Legal Peptides and Integrative Chiropractic Care: A Clear Guide
Abstract
This article explains legal peptide use in plain language. Legal peptide use means giving, making, or prescribing certain short chains of amino acids that regulatory bodies such as the Food and Drug Administration (FDA) have officially approved for medical use. Readers will learn how approved drugs differ from compounded products and research-only chemicals. The article then reviews the New Mexico Board of Nursing’s September 2026 peptide FAQs. It covers a valid patient-provider relationship, telehealth, advertising, nutrition, and muscle care. The last sections show how integrative chiropractors and nurse practitioners work together, and how Dr. Alexander Jimenez, DC, APRN, FNP-BC, and Dr. Maria Guadalupe Cardenas, MD, run that model at Injury Medical Clinic PA in El Paso.
What Legal Peptide Use Means
Peptides are short chains of amino acids. The body already makes many of them. They act like small messages that can change appetite, hormone release, inflammation, and tissue repair (Findlay, 2026; Vibrant Health of Colorado, 2026).
Legal peptide use means giving, making, or prescribing certain short chains of amino acids that regulatory bodies such as the Food and Drug Administration (FDA) have officially approved for medical use (Findlay, 2026; Peptide Laws, n.d.). In everyday terms, a peptide plan is safer when:
A regulator has officially approved that product for medical use.
A licensed clinician examines the patient and writes a prescription.
Any compounded version follows federal compounding law and state pharmacy rules.
The chart shows a reason, informed consent, and follow-up (ByrdAdatto, n.d.; LumaLex Law, n.d.).
Insulin, semaglutide, tirzepatide, tesamorelin, and bremelanotide (PT-141) are examples of peptides with FDA-approved products for specific conditions (Findlay, 2026; DJ Holt Law, 2026). Approval covers a product and its use. It does not make every similar vial on the internet legal.
Approved, Compounded, or Research-Only
FDA-approved medicines have finished clinical trials and manufacturing review. A clinician may use an approved drug off-label when science and judgment support that choice, but the product itself is still an approved drug (DJ Holt Law, 2026; ByrdAdatto, n.d.).
Compounded peptides are custom medicines made for one named patient when the law allows it. They are not FDA-approved. They may differ in formula, stability, and oversight (New Mexico Board of Nursing, 2026). After branded GLP-1 shortages eased, federal policy tightened around copies of those products (DJ Holt Law, 2026; Peptide Laws, n.d.).
Research-only chemicals are often sold as “not for human use.” Popular names include BPC-157, TB-500, and several growth-hormone secretagogues. That label does not make clinical use legal. The FDA treats marketing for human treatment as a drug claim (Findlay, 2026; LumaLex Law, n.d.). Status can also change as compounding committees review bulk substances (DJ Holt Law, 2026).
State boards rarely ban peptides as a whole class. They do ask whether the prescriber stayed in scope, did a real exam, and used a lawful pharmacy (Peptide Journal, 2026; ByrdAdatto, n.d.).
What the New Mexico Board of Nursing Said
In September 2026, the New Mexico Board of Nursing published clinical-practice FAQs on peptide therapies. The Board said the page is guidance, not a legal opinion, and it does not change the Nursing Practice Act (New Mexico Board of Nursing, 2026). The answers still give a clear map.
Key points include:
APRNs may prescribe compounded medicines within their population focus and prescriptive authority if they have the education and judgment to do so. The Board uses LACE: licensure, accreditation, certification, and education.
GLP-1 medicines are among the most watched peptides because they help and they carry risk.
A valid patient-provider relationship must exist before prescribing.
A compounded GLP-1 vial must stay patient-specific. It cannot be shared.
Pharmacies should be licensed and able to share sterility testing.
Patients must be told when a product is compounded rather than a brand-name FDA-approved drug.
Reckless prescribing—not peptide use alone—invites discipline (New Mexico Board of Nursing, 2026).
New Mexico grants nurse practitioners full practice authority. Texas generally requires a collaborating physician (Peptide Journal, 2026). The clinical standard still looks the same: exam, reason, consent, monitoring, and a clean pharmacy.
The Exam, Telehealth, and Honest Ads
The Board listed what should happen before GLP-1 or related peptide care starts (New Mexico Board of Nursing, 2026):
A health history and a review of current medicines
A check for higher-risk problems, such as family medullary thyroid cancer or MEN-2, pancreatitis, gallbladder disease, kidney disease, pregnancy plans, eating disorders, or frailty
A physical exam and baseline labs when they are needed
Consent that covers benefits, common side effects, serious risks, other options, how long care may last, lifestyle changes, and weight regain after stopping
A written plan and later checks of weight, nutrition, tolerance, and dose
Telehealth can be used when the standard of care is still met. A questionnaire alone is not enough. The prescriber must also be licensed in the state where the patient is located (New Mexico Board of Nursing, 2026). Ads must be truthful. Claims of guaranteed weight loss do not meet professional standards. The Federal Trade Commission watches those claims (New Mexico Board of Nursing, 2026). A med-spa name does not change the duty of the person who evaluates and prescribes.
Food and Muscle Still Come First
The Board was clear: medicine is not the whole treatment. Providers should counsel patients on protein, resistance exercise, lean-mass protection, vitamins, and long-term habits. Skipping that work can lead to muscle loss, frailty, and poor results after the drug stops (New Mexico Board of Nursing, 2026). Integrative clinics make the same point. Peptides work best when you address food, sleep, and movement (Nourish House Calls, n.d.; Evolution Integrative Medicine, n.d.).
How Integrative Chiropractic Care Fits
Teams of integrative chiropractors and nurse practitioners (NPs) work together in integrative medical offices. Most of the time, chiropractors do the manual therapies, biomechanics, and structural rehabilitation. Nurse practitioners, on the other hand, conduct clinical evaluations and have the medical authority to prescribe and oversee therapies (ProCredits, n.d.; Jimenez, 2026a). That split protects both the patient and the license.
Chiropractic care links to peptide treatment by making muscles and bones stronger:
Adjustments and mobilization restore joint motion and lower mechanical stress on nerves and soft tissue.
Better motion lets a person load a tendon, hip, or spine pattern with less guarding.
Rehab—easy isometrics, then controlled loading—tells muscle, tendon, and bone to remodel.
Protein-forward eating provides the building blocks those tissues need.
A legal metabolic peptide, when indicated, may help appetite, blood sugar, and body composition so rehab is easier to finish.
Any tissue-support peptide is an add-on to loading, not a replacement for it (El Paso Back Clinic, n.d.; Gruber Chiropractic, n.d.).
Dr. Jimenez has written that peptides should not be sold as a shortcut to grow cartilage, discs, or ligaments. Food cannot unlock a stuck joint. An adjustment cannot replace protein. Each tool has a job (Jimenez, 2026a).
The El Paso Team: Dr. Jimenez and Dr. Cardenas
Injury Medical Clinic PA in El Paso shows how those roles work in daily care. Dr. Alexander Jimenez, DC, APRN, FNP-BC, CCST, CFMP, IFMCP, ATN, is a dual-licensed chiropractor and board-certified family nurse practitioner. He leads conservative care, rehabilitation, functional medicine, and personal-injury documentation (Jimenez, n.d.).
Dr. Maria Guadalupe Cardenas, MD, is board-certified in internal medicine (NPI #1164426749; Texas MD License #J2933). With more than 40 years of experience as an internist, she serves as medical director and collaborative physician. This multidisciplinary setup is common in integrative or injury clinics, where an MD provides medical direction alongside a chiropractor. The team integrates chiropractic care from Dr. Jimenez with medical oversight by Dr. Cardenas, plus functional medicine, personal injury care, rehabilitation, and related services (Jimenez, n.d.; El Paso Back Clinic, n.d.).
A simple path for crash, sports, or chronic back pain recovery looks like this:
Map the problem with history, exam, and movement testing.
Restore motion with chiropractic and soft-tissue care.
Rebuild muscle and bone loading with graded rehab.
Address nutrition and metabolic gaps.
Add a legal, patient-specific peptide only after the reason, labs, and consent are on the chart.
Clinical Observations on Strength and Recovery
Clinical observations shared by Dr. Jimenez describe peptides as possible signaling helpers, not magic. Progress often looks better when spinal care is paired with inflammation control, body-weight support, protein intake, and sleep (Jimenez, 2026a; El Paso Back Clinic, n.d.). Other clinics describe peptides for recovery, metabolism, gut integrity, sleep, and connective tissue (New Life Physicians, n.d.; RevitalIV, n.d.). Those descriptions are not the same as FDA approval. Patients should ask which product is approved, which is compounded for them alone, and which is still experimental.
Questions to Ask Before Starting
Before any peptide begins, ask four plain questions:
Is this an FDA-approved product or a compounded one?
Who is the licensed prescriber, and which state does the patient live in?
What exam, labs, and follow-up will I receive?
How will chiropractic care, exercise, and nutrition work with the medicine?
Boards expect those answers in the record (New Mexico Board of Nursing, 2026; ByrdAdatto, n.d.). Legal peptide use is a medical act. Integrative chiropractic care is a movement and strength act. When a clinic keeps both lines clear, patients build stronger muscles and bones—and, when appropriate, receive carefully chosen peptide support without a gray-market detour.
Abstract
Subcutaneous testosterone injections place hormone therapy in the fat layer just under the skin instead of deep inside a muscle. Men and women can both receive this type of shot when a clinician decides it is appropriate. The smaller needle is often easier to use at home, and weekly levels can stay more even than with a deep muscle shot. This article explains how the method works, how testosterone supports muscle and bone, and how integrative chiropractic care in El Paso can sit beside medical hormone care. It is an option for people who don’t want pellets or a deep intramuscular injection.
What a Subcutaneous Shot Is
A subcutaneous (SubQ) injection goes into the thin layer of fat beneath the skin. Common sites are the belly and the outer thigh. The needle is short and thin. An intramuscular (IM) shot goes deeper into muscle, often the glute or thigh, and usually requires a longer needle.
Both routes can use the same familiar esters, such as testosterone cypionate or enanthate. The medicine is not a brand-new drug. The change is where the oil sits. Fat has less blood flow than muscle, so the hormone often leaves the depot more slowly. Average blood levels can land in a similar place. The shape of the week is often calmer.
For about eighty years, deep muscle injection was simply the habit. In The Quiet Case for the Subcutaneous Needle, Dr. Thomas A. Hatzilabrou, M.D., of Worldborne Medical, makes a narrow claim: move the same ester from muscle to fat, and therapy can become easier to live with without giving up the average level guidelines care about (Hatzilabrou, n.d.).
That claim is about a route, not a brand.
Why the Weekly Curve Matters
The Endocrine Society and the American Urological Association tell clinicians to restore testosterone to a mid-normal range in men who truly need treatment, match the plan to the person, and check labs on a schedule.
Two plans can share the same average and still feel like different weeks. A deep IM shot can spike high, then sag before the next dose. People feel that sag as low energy, low mood, or a crash. Modeling of testosterone enanthate found that SubQ dosing blunts that peak-to-trough swing. The average is the number on the lab report. The swing is the number a person lives in (Hatzilabrou, n.d.; Figueiredo et al., 2022).
A review found SubQ testosterone to be feasible, practical, and reasonable for routine use, with comparable mean levels. A 52-week study of weekly SubQ enanthate found that 92.7% of men were in the target range by week 12, and more than 95% reported no injection-related pain.
One dosing rule matters at every switch visit. A milligram under the skin may not equal a milligram in the muscle. After a change, assess the level and how the person feels. Do not assume syringe-for-syringe equality.
SubQ Testosterone for Men and for Women
Both men and women can receive SubQ testosterone when a licensed clinician chooses that plan. The smaller needle is often more convenient for women and for anyone who prefers not to receive a deep glute injection.
The research is not even, and that honesty belongs here.
In men with low testosterone, SubQ shots have produced target-range levels and better comfort than IM.
In gender-affirming care, people who switched from IM to SubQ often preferred SubQ, and levels still reached the intended range.
In women, no testosterone product is FDA-approved in the United States. Use is off-label. The goal is a physiologic, premenopausal-range level—not a male dose. The strongest randomized evidence in women is still transdermal gel, not injection (Hatzilabrou, n.d.).
So SubQ can be easier as a technique. It is not automatically the best-proven female route. Any plan in women should stay inside a safe female range, with labs to prove it. Start low. Go slow. Watch skin, hair, voice, and mood.
What This Route Wins On
If average exposure is close to a tie, daily life breaks the tie.
A short, fine needle is easier to use on your own.
Pain and dread before the shot are usually lower.
There is no awkward reach to the glute and less concern about the sciatic path.
The week can feel steadier.
Cost can stay low because the same generic esters are used.
There is no skin-to-skin transfer risk like gels and patches.
Needle fear is common. It turns a five-minute task into the one a person keeps putting off. A delayed dose becomes a missed dose. A missed dose becomes “this isn’t working.” An easier shot is not a luxury. It is how long-term care survives.
Safety does not get lighter because the needle is shorter. High red-cell count, fertility changes, prostate checks in men, and androgenic effects in women track with the hormone level, not with “IM versus SubQ.” Monitoring stays the same.
How the Home Shot Is Done
A clinician teaches the first doses. The usual steps are simple:
Wash hands. Set out a clean syringe, a short needle (often 25- to 30-gauge and about half an inch), an alcohol wipe, and a sharps container.
Choose a clean site on the abdomen or outer thigh. Rotate sites.
Pinch a fold of skin. Insert the needle at about a 45-degree angle. Inject slowly.
Do not share syringes. Place used needles in a sharps box.
Xyosted is one FDA-cleared weekly auto-injector for men that is used in the abdomen. Some clinics use compounded syringes. The treating clinician still manages the dose, storage, and follow-up.
This method is straightforward for people who don’t want pellet placement or a deep muscle shot. It is still an injection. It is a middle-path option.
What Testosterone Does for the Body
Testosterone helps the body maintain lean muscle, support bone health, recover after strain, and maintain energy and drive. When levels stay too low, people often feel weak, foggy, and slow to bounce back. Stairs feel taller. Rehab after a sprain, a fall, or a car crash lasts longer.
That is the link to musculoskeletal health. Weaker muscles mean less support around the spine, hips, and knees. Joints take more load. Guarding becomes a habit. Sleep and mood often fall with the strength loss.
A steadier hormone curve does not replace exercise or alignment work. It can give muscle and bone a clearer internal signal while those programs run.
How Integrative Chiropractic Care Fits
Hormone therapy works inside the body. Chiropractic care works on the frame that carries the body.
When the spine and pelvis are restricted, muscles stay tight. Joints load on one side. The nervous system stays loud. That mix can blunt the gains people hope to see from hormone care. Integrative chiropractic care aims to restore motion, ease muscle tightness, and improve how the body shares load. Strength work then has a better platform for these gains.
In my clinical observations, patients often report easier hip and low-back mechanics after treatment for spinal and pelvic restrictions alongside other therapies. I have also seen some men do better when large, infrequent depot shots are changed to smaller, more frequent SubQ doses. The mid-cycle crash—fatigue, irritability, a sense that “the shot wore off”—often settles when the curve flattens. Labs still decide the number. The person decides whether the week feels livable (Jimenez, n.d.).
Chiropractic care does not replace testosterone. Testosterone does not replace an adjustment, a rehab plan, or a strength progression. Together they treat the signal and the structure.
The El Paso Team Model
Injury Medical Clinic PA uses a multidisciplinary model. I serve as clinical director, a chiropractor, and a board-certified family nurse practitioner. Dr. Maria Guadalupe Cardenas, MD, is board-certified in internal medicine (NPI #1164426749, Texas MD License #J2933). She has more than 40 years of experience as an internist and serves as medical director and collaborative physician.
This setup is common in integrative and injury clinics. The MD provides medical direction, internal medicine risk review, and hormone oversight. The chiropractic and rehab team addresses alignment, soft tissue, personal injury recovery, and return to work or sport. Functional medicine adds labs, nutrition, sleep, and gut-muscle links so the plan isn’t just a shot.
A person in this model may move through:
Medical review of symptoms, medicines, fertility goals, and safety screens
Targeted hormone and metabolic labs
Chiropractic care for spinal and pelvic mechanics
Rehabilitation for strength, balance, and daily demands
Nutrition and recovery habits that support hormone work
Follow-up labs for testosterone, hematocrit, and PSA when indicated
Main East Side clinic: 11860 Vista Del Sol, Suite 128, El Paso, TX 79936. Office: 915-850-0900 or 915-412-6677.
Who This Option May Suit
SubQ testosterone may be worth a supervised talk when:
Labs and symptoms support treatment, and the person can learn a home shot.
Deep IM shots cause pain, fear, or missed doses.
Pellets feel like too much commitment or are difficult to fine-tune.
Gels are messy or raise transfer concerns at home.
The goal is a steadier week, not a bigger peak.
It is a poor first choice when fertility is an immediate goal, when there is a prostate or breast cancer concern, when hematocrit is already high, or when a woman needs the route with the strongest female trial data. Those calls belong in the clinic.
Conclusion
The quiet case for the subcutaneous needle is simple. Same ester. Different depot. Comparable average levels for many patients. It’s a shot that most people can keep getting. Pair that with integrative chiropractic care, and the aim isn’t just a better lab printout. The aim is a body that can still move.
This article is educational. The FDA does not review compounded medicines in the same way it reviews approved branded products. The prescribing clinician makes final treatment decisions after a full evaluation.
Integrative Nerve Block and Forehead Lesion Removal: A Step-by-Step, Evidence-Based Guide for Patients and Clinicians
Abstract: In this educational post, I walk you through a patient-centered, step-by-step approach to performing a supraorbital and supratrochlear nerve block. This approach helps comfortably remove a small forehead lesion. I present the latest findings from leading researchers on regional anesthesia safety, dosing, and anatomical precision. I also explain how integrative chiropractic care, functional medicine, and medical oversight fit into a modern multidisciplinary practice. You will learn the anatomy of the supraorbital and supratrochlear nerves. Specifically, you will discover why targeted nerve blocks reduce pain with minimal medication. You will also see how we coordinate between internal medicine and chiropractic. You will also learn how we embed rehabilitation, personal injury protocols, and functional strategies into the patient’s care plan at Injury Medical Clinic PA in El Paso, Texas.
About Our Integrative Care Team
I am Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. I practice at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas. Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933) provides medical oversight for modern, integrative musculoskeletal and functional care. Dr. Cardenas has served patients for more than 40 years. As our medical director and collaborative physician, she ensures evidence-based protocols, safety, and continuity of care. Together, we integrate:
Chiropractic and manual therapies
Medical diagnostics and procedural oversight
Functional medicine and systems biology
Personal injury care and comprehensive rehabilitation
Neuromuscular re-education and ergonomic guidance
Patient-Friendly Roadmap: Forehead Lesion Removal with Precision Nerve Blocks
Today, I describe the process and reasoning behind using a supraorbital and supratrochlear nerve block to comfortably remove a small forehead lesion. This approach minimizes systemic anesthetic exposure. Moreover, it improves pain control at the exact site of care. It allows a calm, efficient procedure.
Why Use Regional Nerve Blocks for Forehead Lesions?
Targeted analgesia: Blocking the supraorbital and supratrochlear nerves numbs sensation to the forehead and anterior scalp, producing a painless window for dermatologic procedures.
Reduced need for multiple local injections: Instead of repeatedly infiltrating the lesion with anesthetic, a well-placed block numbs the area broadly, lowering the total dose.
Faster onset and reliable effect: These superficial branches are accessible, allowing precise anesthesia with low-volume lidocaine, minimizing risk when properly dosed and monitored.
Patient comfort and safety: Patients often report lower anxiety and discomfort when they experience quick, controlled analgesia before lesion excision.
The Anatomy: Finding the Target Safely
When planning a forehead block, topographical anatomy and tactile confirmation guide safe technique.
Supraorbital nerve: A branch of the ophthalmic division (V1) of the trigeminal nerve, exiting through the supraorbital notch or foramen typically located along the superior orbital rim. Clinically, we palpate just above the eyebrow in a vertical line superior to the center of the pupil. This region carries cutaneous sensation for the mid-forehead and anterior scalp.
Supratrochlear nerve: Also from V1, it emerges more medially, above the inner canthus of the eye, and travels along the medial superior orbital rim to supply sensation to the medial forehead and glabellar region.
Understanding this anatomy avoids intravascular injection. It protects the globe and ensures predictable coverage with small volumes.
Step-by-Step: My Clinical Technique
To keep the experience clear and comfortable, I narrate each step. This includes reassuring the patient and dosing safely.
Identify landmarks: I palpate the orbital rim and align my injection points:
For the supraorbital nerve: just superior to the mid-pupillary line above the eyebrow.
For the supratrochlear nerve: at the medial orbital rim above the inner canthus.
Prepare the skin: I clean the area thoroughly with alcohol to reduce microbial load.
Pinch and stabilize: I gently pinch the skin to control superficial motion and provide mild counter-stimulation that can reduce the perception of needle entry.
Needle placement and bone touch: Using a fine-gauge needle, I advance carefully until I lightly contact bone at the superior orbital rim—this tactile stop confirms I am at the correct depth and location without traversing deeper structures.
Aspirate and inject safely: After confirming safety, I inject approximately 0.5 mL of lidocaine at each site. With careful technique, I feel a soft bulge against my thumb, confirming adequate local spread near the nerve.
Pressure and observation: I apply gentle pressure to limit bruising, monitor for comfort, and reassess coverage.
Supplemental local infiltration: If needed for the lesion margins, I add a small ring of local infiltration around the lesion to strengthen anesthesia precisely where the excision will occur.
Proceed with the procedure: Once comfort is confirmed, we remove the lesion with attention to aseptic technique and cosmetic incision alignment.
Physiological Basis: How Local Anesthetics Work
Sodium channel blockade: Agents like lidocaine enter neuronal membranes and block voltage-gated sodium channels, preventing the depolarization needed to conduct pain signals. This effect is reversible and concentration-dependent.
Fiber sensitivity: A-delta and C fibers (pain-transmitting) are more susceptible to blockade than larger motor fibers in this region, which is why sensation is selectively reduced without affecting facial expression.
pH and onset: Lidocaine is weakly basic; tissue pH influences ionization and the speed of membrane penetration. Forehead tissue is typically well perfused, supporting consistent onset.
Safety margin: Low-volume, superficial injections at the specified sites minimize the risk of intravascular injection and systemic toxicity while providing broad cutaneous anesthesia.
Evidence-Based Considerations: Dosing, Safety, and Monitoring
Contemporary literature highlights practical safeguards and dosing strategies for facial regional blocks:
Use the lowest effective dose to achieve sensory blockade, especially in facial procedures with small fields (NYSORA – Peripheral nerve blocks).
Watch for early signs of local anesthetic systemic toxicity (LAST), such as perioral numbness, tinnitus, metallic taste, or CNS changes; keep resuscitation protocols ready if using larger volumes, though small facial blocks carry an extremely low risk (American Society of Regional Anesthesia – LAST checklist).
Consider the patient’s comorbidities, medications, and allergies, particularly with internal medicine oversight to ensure whole-person safety.
In our clinic, Dr. Cardenas reviews medical risk factors and ensures that protocols match the patient’s cardiovascular, neurologic, and metabolic profile, integrating internal medicine safeguards into a musculoskeletal and procedural workflow.
Integrative Chiropractic Care: Why It Fits and How We Use It
Chiropractic and functional rehabilitation enhance outcomes before and after minor procedures by optimizing soft tissue tone, posture, and neuromuscular control.
Pain modulation and autonomic balance: Gentle cervical and thoracic mobilization, myofascial release, and breathing retraining downregulate sympathetic drive that can heighten pain perception, facilitating smoother procedures and better recovery. Clinical observations in our practice show that patients experience lower tension and improved tolerance when we apply pre-procedural soft tissue techniques judiciously (El Paso Back Clinic – Clinical observations and outcomes).
Postural optimization: Forward head posture and frontal muscle overuse can contribute to tension headaches and frontal neuralgia; chiropractic care, ergonomic counseling, and targeted corrective exercise reduce strain on the supraorbital and supratrochlear pathways.
Scar management and tissue glide: Following lesion removal, gentle scar mobilization and instrument-assisted soft tissue techniques can improve collagen alignment and prevent restriction of the frontalis and corrugator supercilii fascia, improving comfort and aesthetics.
Integrative care is not just about manual techniques—it is about aligning nervous system regulation, tissue health, and biomechanics to support healing. Paired with precise anesthesia and medical oversight, this approach provides comprehensive, individualized care.
Functional Medicine Integration: Systems-Based Support for Healing
We incorporate functional medicine principles to support tissue repair, immune balance, and skin health:
Nutritional support: Adequate protein, vitamin C, zinc, and omega-3 fatty acids support collagen synthesis, angiogenesis, and inflammation resolution. For patients with recurring skin lesions or delayed healing, we assess dietary intake and relevant labs.
Inflammation mapping: We screen for systemic inflammatory drivers (sleep apnea, gut dysbiosis, chronic stress) and address them with lifestyle, sleep hygiene, and targeted nutraceuticals when appropriate (IFM – Functional medicine approaches to inflammation).
Dr. Cardenas’s internal medicine oversight complements this approach by evaluating comorbidities, adjusting medications, and coordinating lab work to ensure safety and efficacy.
Personal Injury and Rehabilitation: Restoring Function and Confidence
In personal injury cases—such as facial trauma from accidents—regional nerve blocks, minor procedures, and rehabilitation may be combined:
Acute care coordination: Medical evaluation to rule out orbital fractures, cranial nerve injuries, or hematomas, followed by precise analgesia and wound management.
Rehabilitation pathway: Chiropractic-guided cervical stabilization, vestibular exercises if indicated, and postural retraining to reduce head strain and promote healing without exacerbating neural sensitivity.
Return-to-work planning: Ergonomic adjustments, task modification, and graded exposure to activities to prevent flare-ups in the frontal musculature and peri-orbital tissues.
Our clinic focuses on structured progressions and measurable outcomes, ensuring patients move from acute comfort to long-term resilience.
Clinical Observations: What We See in Practice
Drawing from my clinical experience and shared outcomes reported through our channels:
Patients frequently report improved tolerance and reduced anxiety with a clear explanation of the nerve block process and gentle stabilization of the injection site.
Low-volume, well-placed lidocaine blocks provide reliable anesthesia for forehead lesions without distorting tissue architecture, making cosmetic closures more precise.
Integrating soft tissue work and breathing strategies before the procedure helps attenuate anticipatory pain and sympathetic arousal, making the block feel less intense.
Post-procedure, patients benefit from simple forehead mobility drills, hydration, and nutritional support to optimize scar remodeling—leading to smoother outcomes and fewer adhesions.
In personal injury settings, coupling procedural precision with spine care and functional rehab accelerates return to normal activities and reduces downstream pain syndromes.
For more insights into our integrative protocols and case studies, visit our practice resources:
El Paso Back Clinic: https://elpasobackclinic.com/
Professional profile: https://www.linkedin.com/in/dralexjimenez/
Our Multidisciplinary Workflow: Safety, Clarity, and Results
Here is how we structure patient care at Injury Medical Clinic PA:
Intake and evaluation:
Medical history, medications, allergies, and risk factors
Anatomic mapping and functional assessment
Coordinated plan:
Internal medicine oversight by Dr. Cardenas
Procedural planning by me with a clear anesthesia strategy
Functional and chiropractic support to regulate nervous system tone and improve tissue health
Intervention:
Pre-procedural soft tissue preparation when appropriate
Supraorbital and supratrochlear nerve blocks
Lesion removal with attention to aesthetics and aseptic technique
Recovery and follow-up:
Scar care, nutrition, and movement guidance
Ergonomic and postural coaching
Monitoring and adjustments coordinated between disciplines
This approach ensures patients receive precise, compassionate care grounded in modern evidence.
Practical Tips for Patients
Ask about the plan: Understanding your nerve block and lesion removal steps reduces anxiety and improves your experience.
Share your history: Disclose medications, bleeding risks, allergies, and prior reactions to local anesthetics.
Prepare for recovery: Plan for gentle care of the site, adequate hydration, and nutrition; avoid picking or excessive facial expressions until sutures are removed.
Follow movement and posture guidance: Simple exercises and ergonomic habits support better outcomes and comfort.
Why This Matters: Precision Care with Whole-Person Support
Facial procedures deserve meticulous technique. By combining anatomical precision, low-dose regional anesthesia, and integrative care, we honor both the science and the human experience of healing. With Dr. Cardenas’s medical leadership, evidence-based protocols, and chiropractic-functional rehabilitation, we deliver care that is safe, efficient, and tailored to your needs.
Key Takeaways
Supraorbital and supratrochlear nerve blocks provide targeted, efficient analgesia for forehead lesion removal.
Low-volume lidocaine with careful anatomical technique enhances safety and cosmetic outcomes.
Integrative chiropractic and functional medicine support nervous system regulation, tissue healing, and long-term resilience.
Internal medicine oversight ensures comprehensive risk management and continuity of care.
A multidisciplinary pathway—from evaluation to rehabilitation—optimizes patient comfort and outcomes.
Evidence-Based Excision of a Dysplastic Nevus With Integrative Chiropractic and Functional Medicine Support
Abstract
In this educational post, I guide you through a precise, evidence-based approach to excising a dysplastic nevus with moderate atypia using a pain-free field block technique and narrow margins. I explain my step-by-step method, the anatomical and physiological rationale for local anesthesia and intradermal infiltration, and the clinical decision-making behind margin selection. I also introduce our multidisciplinary model in El Paso, Texas, where I work alongside Dr. Maria Guadalupe Cardenas, MD, our internal medicine medical director, to integrate chiropractic care, functional medicine, personal injury care, rehabilitation, and patient-centered follow-up. Throughout, I present the latest findings from leading dermatologic surgery and pain science researchers, connect these principles to chiropractic neurophysiology, and describe how integrative chiropractic care fits into peri-procedural and long-term outcomes.
Dysplastic Nevus Excision: My First-Person Clinical Approach
I am Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. Today, I share my clinical approach to excising a dysplastic nevus with moderate atypia—an area previously shaved and biopsied about one month prior—using narrow but appropriate margins and a meticulous, pain-minimizing anesthesia technique. As the patient sits comfortably, I begin by cleaning the site with alcohol, re-prepping to reduce transient skin flora before marking the excision plan.
Clinical context: The original lesion measured approximately 5 by 6 millimeters. With moderate atypia, evidence supports complete removal with narrow margins when severe atypia or melanoma features are absent.
Excision planning: I use a sterile template to visualize an elliptical excision, aiming for about 2-millimeter margins around the residual scar. Because the original lesion was 5 x 6 mm, the post-biopsy excision boundary effectively spans about 5 mm beyond the original footprint to ensure complete removal of dysplastic tissue, both visible and microscopic, along the shave plane.
Creating a Pain-Free Field Block: Technique and Rationale
My goal in minor surgical procedures is a pain-free patient experience. I set up a field block—a circumferential ring of local anesthetic that interrupts sensory nerve conduction—so the patient does not feel the needle or the intradermal distension.
Anesthetic choice: I use 1% lidocaine with epinephrine.
Lidocaine blocks voltage-gated sodium channels on nociceptive and mechanoreceptive fibers, preventing depolarization and conduction of pain signals.
Epinephrine induces local vasoconstriction via alpha-adrenergic receptors, prolonging lidocaine’s residence time, reducing bleeding, and minimizing systemic absorption, thereby extending anesthesia duration and improving hemostasis.
Spray analgesia: Before needle entry points, I apply a brief vapocoolant “freeze spray.” The cold exposure rapidly reduces superficial nociceptor firing (TRPM8-mediated cold sensing and transient gating of pain fibers), ensuring the patient feels no needle prick. He confirms: “No pain.” This instant desensitization is especially helpful in field blocks that require multiple passes.
Needle Control, Intradermal, and Subcutaneous Delivery: Why It Works
I insert the needle at a chosen point, advance subcutaneously, and inject as I withdraw. Before exiting the skin, I rotate the bevel and repeat on the opposite side. This “inject-on-withdrawal” method creates an even distribution of anesthetic parallel to dermal nerve plexuses.
Physiological basis:
The dermis contains a dense network of free nerve endings and mechanoreceptors. Intradermal distension with anesthetic rapidly silences A-delta and C-fiber nociceptors via sodium channel blockade.
Subcutaneous infiltration saturates the tissue beneath the lesion, interrupting deeper cutaneous nerve branches that feed the operative field.
Technique advantages:
By threading the needle just past midline and injecting on withdrawal, a visible wheal forms—a sign of intradermal spread.
Slightly bending a longer needle allows steering to contour around the template. This helps me remain just outside the marked ellipse, preventing anesthetic pooling in the incision path while fully covering perilesional innervation.
Multiple entry points may be necessary for large or anatomically curved sites. With cooling spray and prior subcutaneous saturation, new entry points remain pain-free.
The patient confirms repeatedly: no pain. This validates that the circumferential anesthetic fence is intact and effective.
Margin Selection for Moderate Atypia: Evidence-Based Considerations
A dysplastic nevus with moderate atypia warrants complete excision, but the margin need not be wide if there is no severe atypia or melanoma in situ. Contemporary studies suggest that 2 mm clinical margins often achieve histologic clearance for moderate atypia, particularly when initial shave biopsy delineated architecture and ruled out more aggressive pathology (Kittler et al., 2020; Swetter et al., 2019).
Why narrow margins:
Preserve healthy tissue and reduce scarring while achieving oncologic adequacy for moderate atypia.
Epinephrine-assisted hemostasis reduces bleeding and improves visibility, allowing precise adherence to planned margins.
Post-excision pathology:
We send the specimen for histologic assessment to confirm clear margins and exclude residual atypia. If margins are positive or close, we discuss re-excision based on the pathologist’s recommendations and the patient’s goals.
Step-by-Step Workflow: From Prep to Incision
Second prep: I re-clean the site and confirm sterile field integrity.
Template marking: I trace an ellipse aligned with skin tension lines (Langer lines) to enhance cosmetic outcomes and minimize wound tension.
Field block completion: Intradermal wheals surround the template; subcutaneous anesthesia saturates the bed beneath the lesion.
Patient check-in: I ask about sensation; he reports no pain.
Incision and removal: With a sharp blade, I incise along the outside of the template, dissect through the dermis and minimal subcutis to remove the lesion and scar bed en bloc. I maintain hemostasis with epinephrine and use meticulous cautery only when appropriate for the site.
Layered closure: Where needed, I approximate with deep absorbable sutures to reduce tension, then close the epidermis with fine non-absorbable sutures aligned to natural creases. This supports rapid healing and improved cosmesis.
Integrative Chiropractic Care in Dermatologic Procedures: Why It Matters
While excising a skin lesion may seem purely dermatologic, integrative chiropractic care supports peri-procedural comfort, autonomic regulation, and recovery. At Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, I collaborate closely with Dr. Maria Guadalupe Cardenas, MD (Board Certified Internal Medicine; NPI #1164426749; Texas License #J2933). Our model leverages chiropractic neurophysiology, functional medicine, and internal medicine oversight to optimize patient outcomes.
Chiropractic neurophysiology:
Gentle cervical and thoracic mobility work can reduce sympathetic overactivity and anxiety, thereby lowering perceived pain via descending inhibitory pathways (periaqueductal gray modulation).
Soft tissue techniques around the shoulder girdle and thoracic cage relieve myofascial tension that can amplify cutaneous pain through central sensitization.
Autonomic balance:
Breathing mechanics, rib cage mobility, and vagal tone optimization help stabilize heart rate and blood pressure during minor procedures. Patients report better comfort and less discomfort from injections when sympathetic tone is moderated.
Functional ergonomics:
Post-procedure, appropriate postures and scapular mechanics reduce strain on healing sites in the back, shoulder, or trunk areas, decreasing shear forces across the incision and promoting better scar formation.
Internal Medicine Oversight: Safety, Risks, and Comorbidities
Dr. Cardenas provides medical direction and co-management for patients with complex medical histories. Together, we tailor anesthesia choices, wound plans, and follow-up based on comorbidities.
Hypertension and cardiovascular disease:
Epinephrine in lidocaine is generally safe for small dermatologic fields, but we confirm medication lists (beta-blockers, MAO inhibitors) and assess cardiovascular stability. Internal medicine oversight ensures risk stratification and informed consent aligned with the patient’s health status.
Diabetes and wound healing:
Glycemic control is vital to prevent infection and optimize collagen synthesis and cross-linking in the wound. We coordinate glucose monitoring and provide nutrition guidance consistent with functional medicine principles that support wound healing (adequate protein, vitamin C, and zinc).
Anticoagulants and antiplatelets:
For patients on warfarin, DOACs, or aspirin, we plan hemostasis strategies, pressure dressings, and post-op monitoring. Most dermatologic excisions proceed without stopping therapy, but Dr. Cardenas ensures that decisions align with evidence and safety.
Functional Medicine and Nutritional Support for Skin Healing
As a Certified Functional Medicine Practitioner (CFMP, IFMCP), I incorporate nutritional and lifestyle strategies to enhance skin repair.
Nutrient optimization:
Protein targets (1.2–1.6 g/kg/day in older adults during recovery) support fibroblast activity and collagen deposition.
Vitamin C and zinc are essential cofactors in collagen hydroxylation and DNA synthesis; deficiencies prolong healing time.
Omega-3 fatty acids can modulate inflammatory cytokines, promoting resolutive healing without impairing necessary inflammatory phases.
Glycemic control and inflammation:
Stable blood sugar reduces advanced glycation end-products that stiffen collagen and impair tensile strength of healing tissue.
Sleep and stress:
Adequate sleep supports growth hormone and tissue repair, while stress reduction techniques blunt cortisol’s catabolic effects on skin.
Personal Injury Care Integration: Biomechanics and Scar Protection
In personal injury cases, excision sites often lie across regions of high biomechanical load. Our integrative chiropractic and rehabilitation approach minimizes scar widening and pain flares.
Biomechanics:
Assess regional movement patterns to reduce shear across the healing incision.
Educate on movement strategies—log-rolling, hip hinge, and scapular setting—to protect the site in the first 1–2 weeks.
Myofascial release:
Gentle, indirect techniques adjacent to the excision (not on the wound) decompress fascial layers that, if tight, can pull on the scar and provoke pain.
Graded activity:
As collagen matures (weeks 3–6), we introduce light isometrics and, later, controlled mobility to align collagen fibers along lines of stress and improve scar pliability.
Keep the area clean and protected for the first 24–48 hours; petrolatum-based occlusion maintains moisture and accelerates re-epithelialization.
Scar modulation:
Silicone sheets or gels reduce hypertrophic scarring by regulating hydration and fibroblast activity.
Gentle massage after complete epithelialization (usually after suture removal) remodels scar tissue, improving mobility and sensation.
Sun protection:
UV exposure can cause hyperpigmented scars; broad-spectrum SPF 30+ prevents cosmetic discoloration and protects collagen integrity.
Collaborative Model at Injury Medical Clinic PA: Roles and Workflow
Our El Paso clinic exemplifies integrative care, common in injury and functional medicine settings, where an MD provides medical direction alongside a chiropractor. Dr. Cardenas, MD, serves as the medical director and collaborative physician, and I lead integrative chiropractic and functional care.
Pre-procedure:
Medical review: Dr. Cardenas assesses comorbidities, medications, and risk factors.
Chiropractic preparation: I provide autonomic regulation techniques and positioning strategies to enhance comfort and reduce nociception.
Procedure:
Evidence-based anesthesia and excision: I perform a field block and precise excision, with hemostasis and ongoing patient communication.
Post-procedure:
Follow-up: Internal medicine oversight ensures safe healing. Functional medicine guidance supports nutrition and lifestyle modifications.
Rehabilitation: Chiropractic-directed movement strategies, scar protection, and graded return to activity.
Clinical Observations from Practice: Patient Comfort and Outcomes
Across my clinical work in El Paso, patients often report extraordinarily low pain during our field blocks. As reflected in today’s case, the patient experienced no pain during multiple entries and intradermal distension—exactly the outcome we aim for.
Patient Education and Safety: What to Expect After Excision
Normal sensations: Mild tightness or itch as healing progresses; avoid scratching.
Red flags: Excessive bleeding, spreading redness, purulent discharge, fever, or severe pain—contact us immediately.
Activity:
Keep the area dry for the first day unless instructed otherwise.
Avoid stretching or heavy lifting that places tension across the excision line until cleared.
Follow-up:
Suture removal typically occurs within 5–14 days depending on body location and tension.
Pathology results guide any additional steps. If margins are clear, we move to standard surveillance; if not, we discuss re-excision.
Latest Research Insights Supporting This Approach
Local anesthesia with epinephrine is safe and effective for most dermatologic procedures, enhancing duration and hemostasis without increasing necrosis when used within recommended doses (Krunic et al., 2004; Alam & Dover, 2008).
Narrow margins for moderate atypia in dysplastic nevi can be appropriate when clinical-pathologic correlation rules out severe atypia or melanoma (Swetter et al., 2019; Kittler et al., 2020).
Vapocoolant sprays reduce injection pain by activating cutaneous cold receptors and transiently inhibiting nociception (Gallagher et al., 2009).
Layered closure aligned with tension lines optimizes cosmetic outcome and reduces dehiscence risk (Borges, 1984; Alam & Wrone, 2007).
Integrative care models with chiropractic and internal medicine collaboration can improve patient satisfaction, reduce pain, and support functional recovery via autonomic modulation and biomechanical optimization (Goertz et al., 2018; Schneider et al., 2015).
Why Integrative Chiropractic Care Fits in This Treatment Plan
Whole-person care: Skin health intersects with systemic physiology—autonomic tone, metabolic status, and biomechanics. Chiropractic and functional medicine address these intersections.
Peri-procedural calm: Breathing and gentle mobilization improve patient comfort and experience during minor surgery.
Long-term outcomes: Scar integrity and function rely on movement patterns, tissue nutrition, and stress regulation—core areas where chiropractic and functional medicine strategies excel.
Our Commitment to Modern, Evidence-Based, Patient-Centered Care
At Injury Medical Clinic PA, our mission is to provide modern, evidence-based care that respects the patient’s experience, safety, and long-term health. By integrating internal medicine oversight from Dr. Cardenas with chiropractic and functional medicine strategies, we ensure that each procedure—from a simple excision to complex injury rehabilitation—benefits from rigorous science and compassionate execution.
Unlocking Tendon Healing: An Inside Look at Percutaneous Tenotomy
Abstract
Chronic tendon pain, or tendinopathy, can be debilitating and significantly affect quality of life. Traditional treatments often provide only temporary relief, leaving patients searching for more definitive solutions. In this educational post, I will explore a groundbreaking, minimally invasive procedure known as percutaneous tenotomy. We will get into the science behind this ultrasound-guided technique, which removes damaged tendon tissue to stimulate the body’s natural healing processes. Specifically, we will examine the two leading methods, Tenex and TenJet, and discuss their applications for conditions like tennis elbow, Achilles tendinopathy, and plantar fasciitis. As we explore the mechanics of this procedure, I will also explain how we at Injury Medical Clinic integrate this advanced medical intervention into our comprehensive, multidisciplinary approach. This includes integrative chiropractic care, functional medicine, and personalized rehabilitation, all under the medical direction of Dr. Maria Guadalupe Cardenas, MD, to ensure our patients achieve optimal, long-lasting recovery.
As a practitioner with dual credentials in chiropractic (DC) and as an advanced practice registered nurse (APRN), I have dedicated my career to bridging gaps between medical disciplines. My goal has always been to find the most effective, evidence-based solutions for my patients. Today, I want to share insights into a fascinating procedure that has revolutionized how we treat chronic tendon pain: percutaneous tenotomy. This technique, once confined to surgical suites, is now a powerful tool accessible in an office setting, offering hope to those suffering from persistent tendinopathies.
At our practice, Injury Medical Clinic, we pride ourselves on a collaborative, integrative model. Our medical director and collaborative physician, Dr. Maria Guadalupe Cardenas, MD, an internist with over 40 years of experience, provides essential medical oversight. This partnership allows us to combine my expertise in chiropractic, functional medicine, and rehabilitation with her deep knowledge of internal medicine. This combination ensures that when we recommend and facilitate a procedure like percutaneous tenotomy, it is part of a holistic and well-managed treatment plan designed for comprehensive healing.
Understanding Chronic Tendinopathy: When Rest Isn’t Enough
Before we explore the solution, let’s understand the problem. Tendinopathy is not simply inflammation, as the term “tendinitis” might suggest. It’s a degenerative condition where the collagen fibers that make up the tendon begin to break down. This often happens with repetitive overuse, which prevents the tendon from healing properly. Instead of organized, strong collagen, the body lays down a disorganized, weak, and painful matrix of scar tissue. This abnormal tissue is metabolically inactive, has a poor blood supply, and doesn’t respond well to conservative treatments like rest, ice, or stretching.
Clinically, I see patients who have been struggling for months, or even years, with conditions such as:
Tennis Elbow (Lateral Epicondylitis or Extensor Carpi Radialis Brevis Tendinopathy)
Golfer’s Elbow (Medial Epicondylitis)
Jumper’s Knee (Patellar Tendinopathy)
Achilles Tendinopathy
Plantar Fasciitis (Plantar Fasciopathy)
These individuals often report a cycle of pain, temporary relief, and frustrating recurrence. This is precisely where a more targeted intervention becomes necessary.
Percutaneous Tenotomy: A Minimally Invasive Revolution
Percutaneous tenotomy is a cutting-edge, FDA-approved procedure designed to precisely remove the damaged, degenerative tissue from a tendon under ultrasound guidance. The term “percutaneous” means “through the skin,” highlighting its minimally invasive nature. Unlike open surgery, which requires large incisions and longer recovery times, percutaneous tenotomy is performed through a very small entry point, often requiring just a sterile bandage afterward.
The core principle is simple but powerful: by selectively debriding (removing) the diseased tissue, we create a controlled injury that triggers the body’s natural inflammatory and healing cascade. This process brings fresh blood, growth factors, and specialized cells to the area, encouraging new, healthy tendon tissue to grow.
Leading researchers in musculoskeletal medicine have shown that this targeted debridement is key to breaking the cycle of chronic pain and dysfunction (Knutsen et al., 2023). It’s a precise and elegant solution that addresses the root cause of the problem.
The Two Leading Techniques: Tenex and TenJet
Two primary technologies currently dominate the market for percutaneous tenotomy. While both achieve the same goal, they use different mechanisms.
Tenex Health TX System: This technique relies on phacoemulsification, the same ultrasonic energy used in modern cataract surgery. A specialized handheld instrument uses a small, 18-gauge double-lumen needle. The needle tip vibrates at an ultrasonic frequency, emulsifying (liquefying) the targeted pathologic tissue. At the same time, a second lumen within the needle suctions the emulsified debris out of the body. This is performed in real time under direct ultrasound visualization, ensuring that only damaged tissue is removed while the surrounding healthy tendon is preserved.
TenJet System: This technology offers an alternative to ultrasonic energy. It uses a high-velocity, pressurized stream of saline to create a “cutting” effect. The focused water jet precisely dissects and removes the degenerated tissue, which is then aspirated away through the same instrument.
In our collaborative network, we often use the Tenex device for its precision and effectiveness. The procedure is typically performed in an office or a minor procedure suite, making it incredibly convenient for patients. A foot pedal controls the device, and the settings are calibrated for the specific tendon and severity of the condition.
A Glimpse into the Procedure: Debriding Tennis Elbow
To help you visualize how the device works, let’s walk through a typical procedure for extensor carpi radialis brevis tendinopathy, commonly known as tennis elbow. This is one of the most common and well-studied applications for percutaneous tenotomy.
Preparation and Sterilization: The patient is positioned comfortably, and the area is prepped using a sterile technique. The ultrasound probe itself is covered with a sterile sheath to maintain a clean field. Local anesthetic numbs the area completely, ensuring the procedure is painless.
Ultrasound Visualization: The first and most critical step is using the ultrasound to identify the exact location and extent of the tendinopathy. The damaged tissue appears distinct on the screen—often hypoechoic (darker) and thickened compared with the bright, organized fibers of a healthy tendon.
Needle Insertion: Under continuous ultrasound guidance, the provider carefully inserts the Tenex needle through the skin and advances it directly into the degenerated tissue. Real-time imaging lets the provider see the needle tip at all times, ensuring pinpoint accuracy.
Debridement: The provider activates the device with the foot pedal. The ultrasonic tip begins to vibrate, and the provider moves the needle back and forth through the diseased tissue in a technique similar to fenestration (a needling procedure that promotes bleeding and healing). You can often hear a subtle hum as the device works. The device simultaneously suctioned away the emulsified, unhealthy tissue.
Completion: The entire “cutting time” is remarkably short, typically ranging from 30 seconds to two minutes. Once the provider has sufficiently debrided the pathologic area, they remove the needle and apply a small bandage.
This removes the source of pain and creates fertile ground for true healing to begin. Studies have demonstrated significant improvements in pain and function following this procedure for various tendinopathies (Seng et al., 2016).
Our Integrative Approach: Beyond the Procedure
At Injury Medical Clinic, performing a procedure like percutaneous tenotomy is just one part of a larger, more comprehensive approach. True and lasting recovery requires a multi-faceted approach that supports the body’s healing journey from every angle. This is where our unique integrative model, supervised by Dr. Cardenas, truly shines.
1. The Role of Integrative Chiropractic Care
As a chiropractor, I focus on the biomechanical integrity of the entire musculoskeletal system. The tendon issue didn’t arise in isolation. It often results from underlying biomechanical faults, postural imbalances, or compensatory movement patterns. My role, both before and after the tenotomy procedure, is to:
Assess and Correct Joint Dysfunction: I perform specific chiropractic adjustments to the elbow, wrist, shoulder, and even the spine to restore proper joint mechanics. If the joints don’t move correctly, the attached tendons remain under abnormal stress, hindering recovery and increasing the risk of reinjury.
Address Myofascial Restrictions: Using techniques like Active Release Technique (ART) and Graston Technique, we break down adhesions in the muscles and fascia surrounding the affected tendon. This improves flexibility, reduces muscle tension, and helps the tendon glide smoothly.
Prescribe Rehabilitative Exercises: After the procedure, a carefully graded exercise program is crucial. We start with gentle range-of-motion exercises and progress to eccentric loading exercises. Eccentric exercises (lengthening the muscle-tendon unit under load) are scientifically proven to stimulate collagen production and help the new tendon fibers align correctly, making them strong and resilient (Alfredson, 2005).
2. Functional Medicine and Nutritional Support
Healing is a metabolically demanding process. As a Certified Functional Medicine Practitioner (CFMP), I consider the biochemical factors that can support or hinder tissue repair. We may assess for and address:
Systemic Inflammation: Chronic inflammation can impede healing. We recommend anti-inflammatory diets rich in omega-3 fatty acids, antioxidants, and phytonutrients.
Nutrient Deficiencies: Key nutrients like Vitamin C, zinc, manganese, and certain amino acids (proline, glycine) are essential building blocks for collagen. We may recommend targeted supplementation to ensure the body has the raw materials it needs to build a strong new tendon.
Gut Health: Emerging research shows a strong link between gut health and systemic inflammation. Optimizing the gut microbiome can profoundly affect the body’s ability to heal.
3. Medical Oversight and Comprehensive Care
Having Dr. Cardenas as our medical director is invaluable. Her internal medicine expertise ensures we consider all aspects of the patient’s health. She provides medical clearance for procedures, manages any co-existing medical conditions (like diabetes or hypertension) that could affect healing, and can prescribe medications for pain management if necessary. This collaborative oversight ensures patient safety and a truly integrated standard of care that addresses the whole person, not just the injured tendon.
A New Era in Tendon Treatment
Percutaneous tenotomy represents a significant leap forward from older, more invasive methods. When skilled providers use it and integrate it into a comprehensive rehabilitation plan, this powerful tool delivers remarkable outcomes. It bridges the gap between failed conservative care and major surgery.
At our clinic, we use the latest evidence-based research to guide our practice. By combining advanced medical procedures like percutaneous tenotomy with the foundational principles of chiropractic care, functional medicine, and targeted rehabilitation, we create a synergistic healing environment. Our goal is to eliminate your pain, restore your function, strengthen your body, and empower you to return to the activities you love, stronger and more resilient than before.
If you have been struggling with chronic tendon pain, know that there are innovative and effective options available. It may be time to explore a more definitive solution that addresses the true source of your condition.
References
Alfredson, H. (2005). The chronic painful Achilles and patellar tendon: Research on basic biology and treatment. Scandinavian Journal of Medicine & Science in Sports, 15(4), 252–259. https://doi.org/10.1111/j.1600-0838.2005.00478.x
Seng, K., Mohan, P. C. S., & Koh, J. S. B. (2016). Percutaneous ultrasonic tenotomy for chronic tendinopathies: A systematic review. Journal of Orthopaedic Surgery, 24(1), 92–97. https://doi.org/10.1177/160240021602400120
Hydrodistension Treatment for (Frozen) Shoulder Pain and Stiffness
Abstract
As a clinician dedicated to exploring the frontiers of musculoskeletal health, I’m excited to share insights into an advanced, evidence-based procedure for one of the most stubborn and painful conditions we encounter: adhesive capsulitis, more commonly known as frozen shoulder. This condition, marked by severe pain and a progressive loss of shoulder motion, can be debilitating. Today, we’ll journey through the intricacies of a procedure called hydroplasty, or hydrodistension, a technique designed to physically release the constricted shoulder joint capsule.
We’ll review the latest research from leading scientists, including a close look at a hydrodistension procedure performed by a primary care sports medicine doctor. I will explain the physiological basis of this condition, the step-by-step mechanics of the procedure, and most importantly, how we integrate this advanced intervention with our comprehensive, multidisciplinary approach at Injury Medical Clinic. Our model combines medical oversight from Dr. Maria Guadalupe Cardenas, MD, with my expertise in chiropractic, functional medicine, and rehabilitation to create a powerful synergy that promotes not just relief, but true, lasting recovery.
Who We Are
Hello, I’m Dr. Alex Jimenez. With my extensive background in chiropractic, functional medicine, and family nursing, my mission has always been to provide my patients with the most effective, evidence-based treatments. At our clinic, we operate under a collaborative, integrative model. Our medical director, Dr. Maria Guadalupe Cardenas, a board-certified internist with over 40 years of experience, provides essential medical oversight. This partnership allows us to blend the best of conventional medicine with chiropractic care, physical rehabilitation, and functional medicine principles, creating a patient-centered treatment ecosystem.
Today, I want to focus on a particularly challenging condition: frozen shoulder. In our practice, we see many patients who have lost the ability to do simple daily tasks—combing their hair, reaching for a seatbelt, or lifting a grocery bag—because of the intense pain and stiffness of adhesive capsulitis. While conservative care is always our first line of defense, some cases require a more definitive intervention. This is where hydroplasty, also known as hydrodistension, comes in. This post presents the latest findings and highlights the work of leading experts, explaining how this procedure fits within our integrative chiropractic care framework to restore function and improve our patients’ quality of life.
Understanding Adhesive Capsulitis: The “Frozen” Shoulder
Before we explore the solution, it’s crucial to understand the problem. Adhesive capsulitis is an inflammatory condition that affects the glenohumeral joint capsule, the flexible, ligamentous sac that surrounds the ball-and-socket joint of the shoulder.
Pathophysiology: In a healthy shoulder, this capsule is elastic and allows for a wide range of motion. In frozen shoulder, the capsule becomes inflamed, thickened, and fibrotic. It develops adhesions, essentially becoming scarred and contracted. This process shrinks the capsule, physically restricting the movement of the humeral head within the glenoid socket.
The Three Phases: The condition typically progresses through three overlapping stages:
Freezing (Painful) Stage: This is characterized by the gradual onset of diffuse, severe shoulder pain. As the pain worsens, range of motion begins to decrease. Inflammation is the dominant process here.
Frozen (Stiff) Stage: During this phase, the pain may start to subside, but stiffness becomes the primary complaint. The joint capsule has significantly thickened and contracted, leading to a dramatic loss of both active and passive range of motion.
Thawing (Resolution) Stage: In this final stage, the shoulder’s range of motion slowly begins to improve. This phase can be very slow, sometimes lasting for months or even years.
Our goal with any intervention is to shorten these phases and restore function as quickly and completely as possible. This is where the synergy of medical procedures and chiropractic rehabilitation becomes invaluable.
Hydroplasty: A Targeted Intervention for a Constricted Joint
Hydroplasty is a minimally invasive procedure performed under ultrasound guidance. The core principle is simple yet powerful: to inject a large volume of sterile fluid directly into the glenohumeral joint capsule. The goal is to use hydraulic pressure to stretch and ultimately rupture the fibrotic adhesions restricting movement. Think of it like inflating a balloon until it stretches and breaks its constraints.
I want to showcase a respected primary care sports medicine physician. Their meticulous technique provides a clear, real-world example of how this procedure is performed. By understanding his approach, we can better appreciate the precision required and the rationale behind each step.
Here is a visual from an ultrasound-guided procedure. We are looking at the back of the shoulder, across the posterior glenohumeral joint. You can see the deltoid and infraspinatus muscles, the posterior capsule, and the humeral head. The needle is precisely positioned within the joint space, ready to deliver the therapeutic fluid. This image highlights the importance of ultrasound guidance to ensure accuracy and safety.
The Hydrodistension Procedure: A Step-by-Step Breakdown
The approach is methodical and prioritizes patient comfort and procedural success. It breaks down into three key stages. Let’s look at the “why” behind each one.
Step 1: The Suprascapular Nerve Block
The first step isn’t the joint injection itself, but a nerve block targeting the suprascapular nerve at the spinoglenoid notch.
The “What”: A 5 mL syringe of 1% lidocaine is used to numb this nerve. The spinoglenoid notch is a small passageway located just medial to the shoulder joint, where the suprascapular nerve runs.
The “Why”: The suprascapular nerve provides approximately 70% of the sensory innervation to the shoulder joint. By blocking this nerve, we achieve significant analgesia (pain relief). This serves two purposes:
Procedural Comfort: It makes the subsequent, more intensive part of the procedure far more tolerable for the patient.
Short-Term Pain Relief: It provides immediate relief that can last several hours, breaking the pain cycle and allowing gentle movement after the procedure.
This initial step is a clear example of thinking ahead in patient care—addressing pain before it becomes a barrier to treatment.
Step 2: Numbing the Joint Capsule Pathway
Next, the doctor anesthetizes the pathway for the main injection.
The “What”: Using a smaller, 25-gauge needle, the doctor injects a small amount of buffered 1% lidocaine directly into the subcutaneous tissue and down to the posterior glenohumeral joint capsule. He adds sodium bicarbonate to the lidocaine to buffer it.
The “Why”: Lidocaine is naturally acidic, which can cause a stinging sensation upon injection. Adding a bicarbonate buffer raises the solution’s pH, bringing it closer to the body’s natural pH. This simple modification significantly reduces injection discomfort. This step ensures the path for the larger needle is completely numb, further enhancing patient comfort.
Step 3: The Main Injection – Distending the Capsule
This is the therapeutic core of the procedure.
The “What”: A larger, 18-gauge needle is guided under ultrasound into the posterior glenohumeral joint. It’s connected via IV tubing to a large syringe containing the injectate. In protocol, this is a 51 mL cocktail:
10 mL of 1% lidocaine (a short-acting anesthetic)
10 mL of 0.5% ropivacaine (a longer-acting anesthetic for sustained pain relief)
30 mL of sterile saline (the primary fluid for creating hydraulic pressure)
1 mL of Kenalog (40 mg) (a corticosteroid to reduce inflammation)
The “Why”: This is a two-person job for safety and efficacy. While the physician holds the ultrasound probe and guides the needle, a medical assistant pushes the fluid from the syringe. The physician feels the resistance and watches the ultrasound screen in real time. Initially, the fluid flows freely into the small joint space. As the injection continues, pressure builds. On the screen, you can see the posterior capsule dramatically lift off the humeral head as it distends.
The “pop” isn’t always audible, but it’s visible on ultrasound. You see the capsule expand rapidly, then suddenly deflate as the adhesions tear and fluid escapes the joint space. This visual confirmation signifies a successful procedure—the capsule has been released. The combination of anesthetics provides a window of pain relief, while the corticosteroid helps manage the post-procedural inflammation caused by the mechanical tearing of the adhesions.
The Critical Role of Integrative Chiropractic Care Post-Procedure
The hydrodistension procedure is a powerful “reset” button, but it is not the end of the treatment. It is the beginning of a crucial window of opportunity. The adhesions have been broken, but without immediate, proper rehabilitation, they can reform, and the stiffness can return. This is where our integrative model truly shines.
As a chiropractor, I immediately focus on capitalizing on this newly created mobility. The period after hydrodistension is when we can make the biggest gains.
Gentle Mobilization and Adjustments: Immediately after the procedure, while the joint is still numb, we begin gentle, passive range-of-motion exercises. My role includes specific chiropractic mobilizations of the glenohumeral joint and surrounding joints (scapulothoracic, acromioclavicular, and sternoclavicular). These aren’t forceful manipulations but precise, controlled movements designed to guide the joint through its newly regained range and prevent adhesions from reforming. We also assess and adjust the cervical and thoracic spine, as dysfunction in these areas often contributes to poor shoulder mechanics.
Targeted Physical Rehabilitation: Our rehabilitation team designs a progressive program that evolves with the patient.
Initial Phase (Days 1-7): The focus is on pendulum exercises, passive stretching, and active-assisted range of motion. The goal is to maintain the mobility gained from the procedure and manage inflammation.
Intermediate Phase (Weeks 2-6): We introduce active range-of-motion and isometric strengthening exercises for the rotator cuff and scapular stabilizers (like the serratus anterior and rhomboids). Restoring proper scapulohumeral rhythm—the coordinated movement of the scapula and humerus—is a primary objective.
Advanced Phase (Weeks 6+): The program progresses to include resistive strengthening and functional, sport-specific, or work-specific movements. We retrain the neuromuscular system to use the shoulder correctly and confidently.
Functional Medicine Support: From my functional medicine perspective, we also address underlying systemic factors that may contribute to inflammation. We might assess dietary habits, stress levels, and nutrient deficiencies that could be hindering the healing process. Providing nutritional guidance on an anti-inflammatory diet or recommending supplements like Omega-3 fatty acids, turmeric, or Vitamin C can support the body’s natural healing mechanisms from the inside out.
This integrated approach ensures we treat not just the shoulder, but the whole person. Dr. Cardenas’s medical procedure creates the opening, and the chiropractic and rehabilitative care I provide guides the patient through that opening toward full recovery. It’s a true partnership between intervention and rehabilitation.
Conclusion: A Modern, Synergistic Path to Recovery
Adhesive capsulitis can be a long and frustrating journey for patients. As leading experts have shown, hydrodistension offers a modern, evidence-based way to break the cycle of pain and stiffness. However, this intervention’s success is magnified when embedded in a comprehensive, integrative care plan.
At our clinic, we have seen this synergy in action. By combining the precision of ultrasound-guided medical procedures under Dr. Cardenas’s direction with the hands-on, functional approach of chiropractic care and physical rehabilitation that I lead, we provide our patients with a structured path back to a pain-free, active life. We unlock the frozen shoulder with the procedure and then retrain it for lasting function through dedicated rehabilitation. This is the future of musculoskeletal care—a collaborative, patient-centered model that leverages the best of multiple disciplines to achieve superior outcomes.
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:
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.
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).
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.
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.
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