Abstract
As a clinician dedicated to integrating cutting-edge, evidence-based therapies, I continually explore innovative methods to address complex musculoskeletal conditions. In this educational post, we will journey into the advanced technique of High-Volume Injection (HVI), also known as brisement, a powerful tool for managing chronic tendinopathies. Drawing on the latest research and clinical expertise, I will explain the physiological principles behind this procedure, its application for conditions like Achilles and patellar tendinopathy, and how it represents a significant leap forward from traditional treatments. We'll explore the "why" and "how" of HVI, detailing hydrostatic tissue decompression and the disruption of pain-generating neovessels and neonerves. This post aims to provide a clear, easy-to-understand guide for patients and practitioners alike, illuminating how this modern intervention integrates into a comprehensive care plan, such as the one we offer at our clinic, to promote healing and restore function.
A Collaborative Approach to Advanced Musculoskeletal Care
At Injury Medical Clinic PA, our philosophy is rooted in a multidisciplinary and integrative model of care. I am Dr. Alex Jimenez (DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST), and I have the distinct privilege of working alongside our Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is a board-certified internist with over 40 years of invaluable experience (NPI #1164426749, Texas MD License #J2933).
This unique collaboration allows us to blend the best of several disciplines. As a Doctor of Chiropractic with advanced certifications in functional and integrative medicine, my focus is on biomechanics, nervous system function, and holistic wellness. Dr. Cardenas provides essential medical oversight, diagnostic expertise, and a deep understanding of internal medicine, ensuring our patients receive safe, comprehensive, and medically sound care. Together, our team integrates:
Chiropractic Care: Focused on spinal and extremity joint alignment, nervous system integrity, and biomechanical optimization.
Medical Oversight: Guided by Dr. Cardenas to ensure all treatments are appropriate and to manage any underlying medical conditions.
Functional Medicine: Investigating the root causes of dysfunction, from metabolic imbalances to nutritional deficiencies.
Advanced Rehabilitation & Personal Injury Care: Utilizing state-of-the-art techniques to restore function and mobility after injury.
This integrated model is particularly effective when addressing complex conditions like chronic tendinopathy, where a single-modality approach often falls short. Procedures like High-Volume Injection (brisement) are a strong example of an advanced therapy we can offer within this collaborative framework, ensuring it is applied with biomechanical precision and medical prudence.
Understanding Tendinopathy: Beyond Simple Inflammation
For decades, we used the term "tendonitis" to describe tendon pain, assuming it was primarily inflammatory. However, modern research has reshaped our understanding. We now know that in chronic cases, the condition is better described as tendinopathy. This term reflects a degenerative process within the tendon, characterized by:
Collagen Disorganization: The strong, parallel fibers of the tendon become weak and disorganized.
Cellular Changes: Immature tendon cells increase, and the extracellular matrix breaks down.
Neovascularization and Neoinnervation: This is a crucial finding. New, dysfunctional blood vessels (neovessels) and nerve endings (neonerves) grow into the tendon, often in the space just adjacent to it. These new structures are not helpful for healing; instead, they are a primary source of the persistent pain associated with chronic tendinopathy (Alfredson et al., 1999).
Traditional treatments often focused on reducing inflammation, but in degenerative tendinopathy, this approach may not address the core problem. This is where advanced techniques like High-Volume Injection (HVI) come into play.
What Is High-Volume Injection (Brisement)?
High-Volume Injection (HVI), or brisement (a French term meaning "disruption" or "breaking"), is a specialized, ultrasound-guided procedure designed to treat chronic tendinopathies. It's important to distinguish it from other needle-based procedures:
Fenestration or Tenotomy: In these procedures, a needle is repeatedly passed directly into the degenerated tendon tissue to stimulate a localized healing response.
Brisement (HVI): The focus here is not on the tendon itself, but on the space adjacent to the tendon—specifically, the interface between the tendon and the surrounding structures, like a fat pad or the tenosynovium (the sheath surrounding some tendons).
The primary goal of brisement is to perform a hydrostatic dissection. We inject a large volume of fluid (typically a mixture of saline and a local anesthetic like lidocaine) into this very specific space. This accomplishes several critical objectives.
The Mechanism of Action: How Brisement Works
The power of HVI lies in its multifaceted mechanism of action. By injecting a large fluid volume under ultrasound guidance, we achieve more than temporary pain relief.
Mechanical Disruption of Neovessels and Neonerves: The forceful injection of fluid physically breaks apart and strips away the fragile, pain-generating neovessels and neonerves that have infiltrated the space anterior to the tendon. This is the "brisement," or disruption effect. Research by leading experts like Håkan Alfredson has shown that these new vessels and nerves are intimately linked to the pain of tendinopathy. By eliminating them, we remove a major source of nociceptive (pain) signals (Chan et al., 2008).
Hydrostatic Decompression: In chronic tendinopathy, adhesions can form between the tendon and adjacent tissues, such as the paratenon or, in the case of the Achilles, Kager's fat pad. These adhesions can tether the tendon, restricting its normal gliding motion and causing mechanical irritation. The high-volume injectate acts like a hydraulic jack, creating space and freeing the tendon from these restrictive adhesions. This is what we call hydrostatic decompression. It restores the tendon's ability to move smoothly.
Chemical and Volume Effect:
Local Anesthetic: The lidocaine provides immediate pain relief and can also have a toxic effect on the fragile neovessels, further aiding their breakdown.
Volume Dilution: The large volume of saline can dilute and wash out inflammatory chemicals and pain-sensitizing substances that have accumulated in the area.
From my clinical observation, patients often report a sensation of "release" or "opening up" during the procedure as these adhesions are separated. This immediate mechanical effect often precedes long-term functional improvement.
A Clinical Walkthrough: The High-Volume Injection Procedure
To truly understand this technique, let's walk through the steps of a typical HVI procedure for Achilles tendinopathy, a common application.
Step 1: Patient Positioning and Initial Assessment
The patient is positioned comfortably, usually lying face down (prone) with their feet hanging off the end of the table. This allows for easy access to the Achilles tendon. Using a high-frequency linear ultrasound probe, I perform a thorough diagnostic scan of the tendon in both long-axis (parallel to the tendon fibers) and short-axis (perpendicular) views. This allows me to:
Identify the precise area of tendinopathy, often seen as a thickened, hypoechoic (darker) region.
Visualize the neovascularity using color or power Doppler ultrasound, which shows blood flow in the problematic neovessels.
Map the target area: the fascial plane between the anterior border of the Achilles tendon and Kager's fat pad.
Step 2: Anesthesia
Patient comfort is paramount. Using a very fine-gauge needle (25 or 27-gauge), I administer a small amount of local anesthetic (e.g., lidocaine) to numb the skin and the subcutaneous pathway the larger injection needle will take. This helps keep the main procedure as comfortable as possible. We often use a vapor coolant spray on the skin just before this initial needle entry for added comfort.
Step 3: The High-Volume Injection
Once the area is numb, I switch to a slightly larger needle (21- or 22-gauge) attached to a syringe containing the high-volume injectate. The literature describes a wide range of volumes, from 5 mL to as much as 100 mL, though most Achilles tendon procedures use between 20 mL and 50 mL (Morton et al., 2022). The choice of volume depends on the severity of the condition and the patient's tolerance.
Under continuous ultrasound guidance, I advance the needle to the target plane—the space anterior to the Achilles tendon. It's critical to stay outside the tendon fibers. Ultrasound lets me see the needle tip in real time.
Out-of-Plane vs. In-Plane Approach:
An in-plane approach means the needle shaft and tip are visible along their entire length.
An out-of-plane approach, often used for this procedure, shows the needle tip as a bright dot on the screen.
As I begin to inject the fluid, the magic of the procedure becomes visible on the ultrasound screen. You can literally watch the fluid enter the space and begin to hydrostatically dissect the tissues. The dark line of fluid expands, pushing the Achilles tendon away from the underlying fat pad and separating the adhesions. I can see the tendon being "lifted" off the tissue below as the space is created. I continue to inject until I feel a firm resistance or the patient reports a feeling of significant pressure, indicating the space is filled.
Integrating Chiropractic Care for Optimal Recovery
The HVI procedure is a powerful intervention, but it is not a standalone cure. True, lasting recovery requires addressing the underlying biomechanical factors that contributed to the tendinopathy in the first place. This is where our integrative model shines. Following a brisement procedure, a comprehensive rehabilitation plan is essential.
Eccentric Loading Protocols: Once the initial post-injection sensitivity subsides (typically after a few days), we introduce a structured eccentric loading program. This involves exercises in which the muscle lengthens under tension (e.g., heel drops for Achilles tendinopathy). This exercise type has been shown to stimulate collagen remodeling and strengthen the tendon matrix, promoting the formation of healthy, organized tendon fibers (Alfredson et al., 1998).
Chiropractic Adjustments: Tendinopathy in the lower limb is rarely just a local problem. It is often linked to biomechanical imbalances higher up the kinetic chain. As a chiropractor, I assess and correct dysfunctions in the:
Ankle and Foot: Restricted subtalar joint motion or a collapsed arch can alter gait and place abnormal stress on the Achilles tendon.
Knee and Hip: Poor hip stability or knee alignment can change the way force is transmitted through the leg during walking and running.
Pelvis and Lumbar Spine: Sacroiliac joint dysfunction or spinal misalignments can lead to compensatory movement patterns that overload the lower extremities.
By performing specific chiropractic adjustments, we restore proper joint mechanics, which reduces aberrant strain on the healing tendon. This helps prevent recurrence by addressing the root cause of the overload.
Soft Tissue and Functional Movement Therapies: We complement this with soft tissue techniques (like Active Release Technique or Graston) to address fascial restrictions and incorporate functional movement screening to retrain proper movement patterns, ensuring the patient returns to activity with improved, more efficient biomechanics.
This integrated approach—combining the targeted physiological disruption of HVI with the foundational biomechanical corrections of chiropractic care and structured rehabilitation—provides a robust recovery framework that addresses both local tissue pathology and global functional deficits.
A Modern, Evidence-Based Solution
The landscape of musculoskeletal medicine is continually evolving, driven by pioneering researchers and innovative clinical applications. High-volume injection (brisement) represents a significant advancement in managing chronic, recalcitrant tendinopathies. By moving beyond a simple anti-inflammatory model and directly targeting the neurovascular and mechanical drivers of pain and dysfunction, we can offer hope to patients who have struggled with this debilitating condition.
At our clinic, we are proud to offer these advanced, evidence-based therapies within a collaborative and integrative framework. By combining the precision of ultrasound-guided injections under medical supervision with the holistic, biomechanical focus of chiropractic and functional medicine, we can create a truly comprehensive and personalized path to recovery for our patients.
References
The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, and physical medicine, as well as wellness, sensitive health issues, and functional medicine articles, topics, and discussions. We provide and facilitate clinical collaboration with specialists across disciplines. Each specialist is governed by their professional scope of practice and the jurisdiction in which they are licensed. We utilize functional health and wellness protocols to treat and support care for musculoskeletal injuries or disorders. Our videos, posts, topics, subjects, and insights cover clinical matters and issues that directly or indirectly support our clinical scope of practice. Our office has made a reasonable effort to provide supportive citations and identify relevant research studies for our posts. We provide copies of supporting research studies upon request to regulatory boards and the public.
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Blessings
Dr. Alex Jimenez, DC, MSACP, APRN, FNP-BC*, CCST, IFMCP, CFMP, ATN
Email: coach@elpasofunctionalmedicine.com
Multidisciplinary Licensing & Board Certifications:
Licensed as a Doctor of Chiropractic (DC) in Texas & New Mexico*
Texas DC License #: TX5807, Verified: TX5807
New Mexico DC License #: NM-DC2182, Verified: NM-DC2182
Multi-State Advanced Practice Registered Nurse (APRN*) in Texas & Multi-States
Multi-State Compact APRN License by Endorsement (42 States)
Texas APRN License #: 1191402, Verified: 1191402 *
Florida APRN License #: 11043890, Verified: APRN11043890 *
New York APRN License #: N25929, Verified: APRN-N25929*
License Verification Link: Nursys License Verifier
* Prescriptive Authority Authorized
ANCC FNP-BC: Board Certified Nurse Practitioner*
Compact Status: Multi-State License: Authorized to Practice in 40 States*
Graduate with Honors: ICHS: MSN-FNP (Family Nurse Practitioner Program)
Degree Granted. Master's in Family Practice MSN Diploma (Cum Laude)
Dr. Alex Jimenez, DC, APRN, FNP-BC*, CFMP, IFMCP, ATN, CCST
My Digital Business Card
Dr. Maria Cardenas, MD
(Board Certified in Internal Medicine)
Medical Director & Collaborative Physician
NPI # 1164426749
MD License #: J2933
