinopathy in the first place. This is where our integrative model, particularly the role of chiropractic care, becomes indispensable.

Following a brisement procedure, my focus as a Doctor of Chiropractic shifts to restoring optimal function and building tissue resilience. Our post-procedure protocol is built on several pillars:

1. Eccentric Loading Programs: Decades of research have established that eccentric exercise—where the muscle lengthens under tension—is the gold standard for stimulating healthy collagen remodeling in a degenerative tendon. For Achilles tendinopathy, this may involve the classic Alfredson protocol of eccentric heel drops. For patellar tendinopathy, it might be eccentric squats on a decline board. I carefully prescribe and progress these exercises to apply the right mechanical load to the tendon, encouraging fibroblasts (tendon cells) to lay down strong, organized Type I collagen fibers.
2. Addressing Biomechanical Deficits: A tendon rarely becomes overloaded in isolation. As a chiropractor, I perform a full biomechanical assessment of the entire kinetic chain. For an Achilles issue, I will assess foot mechanics (e.g., overpronation), ankle joint mobility, hip strength, and even spinal alignment. If a patient has a stiff ankle joint (poor dorsiflexion) or weak gluteal muscles, their calf and Achilles tendon will absorb excessive strain with every step. My treatment plan will include:
   • Chiropractic Adjustments: To restore proper mobility in the joints of the foot, ankle, sacroiliac region, and spine.
   • Soft Tissue Mobilization: Using techniques like Active Release Technique (ART) or Graston Technique to release tightness and restrictions in the calf muscles (gastrocnemius and soleus) and plantar fascia.
3. Functional Medicine and Nutritional Support: From my functional medicine perspective, tissue healing is a metabolic process that requires specific nutrients. I may recommend targeted supplementation to support collagen synthesis and manage systemic inflammation, such as Vitamin C, zinc, manganese, and specific amino acids like proline and glycine. We also evaluate and address broader systemic issues like insulin resistance or poor gut health, which can create a pro-inflammatory state that hinders tissue repair.

Our integrative approach combines an advanced, pain-relieving procedure like brisement with a robust, function-focused rehabilitation program. Under the collaborative oversight of Dr. Cardenas, we ensure the patient receives the best of both medical and chiropractic worlds—a precise intervention to solve the immediate problem, followed by a holistic strategy to restore function, prevent recurrence, and optimize overall health.

References

1. Alfredson, H., & Cook, J. (2007). A treatment algorithm for managing Achilles tendinopathy: new treatment options. British Journal of Sports Medicine, 41(4), 211–216. https://bjsm.bmj.com/content/41/4/211
2. Chan, O., O’Dowd, D., Padhiar, N., Morrissey, D., King, J., & Crisp, T. (2008). High volume image guided injections in chronic Achilles tendinopathy. Disability and Rehabilitation, 30(20-22), 1697–1708. https://www.tandfonline.com/doi/abs/10.1080/09638280701830298
3. 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. https://bjsm.bmj.com/content/43/6/409
4. Maffulli, N., Spiezia, F., Longo, U. G., Denaro, V., & Maffulli, G. D. (2013). High-volume image-guided injection for recalcitrant patellar tendinopathy. The American Journal of Sports Medicine, 41(5), 1042–1048. https://journals.sagepub.com/doi/10.1177/0363546513476098