HVI for Tendinopathy: A Modern Treatment Approach

Integrative High-Volume Injection (Brisement) for Tendinopathy: A Clinician’s Guide

Abstract

In this educational post, I walk you through the modern, evidence-based approach to high-volume injection—commonly called brisement—for chronic tendinopathy, with a special emphasis on Achilles and patellar tendon presentations. I explain what brisement is, how it differs from tendon fenestration or tenotomy, and why its hydrostatic decompression of peritendinous soft tissues can alleviate pain and dysfunction associated with neovascularization and neoinnervation. I also detail the ultrasound-guided procedure, fluid volumes, cautionary parameters, and physiological underpinnings.

Importantly, I show how we integrate chiropractic care, functional medicine, rehabilitation, and personal injury management within a multidisciplinary framework at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas. Our care model is directed medically by Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933), who collaborates with me, Dr. Alex Jimenez, DC, to ensure safe, coordinated, and outcome-focused interventions. You will see how integrative chiropractic care fits into high-volume injection protocols, how our clinical observations inform practice, and how we align with the latest findings from leading researchers using modern ultrasound and functional rehabilitation methods.

Understanding High-Volume Injection (Brisement) for Tendinopathy

As a doctor of chiropractic and family nurse practitioner with training in functional medicine and integrative musculoskeletal care, I often encounter patients with chronic tendinopathies that have persisted despite standard conservative measures. One advanced technique we employ, under medical oversight, is the high-volume injection (HVI), also known as brisement. This procedure targets the painful interface around a diseased tendon—not the tendon itself—to hydrostatically decompress the peritendinous soft tissues and disrupt pain-generating neovessels and neoinnervation that commonly drive chronic symptoms.

• Key distinction:
  • Brisement (High-Volume Injection): Injectate is delivered adjacent to the tendon (e.g., at the interface between the tendon and surrounding structures such as the tenosynovium or Kager’s fat pad in the Achilles), aiming to hydrodissect and decompress these planes.
  • Fenestration/Tenotomy: The needle penetrates directly into the tendon substance to provoke localized bleeding and an inflammatory reset. This is a different mechanism and a different target.

This differentiation matters because tendinopathy pain is often maintained not just by degenerative tendon tissue but by pathologic neovascularization—small vessels and accompanying sensory nerve fibers that invade peritendinous tissues, creating a hyperinnervated, hypersensitized environment. By hydrodissecting and mechanically decompressing the space, we can reduce nociceptive input, alleviate mechanical entrapment, and improve tendon gliding.

The Physiological Rationale: Why Brisement Works

Chronic tendinopathy is multifactorial. The tendon may exhibit mucoid degeneration, disorganized collagen fibers, increased proteoglycan content, and altered tenocyte biology. Around the tendon, several pathophysiological events contribute to persistent pain:

• Neovascularization: New but fragile blood vessels sprout into peritendinous tissues, often accompanied by new sensory nerve fibers (neoinnervation). These fibers transmit pain signals and amplify local sensitivity.
• Peritendinous adhesions and thickening: The fat pads (such as Kager’s fat pad in the Achilles region) and tenosynovial tissues can become edematous, fibrotic, or adherent, limiting normal tendon excursion, increasing friction, and sustaining nociception.
• Local compartmental pressure: Tightly approximated fascial planes can create micro-compartment pressures that impair tendon nutrition and healing, especially in repetitive strain contexts.

High-volume injection uses a controlled hydrostatic force to separate these planes, a process known as hydrodissection, which:

• Disrupts and compresses pathologic microvasculature (reducing blood supply to pain-feeding neovessels).
• Mechanically separates adhered fascial layers, allowing improved tendon gliding and reduced friction.
• Decreases local neural entrapment, reducing pain signaling from neoinnervation.
• Restores sliding interfaces between the tendon and adjacent tissues, improving biomechanics.

The net effect can be a rapid reduction in pain and improved functional tolerance to load, allowing rehabilitative strategies—eccentric loading, isometrics, and neuromuscular re-education—to proceed effectively.

Ultrasound-Guided Brisement: Step-by-Step Clinical Process

In our clinic, we perform high-volume injections under ultrasound guidance to precisely identify the target interface and monitor fluid spread. Here’s how I approach it:

• Patient positioning:
  • For Achilles tendinopathy, the patient is typically placed prone with the foot gently plantarflexed to expose the tibiofemoral space anterior to the Achilles tendon and Kager’s fat pad.
• Pre-scan assessment:
  • I scan the involved tendon in both long-axis and short-axis views to identify areas of thickening, hypoechogenicity, or neovascularity. I also map the tendon-fat pad interface and tenosynovium.
• Local anesthesia:
  • The skin and subcutaneous tissues are anesthetized using a 25–27 gauge needle with lidocaine, typically 1–3 mL, ensuring patient comfort prior to hydrodissection.

• Needle selection and approach:

  • I use a 21–22 gauge needle for the brisement procedure to allow smooth fluid delivery.
  • The linear ultrasound probe can be oriented in long or short axis relative to the tendon. Depending on tissue depth and operator preference, the injection may be in-plane (visualizing the full needle) or out-of-plane (seeing the needle tip as a bright dot).
• Injectate composition:
  • A combination of lidocaine and normal saline is commonly used. The lidocaine provides local analgesia, while saline creates the hydrostatic decompression.
• Volume and caution:
  • The literature describes volumes from 5 to 100 mL of fluid, typically titrated to patient tolerance and tissue resistance.
  • While high volumes can be effective for hydrodissection, caution is required to avoid tendon rupture or compartment syndrome. We prioritize gradated (purposefully increasing, adjusting, or stepping up the amount of fluid in a controlled, systematic manner) volumes and continuous ultrasound visualization to confirm safe spread.
• Real-time hydrodissection:
  • As fluid is injected, you can see the hypoechoic plane opening between the tendon and fat pad, with tissue layers gently separating. I look for smooth fluid tracking and the absence of undue resistance or pain.
• Post-procedure checks:
  • After hydrodissection, I reassess the tendon interface on ultrasound, confirm hemostasis, and provide immediate instructions for graduated loading and mobility.

These steps mirror what you would observe on high-quality ultrasound footage: the needle advancing anterior to the Achilles tendon, short bursts of fluid creating a darker plane of separation, and the visible hydrostatic decompression of tissues between the tendon and Kager’s fat pad.

Safety, Nuances, and Evidence-Based Considerations

High-volume injection is effective, but it requires discipline and medical oversight:

• Risks:
  • Potential tendon rupture, particularly with high volumes or if the needle inadvertently enters the tendon substance.
  • Risk of compartment syndrome if excessive fluid accumulates in a confined plane.
  • Local bleeding, infection, or transient numbness.
• Mitigation strategies:
  • Ultrasound guidance with careful needle positioning anterior to the tendon.
  • Titrating fluid volumes and tracking tissue response.
  • Comprehensive patient selection and informed consent.
  • Collaboration with a medical director to evaluate comorbidities (e.g., diabetes, coagulopathies, peripheral vascular disease) that influence safety profiles.

The research landscape supports brisement for resistant Achilles and patellar tendinopathy as a means to reduce pain and improve function when combined with structured rehabilitation programs (e.g., eccentric loading and heavy slow resistance) and patient education on load management and biomechanics (Malliaras et al., 2013; Khan & Scott, 2009).

Our Multidisciplinary Model in El Paso: Medical Direction and Integrative Care

At Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas, our structure mirrors best practices in integrative and injury care:

• Medical Director: Dr. Maria Guadalupe Cardenas, MD, Board Certified in Internal Medicine, NPI #1164426749, Texas MD License #J2933. With more than 40 years of experience as an internist, Dr. Cardenas provides comprehensive medical oversight, patient screening, and risk management.
• Collaborative Chiropractor: I, Dr. Alex Jimenez, DC, lead the chiropractic and functional rehabilitation aspects, coordinate imaging (including ultrasound), and guide musculoskeletal care plans.
• Team integration:
  • We combine chiropractic care, medical oversight, functional medicine, personal injury care, rehabilitation, and recovery services to deliver complete, patient-centered treatment.

This setup ensures that advanced procedures such as brisement are undertaken with rigorous clinical governance, diagnostics, and longitudinal follow-up—especially essential for patients recovering from personal injury or those with complex systemic conditions.

How Integrative Chiropractic Care Fits With Brisement

Chiropractic care is not isolated from these procedures; it is integrated before and after brisement to optimize outcomes:

• Pre-procedure chiropractic support:
  • Regional interdependence assessment: Identifying kinetic chain contributors—limited ankle dorsiflexion, hip weakness, lumbar-pelvic control deficits—that increase tendon load.
  • Gentle manual therapies to address myofascial restrictions in the calf complex, soleus, plantar fascia, and posterior chain, improving tissue pliability and movement quality.
• Post-procedure care pathways:
  • Gradual loading protocols: Starting with isometric holds for pain modulation (e.g., calf isometrics), progressing to eccentric and heavy slow resistance loading as pain permits.
  • Neuromuscular re-education: Rebuilding tendon-brain coordination—proprioception, foot intrinsic control, and dynamic stability.
  • Gait retraining and return-to-sport programming tailored to mechanical demands.
  • Joint alignment and mobility work: Addressing subtalar mechanics, tibial rotation, and lumbopelvic alignment to reduce aberrant strain.

When brisement reduces pain and interface adhesions, patients can tolerate and benefit from loading much more effectively. In our experience, this sequential integration accelerates recovery and reduces relapse.

Functional Medicine Integration: Systemic Contributors to Tendinopathy

In a functional medicine framework, we examine systemic factors that hinder tendon recovery or promote chronic pain:

• Inflammation and nutrition:
  • Optimizing omega-3 to omega-6 ratios, supporting collagen synthesis (vitamin C, proline, lysine), and ensuring adequate protein and micronutrients (zinc, copper, manganese).
• Glycemic control:
  • Hyperglycemia impairs collagen cross-linking and drives advanced glycation end-products (AGEs) that stiffen tissues. We coordinate blood sugar strategies for diabetic or prediabetic patients.
• Hormonal milieu:
  • Thyroid function, cortisol balance, and sex hormones affect tissue repair and pain modulation.
• Sleep and stress:
  • Sleep quality directly influences growth hormone pulses and tissue healing; stress impacts central pain processing.
• Microcirculation and endothelial health:
  • Nitric oxide pathways, vascular health, and activity patterns support tendon nutrition.

By aligning brisement with systemic optimization, we improve both short-term pain and long-term tissue quality, facilitating sustained improvements.

Personal Injury Care and Rehabilitation

In personal injury contexts—workplace trauma, motor vehicle collisions, sports incidents—tendon injuries often coexist with ligament sprains, joint contusions, or nerve irritations:

• Comprehensive triage:
  • We document the mechanism of injury, perform imaging as needed, and build a staged plan that may include brisement if chronic peritendinous pain and functional limitations persist.
• Rehabilitation sequencing:
  • Early pain control and protective loading.
  • Progressive tissue conditioning with eccentric protocols, closed-chain drills, and functional retraining.
• Outcome tracking:
  • Patient-reported outcomes (PROMs), ultrasound follow-ups to visualize interface health, and readiness metrics for return to work/sport.

Our clinical observations, reflected in years of practice and shared insights on our professional pages, show that combining precision-guided procedures with chiropractic biomechanics and functional rehab yields superior recovery trajectories compared with siloed care models (Jimenez, n.d.-a; Jimenez, n.d.-b).

Practical Pearls: Technique Nuances That Improve Outcomes

From what I’ve observed and implemented:

• Ultrasound mastery:
  • Always confirm the anterior border of the tendon and the fat pad plane. In the long axis, expect the needle to be out of plane at times; look for the bright dot of the needle tip moving within the intended hydrodissection plane.
• Incremental injection:
  • Inject in small aliquots, watch the plane open, then reassess. This avoids overpressurization and reduces risk.
• Patient feedback:
  • Ask about pressure sensations versus sharp pain. Adjust trajectory as needed to avoid intratendinous placement.
• Immediate mobility:
  • Encourage gentle range of motion after the procedure to maintain the decompressed plane and prevent refreezing of adhesions.
• Aftercare:
  • Load the tendon intelligently: isometrics first, then eccentrics, then heavy slow resistance, with careful attention to pain monitoring (e.g., ?3/10 during activity and ?24-hour post-load response).

Collaboration With Dr. Maria Guadalupe Cardenas, MD: Safety and Quality

Our medical director, Dr. Cardenas, is central to this process. With more than 40 years of internal medicine experience, she reviews patient histories, medications (e.g., anticoagulants), and systemic risks. She ensures that brisement is indicated, monitors for contraindications, and provides medical clearance. Our collaboration means:

• Safer procedures through medical screening.
• Integrated care plans that marry procedural precision and rehab expertise.
• Coordinated follow-ups and referrals when additional diagnostics or interventions are needed.

This MD-DC synergy represents the multidisciplinary standard in injury and integrative clinics, aligning the scope of practice with patient safety and optimizing outcomes.

Case-Focused Insights: Achilles Tendinopathy

Consider a typical chronic Achilles case:

• Clinical findings:
  • Localized thickening of the tendon, tenderness just proximal to the calcaneal insertion, reduced dorsiflexion, and pain during stair descent or early running phases.
• Ultrasound:
  • Hypoechoic regions with neovascularity at the anterior interface; thickened Kager’s fat pad.
• Intervention:
  • After local anesthesia, we introduce the needle just anterior to the Achilles in long-axis, out-of-plane, and hydrodissect with saline and lidocaine. The interface visibly opens as fluid tracks.
• Outcome:
  • Immediate pressure relief and improved tendon glide, followed by structured isometrics and a progression to eccentrics within the next few days, in alignment with pain-guided protocols.
• Integration:
  • Chiropractic adjustments of the subtalar, midfoot, and lumbopelvic regions support improved load distribution. Functional medicine tweaks enhance healing capacity. Medical oversight ensures safety across comorbidities.

Evidence Alignment and Ongoing Practice Development

We continually align our protocols with current evidence, examining randomized and cohort data on brisement efficacy, ultrasound-guided precision, and rehab integration. Literature from sports medicine and musculoskeletal ultrasound communities underscores that reducing neovessel-related pain at the peritendinous interface, combined with progressive loading, yields meaningful improvements in pain and function (Malliaras et al., 2013; Khan & Scott, 2009). Our real-world outcomes echo these findings, especially when patient education supports adherence and expectations are managed around the gradual nature of tendon remodeling.

Putting It All Together: A Patient-Centered Pathway

• Assessment:
  • Biomechanical analysis, ultrasound mapping, functional screens, and medical evaluation.
• Procedure:
  • Ultrasound-guided brisement with careful volume titration and dynamic visualization.
• Integration:
  • Chiropractic care for alignment, myofascial work, and kinetic chain correction.
  • Rehabilitation to restore load tolerance and motor control.
  • Functional medicine to address systemic healing.
  • Medical oversight for safety and quality assurance.
• Follow-up:
  • Outcome tracking, graded progressions, and adjustments based on real-time responses.

This integrative approach honors the complexity of tendinopathy and empowers patients with a clear, guided journey from pain to performance.

References

• Achilles tendinopathy: Aetiology and management (Khan, K. M., & Scott, A., 2009). British Journal of Sports Medicine. https://doi.org/10.1136/bjsm.2008.046631
• Evidence-based framework for a progressive loading program for tendinopathy (Malliaras, P., Barton, C. J., Reeves, N. D., & Langberg, H., 2013). British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2013-092993
• Clinical observations and integrative musculoskeletal care insights (Jimenez, A., n.d.-a). Personal Injury Doctor Group. https://personalinjurydoctorgroup.com/
• Professional profile and clinical practice updates (Jimenez, A., n.d.-b). LinkedIn. https://www.linkedin.com/in/dralexjimenez/