Brisement Injection for Tendon Pain in El Paso Treatment

Brisement Injection for Tendon Pain in El Paso

As a practitioner dedicated to the forefront of integrative and functional medicine, I constantly seek the latest evidence-based research to better serve my patients. It is also my privilege to share the work of leading researchers. I translate their advanced findings into practical, understandable knowledge for you.

My name is Dr. Alex Jimenez, and I hold several credentials, including DC, APRN, FNP-BC, CFMP, IFMCP, ATN, and CCST. At our clinic, Injury Medical Clinic PA, we pride ourselves on a multidisciplinary approach. This means we combine various specialties in one location to provide comprehensive care. Furthermore, our team is under the medical direction of Dr. Maria Guadalupe Cardenas, MD, an internist with over 40 years of experience. This team integrates chiropractic care, functional medicine, rehabilitation, and medical oversight to create personalized treatment plans. Today, I want to share insights into an advanced technique for treating chronic tendinopathy. We often see this condition in our practice.

Understanding Brisement and High-Volume Injections for Tendinopathy

Abstract

This educational post discusses a minimally invasive procedure called brisement, or high-volume injection (HVI), for treating chronic tendinopathies like Achilles and patellar tendinopathy. As Dr. Jimenez, I will guide you through the physiological basis of this technique and explain how it differs from other treatments like fenestration. We will also cover the procedure itself, from patient positioning to the injection process. We use insights from leading researchers like Dr. Fran O’Connor. The focus is on the mechanical and physiological effects of the injection, particularly hydrostatic decompression and the disruption of problematic neovessels and neonerves that contribute to chronic tendon pain. We will also discuss how this innovative medical procedure integrates seamlessly with our chiropractic and rehabilitative care at Injury Medical Clinic. This promotes optimal healing, restores function, and provides long-term relief for our patients.

What Is Tendinopathy, and Why Does It Become Chronic?

Before we dive into the specifics of the procedure, let’s understand the condition it treats: tendinopathy. Many people use the term “tendinitis,” which implies inflammation. However, in chronic cases, we often find not active inflammation but degeneration and a failed healing response within the tendon. This is more accurately called tendinopathy.

In a healthy healing process, the body repairs damaged tissue. However, with chronic tendinopathy, this process goes awry. The body attempts to heal the area by growing new, disorganized blood vessels and nerve endings. This process is called neovascularization and neoinnervation. These new structures, or neovessels and neonerves, are not beneficial. In fact, they are often the primary source of the persistent pain that patients experience. The disorganized tissue and these new nerve endings create a cycle of pain and dysfunction. This cycle is difficult to break with conventional treatments alone.

At our clinic, we often see athletes, laborers, and individuals with chronic tendon pain from repetitive strain. My clinical observations have shown that conditions like Achilles tendinopathy can be incredibly stubborn, significantly impacting a person’s ability to walk, run, or even stand comfortably. This is where advanced interventions become necessary.

Introducing Brisement: A Targeted Hydrostatic Approach

So, what is brisement, also called a high-volume injection (HVI)? It’s an advanced, ultrasound-guided technique designed to address the root cause of chronic tendon pain. The term “brisement” is French for “breaking” or “disruption.” This procedure is distinct from other needle-based treatments like fenestration or tenotomy. In those treatments, the goal is to repeatedly puncture the tendon itself to stimulate a healing response.

With brisement, the focus is entirely different. We are not targeting the tendon directly. Instead, the needle is carefully guided to the space next to the tendon—specifically, the interface between the tendon and adjacent soft tissues, like the paratenon (the sheath around the tendon) or a nearby fat pad (such as Kager’s fat pad behind the Achilles tendon).

The goal of brisement is twofold:

• Mechanical Disruption: To physically break up the fine, pain-causing neovessels and neonerves that have grown into the area.
• Hydrostatic Decompression: To use the pressure of the injected fluid to separate tissues that have become adhered or scarred together, freeing the tendon and relieving compressive forces.

Think of it as using a precise stream of fluid to gently peel apart layers of tissue that are stuck together. At the same time, we wash away the very structures that transmit pain signals.

The Brisement Procedure: A Step-by-Step Journey

Drawing from the work of experts like Dr. O’Connor, let’s walk through how this procedure is performed, illustrating the precision and care required. For this example, we’ll focus on Achilles tendinopathy, a common and challenging condition.

1. Patient Preparation and Imaging

The first step is proper positioning. The patient is typically placed prone (lying face down), with their feet hanging off the edge of the treatment table. This position provides excellent access to the Achilles tendon. The area is then meticulously prepped and draped to maintain sterility.

Next, we use a high-frequency ultrasound probe to visualize the tendon. This is not just a preliminary step; ultrasound guidance is critical throughout the entire procedure. We examine the tendon in both long-axis (lengthwise) and short-axis (cross-section) views. This allows us to:

• Pinpoint the exact area of tendinopathy, which often appears as a thickened, disorganized, and sometimes darker region on the ultrasound image.
• Identify the crucial interface between the anterior (front) border of the Achilles tendon and the underlying Kager’s fat pad, which is our target zone.

2. Anesthesia

Once the target is identified, we ensure the patient’s comfort. A very fine needle (typically 25- or 27-gauge) is used to administer a local anesthetic, such as lidocaine, to numb the skin and the subcutaneous tissues along the planned needle path. This helps keep the main part of the procedure as painless as possible.

3. The High-Volume Injection

With the area anesthetized, the main procedure begins. A slightly larger needle (21- or 22-gauge) is used for the high-volume injection. The injectate is a combination of a local anesthetic (like lidocaine, for continued pain control) and a large volume of sterile normal saline.

Under continuous ultrasound guidance, the needle is advanced to the target space—the potential space anterior to the Achilles tendon. What happens next is the core of the brisement technique.

• As the fluid is injected, we can see it in real-time on the ultrasound screen. The fluid begins to spread, creating a visible separation between the tendon and the adjacent fat pad. This is hydrostatic decompression in action. You can literally watch the layers of tissue peel apart.
• The pressure and volume of the fluid mechanically “strip” or disrupt the delicate neovessels and neonerves that have infiltrated this space. By breaking these connections, we are directly targeting the source of the pain.

The amount of fluid used can vary significantly, with literature describing volumes anywhere from 5 to 100 cc. The endpoint is determined by either patient tolerance or when we feel significant resistance to further injection. This indicates the space has been sufficiently filled and decompressed. While large volumes are effective, caution is necessary to avoid complications like tendon rupture or compartment syndrome. Therefore, precise, real-time guidance is non-negotiable.

The Integrative Approach: How Chiropractic Care Complements Brisement

A procedure like brisement is a powerful tool. However, in our integrative model at Injury Medical Clinic, it’s one part of a larger, more comprehensive recovery strategy. This is where our expertise in chiropractic, physical therapy, and functional medicine comes into play. Dr. Cardenas provides essential medical oversight for these procedures. Meanwhile, my role focuses on restoring the body’s biomechanical function.

Here’s how we integrate this care:

1. Addressing the Root Biomechanical Cause: Why did the tendinopathy develop in the first place? Often, it’s due to underlying biomechanical imbalances. This could be poor foot mechanics (like overpronation), pelvic misalignment, or muscular imbalances in the kinetic chain (the interconnected system of the feet, ankles, knees, hips, and spine). As a chiropractor, my first step is to perform a thorough biomechanical assessment. I use techniques like spinal and extremity adjustments, soft tissue mobilization, and myofascial release to correct these imbalances. By restoring proper joint alignment and muscle function, we reduce abnormal load on the healing tendon and help prevent re-injury.
2. Post-Procedure Rehabilitation: After the brisement procedure has disrupted the pain-generating tissues, the body needs to heal correctly. This is where a structured rehabilitation program is crucial. Our physical therapy team designs a progressive loading program. This starts with gentle range-of-motion exercises to maintain mobility without stressing the tendon. It then progresses to eccentric exercises (lengthening the muscle-tendon unit under load), which have been shown to stimulate proper collagen remodeling and strengthen the tendon (Alfredson, H., Pietilä, T., Jonsson, P., & Lorentzon, R., 1998).
3. Enhancing Healing with Functional Medicine: From a functional medicine perspective, we look at the body’s internal environment. Healing requires the right nutrients. We may recommend specific supplements like Vitamin C, manganese, zinc, and certain amino acids (proline, glycine) that are essential building blocks for collagen, the primary protein in tendons. We also focus on reducing systemic inflammation through diet and lifestyle modifications, which creates a more favorable environment for tissue repair.
4. Pain and Inflammation Management: In the initial phases after the procedure, we use non-pharmacological methods to manage discomfort and support healing. This can include modalities like laser therapy or acoustic wave therapy, which can help modulate inflammation and enhance cellular repair processes. Chiropractic adjustments also strongly affect the nervous system, helping downregulate pain signals and improve overall function.

By combining the targeted medical intervention of brisement with holistic chiropractic and rehabilitative care, we create a powerful synergy. The injection provides the “reset” by eliminating the chronic pain source. Meanwhile, our therapies address the underlying cause and guide the body through a robust, complete healing process. This integrated model, overseen by Dr. Cardenas and implemented by our dedicated team, ensures that we are not just treating a symptom. We are restoring the patient to full, pain-free function.

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.
• Barker-Davies, R. M., et al. (2017). The Achilles and patellar tendinopathy high volume image guided injection consensus meeting. Biology of Sport, 34(1), 77–83.
• Maffulli, N., & Almekinders, L. C. (2007). The Achilles tendon. Springer Science & Business Media.