Tendon Healing: High-Volume Injections for Tendinopathy

Abstract

In this educational post, I will guide you through an advanced, highly effective technique for managing chronic tendinopathy known as tendon brisement, or high-volume injection (HVI). Drawing from my clinical experience and the latest evidence-based research, we will explore the physiological mechanisms behind this innovative procedure. I will explain how HVI differs from traditional tendon treatments by focusing on hydrostatically decompressing soft tissues and disrupting the problematic neovessels and neonerves that perpetuate chronic tendon pain. We will examine the step-by-step process of performing an HVI, using the Achilles tendon as a primary example. Furthermore, I will discuss how we integrate this advanced procedure at Injury Medical Clinic PA. Our unique multidisciplinary approach combines my expertise in chiropractic and functional medicine with the invaluable medical oversight of our Medical Director, Dr. Maria Guadalupe Cardenas, MD, to provide comprehensive, patient-centered care for complex musculoskeletal conditions.

---

As a practitioner with dual credentials in chiropractic and as a board-certified Family Nurse Practitioner, my journey has always been about integrating the best of multiple disciplines to achieve superior patient outcomes. At Injury Medical Clinic PA in El Paso, Texas, this philosophy is the cornerstone of our practice. I am privileged to work alongside Dr. Maria Guadalupe Cardenas, MD, our Medical Director and Collaborative Physician. With over four decades of experience as a board-certified internist, Dr. Cardenas provides essential medical oversight, allowing us to offer a broad spectrum of advanced treatments safely and effectively.

Our model is built on collaboration. Whether we are managing a complex personal injury case, guiding a patient through rehabilitation, or applying functional medicine principles to address root causes of dysfunction, our team approach ensures every patient receives comprehensive care. This integration is particularly vital when we employ advanced procedures like the one we’ll discuss today: tendon brisement, also known as a high-volume injection (HVI). This technique represents a significant leap forward in treating chronic, stubborn tendinopathies, and it perfectly illustrates how integrative care can unlock new possibilities for healing.

Understanding Tendon Brisement: A Paradigm Shift in Tendon Treatment

When we talk about tendon injuries, many people are familiar with terms like fenestration or tenotomy. These procedures involve using a needle to repeatedly puncture the damaged tendon tissue itself, with the goal of stimulating a new, more organized healing response. While effective in certain cases, they don’t always address the full picture of what causes chronic tendon pain.

This is where tendon brisement comes in. It’s a fundamentally different approach. Instead of focusing on the tendon itself, a brisement procedure primarily targets the space around the tendon. Specifically, we target the interface between the tendon and adjacent structures, such as its synovial sheath (tenosynovium) or the nearby fat pad.

The “Why” Behind the Pain: Neovessels and Neonerves

To truly grasp the power of brisement, we must first understand the pathophysiology of chronic tendinopathy. For years, we believed tendon pain was primarily an inflammatory issue (tendinitis). However, modern research, including histopathological studies, has shown that chronic cases are better described as tendinosis—a degenerative condition characterized by disorganized collagen fibers, a lack of inflammatory cells, and, most importantly, the ingrowth of abnormal, tiny blood vessels and nerves. These are known as neovessels and neonerves.

Leading researchers like Alfredson et al. (2000) have demonstrated that these aberrant structures, which often grow into the tendon from adjacent tissues like the fat pad, are a primary source of pain in conditions like Achilles and patellar tendinopathy. The neonerves transmit pain signals, while the neovessels perpetuate a disorganized, failed healing state.

The goal of a tendon brisement or high-volume injection is to physically and hydrostatically disrupt this pathological neurovascular network. We are not just injecting a substance; we are using the volume and pressure of the fluid to mechanically separate adhered tissues and destroy these pain-generating structures.

The High-Volume Injection Procedure: A Step-by-Step Explanation

Let’s walk through how this procedure is performed, using the Achilles tendon as our clinical example. This condition is notoriously difficult to treat, but HVI has shown remarkable promise.

1. Patient Preparation and Initial Assessment

The first step is always a thorough evaluation. The patient is positioned comfortably, typically lying prone for an Achilles procedure, to allow optimal access to the tendon. We then use a high-resolution ultrasound machine with a linear probe to meticulously examine the Achilles tendon in both a longitudinal (long-axis) and transverse (short-axis) view. This diagnostic imaging is crucial for several reasons:

• Pinpointing the Pathology: We can identify the exact location and extent of tendon thickening, collagen disorganization, and signs of tendinosis.
• Visualizing Neovascularity: Using color or power Doppler ultrasound, we can often directly visualize increased blood flow from neovessels, typically on the anterior aspect of the tendon near Kager’s fat pad.
• Planning the Injection: This detailed anatomical map allows us to plan the safest and most effective needle trajectory to target the precise tissue interface.

2. Anesthesia and Needle Placement

Once the target area is identified, we ensure the patient’s comfort. The skin and superficial subcutaneous tissues are anesthetized using a fine-gauge needle (e.g., 25 or 27-gauge) and a local anesthetic like lidocaine. This minimizes any discomfort from the main procedure.

Next, a slightly larger needle (e.g., 21 or 22-gauge) is used for the brisement itself. Under continuous ultrasound guidance, the needle is advanced to the target zone—the space between the anterior border of the Achilles tendon and Kager’s fat pad. Precision is paramount. The goal is to be juxtaposed to the tendon, not inside it.

3. The Hydrodissection and Brisement

This is the core of the procedure. We begin injecting a large volume of fluid. The injectate typically consists of a combination of:

• Normal Saline: This makes up the bulk of the volume and provides the hydrostatic force needed for the brisement.
• Local Anesthetic (e.g., Lidocaine): This provides immediate pain relief and can also have a therapeutic effect by disrupting nerve signaling.
• Corticosteroid (Optional): Some protocols include a small amount of corticosteroid to help modulate the local inflammatory response that may follow the mechanical disruption, although this is debated and often used sparingly (Maffulli & Spiezia, 2017).

As the fluid is injected, we watch the ultrasound screen in real-time. What we see is remarkable. The fluid forcibly separates the tissue planes, creating a distinct, anechoic (black) space. This is the hydrostatic decompression in action. You can literally see the fluid stripping the anterior surface of the tendon away from the fat pad, tearing the delicate neovessels and neonerves that have tethered these structures together.

The volume of fluid used can vary significantly, with literature reporting anywhere from 10 to 100 cc. The injection continues until either the patient feels significant pressure or we feel a marked increase in resistance, indicating the tissue compartment is full.

Visualizing the Mechanism: What We See on Ultrasound

Let’s break down the visuals from a procedure performed by my esteemed colleague, Dr. Knight.

• Short-Axis View: Initially, the probe is placed perpendicular to the tendon. The needle is introduced from the side, and we see it as a bright dot on the screen when viewed “out-of-plane.” The initial anesthetic injection begins the process of hydrodissection, gently creating space.
• Long-Axis View: The probe is then turned parallel to the tendon fibers. In this view, we can see the needle tracking along the anterior border of the thickened, tendinopathic Achilles.
• The “Fluid Wave”: As the high-volume injectate is introduced, we witness the most important part of the procedure. A wave of fluid spreads along the interface. It physically lifts the tendon away from the underlying fat pad. This mechanical stripping action is what accomplishes the brisement, effectively decompressing the area and obliterating the neurovascular ingrowth that drives the pain.

The entire process is a form of mechanical neurolysis and anti-angiogenesis, achieved through hydrostatic pressure rather than a scalpel. This is precision medicine at its finest, guided by real-time imaging.

Integrating Chiropractic Care for Comprehensive Recovery

Performing a high-volume injection is a powerful intervention, but it’s not the end of the story. In my clinical experience, the most successful and lasting outcomes come when these procedures are integrated into a comprehensive rehabilitation framework. This is where the synergy of our multidisciplinary clinic truly shines.

Following an HVI procedure, the patient enters a structured rehabilitation program where chiropractic care plays a pivotal role.

• Biomechanical Correction: Chronic tendinopathy rarely exists in a vacuum. It often results from underlying biomechanical faults. As a chiropractor, I focus on identifying and correcting these issues. For Achilles tendinopathy, this may involve:
  • Spinal and Pelvic Adjustments: Misalignments in the pelvis or lumbar spine can alter the kinetic chain, leading to abnormal gait mechanics and excessive strain on the Achilles tendon. Chiropractic adjustments help restore proper alignment and nerve function from the spine down.
  • Extremity Adjusting: We assess and correct joint restrictions in the ankle, subtalar joint, and foot. A stiff ankle or foot that overpronates can dramatically increase the load on the Achilles.
  • Soft Tissue Mobilization: Techniques like Graston or Active Release Technique (ART) can be applied to the calf muscles (gastrocnemius and soleus) and plantar fascia to reduce tension and improve tissue mobility, further offloading the healing tendon.
• Guided Loading and Rehabilitation: The period after a brisement procedure is a critical window for healing. The tendon needs to be loaded progressively to stimulate organized collagen remodeling. We guide patients through a specific, evidence-based eccentric loading program, as pioneered by researchers like Alfredson et al. (1998). This involves controlled lengthening of the calf muscles, which has been shown to be highly effective in promoting tendon repair. Our rehabilitation team ensures the exercises are performed with perfect form to maximize benefit and prevent re-injury.
• Functional Medicine Support: From my functional medicine perspective, we also address systemic factors that can impair healing. This includes nutritional counseling to ensure the patient has the necessary building blocks for collagen synthesis (e.g., vitamin C, proline, lysine, zinc) and managing systemic inflammation through diet and targeted supplementation.

This integrated model—combining Dr. Cardenas’s medical oversight for the injection, my procedural skills, our shared rehabilitation protocols, and a foundation of chiropractic and functional medicine—creates a powerful therapeutic cascade. We are not just treating the painful tendon; we are treating the whole person and the entire biomechanical system that contributed to the injury in the first place. This is the future of musculoskeletal medicine.

---

References

Alfredson, H., Pietilä, T., Jonsson, P., & Lorentzon, R. (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. The American Journal of Sports Medicine, 26(3), 360–366. https://doi.org/10.1177/03635465980260030301

Alfredson, H., & Ohberg, L. (2000). Neovascularisation in chronic painful patellar tendinosis–a descriptive study in a prospectively selected group of patients. Knee Surgery, Sports Traumatology, Arthroscopy, 8(4), 232-234. Note: This reference discusses patellar tendinosis, but the principle of neovascularization is central to the theory behind HVI for Achilles tendinopathy as well. https://doi.org/10.1007/s001670000128

Maffulli, N., & Spiezia, F. (2017). High-volume injection for the treatment of chronic Achilles tendinopathy. Operative Techniques in Sports Medicine, 25(2), 143-149. https://doi.org/10.1053/j.otsm.2017.03.011

---