Treating Chronic Tendinopathy With Brisement Insights

Treating Chronic Tendinopathy With Brisement Injections

Abstract

Welcome to our educational series. I’m Dr. Alex Jimenez, and today we’ll explore an innovative, highly effective technique for managing chronic tendinopathies known as high-volume injection (HVI). This technique is also called brisement.

This post is designed to take you on a journey, providing a clear, evidence-based understanding of this procedure. This procedure is changing the way we approach persistent tendon pain. We will explore the physiological mechanisms behind chronic tendinopathy. In particular, we will focus on the role of neovascularization and neo-innervation.

I will explain what brisement is and how it differs from other injection therapies like tenotomy. I will also explain the step-by-step process of its application, which is supported by ultrasound-guided visuals.

Drawing on the latest research from leading experts, we will discuss the clinical rationale for using this hydrostatic decompression technique. We will also explore its application in conditions like Achilles and patellar tendinopathy and discuss the outcomes observed.

We will also explore how this advanced procedure integrates seamlessly into our comprehensive, multidisciplinary approach at Injury Medical Clinic, where we combine integrative chiropractic care, functional medicine, and medical oversight to create personalized and effective treatment plans for our patients.

My name is Dr. Alex Jimenez. As a Doctor of Chiropractic, Advanced Practice Registered Nurse, and Board-Certified Family Nurse Practitioner with extensive certifications in functional and integrative medicine, my mission has always been to seek out and implement the most effective, evidence-based treatments for my patients. At my practice, Injury Medical Clinic PA in El Paso, Texas, we have fostered a unique collaborative environment. I work alongside Dr. Maria Guadalupe Cardenas, MD, a highly respected internist with over 40 years of experience. Dr. Cardenas serves as our Medical Director and Collaborative Physician and provides invaluable medical oversight. This oversight allows us to offer a truly integrative spectrum of care. Our team combines chiropractic adjustments, advanced rehabilitation, functional medicine diagnostics, and, when appropriate, innovative medical procedures. We use these techniques to address the root cause of our patients’ pain and dysfunction.

Today, I want to share insights into an advanced technique that exemplifies our commitment to modern, research-driven care: brisement, also known as a high-volume injection (HVI). This procedure is a powerful tool for those suffering from chronic tendinopathies. It is considered after conventional treatments have failed.

Understanding Chronic Tendinopathy: Beyond Simple Inflammation

For years, we understood tendon pain primarily as “tendinitis”—an inflammatory condition. However, modern research has reshaped this view. We now know that in chronic cases, the issue is often tendinosis. This is a degenerative condition characterized by disorganized collagen fibers, cellular changes, and a notable absence of classic inflammatory cells.

A key pathological feature in chronic tendinopathy is the development of neovascularization and neo-innervation.

• Neovascularization: The formation of new, abnormal blood vessels within and around the degenerated tendon. While one might think more blood flow is beneficial these new vessels are often leaky, disorganized, and accompanied by nerve fibers.
• Neo-innervation: This refers to the ingrowth of new, tiny nerve endings along with these new vessels. These nerves are often nociceptive, meaning they transmit pain signals.

Many researchers now believe this complex of new vessels and nerves, particularly in the fatty tissue adjacent to the tendon (like Kager’s fat pad in the Achilles), is a primary driver of the persistent pain patients experience. These structures create chronic irritation and a feedback loop, which prevents the tendon from healing properly. This is the precise problem that the brisement procedure is designed to address.

What is Brisement, or High-Volume Injection?

It is crucial to distinguish brisement from other needle-based tendon procedures.

• Fenestration or Tenotomy: In these procedures, a needle is intentionally inserted directly into the tendon to repeatedly puncture it. The goal is to stimulate a localized inflammatory and healing response within the damaged tendon tissue itself.
• Brisement (High-Volume Injection): This technique has a completely different target. The needle is not aimed at the tendon substance. Instead, it is precisely guided, using real-time ultrasound imaging, into the space between the tendon and the adjacent tissues (such as the tenosynovium or a fat pad).

The primary goal of brisement is hydrostatic decompression. We inject a large volume of fluid—typically a combination of a local anesthetic like lidocaine and sterile normal saline—into this potential space. This large fluid volume physically separates the tendon from the underlying tissue. It also stretches and breaks apart the delicate, problematic neovessels and neo-nerves that have grown into the area. The term “brisement” comes from the French word for “breaking” or “disruption,” which perfectly describes this mechanical effect on these pain-generating structures.

By disrupting this neurovascular ingrowth, we aim to:

1. Reduce Pain: By severing the pain-transmitting neo-nerves.
2. Interrupt the Pathological Cycle: By eliminating the abnormal neovessels that contribute to the degenerative process.
3. Create a Better Healing Environment: By freeing the tendon from the tethering effect of these adhesions, allowing for improved gliding and function.

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

The precision of brisement is entirely dependent on ultrasound guidance. Let’s walk through what the procedure entails, using Achilles tendinopathy as a classic example.

Step 1: Patient Positioning and Initial Scan

The patient is positioned comfortably, typically lying face down to allow easy access to the Achilles tendon. The area is then prepped and draped using sterile technique to prevent infection. Using a high-frequency linear ultrasound probe, I perform a thorough diagnostic scan of the Achilles tendon in both long axis (along the length of the tendon) and short axis (cross-section). This allows me to identify the exact location of the tendinopathy. It is often seen as tendon thickening, hypoechoic (darker) areas, and disorganized fiber patterns. I pay special attention to the interface between the anterior border of the Achilles tendon and Kager’s fat pad, a common site for neovascularization.

Step 2: Anesthesia

Patient comfort is paramount. Using a very fine needle (25- or 27-gauge), I administer a small amount of local anesthetic (e.g., lidocaine) to numb the skin and the subcutaneous tissues along the planned needle path. This helps keep the main part of the procedure as comfortable as possible.

Step 3: The High-Volume Injection

Once the area is numb, I switch to a slightly larger needle (21- or 22-gauge) for the brisement itself. This needle is attached to a syringe containing the injectate—a mixture of local anesthetic and a significant volume of normal saline. The literature describes a wide range of volumes, from 5 mL up to 100 mL, depending on the specific tendon and the clinician’s judgment.

Under continuous ultrasound guidance, I advance the needle to the target: the space anterior to the Achilles tendon. On the ultrasound screen, I can see the needle tip in real time as it enters this precise location.

The injection begins. As the fluid enters the space, the magic of hydrostatic decompression becomes visible on the ultrasound monitor. We can see the fluid spreading, creating a distinct, anechoic (black) layer that physically separates the Achilles tendon from Kager’s fat pad. This action is literally “peeling” the two structures apart. It disrupts the adhesions and the neurovascular web that has formed between them. This is the procedure’s therapeutic action.

The injection continues until I feel a change in resistance, indicating the space is adequately filled, or until the patient reaches their tolerance. The fluid effectively and mechanically disrupts the pathological structures.

Step 4: Post-Procedure Care

Following the injection, the patient is monitored briefly. We typically recommend a period of relative rest for a few days. This is followed by a gradual re-introduction of activity and a structured rehabilitation program. This is where our integrative approach becomes essential.

Integrating Brisement with Chiropractic Care and Rehabilitation

A brisement injection is not a standalone “cure.” It is a powerful intervention designed to break a pathological cycle and create a window of opportunity for true healing and rehabilitation. This is where our multidisciplinary model at Injury Medical Clinic excels.

Following a high-volume injection, the patient’s pain is often significantly reduced. This allows them to engage in the physical rehabilitation that was previously too painful to perform. Our integrated plan includes:

• Chiropractic Adjustments: We assess and correct biomechanical dysfunctions in the foot, ankle, knee, hip, and spine that may have contributed to the initial tendon overload. For example, a misaligned pelvis or poor foot mechanics can alter gait and place excessive strain on the Achilles tendon. Chiropractic care helps restore proper joint motion and neurological function, addressing the root biomechanical cause.
• Targeted Rehabilitation: Our rehabilitation team designs a progressive loading program. This is critical for stimulating proper collagen remodeling within the tendon. The program typically starts with isometric exercises (contractions without movement), gradually progresses to eccentric exercises (lengthening the muscle-tendon unit under load), and finally moves to sport-specific movements.
• Functional Medicine: We may also look at systemic factors that can impair healing, such as nutritional deficiencies, systemic inflammation, or metabolic issues. A functional medicine approach helps optimize the body’s internal environment for recovery.
• Medical Oversight by Dr. Cardenas: Dr. Cardenas provides essential medical direction, ensuring that the procedure is appropriate for the patient, managing any co-existing medical conditions, and overseeing the overall treatment plan from a medical perspective. This collaborative oversight ensures the highest standards of safety and efficacy.

This combination of breaking the pain cycle with brisement, followed by rebuilding strength and correcting biomechanics with chiropractic and rehab, leads to long-term success.

The Evidence and Rationale

The work of leading researchers in this field has been pivotal. Studies on high-volume injections for Achilles and patellar tendinopathy have shown promising results. The rationale is based on mechanically disrupting neovessels and sensory nerves in the fat pad anterior to the tendon. While injected volume remains debated, the principle of hydrostatic dissection remains consistent. Some authors caution against extremely large volumes because of a theoretical risk of tendon rupture or compartment syndrome. Consequently, this emphasizes the need to perform this procedure under expert guidance.

By combining the latest advancements in interventional procedures with a foundational, holistic approach to health, we can offer our patients a comprehensive and powerful path to recovery. Brisement is an excellent example of how modern, evidence-based techniques can be integrated into a patient-centered model. This integration can achieve outcomes that were once difficult to obtain.

I hope this overview has provided you with a clear understanding of high-volume injections and their role in treating chronic tendinopathy. Our commitment at Injury Medical Clinic is to remain at the forefront of medical science. We bring together the best of different disciplines to help you heal and thrive.

---

References

1. Boesen, M. I., Koenig, M. J., Torp-Pedersen, S., & Bliddal, H. (2011). Tendinopathy: A new paradigm. Ugeskrift for Laeger, 173(25), 1741-1744.
2. Chan, O., O’Dowd, D., Padhiar, N., Morrissey, D., King, J., & Crisp, T. (2008). High volume image guided injections in chronic Achilles tendinopathy. Disability and Rehabilitation, 30(20-22), 1697-1708. https://doi.org/10.1080/09638280701785926
3. Maffulli, N., Spiezia, F., Longo, U. G., Denaro, V., & Maffulli, G. D. (2013). High-volume image-guided injection for recalcitrant patellar tendinopathy. The American Journal of Sports Medicine, 41(5), 1042-1048. https://doi.org/10.1177/0363546513476098
4. Morton, S., Scott, A., & Chan, O. (2017). High-Volume Injection for Chronic Tendinopathy. In O. Chan (Ed.), Ultrasound in Chronic Tendinopathy. Springer.