High-Volume Injections (Brisement) Method Overview

Unlocking Tendon Healing: A Deep Dive into High-Volume Injections (Brisement) for Chronic Tendinopathy

Abstract

Chronic tendon pain, or tendinopathy, can be debilitating and significantly affect daily life and athletic performance. While traditional treatments can offer relief, many individuals seek more advanced, targeted solutions. In this educational post, I will explore an innovative procedure known as brisement, or high-volume injection (HVI). Drawing on the pioneering work of leading researchers in musculoskeletal medicine, we will explore the physiological underpinnings of this technique. In particular, this is useful for conditions like Achilles and patellar tendinopathy.

We will examine how this procedure hydrostatically decompresses tissues, disrupts problematic neovessels and neonerves, and promotes healing. Furthermore, I will explain how we integrate this advanced approach at our clinic within a comprehensive, multidisciplinary framework. This framework combines my expertise in chiropractic and functional medicine with the medical oversight of our Medical Director, Dr. Maria Guadalupe Cardenas, MD. As a result, this collaborative model ensures our patients receive safe, effective, and truly integrated care for their recovery.

Hello, I’m Dr. Alex Jimenez. Throughout my career, holding qualifications 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 practice to seeking and implementing the most effective, evidence-based treatments for my patients. My goal has always been to understand the “why” behind a patient’s pain and dysfunction; I do not just treat the symptoms. This pursuit has led me to explore the frontiers of musculoskeletal and regenerative medicine. In these fields, we are constantly discovering new ways to help the body heal itself.

Today, I want to share insights into a powerful technique called brisement, or high-volume injection (HVI). This procedure is being widely recognized for its success in treating chronic, stubborn tendinopathies that have not responded to other therapies. We will review the latest findings and clinical applications. In particular, we will demonstrate how modern ultrasound-guided methods are transforming patient outcomes.

Our Collaborative Care Model: Integrating Medicine and Chiropractic

At Injury Medical Clinic PA, we believe the future of healthcare is integrative. The most effective patient outcomes are achieved when different disciplines work together, each bringing a unique perspective and skill set to the table. This is why I am proud to work alongside Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is board-certified in Internal Medicine and serves as our Medical Director and Collaborative Physician. With over four decades of experience as an internist, she provides invaluable medical oversight. She also helps guide our comprehensive treatment plans.

This multidisciplinary structure is crucial, especially when incorporating advanced procedures like high-volume injections. My expertise in chiropractic care, rehabilitation, and functional medicine focuses on restoring biomechanical function, addressing musculoskeletal imbalances, and optimizing the body’s internal environment for healing. Dr. Cardenas’s medical guidance ensures that we perform all procedures safely and consider any underlying systemic conditions. As a result, our patients receive care that meets the highest medical standards. Together, we bridge the gap between conventional medicine, chiropractic, and functional wellness. This creates a seamless and holistic patient journey.

Understanding Brisement: A Paradigm Shift from Traditional Injections

When people think of injections for tendon pain, they often envision a corticosteroid shot to reduce inflammation. However, brisement is fundamentally different. It is not about injecting a potent anti-inflammatory agent directly into the tendon tissue. In fact, it is distinct from procedures like fenestration or tenotomy. In these procedures, a needle is intentionally used to create micro-trauma within the tendon to stimulate a healing response.

The primary objective of brisement is to address the environment around the dysfunctional tendon. In chronic tendinopathy, the body often attempts to heal the area by growing a chaotic network of new, fragile blood vessels (neovessels) and nerve endings (neonerves). Research, such as the work presented by Alfredson et al. (2003), has shown that these structures, which often infiltrate the fatty tissue adjacent to the tendon (like Kager’s fat pad in the Achilles), are a primary source of pain. The brisement procedure focuses on disrupting this pathological neurovascular network.

The technique involves precisely injecting a large volume of fluid—typically a mixture of a local anesthetic like lidocaine and sterile saline—into the space between the tendon and the adjacent soft tissues. This creates what we call hydrostatic decompression. The fluid physically separates the tissues, mechanically breaking up the delicate neovessels and neonerves that tether the tendon to surrounding structures and transmit pain signals. It’s a mechanical solution to a biological problem.

The Brisement Procedure: A Step-by-Step Clinical Walkthrough

To truly understand how this works, let’s walk through the process as we would perform it in a clinical setting, guided by real-time ultrasound imaging. Ultrasound is non-negotiable; it turns this from a blind procedure into a precise, targeted intervention.

1. Patient Positioning and Preparation: First, the patient is positioned comfortably to allow optimal access to the affected tendon. For Achilles tendinopathy, the patient typically lies face down with their foot hanging off the edge of the treatment table. The area is then meticulously cleaned and draped to maintain sterility.
2. Ultrasound Assessment: Using a high-frequency linear ultrasound probe, I carefully examine the tendon in both long-axis (lengthwise) and short-axis (cross-section) views. This initial scan is crucial. It allows me to identify the exact location of the tendinopathy—often seen as tendon thickening, disorganized fibers, and neovascularity on color Doppler imaging. I also map out the interface between the tendon and the adjacent fat pad, which is our target zone.
3. Local Anesthesia: Before the main injection, a small-gauge needle (e.g., 25- or 27-gauge) is used to anesthetize the skin and subcutaneous tissues with lidocaine. This ensures the patient’s comfort throughout the procedure.
4. The High-Volume Injection: Once the skin is numb, a slightly larger needle (e.g., 21- or 22-gauge) is guided under continuous ultrasound visualization toward the target area. The goal is to place the needle tip precisely in the fascial plane between the tendon sheath (paratenon) and the adjacent structures.
   • For the Achilles tendon, this is the space between the anterior border of the tendon and Kager’s fat pad.
   • For the patellar tendon, this is typically the space between the posterior aspect of the tendon and Hoffa’s fat pad.
5. Hydrodissection and Decompression: With the needle in place, slowly inject the fluid mixture. On the ultrasound screen, you can see the fluid entering the space and creating a visible separation. This is hydrodissection in action. The fluid wave spreads along the tissue plane, hydrostatically “stripping” adhesions and, most importantly, disrupting the pain-generating neovessels and neonerves. I continue injecting until I feel increased resistance or the patient reports a feeling of fullness, indicating the space has been adequately filled.

The volume of fluid used can vary significantly, with literature reviews like that of Maffulli et al. (2019) noting ranges from 5 to 100 mL, depending on the tendon and the severity of the condition. While larger volumes can be more effective, we must be cautious to avoid complications such as excessive pressure. This pressure could theoretically risk tendon rupture or compartment syndrome, although these are rare when the procedure is done correctly.

The Role of Integrative Chiropractic Care in Recovery

The brisement procedure is a powerful tool for breaking the cycle of chronic tendon pain, but it is not the end of the treatment. This is where our integrative model shines. Lasting recovery requires addressing the root biomechanical and physiological factors that led to the tendinopathy in the first place.

Following the procedure, my role as a chiropractor and rehabilitation specialist becomes central. Here’s how we build on the success of the injection:

• Restoring Biomechanics with Chiropractic Adjustments: Tendinopathies, especially in the lower limbs, often result from faulty movement patterns or misalignments in the kinetic chain. For instance, Achilles tendinopathy can be linked to poor foot mechanics (like overpronation), ankle joint restriction, or even pelvic and spinal imbalances that alter a person’s gait. Through specific chiropractic adjustments, I work to restore proper joint mobility and alignment in the foot, ankle, knee, hip, and spine. This helps ensure that, as the tendon heals, it does not experience the same abnormal stresses that caused the injury.
• Progressive Loading and Rehabilitation: A common misconception is that a painful tendon needs complete rest. Modern evidence, as highlighted in the research of Cook & Purdam (2009), overwhelmingly supports a program of progressive eccentric loading. After the brisement procedure provides a window of pain relief, we immediately initiate a customized rehabilitation program. This involves exercises that place a controlled, lengthening load on the tendon. This stimulus is critical for promoting collagen synthesis, remodeling tendon fibers into a stronger, more organized structure, and improving the tissue’s overall resilience.
• Functional Medicine and Nutritional Support: Healing is a metabolic process. As a certified functional medicine practitioner, I also assess and address systemic factors that may be hindering recovery. This can include:
  • Identifying and reducing systemic inflammation through dietary changes and targeted supplementation.
  • Ensuring adequate intake of key nutrients for collagen production, such as vitamin C, zinc, manganese, and amino acids (proline, glycine).
  • Optimizing gut health, as a dysfunctional gut can be a source of chronic, low-grade inflammation that impairs tissue repair body-wide.

By combining the targeted pain relief of the high-volume injection with chiropractic adjustments, a scientifically designed rehabilitation protocol, and functional medicine support, we create a comprehensive ecosystem for healing. This approach resolves the immediate pain and addresses the underlying causes. As a result, it significantly reduces the risk of recurrence.

The Evidence and the Future

The clinical evidence for high-volume injections is growing. Studies on Achilles and patellar tendinopathy have shown promising results, with many patients experiencing significant, lasting reductions in pain and improved function. This approach marks a shift toward treatments that are more mechanically and physiologically targeted, guided by advanced imaging, and that work with the body’s own healing processes instead of just masking symptoms.

At Injury Medical Clinic PA, under the collaborative guidance of Dr. Cardenas and me, we are committed to providing this level of sophisticated, integrated care. We believe that by combining the best of medicine, chiropractic, and rehabilitation, we can offer hope and real solutions for those suffering from chronic tendon pain.

In health,

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

References

• Alfredson, H., & Öhberg, L. (2003). Neovascularisation in chronic painful patellar tendinosis—A prospective sclerosing injection study in a 2-year follow-up. The American Journal of Sports Medicine, 31(4), 548-552. (Note: While this reference is on sclerosing injections, it establishes the key concept of neovascularization as a pain source targeted by injections like brisement).
• Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409-416.
• Maffulli, N., Spiezia, F., Oliva, F., & Testa, V. (2019). High-volume image-guided injection for the management of chronic recalcitrant patellar tendinopathy in elite athletes. Orthopaedic Journal of Sports Medicine, 7(8), 2325967119868351.