Brisement and Related Procedures

Stuart H. Myers

Lew C. Schon

BACKGROUND

Brisement (French: “breaking”) is the lysis of adhesions around a tendon by high-pressure fluid injection. It is distinct from brisement forcé (French: “forced breaking”), which is the lysis of intra-articular adhesions by joint manipulation.

Achilles tendon brisement, the most studied form of brisement in the foot and ankle, is performed by a wide variety of healthcare providers. Orthopedic surgeons, podiatrists, and interventional radiologists have described and validated a variety of techniques. The greatest variation among the different techniques is the composition of the injection. A second distinction is the presence or absence of ultrasound guidance. Despite these differences, all Achilles brisement is directed toward distention of the paratenon-tendon interface.¹

The mechanism by which brisement is thought to work is the arresting or reversing of the process of tendon neovascularization. Zanetti et al.² showed that neovascularization is associated with painful Achilles tendinopathy. Humphrey et al.³ further showed that brisement reverses this process while reducing tendon thickness, with decreased pain scores.

In dry needling, tissue is stimulated and blood flow is promoted through repeated needle puncture. The reparative process may be further stimulated with injection of platelet-rich plasma (PRP) during needling.

The addition of a steroid to the brisement cocktail is controversial. In a review article, Schepsis et al.¹ recommended against the use of an injectable steroid solution except in the case of retrocalcaneal bursitis. Although Read showed that peritendinous steroid injections in patients with achillodynia did not increase the risk of rupture,⁴ most protocols do not include a steroid in their injection.⁵^, ⁶ However, steroids are used by some investigators for peritendinous injections.³^, ⁷

INDICATIONS

The syndrome of Achilles tendon pain, inflammation, and degeneration is not completely understood. A distinction is often made between peritendinitis (paratenon disease) and tendinosis (tendon disease). Peritendinitis— possibly caused by repetitive injury to the paratenon— has an acute inflammatory phase and a chronic fibrotic stage. Tendinosis has an acute inflammatory stage and a chronic degenerative stage. These processes can coexist. Jones suggests that refractory peritendinitis can be successfully treated with brisement, whereas symptomatic tendinosis requires debridement.⁶

In our experience, peritendinitis tends to occur in younger patients and is often accompanied by squeaking and palpable nodules. Tendinosis tends to occur in older patients and is often associated with a more focal distribution of pain.

Investigations of brisement tend to group these entities together because of the difficulty in distinguishing them or the high rate of concurrence. Indications in the literature for brisement include insertional Achilles tendinitis,¹ chronic Achilles tendinopathy,⁷ chronic resistant Achilles tendinopathy,³ refractory mid-Achilles tendinosis,⁵ achillodynia,⁴ Achilles peritendinitis,⁶ and Achilles tenosynovitis.⁸ It is difficult to review the literature on this subject because the diagnostic language for Achilles
tendon disease is heterogenous and the understanding of its pathophysiology is incomplete.

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