High-Volume Injections for Tendonopathy Techniques

Understanding High-Volume Injections for Tendonopathy: A Modern Approach

By Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST

Medical Direction: Dr. Maria Guadalupe Cardenas, MD

Abstract

In this educational overview, I will be exploring an advanced, evidence-based technique for managing chronic tendonopathy known as brisement, or high-volume injection (HVI). Drawing on the latest findings from leading researchers like Dr. Fran O’Connor, we will explore the physiological basis of this procedure. Then, we’ll discuss its application in conditions like Achilles and patellar tendonopathy. Also, we will explain how it is performed under ultrasound guidance.

We will break down the mechanics of hydrostatic decompression and the disruption of problematic neovessels and neonerves. Importantly, you’ll learn why this approach differs from traditional treatments like fenestration. I will also explain how this cutting-edge modality integrates seamlessly into the comprehensive, multidisciplinary framework we use at Injury Medical Clinic. Our approach combines my expertise in chiropractic and functional medicine. Additionally, we include the invaluable medical oversight of our Medical Director, Dr. Maria Guadalupe Cardenas, MD. As a result, we provide a holistic and effective path to recovery for our patients.

Our Integrative and Collaborative Care Model

At Injury Medical Clinic, our philosophy is rooted in a patient-centered, integrative approach. This is made possible through our unique multidisciplinary structure. I, as a Doctor of Chiropractic and Advanced Practice Registered Nurse, work closely with Dr. Maria Guadalupe Cardenas. Dr. Cardenas is a Board-Certified Internist with over four decades of clinical experience. She serves as our Medical Director and Collaborative Physician. This partnership allows us to blend chiropractic care, functional medicine, rehabilitation, and conventional medical oversight. Notably, all of this happens under one roof.

Our model provides comprehensive solutions, particularly for complex musculoskeletal injuries and chronic pain conditions. While I focus on biomechanical alignment, neuromuscular function, and holistic wellness through chiropractic adjustments and functional medicine protocols, Dr. Cardenas provides essential medical diagnostics and oversight. Additionally, she can prescribe and manage treatments that fall within the scope of internal medicine. This synergy ensures our patients receive a well-rounded, robust treatment plan. It addresses their health from every angle. Procedures like the high-volume injections discussed here are prime examples of how we integrate advanced medical techniques with rehabilitative and chiropractic principles. As a result, our patients achieve superior outcomes.

What is Brisement, or High-Volume Injection (HVI)?

When we encounter persistent tendon pain, or tendonopathy, our goal is to address the underlying cause of the dysfunction. While some procedures focus on directly stimulating the tendon tissue itself, brisement (a French term for “breaking” or “disruption”) takes a different and innovative approach.

• Distinct from Fenestration: It’s crucial to understand that brisement is not the same as tendon fenestration or tenotomy. In those procedures, a needle is used to repeatedly puncture the degenerated portion of the tendon to create micro-trauma and stimulate a healing response.
• Targeting the Peritendinous Tissues: Brisement, in contrast, focuses on the space around the tendon. The primary target is the interface between the tendon and adjacent structures, such as the paratenon (the sheath-like covering of some tendons) or the nearby fat pad (like Kager’s fat pad behind the Achilles tendon).
• Hydrostatic Decompression: The core mechanism of brisement is hydrostatic decompression. We inject a large volume of fluid—typically a mixture of a local anesthetic like lidocaine and sterile saline—into this space. This fluid mechanically and hydraulically separates soft tissues that have adhered to the tendon.

The Science Behind the Pain: Neovessels and Neonerves

To truly appreciate why brisement is effective, we must understand the pathophysiology of chronic tendonopathy. For a long time, we believed tendon pain was primarily an inflammatory condition (“tendinitis”). However, modern research has shown that chronic cases are more accurately described as tendinosis—a degenerative state characterized by disorganized collagen fibers, cellular changes, and a notable absence of inflammatory cells.

A key finding in the development of pain in tendinosis is the ingrowth of new, disorganized blood vessels (neovascularization) and accompanying nerve fibers (neoinnervation) into the tendon and surrounding tissues.

• Neovessels and Neonerves: These new vessels and nerves, often found in the space anterior to the Achilles tendon or within Kager’s fat pad, are not part of the normal, healthy anatomy. They are believed to be a primary source of the persistent, nagging pain associated with the condition.
• The Goal of Disruption: The high-volume injection aims to physically disrupt this delicate and problematic neurovascular network. By injecting a large fluid volume, we create a pressure wave that separates the adhered tissues and, in the process, breaks apart these tiny new vessels and nerves. This process effectively “resets” the local environment, reducing the primary pain generators and creating a better environment for healing.

How is the High-Volume Injection Procedure Performed?

The HVI procedure is a minimally invasive, office-based treatment performed with meticulous precision using ultrasound guidance. This ensures safety and accuracy by allowing us to visualize the target structures in real time. Here is a step-by-step breakdown of the process:

1. Patient Positioning and Preparation: The patient is positioned comfortably to allow optimal access to the affected tendon. For an Achilles tendon, the patient typically lies face down. The area is then sterilized, and a sterile drape is applied.
2. Ultrasound Examination: Using a high-frequency linear ultrasound probe, I conduct a thorough examination of the tendon in both long-axis (parallel to the tendon fibers) and short-axis (perpendicular) views. This allows me to identify the exact area of tendonopathy—often seen as tendon thickening, hypoechoic (darker) regions, and disorganized fiber patterns—and map out the precise injection path.
3. Local Anesthesia: To ensure patient comfort, the skin and superficial tissues are first anesthetized using a very fine needle (25 or 27-gauge) to inject a small amount of lidocaine.
4. The High-Volume Injection: Once the skin is numb, a slightly larger needle (21- or 22-gauge) is guided under direct ultrasound visualization into the target plane—for the Achilles, this is the space between the anterior border of the tendon and Kager’s fat pad.
5. Real-Time Hydrodissection: As the fluid mixture (saline and lidocaine) is injected, we can watch on the ultrasound screen as it flows into the space, visibly lifting the tendon away from the underlying fat pad. This is the hydrodissection or hydrostatic decompression in action. You can literally see the fluid creating a new, clear space where adhesions once were. The volume of fluid injected can vary significantly, with literature reporting anywhere from 5 to 100 cc, depending on the tendon, the severity, and patient tolerance. We inject until we achieve adequate separation or meet resistance.

This mechanical separation is the key to the procedure’s success. It physically disrupts the adhesions and the pain-generating neovessels and neonerves. Consequently, it provides both immediate and long-term relief by altering the pathological environment.

The Role of Integrative Chiropractic Care in Recovery

Performing a procedure like a high-volume injection is only one part of a comprehensive recovery plan. True healing requires addressing the root biomechanical issues that led to the tendon overload in the first place. This is where integrating chiropractic care becomes essential.

Following an HVI procedure, my focus as a chiropractor and rehabilitation specialist shifts to restoring proper function and preventing recurrence.

• Biomechanical Correction: I assess and correct underlying biomechanical faults in the kinetic chain. For Achilles tendinopathy, this often involves evaluating foot pronation, ankle mobility, pelvic alignment, and lumbar spine function. A misaligned pelvis or sacroiliac joint dysfunction can alter gait mechanics, placing excessive strain on the Achilles tendon. Chiropractic adjustments can restore proper joint motion and neurological function, which normalizes load distribution.
• Soft Tissue Mobilization: We use techniques like Graston or Active Release Technique (ART) on the surrounding musculature (e.g., the gastrocnemius and soleus muscles) to break down scar tissue and improve muscle flexibility, further reducing tension on the treated tendon.
• Personalized Rehabilitation: A structured and progressive loading program is critical. After the initial post-injection phase, we introduce specific eccentric exercises, which have been shown to stimulate collagen remodeling and strengthen the tendon. The program is carefully tailored to the patient’s progress, ensuring the tendon is strengthened without being re-injured.
• Functional Medicine and Nutrition: We also look at systemic factors. Chronic inflammation, nutritional deficiencies (e.g., Vitamin C, zinc, and manganese), and poor metabolic health can all impair tissue healing. Through a functional medicine lens, we may recommend specific dietary modifications or supplements to support collagen synthesis and reduce systemic inflammation, creating an optimal internal environment for recovery.

This multifaceted approach ensures that we not only alleviate the immediate pain through the HVI procedure but also correct the underlying dysfunctions. In turn, this builds resilience and prevents the problem from returning. This synthesis of advanced medical intervention, expert chiropractic care, and holistic wellness strategies defines our commitment to our patients’ long-term health.

References

1. 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://doi.org/10.1080/09638280701785929
2. Maffulli, N., Spiezia, F., Longo, U. G., Denaro, V., & Maffulli, G. D. (2013). High-volume image-guided injection for recalcitrant patellar tendinopathy in athletes. Clinical Journal of Sport Medicine, 23(2), 115–119. https://doi.org/10.1097/JSM.0b013e318269555b
3. Morton, S., Williams, S., Valle, X., & de-la-Fuente, C. (2019). The new age of tendinopathy: new thoughts on the physiopathology and treatment. Current Sports Medicine Reports, 18(11), 385-391. https://doi.org/10.1249/JSR.0000000000000652