Services
Targeted Treatment for Persistent Tendon Pain That Is Not Responding to Exercise
Tendinopathy of the Achilles or patella tendon is among the most frustrating conditions for active individuals. The pain can become entrenched, present not just during exercise, but increasingly at rest, first thing in the morning, or after prolonged sitting. When a structured loading programme has been carried out diligently and progress has plateaued, a high-volume injection can offer a meaningful step forward.
High-volume injection (HVI) therapy uses a large volume of saline, with or without corticosteroid and local anaesthetic, delivered under ultrasound guidance to the area between the tendon and the adjacent tissue (typically the peritendinous or paratendinous space). The volume itself appears to be the active component. It strips neovascular tissue (abnormal new blood vessels associated with chronic tendinopathy) and disrupts the associated neoinnervation that is thought to contribute to chronic tendon pain. The result, in appropriate candidates, is a significant reduction in pain that allows progressive rehabilitation to continue.
This procedure is performed under continuous ultrasound guidance at Motherwell Physio, ensuring accurate delivery to the correct anatomical space without inadvertent intratendinous injection.Who This Is For
High-volume injection therapy may be appropriate for adults with:
- Midportion Achilles tendinopathy that has not responded adequately to a 12-week structured loading programme
- Patellar tendinopathy (jumper's knee) with persistent pain despite rehabilitation
- Evidence of neovascularisation on Doppler ultrasound assessment
- Symptoms that are significantly limiting activity, sport, or daily function
Insertional Achilles tendinopathy, where the tendon meets the heel bone, is managed differently and may not be suitable for HVI. This will be assessed at your consultation.
How the Procedure Works
Assessment and Ultrasound
Your initial appointment includes a clinical assessment and an ultrasound scan of the tendon. The scan evaluates tendon integrity, confirms the diagnosis, and uses Doppler imaging to assess the extent of neovascularisation. This influences both whether HVI is appropriate and how the procedure is targeted.
The Injection
For the Achilles tendon, you will be positioned lying face down with the foot off the end of the couch. For the patella tendon, you will be lying on your back with the knee slightly flexed. The skin is cleaned with antiseptic. Under continuous ultrasound guidance, a needle is placed precisely in the peritendinous space, not into the tendon substance itself. A large volume of fluid (typically 10 ml local anaesthetic and between 10-40 ml saline, with or without corticosteroid) is injected slowly, stripping the neovascularity and related nerve tissue from the tendon surface. The procedure takes approximately 20 to 30 minutes including preparation.
After the Injection
Discomfort following the procedure is variable. Some patients experience a short-lived flare, while others note an immediate reduction in their usual tendon pain. You should avoid high-load tendon stress (running, jumping, heavy loading) for approximately one week following the injection.
A structured loading programme, typically a progressive eccentric or heavy slow resistance exercise protocol, should be resumed or initiated within one to two weeks. The injection is not effective in isolation; it is the combination of HVI and loading that produces the best outcomes.What to Expect at Your First Appointment
Wear shorts if attending for a patellar or Achilles tendon injection, or clothing that allows easy access to the lower leg and knee. Bring any previous imaging or specialist letters. You can self-refer; no GP referral is required.
Most patients can drive home after the procedure, but this depends on individual comfort. If you have concerns, arrange transport.
Your Treatment Team
Shane Ryan, Director, Advanced Practice Physiotherapist
BSc Physiotherapy, PG Cert in Musculoskeletal Ultrasound, Clinical Specialist in Ultrasound guided injections, Independent Prescriber
CSP No. 098175
HCPC No, PH107655
BSc Physiotherapy, PG Cert in Musculoskeletal Ultrasound, Clinical Specialist in Ultrasound guided injections, Independent Prescriber
CSP No. 098175
HCPC No, PH107655
Pricing and Appointments
Book online at motherwellphysio.co.uk or call the clinic directly.
Conveniently Located in Motherwell
- Motherwell Physio, 406 Brandon Street, Motherwell, ML1 1XA
- Mon - Fri 8am - 6pm
- 01698 692086
- info@motherwellphysio.co.uk
- Free car park across the road
Frequently Asked Questions
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A standard steroid injection involves a small volume of corticosteroid, often placed in or around the tendon. High-volume injection uses a much larger volume of fluid (typically 20 to 50 ml in total) delivered specifically to the peritendinous space. The volume itself is the key mechanism, as it mechanically disrupts the neovascular tissue associated with chronic tendinopathy. Injecting directly into the tendon substance is avoided due to the risk of tendon damage.
Yes. HVI is not a first-line treatment. It is intended for patients who have already undertaken a structured loading programme (typically 12 weeks of progressive tendon loading) but have not achieved sufficient improvement. If you have not yet done this, a physiotherapy-led rehabilitation programme should be the starting point.
HVI is not a cure, and no single intervention can reliably claim to be. It is a tool to reduce pain sufficiently to allow loading-based rehabilitation to continue. The underlying tendon changes associated with tendinopathy are managed most effectively through progressive exercise over time; the injection creates the conditions for this to happen more comfortably.
The risk of tendon rupture from a correctly performed HVI is very low. The injection is placed in the peritendinous space, not into the tendon itself. Ultrasound guidance is used throughout to ensure accurate placement. You are advised to avoid high-load tendon stress for approximately one week after the procedure as a precaution.
Some patients notice a reduction in pain within days of the procedure. For others, improvement develops over two to four weeks as the neovascular tissue resolves and rehabilitation progresses. Continued improvement is expected over the following weeks provided the rehabilitation programme is maintained.
Most patients have a single procedure. If symptoms have partially improved but further benefit is felt to be possible, a second HVI may occasionally be considered at a follow-up review. Your response to the first injection and your progress with rehabilitation will guide this decision.
Coverage varies between insurers and policies. Contact your insurer before booking to check whether ultrasound-guided high-volume injection is covered under your policy.
There is no requirement to stop training before the injection, though you should avoid very high-load sessions in the 24 hours prior. After the procedure, high-impact loading of the tendon should be avoided for approximately one week before the structured rehabilitation programme is resumed.
Neovascularisation refers to abnormal new blood vessel growth that develops in and around chronically painful tendons. These vessels are accompanied by new nerve fibres, and it is thought that this neoinnervation contributes significantly to the pain associated with chronic tendinopathy. Disrupting this tissue with a high-volume injection is the primary mechanism by which HVI reduces pain.
Insertional Achilles tendinopathy, where the tendon meets the heel bone, is a distinct presentation from midportion tendinopathy and is managed differently. HVI is not routinely used for insertional pathology. Your clinician will assess the exact location of your symptoms and advise the most appropriate treatment approach.
Ready to Book?
To arrange an assessment for Achilles or patellar tendinopathy, call or book online at motherwellphysio.co.uk. 01698 692086