Pro Sports Medicine provides specialist high-volume image-guided tendon injections in Cardiff for selected patients with persistent tendon pain.

The procedure is delivered through our Consultant Musculoskeletal Radiology service, led by Dr Julian Chakraverty, a fellowship-trained Consultant Musculoskeletal Radiologist and Lead Doctor for Bath Rugby.

High-volume injection is primarily considered for chronic mid-portion Achilles tendinopathy that has not improved sufficiently with appropriate rehabilitation. It may also be considered in carefully selected cases of patellar tendinopathy.

Treatment is always based on an accurate diagnosis and forms part of a structured tendon rehabilitation programme rather than being used as a stand-alone treatment.

What is a high-volume tendon injection?

A high-volume image-guided injection, sometimes abbreviated to HVI or HVIGI, involves introducing a controlled volume of fluid into the tissue plane surrounding the affected tendon.

For the Achilles tendon, the injection is normally placed between the front of the tendon and the fat pad behind the ankle. The needle is continuously visualised using diagnostic ultrasound.

The aim is to mechanically separate the tissue planes around the tendon and influence the abnormal small blood vessels and accompanying nerve fibres that may contribute to persistent tendon pain.

The solution commonly includes sterile saline and local anaesthetic. The precise treatment protocol is determined following consultation and review of your medical history.

The injection is placed around the tendon rather than directly into the tendon fibres.

Which tendon conditions can be treated?

The strongest clinical evidence and most established use of high-volume injection relates to:

Chronic mid-portion Achilles tendinopathy

This typically causes pain, stiffness and thickening several centimetres above the heel. Symptoms may be particularly noticeable during running, walking, calf raises or first thing in the morning.

High-volume injection may be considered when symptoms remain limiting despite an appropriate period of progressive tendon-loading rehabilitation.

Patellar tendinopathy

Selected patients with persistent patellar tendon pain, commonly known as jumper’s knee, may also be considered for high-volume image-guided injection.

The published evidence for patellar tendinopathy is more limited than for Achilles tendinopathy, so treatment is recommended only following specialist assessment and review of the available imaging.

High-volume injection is not automatically appropriate for every tendon problem. Other causes of pain, including partial tendon tears, bursitis, tendon insertion disorders and referred pain, must first be considered.

Why is diagnostic ultrasound important?

High-volume injection should be performed using real-time ultrasound guidance.

Before recommending treatment, diagnostic ultrasound can help assess:

• Tendon thickness and structure

• Areas of degeneration

• Partial tears or delamination

• Abnormal blood flow or neovascularisation

• Surrounding bursae and soft tissues

• The precise location of the patient’s symptoms

During the procedure, ultrasound allows the consultant to monitor the needle and solution throughout the injection. This helps ensure accurate placement while avoiding the tendon fibres and nearby neurovascular structures.

Who may benefit from high-volume injection?

High-volume injection may be considered when:

• Achilles or patellar tendon pain has become persistent

• A structured rehabilitation programme has not produced sufficient improvement

• Diagnostic ultrasound confirms changes consistent with tendinopathy

• Pain is preventing effective tendon loading and rehabilitation

• Other potential causes of symptoms have been excluded

• The patient understands that rehabilitation remains essential after treatment

The procedure is not normally used as a first-line treatment. Exercise-based rehabilitation and appropriate management of tendon load remain central to recovery.

What happens during the procedure?

Your appointment begins with a clinical review and assessment of your previous treatment, symptoms and rehabilitation history.

Dr Chakraverty will review existing scans or perform an ultrasound examination where required. The skin is cleaned, local anaesthetic is administered and the needle is positioned using continuous ultrasound guidance.

The solution is then gradually introduced into the appropriate tissue plane around the tendon.

The procedure is normally completed during an outpatient appointment, and you can return home afterwards. You should arrange for someone to drive you home following treatment.

Recovery after a high-volume tendon injection

You will receive individual aftercare instructions based on the tendon treated, the ultrasound findings and your activity goals.

A typical pathway may include:

First 48 hours: relative rest, with walking limited to essential daily activity.

Following days: gradual return to comfortable normal walking as advised.

Approximately one week: progressive tendon-loading exercises may be restarted under the guidance of your physiotherapist.

Following weeks: strength, energy-storage exercises, running and sporting activity are introduced gradually according to symptoms, strength and function.

Published guidance emphasises that high-impact activity should initially be avoided and that return to loading and sport should be gradual and guided by the treating clinician.

Are there any risks?

High-volume injection is generally well tolerated, but all procedures carry potential risks.

These may include:

• Temporary pain or discomfort

• Bruising or bleeding

• Temporary numbness from local anaesthetic

• Infection

• Allergic reaction

• Failure to improve symptoms

• Injury to surrounding structures

• Tendon injury or rupture, although this is uncommon

Your individual risks, medication, allergies and medical history will be reviewed before treatment. You will also be given clear guidance about activity following the procedure.

Alternative treatments for tendon pain

Depending on your diagnosis, alternatives may include:

• Progressive tendon-loading rehabilitation

• Training-load modification

• Shockwave therapy

• Biomechanical or running assessment

• Platelet-rich plasma injection

• Other targeted image-guided procedures

• Orthopaedic or sports medicine referral

The most appropriate treatment depends on the tendon affected, the stage of the condition, previous rehabilitation and your personal goals.

Frequently asked questions

Is a high-volume tendon injection performed under ultrasound guidance?

Yes. The needle and injected fluid are monitored continuously using real-time diagnostic ultrasound.

Is the injection placed into the tendon?

No. The injection is normally delivered into the tissue plane around the tendon rather than directly into the tendon fibres.

What tendon is most commonly treated?

High-volume injection is most commonly used for chronic mid-portion Achilles tendinopathy. It may also be considered for selected cases of patellar tendinopathy.

How many injections will I need?

High-volume injection is generally planned as a single procedure. Further treatment is considered only after reviewing your response and rehabilitation progress.

How quickly can I return to exercise?

Initial rest is normally required, followed by a gradual return to tendon loading. Running, jumping and high-impact sport should only be restarted when advised by your clinician and physiotherapist.

Do I still need physiotherapy afterwards?

Yes. Rehabilitation is essential for rebuilding tendon strength, capacity and tolerance to activity.

Do I need a referral?

Self-funding patients can contact Pro Sports Medicine directly. We also welcome referrals from physiotherapists, GPs, sports doctors, podiatrists and orthopaedic consultants.

Book a High-Volume Tendon Injection Assessment

Persistent Achilles or patellar tendon pain requires more than temporary symptom relief.

At Pro Sports Medicine, Dr Julian Chakraverty provides consultant-led diagnostic ultrasound and image-guided intervention supported by our specialist Tendon Pain Clinic and advanced rehabilitation team.

To discuss whether high-volume tendon injection may be appropriate:

Telephone: 02920 762000
Email: info@prosportsmedicine.co.uk