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Occipital Neuralgia Treatment for Neck and Head Pain

Occipital Neuralgia Treatment for Neck and Head Pain

Abstract

Occipital neuralgia is a debilitating condition characterized by sharp, throbbing, or electric shock-like pain in the upper neck, back of the head, and behind the ears, often radiating to the scalp. This pain originates from the irritation or compression of the greater and lesser occipital nerves. In this educational post, I, Dr. Alex Jimenez, will take you on a journey to understand the physiological underpinnings of occipital neuralgia, exploring its causes, symptoms, and the latest in diagnostic and treatment strategies. We will delve into how our integrative practice combines evidence-based medicine with a holistic philosophy. A key component of our approach is the collaboration between me, with a background in chiropractic and functional medicine, and our esteemed Medical Director, Dr. Maria Guadalupe Cardenas, MD, a Board-Certified Internist with over four decades of experience. Together, we provide a multidisciplinary framework that integrates chiropractic care, medical oversight, functional medicine, and rehabilitative therapies to offer comprehensive, personalized solutions for patients with this painful condition. We will also examine a specific interventional technique—the occipital nerve block—and discuss how it fits within our broader, patient-centered treatment paradigm.

Occipital Neuralgia Treatment for Neck and Head Pain

Hello, I’m Dr. Alex Jimenez. With my extensive training as a Doctor of Chiropractic (DC), Advanced Practice Registered Nurse (APRN), Family Nurse Practitioner (FNP-BC), and certifications in functional medicine (CFMP, IFMCP), I have dedicated my career to understanding and treating complex neuromusculoskeletal conditions. At Injury Medical Clinic PA, our mission is to provide a beacon of hope for those navigating the often-frustrating world of chronic pain.

A condition I frequently encounter in my clinical practice is occipital neuralgia. This isn’t just a simple headache; it’s a distinct neurological disorder that can severely impact one’s quality of life. The pain is often described as sharp, jolting, and unrelenting, stemming from the occipital nerves that run from the top of the spinal cord up through the scalp.

Our clinic uses a unique, powerful model of integrative care. I work closely with Dr. Maria Guadalupe Cardenas, MD. As a Board-Certified Internist with over 40 years of dedicated patient care (NPI #1164426749, Texas MD License #J2933), Dr. Cardenas serves as our Medical Director and Collaborative Physician. This partnership allows us to seamlessly blend the diagnostic precision and medical oversight of internal medicine with the holistic, biomechanical focus of chiropractic and functional medicine. This multidisciplinary approach ensures our patients receive a comprehensive, well-rounded treatment plan tailored to their individual needs, whether they are dealing with a personal injury, a chronic condition like occipital neuralgia, or are on a journey toward optimal wellness.

The Anatomy of Pain: What Are the Occipital Nerves?

To truly understand occipital neuralgia, we must first explore the anatomy involved. The primary culprits are the greater and lesser occipital nerves. These nerves are not part of the brain but are peripheral nerves that emerge from the upper cervical spine, specifically from the C2 and C3 nerve roots.

  • Greater Occipital Nerve: This is the larger of the two and originates from the C2 nerve root. It travels up through the deep muscles at the back of the neck, pierces the trapezius muscle, and then branches to provide sensation to most of the scalp on the back and top of the head.
  • Lesser Occipital Nerve: This nerve originates from the C2 and C3 nerve roots. It runs along the side of the neck, behind the ear, providing sensation to the skin in that area and the scalp just behind it.

When these nerves become inflamed, compressed, or injured anywhere along their path, they send distress signals that the brain interprets as intense pain. This is the essence of neuralgia—nerve pain.

Identifying the Root Cause of Occipital Neuralgia

Effective treatment depends on identifying the underlying cause of the nerve irritation. Occipital neuralgia is often secondary to another issue. Based on my clinical observations and leading research, common causes include:

  • Muscle Tension and Spasm: Chronic tension in the suboccipital muscles (the small muscles connecting the skull to the top of the spine) is a primary driver. Poor posture, such as “tech neck” from looking down at devices, can lead to hypertonicity in these muscles, effectively entrapping the occipital nerves as they pass through.
  • Trauma or Injury: Whiplash from a car accident, a direct blow to the back of the head, or even repetitive micro-trauma can injure the nerves or surrounding tissues, leading to inflammation and compression.
  • Cervical Spine Misalignments (Subluxations): From a chiropractic perspective, misalignments in the upper cervical vertebrae (atlas and axis) can directly irritate the C2 and C3 nerve roots from which the occipital nerves originate. This biomechanical dysfunction is a critical factor we address with chiropractic adjustments.
  • Degenerative Conditions: Osteoarthritis or degenerative disc disease in the upper cervical spine can lead to bone spurs or narrowing of the spaces where nerves exit the spinal column (foraminal stenosis), causing nerve compression.
  • Systemic Conditions: Less commonly, conditions like gout, diabetes, or infections can cause inflammation that affects the occipital nerves.

The Role of Integrative Chiropractic Care

This is where our integrative model truly shines. As a chiropractor, I focus on the biomechanical integrity of the spine and nervous system. When a patient presents with symptoms of occipital neuralgia, my assessment begins with a thorough examination of the cervical spine.

  1. Chiropractic Adjustments: Using precise, gentle adjustments, I work to restore proper motion and alignment to the C1 (atlas) and C2 (axis) vertebrae. By correcting these vertebral subluxations, we can alleviate direct pressure on the nerve roots. This is not merely “cracking the neck”; it is a specific intervention designed to improve nerve function at its source (Taylor & Murphy, 2020).
  2. Soft Tissue Mobilization: The nerves don’t exist in a vacuum. Muscles, fascia, and other soft tissues surround them. I utilize techniques like myofascial release, trigger point therapy, and instrument-assisted soft tissue mobilization (IASTM) to release tension in the suboccipital and trapezius muscles. This creates space for the nerve, reducing entrapment and inflammation.
  3. Functional Rehabilitation: Treatment doesn’t end in the clinic. We empower patients with specific postural correction exercises, neck-muscle stretches, and strengthening exercises for the deep cervical flexors. This proactive approach helps prevent the recurrence of muscle tension and postural strain that often trigger occipital neuralgia.

This chiropractic foundation sets the stage for resolving the condition’s biomechanical triggers. However, for some patients, the inflammation and pain are so acute that they create a barrier to effective manual therapy. This is where medical intervention, under Dr. Cardenas’s guidance, becomes crucial.

Medical Intervention: The Occipital Nerve Block

For patients experiencing severe, intractable pain, an occipital nerve block can be a game-changer. This minimally invasive procedure serves both diagnostic and therapeutic purposes. It involves injecting a small amount of local anesthetic and a corticosteroid directly around the inflamed occipital nerves.

Let’s walk through the procedure, as performed in our clinic under my scope as a Family Nurse Practitioner, to understand the “why” behind each step.

Step 1: Precise Identification of Tender Points

The first and most critical step is locating the exact points of maximum tenderness. The patient’s feedback is paramount. I use my fingers to palpate the area where the occipital nerves emerge, just below the base of the skull (the occiput). I’ll ask, “Is that the spot?” When the patient confirms, “Yes, that’s it,” I know I’ve found a primary trigger point. Because we’re working in the hairline, I make a small indentation with a capped pen and a tiny ink mark just below it for reference. This ensures absolute precision.

Step 2: Aseptic Preparation

Patient safety is non-negotiable. I thoroughly cleanse the marked areas with alcohol swabs. In a hairy area like the scalp, this is a practical, effective way to prepare the skin and minimize infection risk.

Step 3: The Therapeutic Combination

The syringe contains a carefully measured mixture of two key components:

  • Lidocaine: This is a local anesthetic. It provides immediate pain relief by blocking sodium channels in nerve fibers. This stops pain signals from reaching the brain. The rapid relief it provides also serves a diagnostic function—if the pain disappears almost instantly, it confirms that the occipital nerve was indeed the source of the pain.
  • Cortisone: This is a powerful anti-inflammatory steroid. While lidocaine provides short-term relief, cortisone targets the underlying inflammation. It suppresses the local inflammatory response, reduces swelling around the nerve, and provides longer-lasting pain relief that can last for weeks or even months (Govindappagari & V, 2022). The goal is to break the pain-inflammation cycle.

Step 4: The Injection Process

Using a fine-gauge needle (a 25-gauge in this case) to minimize discomfort, I perform the injection. I always alert the patient, saying, “You’re going to feel a little stick.” I advance the needle until it is near the occiput, in the vicinity of the nerve.

Before injecting, I perform an aspiration. This means I gently pull back on the plunger to ensure the needle tip is not inside a blood vessel. If blood were to enter the syringe, it would indicate an intravascular position, and injecting the steroid there could lead to systemic side effects. Seeing no blood on aspiration confirms we are in the correct tissue plane. I then slowly inject the solution, bathing the nerve in the anesthetic and anti-inflammatory medication. I repeat this for each identified trigger point.

Step 5: Immediate Post-Procedure Assessment

Immediately after the injection, I gently massage the area to help disperse the medication. Then comes the moment of truth. I apply pressure to the same spots that were excruciatingly painful just moments before. I ask, “Does that hurt right there?” The typical response is one of relief: “It feels better.” or “I just feel pressure now.”

This immediate feedback is invaluable. The patient’s significantly reduced pain confirms the block’s success. This relief, even if temporary from the anesthetic, breaks the cycle of pain and muscle guarding. It opens a crucial “window of opportunity” to apply our other therapies more effectively. With pain diminished, the patient can better tolerate chiropractic adjustments and engage in the necessary rehabilitative exercises.

A True Integrative Framework: Tying It All Together

The occipital nerve block is not a standalone cure; it is a strategic tool within our comprehensive care plan. Here is how the pieces fit together:

  1. Initial Crisis Management: The occipital nerve block, overseen medically by Dr. Cardenas and performed by me as an FNP, provides rapid, significant pain relief. This calms the hypersensitive nervous system.
  2. Restoring Biomechanical Function: During the pain-free window created by the block, I implement integrative chiropractic care. This includes targeted upper cervical spinal adjustments and soft tissue work to release muscular entrapment of the occipital nerves.
  3. Addressing Systemic Drivers: As a functional medicine practitioner, I also look deeper. Is there a systemic inflammatory issue at play? We may use advanced lab testing to investigate nutritional deficiencies, food sensitivities, or metabolic imbalances that could be contributing to chronic inflammation. A pro-inflammatory diet can certainly worsen conditions like neuralgia.
  4. Rehabilitation and Empowerment: Our physical therapy and rehabilitation team guides the patient through exercises to correct posture, strengthen supporting muscles, and improve overall spinal health, empowering them to maintain their results and prevent future flare-ups.

This cyclical, mutually reinforcing process is the heart of our practice. Medical intervention makes chiropractic care more effective, and chiropractic care addresses the root biomechanical issues to provide a long-term solution. Dr. Cardenas’s internal medicine expertise ensures we identify and manage any underlying systemic health issues, providing a complete safety net for the patient’s overall health.

By weaving together the latest evidence-based research and techniques from multiple disciplines, we create a patient journey that is not just about managing symptoms, but about restoring function, health, and quality of life. If you are struggling with head and neck pain, know that there are comprehensive, integrative solutions available that go beyond a simple prescription.

References

SubQ Testosterone for Women: Strength and Balance

SubQ Testosterone for Women: Strength and Balance

Abstract

Testosterone is often associated with men, but women naturally produce this hormone throughout life. In women, testosterone contributes to sexual function and interacts with muscle, bone, metabolism, and other body systems. When testosterone therapy is clinically appropriate, treatment should be individualized and monitored so hormone levels remain within the normal female physiologic range. Subcutaneous testosterone injections place a small amount of medication into fatty tissue just beneath the skin, where it is gradually absorbed. However, the strongest clinical evidence for testosterone therapy in women remains with transdermal treatment, especially for postmenopausal women with hypoactive sexual desire disorder, or HSDD.

At ChiroMed – Integrated Medicine in El Paso, Texas, this topic fits within a broader model of coordinated healthcare. Chiropractic care, nurse practitioner services, rehabilitation, nutrition, functional health strategies, and medical oversight can work together to address a patient’s musculoskeletal function and overall health rather than focusing on hormone levels alone. ChiroMed describes its approach as bringing multiple healthcare disciplines together to create individualized, patient-centered treatment plans.

SubQ Testosterone for Women: Strength and Balance

Understanding Testosterone in Women

Testosterone is a natural part of female physiology. The ovaries and adrenal glands contribute to androgen production, and testosterone levels normally change with age. Levels can also fall more quickly after ovary removal.

Testosterone interacts with many tissues throughout the body, including the brain, muscles, bones, reproductive tissues, and blood-forming system. However, recognizing these biological roles does not mean testosterone therapy has been proven to treat every symptom that may occur during menopause.

The strongest evidence currently supports systemic testosterone therapy for appropriately evaluated postmenopausal women with HSDD. HSDD involves persistent loss of sexual desire that causes personal distress. Major international organizations have concluded that this is the clearest evidence-supported indication for testosterone therapy in women (Davis et al., 2019).

A large systematic review and meta-analysis also found that testosterone can improve several areas of sexual function in postmenopausal women, including sexual desire, arousal, pleasure, orgasm, responsiveness, and sexual self-image (Islam et al., 2019).

Testosterone_Therapy_in_Women_Whitepaper_MedivantDownload

What Are Subcutaneous Testosterone Injections?

A subcutaneous, or SubQ, injection places medication into fatty tissue beneath the skin rather than deeply into a muscle.

Testosterone cypionate may be prepared in concentrations that allow very small doses to be administered. Once placed into subcutaneous tissue, the medication forms a depot from which testosterone is gradually absorbed.

For women, the treatment goal is very different from testosterone treatment designed to produce male hormone concentrations. When testosterone is used for female HSDD, expert guidance recommends keeping concentrations within the physiologic range normally seen in premenopausal women rather than pushing testosterone above that range (Parish et al., 2021).

The attached clinical white paper makes an important distinction about SubQ injections. Randomized efficacy evidence in women is strongest for transdermal patches, creams, and gels. It describes subcutaneous injection as a titratable route with physiologic reasoning behind it, but notes that there is no dedicated randomized efficacy trial establishing SubQ testosterone injections for women.

That means SubQ testosterone should not be described as better proven than transdermal therapy. It is an alternative route that requires careful medical prescribing, laboratory monitoring, informed consent, and follow-up.

A “Low Testosterone” Number Is Not the Diagnosis

Laboratory testing is useful, but testosterone therapy in women should not begin solely because one test result falls near the lower end of a reference range.

The ISSWSH clinical guideline recommends a biopsychosocial assessment before treatment. A clinician may need to consider menopause status, medications, relationship factors, depression or anxiety, sleep, vaginal discomfort, pain during intercourse, medical illnesses, and other issues that can affect sexual desire. Total testosterone is useful mainly as a baseline and monitoring measurement rather than as a diagnostic test for HSDD (Parish et al., 2021).

The clinical white paper emphasizes the same principle. Testosterone measurements become especially important after therapy begins, because they help the healthcare team determine whether treatment remains within a physiologic female range and whether the patient is receiving too much hormone.

Testosterone, Muscle, and Musculoskeletal Health

Testosterone interacts with skeletal muscle biology, which is one reason the hormone receives attention in discussions about aging, physical function, and strength.

A randomized study examined different testosterone doses in postmenopausal women who had undergone hysterectomy. Higher testosterone concentrations were associated with changes in lean body mass and some measurements of muscle power. Importantly, the clearer muscle effects occurred with the highest dose and testosterone concentrations above typical female physiologic levels. The authors also stated that longer-term trials were needed to balance potential benefits against long-term risks (Huang et al., 2014).

This research should not be interpreted to mean that testosterone is a proven muscle-building treatment for women. The clinical white paper specifically notes that body-composition benefits have not been established as an approved indication for female testosterone therapy.

This is where physical rehabilitation becomes important. Hormones may influence the environment in which muscle tissue functions, but stronger muscles still require appropriate loading, movement, nutrition, recovery, and neuromuscular training.

Connecting Testosterone Therapy With Chiropractic Care

Chiropractic treatment and testosterone therapy perform very different jobs.

Testosterone therapy is a medical treatment that requires appropriate prescribing and monitoring. Chiropractic care focuses on the musculoskeletal system, including joint movement, spinal mechanics, posture, physical function, and rehabilitation.

For a woman who is also trying to maintain strength and mobility as she ages, an integrated plan may include:

  • medically supervised hormone assessment when clinically indicated;
  • chiropractic evaluation of the spine, pelvis, and extremities;
  • resistance and strength rehabilitation;
  • balance, mobility, and stability exercises;
  • adequate dietary protein and overall nutrition;
  • evaluation of sleep and recovery;
  • management of previous injuries or chronic musculoskeletal limitations;
  • progressive exercise based on the patient’s current ability;
  • laboratory monitoring when hormone therapy is prescribed;
  • ongoing reassessment of both symptoms and physical function.

The important idea is that testosterone does not replace exercise or rehabilitation. Likewise, an adjustment cannot correct a hormone disorder. When appropriate, the two approaches can address different parts of the patient’s health.

How This Fits the ChiroMed Integrated Medicine Model

ChiroMed – Integrated Medicine in El Paso brings several healthcare services into a multidisciplinary setting. The clinic currently describes chiropractic care, nurse practitioner services, rehabilitation, nutrition, acupuncture, and related integrative services as parts of its overall healthcare model.

That structure can be useful when women’s hormone concerns overlap with other health issues.

For example, a woman discussing hormonal symptoms may also have chronic back pain, reduced physical activity, previous injury, poor sleep, loss of conditioning, weight concerns, or difficulty maintaining muscle strength. Treating only a laboratory number would not address all of those factors.

ChiroMed’s integrated injury model similarly describes combining medical evaluation, chiropractic care, rehabilitation, soft-tissue treatment, and functional medicine strategies within a coordinated recovery plan.

Dr. Alexander Jimenez, DC, APRN, FNP-BC, works within this multidisciplinary environment by integrating chiropractic and musculoskeletal assessment with his advanced-practice nursing and functional medicine background. His clinical approach emphasizes movement, nutrition, metabolic health, rehabilitation, and other factors that affect how a patient feels and functions.

Medical oversight is also part of the ChiroMed structure. ChiroMed identifies Maria Guadalupe Cardenas, MD, a board-certified internal medicine physician, as Medical Director, Clinical Director, and Collaborative Physician. The ChiroMed website lists her Texas medical license as J2933 and NPI as 1164426748.

In a multidisciplinary model, the goal is not to make chiropractic treatment a substitute for medical hormone management. Instead, medical and musculoskeletal professionals can contribute within their respective scopes of practice.

Monitoring Testosterone Therapy in Women

If testosterone treatment is selected, follow-up is an essential part of care.

The clinical guideline recommends monitoring testosterone concentrations to prevent exposure above the physiologic premenopausal range. Patients should also be evaluated for clinical signs of androgen excess (Parish et al., 2021).

Possible concerns can include acne, increased facial or body hair, scalp hair changes, and other androgenic effects. Voice changes are less common but deserve prompt attention. The attached white paper explains that these effects tend to be dose-related and that scheduled reassessment helps identify excessive exposure early.

A clinician may also consider the patient’s overall medical history, cardiovascular health, breast health, medications, and other hormone therapy.

Importantly, testosterone should not simply be increased because symptoms have not changed quickly. Expert guidance suggests evaluating response over several months and stopping treatment when there is no meaningful benefit rather than pushing testosterone beyond the normal female physiologic range.

What We Still Do Not Know

Testosterone therapy in women is an area where evidence and clinical practice do not always move at the same speed.

Transdermal testosterone has the strongest randomized evidence. The evidence supporting subcutaneous injections in women remains much more limited. The attached white paper specifically identifies subcutaneous injection evidence as pharmacokinetic rather than supported by dedicated female efficacy trials.

Long-term cardiovascular and breast safety also remain incompletely defined. Available shorter-term findings at physiologic doses are reassuring, but researchers still lack adequately powered studies that answer every safety question over many years.

This is why individualized treatment and shared decision-making matter.

Integrating Hormone Health With Movement and Strength

Women’s health is rarely about one hormone, one joint, or one treatment.

For selected women with HSDD, properly monitored testosterone therapy may be one part of care. If a SubQ route is considered, the treatment should remain medically supervised and should recognize that evidence for female subcutaneous injections is still developing.

At the same time, maintaining musculoskeletal health requires movement.

Progressive resistance exercise, adequate nutrition, good sleep, rehabilitation, healthy body composition, joint mobility, and injury management all contribute to maintaining strength and physical independence.

That concept fits naturally with the ChiroMed – Integrated Medicine approach in El Paso: combining conventional medical oversight with chiropractic care, rehabilitation, nutrition, functional strategies, and individualized patient education. ChiroMed describes its purpose as bringing different disciplines together so treatment plans can address both symptoms and underlying contributors to health and function.

Testosterone therapy and chiropractic care should therefore not be viewed as competing treatments. When clinically appropriate, each addresses different parts of the larger goal—helping women maintain healthy physiology, functional muscles and joints, mobility, and quality of life.

References

Davis, S. R., Baber, R., Panay, N., et al. (2019). Global consensus position statement on the use of testosterone therapy for women. Journal of Clinical Endocrinology & Metabolism, 104(10), 4660-4666.

Hatzilabrou, T. A. (n.d.). Testosterone therapy in women. Worldborne Medical, Clinical Frontiers: Androgens Series.

Huang, G., Basaria, S., Travison, T. G., et al. (2014). Testosterone dose-response relationships in hysterectomized women with or without oophorectomy: Effects on sexual function, body composition, muscle performance and physical function in a randomized trial. Menopause, 21(6), 612-623.

Islam, R. M., Bell, R. J., Green, S., Page, M. J., & Davis, S. R. (2019). Safety and efficacy of testosterone for women: A systematic review and meta-analysis of randomised controlled trial data. The Lancet Diabetes & Endocrinology, 7(10), 754-766.

Parish, S. J., Simon, J. A., Davis, S. R., et al. (2021). International Society for the Study of Women’s Sexual Health clinical practice guideline for the use of systemic testosterone for hypoactive sexual desire disorder in women. The Journal of Sexual Medicine, 18(5), 849-867.

ChiroMed – Integrated Medicine. (2026). ChiroMed – Integrated Medicine: Holistic healthcare in El Paso, Texas.

ChiroMed – Integrated Medicine. (2026). Integrated medicine services in El Paso, Texas.

Legal Peptide Therapy and Integrative Chiropractic Care in El Paso

Legal Peptide Therapy and Integrative Chiropractic Care in El Paso

Abstract

Peptide therapy is becoming an important topic in integrative medicine, metabolic health, weight management, hormone care, and physical recovery. However, not every peptide sold online or discussed on social media is FDA-approved or appropriate for medical treatment. Legal peptide use depends on the specific medication, its FDA status, how it is prescribed or compounded, the patient’s medical needs, and federal and state laws.

At ChiroMed – Integrated Medicine in El Paso, Texas, an integrative model can bring medical evaluation, nurse practitioner services, chiropractic care, functional medicine, nutrition, and rehabilitation together. Medical providers handle evaluation and prescription decisions within their professional authority, while chiropractic care focuses on biomechanics, joint function, movement, strength, and musculoskeletal rehabilitation. This article explains how these roles can work together while keeping peptide treatment patient-centered, medically appropriate, and within professional scope.

Legal Peptide Therapy and Integrative Chiropractic Care in El Paso

What Is Legal Peptide Therapy?

Peptides are short chains of amino acids. Amino acids are the building blocks of proteins, and many naturally occurring peptides act as signals inside the body.

Some peptide-based medicines have established medical uses. Others remain experimental or have limited evidence in people.

The important question is not simply, “Are peptides legal?”

A better question is:

Is this specific peptide legally available and medically appropriate for this particular patient, from this particular source, and for this particular use?

Legal medical use can include several different situations:

  • An FDA-approved peptide-based drug used for an approved indication
  • An FDA-approved medication prescribed for a medically appropriate off-label use
  • A compounded medication prepared under applicable federal and state requirements
  • An investigational drug being used through an authorized research pathway

These categories are not interchangeable.

The FDA makes an especially important distinction regarding compounded medications. Compounded medications can serve a medical need for certain patients, but they are not FDA-approved. The FDA does not review each compounded medication for safety, effectiveness, or manufacturing quality before it reaches the patient (U.S. Food and Drug Administration [FDA], 2026a).

Why “Research Peptides” Are Different

Patients may see peptides advertised online with labels such as:

  • “Research use only”
  • “Not for human consumption”
  • “Laboratory use only”

These labels should not be confused with an FDA-approved prescription medication or a lawfully prepared compounded prescription.

The fact that a chemical can be purchased through a website does not establish that it is approved or appropriate for human treatment.

This is especially important because peptide regulation continues to change. Different substances may have different FDA classifications, compounding restrictions, safety concerns, and available evidence.

Under Sections 503A and 503B of the Federal Food, Drug, and Cosmetic Act, the FDA limits which bulk drug substances may be used. These lists and regulatory policies can change as new evidence becomes available (FDA, 2026b).

For this reason, healthcare professionals should evaluate the current regulatory status of the specific peptide rather than assuming that all peptides fall into the same category.

Compounded Peptides Require Special Attention

Compounding can be valuable when a commercially available FDA-approved medication cannot meet a patient’s individual medical need.

For example, a patient might need a different dosage form because of an allergy or another clinical concern.

However, compounding does not automatically make a peptide legal, FDA-approved, or appropriate.

Under federal rules, Section 503A compounders face requirements about which bulk substances they may use. Section 503B outsourcing facilities also operate under specific limits regarding bulk substances and drug shortages (FDA, 2026b).

Patients should understand an important difference:

An FDA-approved medication and a compounded version of a medication are not the same regulatory product.

The FDA states that compounded drugs have not gone through FDA premarket approval for safety, effectiveness, and quality (FDA, 2026a).

This makes pharmacy selection, clinical justification, documentation, dosing, patient education, and follow-up especially important.

What the New Mexico Board of Nursing Says

The September 2026 New Mexico Board of Nursing Peptide Therapies FAQ provides a useful example of how one state nursing board is approaching this rapidly changing field.

The Board emphasizes that its FAQ provides general interpretation only. It specifically states that the document is not a legal opinion and cannot be cited as legal authority.

The guidance states that APRNs prescribing compounded medications should remain within their education, experience, population focus, and prescriptive authority. It also emphasizes a valid provider-patient relationship, appropriate history and physical examination, clinical justification, informed consent, monitoring, and documentation.

The Board also recommends that clinicians:

  • Make sure compounding is legally permitted
  • Use appropriately licensed pharmacies
  • Explain when a patient is receiving a compounded medication
  • Document the reason for using the compounded product
  • Avoid questionable or unverified sources

The New Mexico guidance is useful for understanding professional safety principles, but ChiroMed is located in Texas. Therefore, Texas law and Texas professional licensing requirements govern care delivered in Texas.

Chiropractic and Medical Roles Must Remain Clear in Texas

ChiroMed describes itself as an integrated healthcare practice bringing chiropractic care, nurse practitioner services, rehabilitation, nutrition, and other healthcare disciplines together in one setting.

Clear professional roles are important in this type of practice.

Under Texas Occupations Code §201.002, chiropractic practice includes evaluation of the biomechanical condition of the spine and musculoskeletal system and nonsurgical, noninvasive procedures intended to improve musculoskeletal biomechanics.

The same law states that chiropractic practice does not include prescribing controlled substances, dangerous drugs, or other prescription drugs.

Therefore, a clinician cannot prescribe peptides under a Texas chiropractic license alone.

This distinction is especially important for a clinician such as Dr. Alexander Jimenez, DC, APRN, FNP-BC, who holds both chiropractic and advanced practice nursing credentials.

His chiropractic license supports chiropractic and musculoskeletal care. Medical evaluation and prescription decisions must be performed under the appropriate APRN authority and applicable Texas rules.

The Nurse Practitioner’s Role in Peptide Therapy

Texas APRNs who prescribe medications must meet Texas requirements for prescriptive authority.

Texas law allows qualified APRNs and physicians to enter into prescriptive authority agreements. These agreements define the practice setting, medication categories, consultation, communication, quality assurance, and referral processes.

This makes the medical side of peptide therapy different from chiropractic treatment.

Depending on the patient’s needs, the medical evaluation may include:

  • Medical history
  • Current medications and supplements
  • Physical examination
  • Laboratory testing
  • Contraindications and risk factors
  • Diagnosis
  • Treatment alternatives
  • Medication selection
  • Informed consent
  • Follow-up laboratory testing
  • Response to treatment
  • Side-effect monitoring

Do not select a peptide simply because it is popular.

The patient’s diagnosis, health history, goals, risks, available evidence, and legal treatment options should guide the medical decision.

ChiroMed’s Multidisciplinary Model

At ChiroMed – Integrated Medicine, the goal is to bring different parts of healthcare together rather than treating each problem in isolation.

ChiroMed describes its services as including chiropractic care, nurse practitioner services, rehabilitation, nutrition, and integrative approaches for patients with musculoskeletal, injury, chronic pain, and wellness concerns.

The multidisciplinary team also includes Dr. Maria Guadalupe Cardenas, MD, whom ChiroMed identifies as a board-certified internal medicine physician, Medical Director, and Collaborative Physician with more than four decades of experience.

Public NPI information lists Dr. Maria Guadalupe Cardenas as an internal medicine physician in El Paso with NPI 1164426748 and Texas medical license J2933.

Within this model, Dr. Cardenas provides medical direction and internal medicine experience alongside Dr. Jimenez’s work in advanced practice nursing, chiropractic care, functional medicine, injury management, and rehabilitation.

The goal is coordinated care, while each clinician works within the appropriate professional scope.

How Chiropractic Care Can Complement Peptide Treatment

Chiropractic treatment should not be promoted as making a peptide medication more powerful.

Instead, these treatments may address different parts of a patient’s overall health and recovery.

A medically managed therapy may address a specific metabolic, hormonal, or medical problem.

Chiropractic and rehabilitation care can focus on the patient’s ability to move and function.

At ChiroMed, integrative chiropractic care may support:

  • Joint mobility
  • Spinal biomechanics
  • Range of motion
  • Posture
  • Muscle balance
  • Functional strength
  • Neuromuscular coordination
  • Progressive exercise
  • Return to normal activities
  • Injury rehabilitation

ChiroMed’s published clinical model emphasizes connecting medical evaluation with chiropractic care and rehabilitation rather than replacing one healthcare profession with another.

This can be particularly useful when a patient has both a medical concern and a musculoskeletal limitation.

For example, a patient receiving medical weight-management treatment may need help maintaining muscle mass, increasing activity, and improving physical function.

Strength and Muscle Preservation Matter

Muscle health deserves special attention during some medical weight-management programs.

The New Mexico Board of Nursing guidance recommends attention to:

  • Adequate protein
  • Resistance exercise
  • Preservation of lean body mass
  • Vitamin and nutrient intake
  • Long-term lifestyle changes

Rehabilitation and integrative chiropractic care may fit naturally into a broader treatment plan.

A patient with back pain, knee pain, poor mobility, or an old injury may find exercise difficult. Treating mechanical barriers and developing a progressive rehabilitation program may help that person become more physically active.

The goal is not simply weight loss.

It is to help patients maintain:

strength + mobility + muscle + function.

Clinical Observations From Dr. Alexander Jimenez

In his clinical writings, Dr. Alexander Jimenez, DC, APRN, FNP-BC, CCST, CFMP, IFMCP, ATN, describes health and recovery through a systems-based approach.

Instead of relying on one treatment, his clinical model connects areas such as:

  • Chiropractic biomechanics
  • Functional medicine
  • Nutrition
  • Musculoskeletal rehabilitation
  • Laboratory findings when appropriate
  • Strength and conditioning
  • Injury recovery
  • Medical evaluation
  • Lifestyle modification

This philosophy is also reflected throughout ChiroMed’s published material, which describes integrated injury care as a combination of medical evaluation, chiropractic care, functional medicine, rehabilitation, and other supportive options.

Peptide treatment, when medically appropriate and legally available, can therefore be one part of a larger care plan, not a replacement for good nutrition, exercise, rehabilitation, sleep, or medical monitoring.

A Patient-Centered Approach to Peptide Therapy

Responsible peptide treatment should begin with the patient—not with a product.

Before considering treatment, the healthcare team should determine:

  • What problem is being treated?
  • Is there an established diagnosis?
  • Is the medication FDA-approved?
  • If it is compounded, why is compounding medically appropriate?
  • Is there reasonable evidence supporting its use?
  • What are the risks and alternatives?
  • Does the patient’s medical history create contraindications?
  • What monitoring will be needed?
  • Who is responsible for prescribing and follow-up?
  • Is the pharmacy properly licensed?
  • Is the treatment permitted under current federal and state requirements?

The New Mexico Board’s guidance similarly emphasizes history, examination, laboratory testing when indicated, informed consent, documentation, treatment response, adverse effects, and follow-up.

Integrating Medicine, Movement, and Recovery at ChiroMed

The future of integrative healthcare is not about one profession trying to perform every type of treatment.

It is about different professionals contributing their expertise to the same patient.

At ChiroMed – Integrated Medicine in El Paso, chiropractic care can address biomechanics, movement, spinal and joint health, physical strength, and rehabilitation. Advanced practice nursing can provide appropriate medical evaluation and treatment within APRN scope and Texas prescriptive authority. Internal medicine leadership can add another layer of medical direction and clinical coordination.

Nutrition, functional medicine, personal injury care, and rehabilitation can then support the patient’s larger goals.

This creates a practical model:

Medical care addresses medical needs.
Chiropractic care addresses biomechanics and musculoskeletal function.
Rehabilitation develops strength and movement.
Nutrition provides the building blocks for recovery.
Medical oversight helps keep the entire plan appropriate and coordinated.

Peptide science will continue to change. Some peptide-based medications already have established medical roles, while other substances remain investigational, restricted, or supported by limited human evidence.

For patients and clinicians alike, the safest approach is to focus on evidence, professional scope, current regulations, appropriate medical evaluation, legitimate pharmacy sources, and careful follow-up.

At ChiroMed, integrated care means looking beyond one medication or one adjustment and building a treatment plan around the health and functional needs of the whole person.

References

ChiroMed – Integrated Medicine. (2026a). Integrated medicine services in El Paso, Texas.

ChiroMed – Integrated Medicine. (2026b). ChiroMed – Integrated Medicine: Holistic healthcare in El Paso, TX.

ChiroMed – Integrated Medicine. (2026c). Integrated injury care in El Paso, TX.

ChiroMed – Integrated Medicine. (2026d). Peptide therapy, nutrition, and integrative chiropractic care.

Food and Drug Administration. (2026a). Compounding and the FDA: Questions and answers.

Food and Drug Administration. (2026b). Bulk drug substances used in compounding under Section 503A of the FD&C Act.

Food and Drug Administration. (2026c). Human drug compounding.

Jimenez, A. (2026). Peptide therapy, nutrition, and chiropractic care explained.

New Mexico Board of Nursing. (2026). Peptide therapies: Clinical practice frequently asked questions.

Texas Board of Nursing. (2026). APRN practice frequently asked questions.

Texas Legislature. (2026a). Texas Occupations Code Chapter 157: Authority of physician to delegate certain medical acts.

Texas Legislature. (2026b). Texas Occupations Code Chapter 201: Chiropractors.

SubQ Testosterone Therapy and Chiropractic in El Paso

SubQ Testosterone Therapy and Chiropractic in El Paso

Abstract

Subcutaneous testosterone injections, often called SubQ or SC injections, place testosterone into the fatty tissue just under the skin instead of deep into a muscle. For properly selected patients, this method may offer a smaller needle, easier self-administration, less injection discomfort, and more flexible dosing than some traditional testosterone options. Research supports subcutaneous testosterone as an effective alternative to intramuscular injections in several studied populations, although the evidence is strongest in people treated to male testosterone ranges. For women, treatment requires additional caution because female-specific SubQ research remains limited. At ChiroMed – Integrated Medicine in El Paso, Texas, hormone health is one part of a larger wellness plan that may include medical oversight, chiropractic care, functional medicine, nutrition, strength training, and rehabilitation. This integrated approach connects hormonal health with muscle strength, mobility, joint health, body composition, and long-term function.

SubQ Testosterone Therapy and Chiropractic in El Paso

What Is a Subcutaneous Testosterone Injection?

Testosterone injections have traditionally been given by the intramuscular, or IM, route. An IM injection places medication deep into a muscle. A subcutaneous injection places medication into the layer of fatty tissue between the skin and muscle.

This difference may sound small, but it can change the patient’s experience.

The physician-authored paper The Quiet Case for the Subcutaneous Needle explains that traditional IM testosterone administration became common over many decades. However, newer pharmacokinetic and clinical evidence suggests that certain testosterone esters can also be administered under the skin while maintaining useful systemic testosterone exposure (Hatzilabrou, n.d.).

SubQ testosterone is still an injection. Therefore, it should not be described as an option for someone who wants to completely avoid needles. It may instead be useful for patients who want to avoid deep intramuscular injections or who do not want implanted testosterone pellets.

Why Patients May Consider SubQ Testosterone

Long-term hormone treatment needs to be medically appropriate, but it also needs to be practical. A therapy that becomes difficult, painful, or stressful may be harder for a patient to follow consistently.

Possible advantages of SubQ testosterone may include:

  • A shorter, finer needle compared with many traditional IM injections
  • Easier access to injection sites
  • Less deep muscle soreness
  • Easier self-administration after proper training
  • Greater flexibility for future dose changes
  • No pellet insertion procedure
  • No need to remove an implanted product before changing the next dose
  • The possibility of smaller, more frequent doses when medically appropriate

In a comparative study by Spratt et al. (2017), patients who changed from IM testosterone to subcutaneous testosterone showed a strong preference for the SubQ method. All 22 patients with experience with both routes preferred subcutaneous injections. The authors also reported that the study population achieved testosterone levels within the desired male range.

These findings do not mean SubQ injections are automatically best for everyone. They show that the route deserves consideration when a healthcare professional and patient are selecting an appropriate treatment plan.

The_Quiet_Case_for_the_Subcutaneous_Needle_Whitepaper_MedivantDownload

Subcutaneous Versus Intramuscular Testosterone

Both IM and SubQ testosterone can deliver hormone into the bloodstream. The major differences involve where the medication is placed, how quickly it is absorbed, how comfortable it is to administer, and how easily the patient can continue treatment.

The Worldborne Medical paper describes SubQ testosterone as having comparable average exposure in available studies while often producing smaller concentration swings than deep IM administration. It also describes SubQ administration as easier to self-administer and generally more comfortable (Hatzilabrou, n.d.).

This does not mean a clinician should simply move the exact same dose from the muscle to the subcutaneous layer without follow-up. Absorption may differ. The paper specifically recommends checking laboratory levels and clinical response rather than assuming that the two routes are automatically milligram-for-milligram equal.

The goal is not simply to give testosterone. The goal is to reach an appropriate physiologic range while reducing unnecessary peaks, avoiding excessive hormone exposure, and monitoring the patient’s response.

SubQ Testosterone Compared With Pellets

Testosterone pellets offer another approach. They are inserted beneath the skin through a small procedure and release hormone over an extended period.

For some patients, that convenience is attractive.

Other patients may prefer a treatment that’s easily to adjust. Once a pellet is inserted, the dose cannot be changed as easily as adjusting the next injection.

SubQ injections may therefore appeal to patients who want:

  • A treatment they can administer at home after training
  • More control over dosing schedules
  • Easier dose adjustment
  • No minor pellet insertion procedure
  • A shorter-acting option that can be modified during future follow-up

The paper compares IM injections, pellets, transdermal therapy, oral testosterone, and subcutaneous injections. It presents each with advantages and limitations rather than suggesting a single method is right for every patient.

Subcutaneous Testosterone for Men

Clinical evidence for subQ testosterone is strongest in populations receiving testosterone concentrations within male physiologic ranges.

Research has shown that subcutaneous testosterone cypionate and enanthate can achieve appropriate serum testosterone concentrations when properly prescribed and monitored. Spratt et al. (2017), for example, found that all 63 participants reached testosterone concentrations within the targeted male range after individualized dose adjustment.

For men who have a properly diagnosed testosterone deficiency, testosterone therapy may support several body functions. Testosterone plays a role in:

  • Muscle mass
  • Muscle strength
  • Bone health
  • Sexual function
  • Red blood cell production
  • Body composition
  • Energy and general well-being

Testosterone therapy should not be viewed simply as a muscle-building treatment. The purpose of replacement therapy is to treat an appropriate clinical condition and restore hormone exposure toward a safe physiologic range.

What About SubQ Testosterone for Women?

Testosterone is also an important hormone in women. However, female testosterone therapy is a more complex area.

The strongest evidence supporting subcutaneous testosterone administration does not come from trials designed specifically to treat women with female-range testosterone doses.

The Worldborne Medical paper clearly points out this limitation. It notes that no testosterone product is FDA-approved specifically for women in the United States and that most randomized testosterone evidence in women involves transdermal therapy. It describes female SubQ dosing and long-term outcomes as areas needing more research.

This distinction is important.

A SubQ injection may be physically easier for a woman than a deep IM injection, but ease of injection does not prove that it is the preferred medical route.

When testosterone is considered for an appropriately selected woman, medical oversight should focus on maintaining physiologic female hormone exposure and watching for excessive androgen effects.

These can include:

  • Acne
  • Increased facial or body hair
  • Scalp hair changes
  • Voice changes
  • Changes in mood
  • Other signs of excessive testosterone exposure

Women considering testosterone therapy should therefore have an individualized discussion about symptoms, diagnosis, treatment goals, available evidence, dose, delivery route, risks, and laboratory monitoring.

Testosterone, Muscle Strength, and Musculoskeletal Health

Hormone health and musculoskeletal health can influence each other, but they are not the same.

Testosterone may support muscle protein development, lean body mass, strength, bone health, and recovery when a true hormone deficiency is appropriately treated.

Chiropractic care does something different.

Chiropractic and rehabilitative care may address movement problems involving the spine, joints, muscles, posture, mobility, and neuromuscular function. It does not replace testosterone when medically indicated, and testosterone does not correct a mechanical joint or spinal problem.

This is where an integrated treatment model can become useful.

For example, a patient with low testosterone may begin medically supervised hormone treatment but may also have:

  • Reduced strength
  • Low activity levels
  • Back pain
  • Hip stiffness
  • Poor balance
  • Old injuries
  • Deconditioning
  • Difficulty exercising

Correcting hormone levels alone may not fix those problems.

How ChiroMed Connects Hormone Health and Chiropractic Care

ChiroMed – Integrated Medicine in El Paso is built around a multidisciplinary model rather than a single treatment. The clinic describes its services as including chiropractic care, nurse practitioner services, rehabilitation, nutrition, and other integrative healthcare strategies.

Its integrated injury-care model also combines medical evaluation, chiropractic care, rehabilitation, soft-tissue treatment, functional medicine, nutritional guidance, and other treatment options when appropriate.

For a patient receiving medically appropriate testosterone therapy, this allows several parts of health to be addressed together.

Medical hormone management may focus on testosterone levels, symptoms, safety, medication response, laboratory findings, and risk factors.

Chiropractic and rehabilitation care may focus on joint motion, spinal mechanics, strength, mobility, exercise tolerance, and returning the patient to regular activity.

Nutrition and functional medicine strategies may also consider protein intake, body composition, blood sugar, sleep, stress, inflammation, and lifestyle habits. ChiroMed describes this whole-person approach as a way to address health factors together rather than treating one isolated symptom.

Dr. Jimenez and Dr. Cardenas: A Team-Based Approach

Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, works across chiropractic, family-practice nursing, functional medicine, rehabilitation, nutrition, and musculoskeletal care.

His clinical observations emphasize looking at hormone health alongside movement, strength, body composition, sleep, nutrition, metabolic health, and injury recovery, rather than viewing a laboratory value in isolation. ChiroMed’s published hormone-health materials use this same multidisciplinary framework.

Dr. Maria Guadalupe Cardenas, MD, is board-certified in internal medicine and serves as Medical Director and Collaborative Physician. ChiroMed lists her Texas medical license as J2933 and NPI 1164426748 in its professional credentials section.

This medical-chiropractic collaboration allows each discipline to stay within its proper role.

Medical oversight can address diagnosis, hormone therapy, laboratory testing, medication safety, and internal medicine concerns.

Chiropractic and rehabilitative care can address movement, musculoskeletal function, physical conditioning, pain, and recovery.

Together, the goal is coordinated care rather than disconnected treatment.

Strength Training Matters Too

Testosterone therapy should not replace exercise.

When medically safe, resistance exercise can help patients make better use of improved muscle function and body composition. Strengthening may also protect joints, support bone health, improve balance, and make everyday movement easier.

An integrated plan may include:

  • Progressive resistance training
  • Core stabilization
  • Mobility exercises
  • Chiropractic treatment when appropriate
  • Injury rehabilitation
  • Adequate protein
  • Healthy sleep
  • Weight management
  • Metabolic health support
  • Medical monitoring of testosterone therapy

The goal is not merely to improve a hormone number. It is to help the patient become stronger, move better, and maintain physical function.

Testosterone Still Requires Medical Monitoring

A smaller needle does not make testosterone a minor medication.

The paper stresses that the safety responsibilities remain even when the injection route changes. Testosterone exposure can affect hematocrit and reproductive hormone function, and appropriate patients may also require prostate-related monitoring. Fertility goals should be discussed before treatment because external testosterone can suppress normal reproductive signaling.

Subcutaneous injections may also cause temporary:

  • Redness
  • Tenderness
  • Bruising
  • Itching
  • Small injection-site lumps

The Mayo Clinic and Cleveland Clinic both emphasize using testosterone exactly as directed and maintaining medical follow-up during therapy.

The ChiroMed Approach to Whole-Person Hormone and Musculoskeletal Health

Subcutaneous testosterone gives appropriately selected patients another option for medically supervised hormone therapy.

It may be especially useful for someone who does not want testosterone pellets or repeated deep intramuscular injections. For many patients treated to male testosterone ranges, research supports SubQ testosterone as a practical and well-tolerated alternative to traditional IM treatment.

For women, greater caution is needed because evidence for female-specific SubQ therapy remains limited. Treatment decisions should be individualized and guided by current evidence, symptoms, laboratory findings, medical history, and careful monitoring.

At ChiroMed – Integrated Medicine in El Paso, the larger goal is to connect hormone health with the rest of the body. Testosterone therapy may address an appropriate hormonal problem, while chiropractic care, rehabilitation, functional medicine, nutrition, and exercise address the physical systems that help patients move, build strength, recover, and stay active.

That is the value of integrated care: the hormone, the muscles, the joints, movement, nutrition, and overall health are considered as connected parts of the same patient.

References

Figueiredo, M. G., Gagliano-Jucá, T., & Basaria, S. (2022). Testosterone therapy with subcutaneous injections: A safe, practical, and reasonable option. Journal of Clinical Endocrinology & Metabolism, 107(3), 614–626. Testosterone Therapy With Subcutaneous Injections

Hatzilabrou, T. A. (n.d.). The quiet case for the subcutaneous needle. Worldborne Medical.

Mayo Clinic. (n.d.). Testosterone: Intramuscular route, subcutaneous route. Testosterone—Intramuscular and Subcutaneous Routes

Spratt, D. I., Stewart, I. I., Savage, C., et al. (2017). Subcutaneous injection of testosterone is an effective and preferred alternative to intramuscular injection: Demonstration in female-to-male transgender patients. Journal of Clinical Endocrinology & Metabolism, 102(7), 2349–2355. Subcutaneous Injection of Testosterone Study

Cleveland Clinic. (n.d.). Subcutaneous testosterone injection: Uses and side effects. Subcutaneous Testosterone Injection

ChiroMed – Integrated Medicine. (2026). Integrated injury care in El Paso, TX. Integrated Injury Care in El Paso, TX

ChiroMed – Integrated Medicine. (2026). BHRT nutrition and integrative chiropractic care in El Paso. BHRT Nutrition and Integrative Chiropractic Care

ChiroMed – Integrated Medicine. (2026). Hormone balance, joint health, mobility, and flexibility. Hormone Balance, Joint Health, Mobility, and Flexibility

Forehead Lesion Treatment with Nerve Blocks and Integrative Care

Forehead Lesion Treatment with Nerve Blocks and Integrative Care

Abstract

In this educational post, I will guide you through a common minor surgical procedure: removing a forehead lesion. My goal is to demystify the process by explaining the science behind a crucial component of patient comfort—the nerve block. We will explore the anatomy of the supraorbital and supratrochlear nerves, explain why a nerve block is a superior choice for pain management in this area, and detail the step-by-step technique we use in our clinic. I will also discuss how this procedure fits into our broader philosophy of integrative care at Injury Medical Clinic PA. Our model combines my expertise in chiropractic and functional medicine with the invaluable medical direction of Dr. Maria Guadalupe Cardenas, MD, our board-certified internist. This collaborative approach ensures we provide comprehensive, patient-centered care that addresses both immediate needs and long-term wellness.

Forehead Lesion Treatment with Nerve Blocks and Integrative Care

As a practitioner with a diverse background spanning chiropractic, advanced practice nursing, and functional medicine, I am deeply committed to a patient-first approach. At Injury Medical Clinic PA, we have fostered a unique environment where different medical disciplines converge to offer the most effective and comprehensive care possible. This collaborative spirit is embodied in my work alongside our Medical Director, Dr. Maria Guadalupe Cardenas, MD.

Dr. Cardenas is a highly respected, board-certified internist with over 40 years of clinical experience. Her vast knowledge and medical oversight are foundational to our practice. As my collaborative physician (NPI #1164426749, Texas MD License #J2933), she provides the essential medical direction that allows our multidisciplinary team to function seamlessly. This structure is common in modern integrative and injury care settings, where the expertise of a Doctor of Chiropractic (DC) like myself is complemented by the medical authority and diagnostic acumen of a Medical Doctor (MD). Together, we integrate chiropractic adjustments, functional medicine protocols, rehabilitation, and, when necessary, minor medical procedures to create a truly holistic treatment plan for our patients in El Paso, Texas.

Today, I want to take you behind the scenes of a procedure I recently performed, illustrating how we prioritize patient comfort and safety through evidence-based techniques.

A Case Study in Patient-Centered Care

A patient presented with a benign lesion on her left forehead that she wished to have removed. While the removal itself is relatively straightforward, my paramount concern is keeping the patient comfortable and pain-free. For facial procedures, especially on the forehead, a nerve block is often the most elegant and effective anesthesia option.

Why Choose a Nerve Block Over Local Infiltration?

Before we delve into the procedure, let’s understand the “why.” When anesthetizing an area, we have a few options. The most common is local infiltration, where an anesthetic like lidocaine is injected directly into and around the tissue we plan to excise. While effective, this method has drawbacks:

  • Tissue Distortion: Injecting fluid directly into the surgical site can cause the tissue to swell and change shape. This distortion can make precise excision more challenging and may affect the cosmetic outcome.
  • Increased Discomfort: Local infiltration often requires multiple injections around the lesion to achieve adequate numbness, which can be uncomfortable for the patient.
  • Larger Volume of Anesthetic: Numbing a broad area via infiltration can require a larger total volume of anesthetic compared to the targeted approach of a nerve block.

A nerve block, by contrast, is a more sophisticated technique. Instead of numbing the target tissue itself, we anesthetize the nerve trunk that supplies sensation to that entire region. By depositing a small amount of anesthetic at a specific anatomical point where the nerve is accessible, we can achieve profound numbness over a wide area with minimal injections and no tissue distortion at the surgical site.

The Anatomy of Forehead Sensation

To perform a successful forehead nerve block, a detailed understanding of the underlying anatomy is non-negotiable. The sensory information from the forehead is primarily transmitted to the brain by two nerves, both of which are branches of the trigeminal nerve (Cranial Nerve V).

  • Supraorbital Nerve: This is the larger of the two nerves. It exits the skull through a small opening or notch in the upper rim of the eye socket, known as the supraorbital foramen or notch. From there, it travels upward, providing sensation to the majority of the forehead on that side, extending nearly to the top of the head. Clinically, we can locate this exit point by drawing a vertical line upward from the center of the pupil while the patient looks straight ahead. The nerve emerges right on the bony ridge you can feel above your eyebrow (orbital rim).
  • Supratrochlear Nerve: This smaller nerve emerges from the skull more medially (closer to the nose) than the supraorbital nerve. It exits just above the inner corner of the eye (medial canthus) and supplies sensation to the lower, central part of the forehead, near the bridge of the nose.

By targeting these two nerves, we can effectively anesthetize the entire half of the forehead, ensuring a completely pain-free experience for the patient during the lesion removal.

The Nerve Block Procedure: A Step-by-Step Explanation

With my patient prepped and comfortable, I began the nerve block. Here is a detailed breakdown of the technique, grounded in anatomical precision.

Step 1: Preparation and Anatomical Landmark Identification

The first step in any procedure is ensuring a sterile field. I had already cleaned the patient’s left forehead with an alcohol prep pad. Next, I precisely located the nerve exit points.

  • Locating the Supraorbital Nerve: I asked the patient to look straight ahead. I then visually drew a line from her pupil up to her eyebrow. With my non-dominant thumb, I palpated the bony orbital rim until I felt the slight indentation of the supraorbital notch. This is the target. Placing my thumb firmly on the orbital rim just below this point serves two purposes: it confirms my landmark and acts as a physical barrier to prevent the needle from accidentally going below the rim and endangering the eye.

Step 2: Anesthetizing the Supraorbital Nerve

I used a syringe containing lidocaine, a fast-acting local anesthetic.

  1. I gently pinched the skin just above my thumb. This technique, known as the gate control theory of pain, can help distract from the initial needle prick by activating non-pain nerve fibers.
  2. I told the patient, “One, two, three,” and inserted the needle perpendicular to the skin. The goal is to advance the needle until it gently makes contact with the bone (periosteum) just above the orbital rim. This confirms the correct depth.
  3. With the needle in position, I slightly withdrew it to ensure I was not inside a blood vessel (a technique called aspiration) and then slowly injected approximately 0.5 mL of lidocaine.
  4. As I injected, I felt the fluid create a small bulge, or bleb, against my palpating thumb. This tactile feedback confirms that the anesthetic is being delivered to the correct tissue plane, bathing the supraorbital nerve as it exits the foramen.

Step 3: Anesthetizing the Supratrochlear Nerve

Next, I moved to the second target.

  1. Locating the Supratrochlear Nerve: I palpated the medial aspect of the orbital rim, just above the inner corner of the eye. The supratrochlear nerve is located here. Again, I placed my thumb on the rim for safety and guidance.
  2. Following the same process, I informed the patient and inserted the needle, advancing it until it touched bone.
  3. After aspirating, I injected another 0.5 mL of lidocaine. Once more, I felt the fluid expand in the correct location against my thumb, confirming a successful block of the supratrochlear nerve.

After both injections, I applied gentle pressure to the sites for a moment to help disperse the anesthetic and minimize any potential bruising. Within minutes, the patient’s entire left forehead became profoundly numb, allowing me to proceed with the lesion removal without causing any pain. I gave a small supplemental injection of lidocaine right around the lesion as a final precaution, and the procedure was completed smoothly and efficiently.

The Role of Integrative and Chiropractic Care

You might be wondering how a procedure like this fits into a practice that has chiropractic care at its core. This is where our integrative model shines. At Injury Medical Clinic PA, we see the patient as a whole, interconnected system.

My training as a Doctor of Chiropractic provides me with a deep understanding of the neuromusculoskeletal system. This perspective is invaluable, even in minor surgical procedures. For example, chiropractic insights help with patient positioning, post-procedural muscle tension in the neck and shoulders due to anxiety, and the body’s overall inflammatory response.

  • Managing Systemic Inflammation: A cornerstone of both chiropractic and functional medicine is managing inflammation. Even minor procedures trigger a local inflammatory response. Our protocols, which may include dietary recommendations, targeted supplementation (like curcumin or omega-3 fatty acids), and lifestyle advice, help the body manage this response more effectively, promoting faster and cleaner healing (Maroon & Bost, 2006).
  • Addressing Somatic Responses to Pain and Stress: The experience of pain or even the anticipation of it can cause a person to hold tension in their body. This often manifests as tightness in the neck, shoulders, and upper back. As a chiropractor, I can identify and address this somatic dysfunction through manual adjustments, soft tissue therapy, and postural correction. This not only improves patient comfort but also helps prevent the procedure-related stress from causing secondary musculoskeletal issues.
  • A Foundation of Trust: The hands-on nature of chiropractic care builds a strong therapeutic alliance between practitioner and patient. This trust is essential when performing any procedure. Patients who know and trust me through their chiropractic and functional medicine journey feel more at ease, which research shows can improve outcomes and reduce perceived pain (Kelley et al., 2014).

Our integrated approach, with the expert medical direction of Dr. Cardenas, ensures we always practice to the highest standards of safety and efficacy. Whether a patient comes to us for a spinal adjustment following a car accident, a functional medicine workup for chronic fatigue, or the removal of a skin lesion, they receive care that is coordinated, comprehensive, and centered on their total well-being.

By understanding the “why” and “how” behind even the most routine procedures, we empower our patients with knowledge and reassure them that their health is in capable, caring hands.

References

Kelley, J. M., Kaptchuk, T. J., Cusin, C., Lipkin, S., & Fava, M. (2014). The role of the patient-clinician relationship in the placebo effect. In Placebo (pp. 95-106). De Gruyter. https://doi.org/10.1515/9783110309975.95

Maroon, J. C., & Bost, J. W. (2006). ω-3 Fatty acids (fish oil) as an anti-inflammatory: an alternative to nonsteroidal anti-inflammatory drugs for discogenic pain. Surgical Neurology, 65(4), 326–331. https://doi.org/10.1016/j.surneu.2005.10.023

El Paso Dysplastic Nevus Excision & Integrative Care

El Paso Dysplastic Nevus Excision & Integrative Care

Abstract: In this educational post, I guide you through a clear, step-by-step clinical approach to excising a dysplastic nevus with moderate atypia using modern, evidence-based methods. You will see how a properly executed anesthetic field block creates a pain-free experience, why dermatologic surgery for moderate atypia uses narrow margins, and how meticulous tissue handling supports definitive histologic assessment. I also share how our multidisciplinary team at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas integrates chiropractic care, internal medicine oversight, functional medicine, and rehabilitation. Under the medical direction of Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933), and in collaboration with me, Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, we blend precision procedural care with whole-person strategies grounded in current research. This post highlights how integrative chiropractic care fits into surgical dermatology and personal injury care to optimize healing, reduce pain, and support long-term outcomes.

El Paso Dysplastic Nevus Excision & Integrative Care

Introduction: Perspective on Modern, Multidisciplinary Skin Lesion Care

I am Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. In our El Paso clinic, we often see patients who need carefully planned excisions following a diagnostic shave biopsy. Today, I’ll walk you through a real case: a 62-year-old gentleman returning approximately one month after a shave biopsy revealed a dysplastic nevus with moderate atypia. Our goals: remove the residual lesion with clinically appropriate narrow margins, enable a pain-free experience using a precise anesthetic field block, and ensure the tissue specimen is ideal for pathology.

What makes this care unique is our integrative model. As the Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD (Internal Medicine), provides medical oversight and coordinates care pathways common to multidisciplinary injury and integrative clinics. In parallel, our chiropractic services, functional medicine strategies, and rehabilitation protocols create a cohesive system designed to keep the patient safe, comfortable, and moving toward recovery based on the best available evidence.

Building the Plan: Why Dysplastic Nevus with Moderate Atypia Requires Focused Margins

  • Key concept: Dysplastic nevi with moderate atypia are atypical moles with architectural and cytologic changes that warrant complete excision to reduce the risk of residual atypical tissue.
  • Evidence rationale: For moderate atypia, many dermatologic guidelines support excision with narrow margins (often around 2 mm beyond the visible or scar boundary) to ensure complete removal while preserving healthy tissue. Histopathologic evaluation confirms clearance.

In this case, the original lesion measured approximately 5 x 6 millimeters. I planned margins of roughly 2 millimeters around the current scar, translating to about 5 millimeters around the original lesion perimeter. Using a template helps me create a symmetric, fusiform design aligned with relaxed skin tension lines, minimizing postoperative tension and optimizing cosmetic results. Templates reduce human error in margin symmetry, and a well-planned ellipse supports primary closure with minimal dog-ears.

Design and Anesthesia: A Pain-Free Field Block by Interrupting Cutaneous Nerve Signaling

My goal with anesthesia is simple: make the experience pain-free and efficient. I start by prepping with alcohol, then reinforce the concept of a field block—a circumferential anesthetic “fence” that interrupts nerve signals entering the skin around our excision site.

Technique overview:

  • I select an ideal entry point near the planned excision boundaries.
  • I advance the needle, then inject while withdrawing, turning within the dermis/subcutaneous plane to create a continuous ring of anesthesia.
  • I repeat on the opposite side and, as needed, add lateral entry points to ensure complete coverage, always aiming for minimal needle insertions that produce maximal numbing.

Why it works physiologically:

  • The field block targets the terminal branches of sensory nerves within the dermis and subcutaneous tissue. By bathing these fibers with 1 percent lidocaine with epinephrine, we block voltage-gated sodium channels, preventing depolarization and halting nociceptive transmission.
  • Epinephrine causes local vasoconstriction, reducing bleeding and prolonging lidocaine’s dwell time near nerves. This prolongs anesthesia, helps maintain a bloodless field, and enhances visualization during precise excision.
  • Injecting in subcutaneous tissue to “saturate” beneath the lesion creates a foundational blockade. When we perform intradermal injections after subcutaneous saturation, patients typically report little or no sensation because the deeper nociceptive input has already been interrupted.

Adjunct comfort measures:

  • I use a cold “free spray” over the injection point. Rapid cooling stimulates A-delta fibers, which preferentially transmit cold sensations, creating a gating effect that reduces pain perception as the needle enters. This immediate numbing means they rarely feel the injection.
  • I steer the needle by slight bending to guide the tip across the dermal plane, carefully visualizing the trajectory under the skin. Injecting while withdrawing forms a visible intradermal wheal line that confirms even distribution.

Patient response:

  • Using these methods, our patient reported no pain throughout the anesthetic process. This is exactly the outcome we strive for—an effective, pain-free field block before excision.

Precision Excision: Narrow Margins and Tissue Integrity

With anesthesia confirmed and a clean field, the next step is the excision. Narrow margins are not arbitrary; they balance oncologic safety with tissue preservation, especially in cosmetically sensitive areas.

Core principles:

  • Margin control: For moderate atypia, 2-mm margins are commonly used; they are sufficient for complete removal while minimizing unnecessary tissue loss.
  • Fusiform design: An ellipse aligned with skin tension lines enables linear closure under reduced tension, decreasing the risk of hypertrophic scarring and optimizing cosmesis.
  • Specimen integrity: Gentle handling and correct orientation markings help pathologists assess margins and architecture accurately, confirming clearance.

Physiology of healing:

  • Minimal tension reduces micro-ischemia at wound edges, aiding angiogenesis and fibroblast activity necessary for collagen deposition.
  • Vasoconstriction from epinephrine tempers intraoperative bleeding, stabilizing the clot and early extracellular matrix formation.

Integrative Chiropractic Care in Dermatologic Surgical Recovery

While excision of a skin lesion may seem isolated from musculoskeletal care, an integrative approach adds value for recovery, comfort, and function—especially in older adults or those with comorbidities.

How chiropractic care fits:

  • Posture and movement optimization: After excision, patients often guard movement due to fear of pulling sutures. Chiropractic and rehabilitative strategies help maintain normal biomechanics and prevent compensatory strain.
  • Neuromuscular re-education: Gentle manual therapy and targeted exercises support proprioception and movement confidence, reducing myofascial tension near or distant from the surgical site.
  • Pain modulation: Chiropractic interventions can engage descending inhibitory pathways, reducing central sensitization that sometimes amplifies minor post-procedural discomfort.
  • Circulatory support: Mobility, diaphragmatic breathing, and safe motion progressions improve local perfusion, supporting oxygen delivery and waste clearance in healing tissues.

In practice, I assess global movement patterns and provide tailored strategies to keep patients functional without stressing the incision. For example, we may adjust daily ergonomic habits, teach safe range-of-motion techniques, and implement light isometrics that maintain muscle tone without disturbing the wound.

Multidisciplinary Oversight: Internal Medicine Leadership with Dr. Maria Guadalupe Cardenas, MD

Our clinic operates within a multidisciplinary framework common in integrative and injury care settings. Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933) serves as our Medical Director and Collaborative Physician. With over 40 years of experience as an internist, Dr. Cardenas supervises medical protocols, ensures safety for patients with complex health histories, and aligns the plan with best practices.

Medical oversight matters because:

  • Risk stratification: Internal medicine evaluates cardiovascular status, diabetes control, anticoagulation, and immunomodulating conditions that might impact bleeding, infection risk, or wound healing.
  • Medication management: Guidance on peri-procedural adjustments for antiplatelets/anticoagulants or immunosuppressants balances safety and procedural efficacy.
  • Systems-based care: Internal medicine connects dermatologic procedures with broader health concerns—sleep, nutrition, metabolic status—each influencing recovery timeline and scar quality.

Collaborative roles:

  • Dr. Cardenas provides medical direction, reviews histories, and creates safe peri-procedural pathways.
  • I deliver the procedure, chiropractic integration, functional medicine insights, and rehabilitative planning.
  • Together, we coordinate personal injury processes, documentation, and patient education.

Functional Medicine Integration: Optimizing Healing Physiology

Functional medicine supports the body’s innate healing mechanisms through targeted lifestyle and nutritional strategies tailored to the patient’s biology.

Focus areas:

  • Inflammation modulation: Adequate omega-3 intake, polyphenols (curcumin, quercetin), and antioxidant-rich foods can support controlled inflammation necessary for healing while preventing prolonged inflammatory states that delay recovery.
  • Glycemic control: Stable blood sugar supports fibroblast function, collagen cross-linking, and reduces infection risk; critical in older adults and those with metabolic syndrome.
  • Micronutrient sufficiency: Vitamin C (collagen synthesis), zinc (DNA replication and immune function), and vitamin A (epithelial integrity) are essential. We personalize supplementation cautiously, consistent with medical oversight.

Reasoning:

  • The acute wound healing phases—hemostasis, inflammation, proliferation, remodeling—depend on energy availability, micronutrient cofactors, and balanced immune signaling. Diet and lifestyle calibrate these processes.
  • Sleep quality and stress modulation (e.g., paced breathing) influence HPA axis activity and cytokine profiles that can either facilitate or impair tissue repair.

Rehabilitation Strategy: Safe Motion, Scar Care, and Long-Term Outcomes

Rehabilitation begins as soon as the procedure ends.

Key steps:

  • Early wound protection: Educate on dressing care, signs of infection, and avoiding tension across the incision.
  • Progressive mobility: Introduce gentle, non-straining movements to prevent stiffness and maintain circulation.
  • Scar optimization: Once the wound has closed, consider silicone sheeting, gentle massage, and sun protection to improve scar quality.
  • Ergonomics: Adjust lifting strategies, workstation setup, and daily routines to prevent undue strain near the surgical site.

Physiologic reasoning:

  • Controlled motion stimulates mechanotransduction pathways in fibroblasts, guiding orderly collagen alignment and increasing tensile strength.
  • Silicone occlusion modulates hydration and reduces excessive collagen deposition, decreasing hypertrophic scar risk.

Personal Injury Care and Documentation

In injury care settings, precision documentation complements clinical excellence:

  • Clear procedural notes with lesion size, margin plan, anesthesia specifics, and patient responses.
  • Photo documentation for pre- and post-excision views (when appropriate).
  • Communication with referring providers and insurers regarding necessity, medical oversight, and outcomes.

Clinical Observations from My Practice

At Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic), I have observed:

  • Patients experience significantly better comfort with a well-executed field block using 1% lidocaine with epinephrine and adjunct cold spray.
  • Narrow, well-planned margins for moderate atypia yield high clearance rates while preserving cosmesis.
  • Integrative chiropractic and functional medicine improve confidence in movement, reduce compensatory pain patterns, and support faster return to normal activities.

Step-by-Step Narrative: From Planning to Excision

  • Pre-Procedure:
    • Confirm pathology: dysplastic nevus with moderate atypia.
    • Explain margins and expectations to the patient.
    • Prepare sterile field with antiseptic; use alcohol for initial prep and repeat.
  • Field Block:
    • Choose entry point; advance needle; inject while withdrawing to create a continuous anesthetic ring.
    • Turn within the tissue plane to cover both sides without fully removing the needle.
    • Add lateral points if needed; saturate subcutaneous tissue under the lesion.
    • Verify numbness; apply cold spray before further injections.
  • Intradermal Distribution:
    • Thread the needle across the dermis; visualize tip; inject on withdrawal to form a visible wheal line indicating spread.
    • Assess patient comfort continuously; recalibrate if sensation persists.
  • Excision:
    • Mark ellipse with template; align with skin tension lines.
    • Excise along just outside the marked borders to respect margins.
    • Handle tissue gently; orient specimen; achieve hemostasis; close in layers if indicated.
  • Post-Procedure:
    • Educate on dressing changes, signs of infection, and motion precautions.
    • Schedule follow-up for pathology results and suture removal.
    • Provide integrative guidance on movement, nutrition, sleep, and stress.

Why Each Technique Matters

  • Template-guided marking: Ensures symmetry, facilitates linear closure, and reduces dog-ears.
  • Field block with epinephrine: Prolongs anesthesia, reduces bleeding, and improves operative field visibility.
  • Injecting on withdrawal: Distributes anesthetic evenly and reduces intratissue pressure spikes that can be uncomfortable.
  • Cold spray: Activates sensory gating to reduce needle pain.
  • Narrow margins: Balance complete excision of atypia with tissue preservation, aligning with evidence and cosmetic considerations.
  • Integrative follow-through: Addresses systemic determinants of healing and functional recovery beyond the incision line.

Safety Considerations

  • Avoid epinephrine in end-arterial regions if risk factors exist; assess peripheral vascular disease.
  • Screen for lidocaine allergies and arrhythmic history.
  • Coordinate with internal medicine on anticoagulation decisions and infection-risk mitigation.

Our Team-Based Care in El Paso, Texas

At Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic), our care model weaves together:

  • Chiropractic care (Dr. Jimenez): Movement analysis, manual therapy, neuromuscular re-education, ergonomic optimization.
  • Medical oversight (Dr. Cardenas, MD): Risk stratification, medication management, systems-based medical direction.
  • Functional medicine: Nutrition, sleep, stress, and personalized supplementation.
  • Rehabilitation: Progressive mobility, scar care, and return-to-function planning.
  • Personal injury services: Comprehensive documentation, coordination with legal and insurance entities where applicable.

Conclusion: Modern, Evidence-Based, Integrative Care for Skin Surgery

Excision of a dysplastic nevus with moderate atypia is more than a precise cut; it is a coordinated effort grounded in physiology, patient comfort, and multidisciplinary safety. By pairing a pain-free field block with careful margin planning and whole-person support, we improve outcomes and the patient experience. Under the medical direction of Dr. Maria Guadalupe Cardenas, MD, and through our integrative chiropractic, functional medicine, and rehabilitative care, patients receive comprehensive, evidence-based support from diagnosis to recovery.

References

Percutaneous Tenotomy for Chronic Tendinopathy

Percutaneous Tenotomy for Chronic Tendinopathy: An Integrative Approach

Abstract

Hello, I’m Dr. Alex Jimenez. Welcome to our educational corner, where we delve into the latest advancements in musculoskeletal health. My extensive background, holding titles like DC, APRN, FNP-BC, and multiple functional medicine certifications, allows me to bridge various disciplines to offer comprehensive, evidence-based care.

In this post, we will explore percutaneous tenotomy, a groundbreaking, minimally invasive procedure for treating chronic tendinopathies such as tennis elbow, plantar fasciitis, and Achilles tendinopathy. We will detail the two leading techniques, Tenex (ultrasonic emulsification) and TenJet (hydroresection), explain their physiological mechanisms, and show how they remove diseased tendon tissue while preserving healthy structures. This discussion is grounded in the latest evidence-based research from leading experts in the field.

Furthermore, I will explain how our unique multidisciplinary practice in El Paso, Texas, integrates these advanced procedures. At Injury Medical Clinic, I work alongside our Medical Director, Dr. Maria Guadalupe Cardenas, MD. With over 40 years of experience as a Board-Certified Internist, Dr. Cardenas provides essential medical oversight, ensuring a safe, effective, collaborative environment. Together, we combine functional medicine, rehabilitative science, and integrative chiropractic care to create a holistic treatment journey that resolves pain, restores optimal function, and prevents recurrence.

Join me as we explore the science behind percutaneous tenotomy and discover how this innovative treatment, combined with a patient-centered, integrative framework, is transforming outcomes for those with chronic tendon pain.

Percutaneous Tenotomy for Chronic Tendinopathy

Understanding the Challenge of Chronic Tendinopathy

As a clinician with decades of experience, I’ve seen countless patients struggle with tendinopathy, a condition often mislabeled as “tendinitis”. The key difference is that tendinitis implies active inflammation, whereas tendinopathy describes a degenerative state of the tendon. In tendinopathy, the tendon’s collagen fibers become disorganized, weakened, and filled with abnormal, painful tissue and sometimes microcalcifications. This is not an inflammatory problem but a structural failure of the tissue.

Conditions like lateral epicondylosis (tennis elbow), patellar tendinopathy (jumper’s knee), Achilles tendinopathy, and plantar fasciitis can be notoriously difficult to treat. Traditional conservative measures like rest, ice, and physical therapy are often effective for acute injuries but may fall short once the condition becomes chronic. In these cases, the degenerative tissue itself prevents healing, creating a cycle of pain and dysfunction. This is where modern, targeted interventions become essential.

Introducing Percutaneous Tenotomy: A Minimally Invasive Revolution

One of the most exciting advancements in musculoskeletal medicine is percutaneous tenotomy, an FDA-approved, ultrasound-guided procedure designed to debride, or remove, diseased tendon tissue. The term “percutaneous” simply means “through the skin,” highlighting its minimally invasive nature. This procedure represents a significant leap forward, offering a more definitive solution than conservative care but far less invasive than traditional open surgery.

The beauty of percutaneous tenotomy lies in its precision. Using real-time ultrasound imaging, we can guide a specialized instrument directly to the damaged tissue. This lets us selectively remove the degenerative, pain-generating portions of the tendon while leaving the surrounding healthy tissue intact. This precision is critical for promoting a robust healing response.

Two primary technologies dominate this field: Tenex and TenJet. Both are now accessible to appropriately trained primary care and specialty providers, allowing these procedures to be performed safely and effectively in the office.

The Tenex Health TX System: Ultrasonic Debridement

At our clinic, we utilize the Tenex Health TX system. This technology is a marvel of bioengineering, leveraging the principles of phacoemulsification—a technique famously used in modern cataract surgery.

  • How It Works: The Tenex system uses a handheld device connected to a console. The key component is an 18-gauge, double-lumen needle. When activated by a foot pedal, the needle tip vibrates at an ultrasonic frequency (around 20,000 Hz). This ultrasonic energy precisely emulsifies, or liquefies, the targeted degenerative tendon tissue.
  • The Double-Lumen Design: The Tenex probe’s ingenuity lies in its dual functionality. While the vibrating tip breaks down the pathologic tissue, a second, parallel lumen within the same needle simultaneously irrigates the area with saline and suctions the emulsified debris away. This “cut and remove” action is performed in a single, efficient step.
  • The Procedure: The procedure is performed under sterile conditions. After administering a local anesthetic, I use an ultrasound probe (covered in a sterile sheath) to visualize the damaged tendon. I insert the Tenex needle through the skin and guide it in real time to the area of tendinopathy. I then activate the device and methodically move the needle tip back and forth through the diseased tissue. The entire debridement process, or “cutting time,” is remarkably short, typically lasting between 30 and 90 seconds. The patient hears a humming sound but feels no pain due to the local anesthetic.

The TenJet System: A High-Velocity Saline Jet

The primary alternative to Tenex is the TenJet system. While the goal is the same—to remove diseased tendon tissue—the mechanism is different.

  • How It Works: TenJet uses a technology called hydroresection. Instead of ultrasonic energy, it employs a highly pressurized, high-velocity jet of sterile saline that shoots out from the tip of its specialized needle. This powerful fluid stream acts like a water knife, cutting and excising soft, degenerative tissue.
  • Simultaneous Aspiration: Like Tenex, the TenJet wand has a built-in suction feature that immediately removes resected tissue and excess saline, keeping the operative field clear and preventing pressure buildup.
  • Comparison: Both Tenex and TenJet are excellent tools. The choice between them often comes down to physician preference, training, and the specific characteristics of the tendon being treated. Both offer a significant advantage over traditional surgery by minimizing tissue trauma and accelerating recovery.

The Power of Integrative Care: Our Multidisciplinary Model

Performing an advanced procedure like percutaneous tenotomy is only one piece of the puzzle. True, lasting healing requires a comprehensive, integrative approach that addresses the patient as a whole. This is the core philosophy of our practice at Injury Medical Clinic.

My unique qualifications as a Doctor of Chiropractic (DC), an Advanced Practice Registered Nurse (APRN), a Family Nurse Practitioner (FNP-BC), and a certified Functional Medicine practitioner allow me to view health through multiple lenses. This is further strengthened by our collaborative structure with Dr. Maria Guadalupe Cardenas, MD, our esteemed Medical Director.

Dr. Cardenas is a Board-Certified Internist with an NPI of #1164426749 and Texas Medical License #J2933. With over four decades of clinical experience, she provides invaluable medical oversight for our practice. This multidisciplinary setup, where an MD and a DC work in tandem, ensures that our patients receive care that is both holistic and medically sound. We integrate the following services to create a powerful, synergistic treatment plan:

  1. Medical Oversight and Diagnosis (Dr. Cardenas): Dr. Cardenas’s internal medicine expertise is crucial for screening patients, managing comorbidities, and ensuring advanced procedures are medically appropriate. Her role guarantees the highest standards of patient safety.
  2. Functional Medicine Investigation (Dr. Jimenez): Why did the tendon fail in the first place? Functional medicine helps us answer this question. We investigate underlying factors like nutritional deficiencies (e.g., Vitamin C, zinc), systemic inflammation, metabolic dysfunction (like insulin resistance), and hormonal imbalances that can impair tissue repair. Addressing these root causes is essential for preventing recurrence.
  3. Integrative Chiropractic Care (Dr. Jimenez): A tendinopathy in the elbow or foot doesn’t exist in a vacuum. It is often linked to biomechanical dysfunction elsewhere in the body. As a chiropractor, I assess and correct kinetic chain imbalances. For example:
    • Tennis Elbow: This is often related to poor mechanics in the shoulder, scapula, and even the thoracic spine. Chiropractic adjustments and soft tissue mobilization can restore proper joint mobility and muscle firing patterns, reducing strain on the elbow.
    • Plantar Fasciitis: This is frequently linked to ankle immobility, tight calf muscles, or even pelvic misalignments that alter gait mechanics. Chiropractic care can address these upstream biomechanical faults. By correcting the body’s overall structure and movement patterns, we offload the healing tendon and create an environment where it is no longer subjected to repetitive microtrauma.
  4. Targeted Rehabilitation: Following a procedure like Tenex, the body needs the right signals to rebuild the tendon with strong, organized collagen. Our rehabilitation programs are designed to do just that. We progress patients from gentle range-of-motion exercises to eccentric loading exercises, which are scientifically proven to stimulate collagen synthesis and tendon remodeling (Alfredson et al., 1998). This phase is critical for translating the procedure’s structural fix into functional strength and resilience.

A Patient’s Journey at Our Clinic: From Pain to Performance

Let’s walk through a typical patient journey for someone with chronic tennis elbow:

  1. Initial Consultation & Diagnosis: The journey begins with a comprehensive evaluation. This includes a detailed history, physical exam, and diagnostic ultrasound to confirm tendinopathy and pinpoint the exact location of the diseased tissue.
  2. Collaborative Review: Dr. Cardenas and I review the case to confirm the diagnosis and ensure the patient is a good candidate for percutaneous tenotomy. We rule out any medical contraindications.
  3. Root Cause Analysis: We conduct a functional medicine workup, which may include blood tests to check inflammatory markers, nutrient levels, and metabolic health indicators.
  4. The Procedure: We perform the Tenex procedure in our office. The patient walks in and walks out, typically needing only a small adhesive bandage over the entry site.
  5. Post-Procedure Care: The initial phase focuses on rest and pain management, then quickly transitions to the active phase.
  6. Integrative Chiropractic & Rehabilitation: This is where the magic happens. The patient begins a structured program that includes:
    • Chiropractic adjustments to the spine, shoulder, and wrist to optimize biomechanics.
    • Soft tissue therapies like Active Release Technique (ART) or Graston to address scar tissue in surrounding muscles.
    • A progressive rehabilitation plan starting with gentle isometrics and progressing to the crucial eccentric strengthening exercises.
  7. Nutritional & Lifestyle Support: Based on the functional medicine findings, we provide targeted nutritional advice and supplements to support collagen production and reduce systemic inflammation.

By combining the precision of percutaneous tenotomy with the holistic framework of integrative chiropractic and functional medicine, we don’t just eliminate pain; we rebuild a more resilient, functional person. This is the future of musculoskeletal care—a future we are proud to offer our patients in El Paso today.

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

Seng, K., & Lee, K. (2020). Percutaneous ultrasonic tenotomy for tendinopathies. Journal of Functional Morphology and Kinesiology, 5(3), 54. https://doi.org/10.3390/jfmk5030054

Unlocking Frozen Shoulder: Hydrodistension and Integrative Care

Unlocking Frozen Shoulder: Hydrodistension and Integrative Care

Abstract

This educational post explores the advanced technique of hydrodistension (or hydroplasty) for treating adhesive capsulitis, commonly known as frozen shoulder. As a practitioner rooted in integrative and functional medicine, I continually seek the most effective, evidence-based solutions for my patients. Here, I’ll guide you through a detailed look at the hydrodistension procedure, drawing on insights from leading sports medicine experts. We will examine the anatomical basis, the procedural steps, and the physiological mechanisms that make this technique a powerful tool for restoring mobility and relieving pain. I will also explain how this intervention fits within our multidisciplinary practice at Injury Medical Clinic, where my work as a Doctor of Chiropractic and Family Nurse Practitioner is complemented by the medical oversight of our Medical Director, Dr. Maria Guadalupe Cardenas, MD. Our goal is to provide a comprehensive treatment journey that combines advanced medical procedures with chiropractic care, rehabilitation, and functional medicine to achieve lasting patient outcomes.

Unlocking Frozen Shoulder: Hydrodistension and Integrative Care

At Injury Medical Clinic, our philosophy is built on collaboration and integration. My name is Dr. Alex Jimenez, and I bring a multifaceted perspective to patient care, holding qualifications as a Doctor of Chiropractic (DC), an Advanced Practice Registered Nurse (APRN), a Board-Certified Family Nurse Practitioner (FNP-BC), and certifications in Functional Medicine (CFMP, IFMCP), among others. This diverse background allows me to view health and injury through a uniquely broad lens.

A cornerstone of our practice is our multidisciplinary team approach. I work closely with Dr. Maria Guadalupe Cardenas, MD, our esteemed Medical Director and an internist with over 40 years of experience. Her role is vital, providing essential medical direction and oversight that ensures our patients receive care that is not only effective but also safe and comprehensive. This partnership between a chiropractor/nurse practitioner and an internist lets us blend the best of the medical and chiropractic worlds, offering services ranging from personal injury rehabilitation and functional medicine to advanced interventional procedures. Today, I want to share insights into one such procedure that exemplifies this integrated model: hydrodistension for frozen shoulder.

Understanding Adhesive Capsulitis (Frozen Shoulder)

Before diving into the procedure, let’s understand the condition it treats. Adhesive capsulitis, or frozen shoulder, is a debilitating condition characterized by severe pain and a progressive loss of shoulder motion. The underlying pathology involves the glenohumeral joint capsule—the strong, fibrous sac that envelops the shoulder joint. In a healthy shoulder, this capsule is flexible and allows for a wide range of motion. In adhesive capsulitis, the capsule becomes inflamed, thickens, and contracts, effectively “shrinking” around the joint. This process leads to the formation of adhesions, which are bands of scar tissue that bind the capsule to the humeral head (the ball of the shoulder joint), severely restricting movement.

Patients typically experience three phases:

  1. Freezing Stage: A gradual onset of deep, aching pain, often worse at night. As pain intensifies, range of motion begins to decrease. This stage can last from weeks to months.
  2. Frozen Stage: Pain may start to subside, but stiffness becomes the primary complaint. The shoulder’s range of motion is significantly limited, making daily activities like dressing or reaching overhead extremely difficult. This phase can last for several months to a year.
  3. Thawing Stage: Shoulder mobility slowly improves as the condition resolves. This can be a very long process, sometimes taking one to two years to regain full or near-full function.

The goal of any effective treatment is to shorten these phases, alleviate pain, and restore function as quickly and completely as possible.

Hydrodistension: An Advanced Technique for Restoring Mobility

Hydrodistension, also known as hydroplasty, is a minimally invasive procedure designed specifically for adhesive capsulitis. The fundamental principle is to physically stretch and break the adhesions within the joint capsule by injecting a large volume of fluid. This creates more space within the joint, allowing for an immediate improvement in range of motion.

I recently had the opportunity to review the work of a primary care sports medicine physician. Their meticulous, ultrasound-guided approach is an excellent model for understanding how to perform this procedure safely and effectively. Let’s break down his process, which serves as a benchmark in modern, evidence-based practice.

To visualize the target area, we can look at an ultrasound image of the posterior (back) shoulder.

In the image, you can clearly see the layers of tissue:

  • The deltoid muscle on the surface.
  • The infraspinatus muscle (one of the rotator cuff muscles) just below it.
  • The posterior capsule, the key target, which appears as a bright, fibrous line.
  • The humeral head, the “ball” of the shoulder joint.
  • The glenoid, the “socket” of the shoulder joint.

The goal is to accurately place a needle into the glenohumeral joint space—the small area between the capsule and the humeral head—to deliver the fluid.

The Three-Step Hydrodistension Procedure

The doctor’s method is a well-orchestrated, three-step process designed for maximum patient comfort and procedural success. It involves precise, ultrasound-guided injections to ensure accuracy and safety at every stage.

Step 1: Suprascapular Nerve Block

The first and arguably most compassionate step is to manage the patient’s pain during and after the procedure. This is achieved with a suprascapular nerve block.

  • The Target: The suprascapular nerve, which provides approximately 70% of the sensory innervation to the shoulder joint. By numbing this nerve, we can significantly reduce procedure-related pain and provide intermediate relief for hours afterward. The nerve is targeted at the spinoglenoid notch, a small anatomical landmark located just medial to the glenohumeral joint.
  • The Technique: Using an ultrasound, Dr. visualizes the spinoglenoid notch and guides a needle to the area. He then injects a local anesthetic, typically a combination of lidocaine (fast-acting) and ropivacaine (long-acting). This dual-anesthetic approach provides both immediate and extended pain control.
  • Why It’s Done: This nerve block is crucial for patient tolerance. The hydrodistension itself can be uncomfortable as the capsule stretches. By preemptively blocking the primary sensory nerve, the patient remains comfortable, and the physician can perform the procedure without causing undue distress. This aligns with our patient-centered approach at Injury Medical Clinic, where comfort and safety are paramount.

Step 2: Numbing the Joint Capsule

Next, anesthetize the injection site and the joint capsule.

  • The Target: The posterior glenohumeral joint space.
  • The Technique: A smaller, 25-gauge needle is guided under ultrasound into the joint space. A small amount of buffered lidocaine is injected. The “buffering” is done by adding sodium bicarbonate to the lidocaine, which raises its pH to be closer to that of the body’s tissues. This simple modification reduces the stinging sensation of the injection, further enhancing patient comfort.
  • Why It’s Done: This local numbing ensures the larger needle in the final step is painless. It also confirms that the needle tip is correctly positioned within the intra-articular space before the main injection begins.

Step 3: The Hydrodistension Injection

This is the main event, where the therapeutic distension occurs.

  • The Injectate: A carefully formulated mixture totaling 51 mL. It consists of:
    • 10 mL of 1% lidocaine (fast-acting anesthetic)
    • 10 mL of 0.5% ropivacaine (long-acting anesthetic)
    • 30 mL of sterile saline (the primary volume for distension)
    • 1 mL of Kenalog (40 mg) (a corticosteroid to reduce inflammation)
  • The Technique: A larger, 18-gauge needle is guided into the same intra-articular position. This is often a two-person job; The doctor guides the needle while his medical assistant steadily pushes the large volume of fluid from the syringe. As the fluid is injected, the ultrasound screen provides real-time feedback. You can literally watch the posterior capsule lift and stretch away from the humeral head as it fills with fluid.
  • The “Break”: The goal is to continue injecting until the capsule is stretched to its limit and the adhesions break. On ultrasound, this appears as a sudden expansion followed by slight deflation as the fluid finds new space within the joint, or may even extravasate (leak) through a small tear in the now-stretched capsule. This visible “break” is the hallmark of a successful procedure. The patient often feels an immediate sense of release and an increase in their range of motion.

Using a corticosteroid like Kenalog is critical. It strongly suppresses the inflammatory process that drives capsule thickening and contraction. This not only relieves pain but also helps prevent rapid re-formation of adhesions, creating a therapeutic window for the next phase of care: rehabilitation.

The Role of Integrative Chiropractic Care Post-Procedure

The hydrodistension procedure is a powerful “reset” for the shoulder, but it is not a standalone cure. The real, long-term success comes from what happens next. The days and weeks following the procedure are a critical window of opportunity to restore normal joint mechanics and muscle function. This is where our integrative model at Injury Medical Clinic truly shines.

As a Doctor of Chiropractic, I immediately focus on capitalizing on the newly gained mobility. My clinical observations, detailed on platforms like my professional website and LinkedIn, consistently show that a structured, multi-faceted rehabilitation program is essential.

Our post-hydrodistension protocol includes:

  • Gentle Chiropractic Mobilization: After the procedure, I perform specific, gentle mobilization techniques on the glenohumeral joint and surrounding joints, including the scapulothoracic (shoulder blade on the rib cage), acromioclavicular, and sternoclavicular joints. The goal isn’t aggressive manipulation, but to encourage smooth, physiological movement and prevent the joint from stiffening again. We must respect the body’s healing process while re-educating the joint on how to move correctly.
  • Targeted Soft Tissue Therapy: Adhesions don’t just form in the capsule; the surrounding muscles often become tight, guarded, and develop trigger points. We use techniques like myofascial release, instrument-assisted soft tissue mobilization (IASTM), and trigger point therapy to release tension in the rotator cuff, deltoid, and periscapular muscles. This restores muscle pliability and reduces compensatory strain patterns.
  • Prescriptive Rehabilitation Exercises: This is the most crucial component. We guide patients through a phased exercise program that begins with gentle pendulum exercises and passive range-of-motion on the day of the procedure. As tolerance improves, we progress to:
    • Active-assisted range of motion (using the other arm or a pulley to help move the affected shoulder).
    • Active range of motion (moving the shoulder under its own power).
    • Strengthening exercises, starting with isometrics and progressing to resistance bands to rebuild the strength and endurance of the rotator cuff and scapular stabilizers.

Under the medical direction of Dr. Cardenas, we ensure this rehabilitation process is medically appropriate for the patient, monitoring for complications and managing post-procedural inflammation. This collaborative oversight allows us to safely push the boundaries of recovery.

Conclusion: An Integrated Path to Recovery

Treating complex conditions like adhesive capsulitis requires more than a single intervention. It demands a holistic, integrated approach that addresses the problem from multiple angles. The hydrodistension procedure, as expertly demonstrated by physicians, provides a powerful mechanical and pharmacological intervention to break the cycle of stiffness and pain. It creates a pivotal opportunity for recovery.

However, the comprehensive, team-based care that follows truly solidifies the gains and leads to lasting results. At Injury Medical Clinic, our unique structure—combining my expertise in chiropractic and functional medicine with the invaluable medical oversight of Dr. Maria Guadalupe Cardenas—allows us to provide that. We bridge the gap between advanced medical procedures and hands-on rehabilitative care, guiding our patients on a seamless journey from profound limitation to renewed function and a life free from pain.

References

  • Boutin, R. D., Darrow, M. A., & Schenker, M. L. (2014). Ultrasound-guided shoulder interventions. Physical Medicine and Rehabilitation Clinics of North America, 25(2), 247–266. https://doi.org/10.1016/j.pmr.2014.01.002
  • Ryan, V., Brown, H., Minns Lowe, C. J., & Lewis, J. S. (2016). The pathophysiology associated with primary (idiopathic) frozen shoulder: A systematic review. BMC Musculoskeletal Disorders, 17(1), 340. https://doi.org/10.1186/s12891-016-1190-9
  • Tveitå, E. K., & Røe, C. (2009). Ultrasound-guided hydrodistension and physiotherapy for patients with frozen shoulder. Physiotherapy Research International, 14(1), 39–51. https://doi.org/10.1002/pri.422

Radial Tunnel Hydrodissection for Nerve Entrapment

Radial Tunnel Hydrodissection for Nerve Entrapment

Abstract

This educational post explores ultrasound-guided hydrodissection, an advanced interventional technique used to address radial nerve entrapment at the entrance of the radial tunnel — a condition frequently misdiagnosed as lateral epicondylitis. Drawing from clinical demonstrations by leading practitioners in musculoskeletal ultrasound, I present the physiological underpinnings of radial tunnel syndrome, the rationale for perineural hydrodissection, and how integrative chiropractic care fits within a multidisciplinary treatment framework. At Injury Medical Clinic PA (also known as Mission Plaza Injury Medical Clinic) in El Paso, Texas, my colleague Dr. Maria Guadalupe Cardenas, MD, Board Certified in Internal Medicine (NPI #1164426749, Texas MD License #J2933), serves as Medical Director and Collaborative Physician, providing over 40 years of internal medicine expertise alongside my chiropractic and functional medicine practice. Together, we outline how cutting-edge procedural techniques, medical oversight, and conservative rehabilitative care converge to deliver superior patient outcomes for complex nerve entrapment conditions.

Radial Tunnel Hydrodissection for Nerve Entrapment

Understanding Radial Tunnel Syndrome: Why Diagnosis Is So Often Missed

One of the most clinically underrecognized conditions in musculoskeletal medicine is radial tunnel syndrome (RTS) — a compressive neuropathy of the deep branch of the radial nerve as it enters the radial tunnel, a fibromuscular passage located just distal to the lateral epicondyle. As a clinician who has evaluated countless patients presenting with lateral elbow pain, I can tell you firsthand that this condition is routinely confused with lateral epicondylitis, commonly known as “tennis elbow.”

The key distinguishing features are critical:

  • Lateral epicondylitis presents with point tenderness directly over the lateral epicondyle
  • Radial tunnel syndrome typically produces pain that is 3–4 cm distal to the lateral epicondyle, over the radial tunnel itself
  • Patients with RTS often describe a dull, burning, aching quality to the pain, frequently worsened by pronation and supination of the forearm
  • The pain may radiate into the dorsum of the forearm, consistent with the sensory distribution of the posterior interosseous nerve (PIN)

This distinction matters profoundly because the treatment approach is entirely different. Injecting a corticosteroid at the lateral epicondyle — the standard intervention for tennis elbow — will do nothing to relieve a nerve entrapment occurring further distally. When six months or more of conservative treatment have failed to produce relief, it becomes necessary to think deeper — both anatomically and clinically.

The Anatomy Behind Radial Nerve Entrapment at the Arcade of Frohse

To fully appreciate why hydrodissection works, one must first understand the precise anatomy involved. The radial nerve, after crossing the lateral aspect of the elbow, divides into two branches:

  • The superficial branch (purely sensory), which continues distally along the radial side of the forearm
  • The deep branch (motor and sensory), which dives into the radial tunnel and passes beneath the arcade of Frohse — a fibrous arch at the proximal edge of the supinator muscle

The arcade of Frohse is the most common site of radial nerve compression. This fibrous band can tighten with repetitive forearm rotation, direct compression, or inflammatory changes in surrounding soft tissue. As the nerve becomes entrapped:

  • Perineural fibrosis develops, restricting the nerve’s normal gliding motion
  • Ischemic changes in the nerve’s intrinsic blood supply reduce conduction velocity
  • Mechanosensitivity increases, producing pain with even minor movements involving pronation or supination
  • Chronic inflammation leads to adhesion formation between the nerve sheath and surrounding fascial planes

This physiological cascade explains why oral anti-inflammatories and physical therapy alone are often insufficient after months of symptomatic progression. The nerve is, in effect, tethered — and it needs to be released.

What Is Ultrasound-Guided Hydrodissection and Why Is It Used

Hydrodissection is a minimally invasive procedure in which fluid is precisely injected around a peripheral nerve to mechanically separate it from surrounding adhesions, scar tissue, or compressive structures. The term itself describes the mechanism: using the hydraulic force of injected fluid to dissect soft tissue planes without the trauma of surgical incision.

In the context of radial nerve entrapment, the technique involves:

  • Guiding a 25-gauge needle under real-time ultrasound visualization (using a high-frequency linear probe)
  • Approaching the deep branch of the radial nerve in a short-axis, in-plane view — meaning the needle is visible on the ultrasound screen along its entire length
  • Injecting a solution — typically lidocaine, in some cases combined with a corticosteroid — perineural (around, not inside) the nerve
  • Creating what is clinically referred to as a “halo effect”: the fluid surrounds the nerve circumferentially, lifting adhesions and restoring the nerve’s natural gliding motion within its tissue bed

The critical safety principle is perineural, not intraneural injection. Injecting fluid directly into the nerve (intraneural) risks serious nerve damage, including axonal disruption and permanent deficit. The goal is always to deposit fluid adjacent to the epineurium — the outermost connective tissue sheath — thereby creating separation between the nerve and surrounding structures while leaving the nerve itself fully intact.

The use of lidocaine serves a dual purpose:

  1. Diagnostic confirmation: If a prior diagnostic injection of lidocaine at the radial nerve produces measurable pain relief, this validates the nerve as the pain generator — as was precisely the case with the patient discussed in this post
  2. Therapeutic hydrodissection: Lidocaine’s volume, when injected incrementally and skillfully around the nerve, provides the hydraulic separation needed to restore normal nerve mobility

Adding a corticosteroid to the hydrodissection solution targets persistent perineural inflammation, reducing the inflammatory milieu that contributes to ongoing neural sensitization and adhesion reformation.

Why This Is Considered an Advanced Technique

I want to be unequivocally clear: hydrodissection is not a technique to be read about and immediately attempted. The skill required involves:

  • Mastery of sonoanatomy: Identifying the deep branch of the radial nerve in real time as it passes through the brachioradialis, alongside the neurovascular bundle, and just proximal to the arcade of Frohse, requires dedicated ultrasound training
  • Precise needle control: The movements involved are described as “very small and subtle.” A millimeter of deviation at this depth can mean the difference between a perineural and an intraneural injection
  • Recognition of real-time landmarks: The practitioner must continuously identify the brachioradialis, supinator muscle, radius, and the nerve itself as the needle advances, adjusting trajectory in real time
  • Controlled fluid pulsing: Rather than a single bolus injection, the fluid is delivered in small, deliberate pulses to progressively expand the perineural space, generating the halo effect while monitoring nerve displacement on screen

A muscle twitch may be observed as the needle approaches the nerve — a sign of proximity that requires the practitioner to recognize and respond to immediately. This level of procedural refinement demands supervised, hands-on training under experienced guidance.

Integrative Chiropractic Care and Its Role in Radial Nerve Recovery

While hydrodissection directly addresses the entrapment at the radial tunnel, integrative chiropractic care plays an essential role in the broader clinical picture. At my practice, I approach radial nerve entrapment not as an isolated peripheral problem but as part of a regional biomechanical and neurological pattern that must be addressed comprehensively.

Chiropractic contributions to radial nerve recovery include:

  • Cervical spine assessment: The radial nerve originates from the C5–C8 nerve roots. Cervical segmental dysfunction — particularly at C6 and C7 — can produce a double crush phenomenon, in which proximal neural compromise reduces the nerve’s capacity to tolerate distal entrapment. Chiropractic spinal manipulation directed at dysfunctional cervical segments helps restore normal neural conduction and reduces the overall compressive burden on the nerve
  • Elbow and forearm joint mobilization: Restoring full radioulnar joint mechanics and reducing capsular tightness decreases mechanical stress on the radial tunnel
  • Soft tissue therapy: Targeted myofascial release to the brachioradialis, supinator, and extensor mass helps reduce the external compressive forces perpetuating nerve entrapment
  • Rehabilitation exercise prescription: Progressive neuromuscular re-education exercises — designed to restore painless pronation and supination — are essential to sustaining the benefits achieved through hydrodissection
  • Postural and ergonomic correction: Many cases of radial tunnel syndrome are driven or perpetuated by occupational postures. Chiropractic rehabilitation includes functional movement analysis and individualized ergonomic modification

Multidisciplinary Care at Injury Medical Clinic PA: Dr. Cardenas and Dr. Jimenez

The clinical model I operate within at Injury Medical Clinic PA in El Paso, Texas exemplifies the best of multidisciplinary integrative care. Dr. Maria Guadalupe Cardenas, MD, Board Certified in Internal Medicine (NPI #1164426749, Texas MD License #J2933), brings over 40 years of internal medicine expertise to our collaborative practice. As Medical Director and Collaborative Physician, Dr. Cardenas provides:

  • Comprehensive medical evaluation and co-management for patients with complex comorbidities
  • Pharmacological oversight, including medication review for patients undergoing procedural interventions
  • Internal medicine consultation for systemic contributors to musculoskeletal and neurological conditions — including metabolic, inflammatory, and autoimmune factors that can predispose patients to peripheral neuropathies
  • Medical direction ensuring all clinical protocols meet the highest standards of patient safety and evidence-based practice

This collaboration between chiropractic functional medicine (my domain) and internal medicine (Dr. Cardenas’s domain) means that patients presenting with conditions like radial tunnel syndrome receive:

  • A thorough systemic workup when indicated
  • Coordinated procedural and rehabilitative planning
  • Functional medicine assessments examining nutritional, metabolic, and inflammatory contributors to nerve health
  • Personal injury care and documentation for patients involved in accident-related musculoskeletal injuries

Evidence-Based Support for Hydrodissection in Peripheral Nerve Entrapment

The growing body of literature supporting ultrasound-guided hydrodissection is compelling. Research consistently demonstrates that perineural injection under ultrasound guidance is both safer and more effective than landmark-based injection for peripheral nerve entrapment syndromes (Wu et al., 2017). Studies examining hydrodissection for carpal tunnel syndrome, cubital tunnel syndrome, and posterior interosseous nerve entrapment have reported significant improvements in pain scores and functional outcomes (Mulvaney, 2011; Cass, 2016).

The 5% dextrose in water (D5W) solution — a popular hydrodissection medium in non-corticosteroid protocols — has been shown to reduce mechanosensitivity by competitively blocking TRPV1 nociceptors at the neural membrane, providing an additional physiological mechanism of pain relief beyond simple mechanical separation (Lyftogt, 2007). When lidocaine is used, as described in this case, the immediate anesthetic effect confirms nerve involvement while the hydraulic dissection restores gliding mechanics.

References

Tendon Healing: High-Volume Injections for Tendinopathy

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.

Tendon Healing: High-Volume Injections for Tendinopathy

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