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A randomized trial of 192 adults found that high-volume injections for midportion Achilles tendinopathy did not significantly improve pain and disability more than sham treatment at 12 months. Hydrocortisone injections offered greater improvement at six weeks, but that advantage faded and outcomes were worse at 26 weeks on some measures.
A randomized trial of 192 adults with midportion Achilles tendinopathy found that high-volume injections of saline and bupivacaine, with or without hydrocortisone, did not significantly improve pain and disability more than a sham injection after 12 months. The steroid-containing injection improved scores more at six weeks, but its early advantage did not persist, raising questions about the value of routine injections for this condition.
The trial, led by Peter Malliaras of Monash University and colleagues, assigned participants to one of three groups: a high-volume injection of bupivacaine and saline with 25 milligrams of hydrocortisone; the same high-volume mixture without the steroid; or a sham injection containing a small amount of bupivacaine. The study was published in The BMJ, according to MedPage Today’s report.
Participants had gradual-onset pain in the middle portion of the Achilles tendon lasting at least three months, with the condition confirmed by ultrasound. The main outcome was change in the Victorian Institute of Sport Assessment-Achilles score, a 100-point measure of pain and function where lower scores indicate worse symptoms. At baseline, average scores were about 50 points across the groups.
At week 52, scores had improved by roughly 25 to 30 points in all three groups, with no statistically significant difference between them. Eleven participants did not provide week-52 scores; the researchers said analyses limited to participants who completed the study produced similar findings. The steroid group showed about a 10-point greater improvement at week six, but the advantage had disappeared by week 12. At week 26, outcomes in that group appeared worse than sham and were significantly worse than the bupivacaine-only group, before the gap narrowed later in the year.
The Limits of Short-Term Relief
The findings challenge the assumption that a temporary improvement after an injection means patients will do better over time. For people weighing treatment options, the trial suggests that early relief from the steroid-containing injection was not matched by a lasting advantage over sham at one year. That distinction matters when deciding whether a procedure’s short-term effects justify its costs and possible longer-term drawbacks.
The study authors said the combination showed short-term clinical benefit and potential healthcare cost reductions over the year, but also reported worse longer-term clinical outcomes. Their conclusion was that the clinical data do not support routine use of these injections for midportion Achilles tendinopathy. This is a finding about the injection regimens and patient group tested, not proof that every injection or tendon condition has the same outcome.
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How the Trial Compared Injections
High-volume injections have been used for Achilles tendinopathy, including mixtures of saline, local anesthetic and sometimes corticosteroid. The approach involves placing a larger volume near the tendon, with the aim of relieving pain and disability. MedPage Today reported that the practice became popular without strong evidence from rigorous trials, and that earlier studies had produced mixed results.
To keep participants unaware of their assigned group, the sham injection was delivered at a site at least 10 millimeters away from the junction targeted by the active injections. It still included bupivacaine to create a numbing effect. Researchers also used a sleeve over the Achilles region so participants receiving the larger injections would not see the temporary bulge. The trial therefore compared the active treatments with a sham designed to preserve blinding, rather than with no procedure.
“The clinical data do not support routine use for midportion Achilles tendinopathy.”
— Peter Malliaras and colleagues, as quoted in the study report
Questions Beyond the One-Year Results
The trial does not establish how the results apply to other forms of Achilles tendon disease, people with a different symptom duration, or injection techniques and doses not tested. The participants had chronic, ultrasound-confirmed midportion tendinopathy, so the findings should not automatically be extended to every cause or location of Achilles pain.
The report also does not establish why the steroid group’s outcomes were worse than the bupivacaine-only group at week 26, or whether that difference reflects a lasting effect of hydrocortisone. The gap later narrowed and was not statistically significant at 12 months. The trial observed a potential reduction in healthcare costs with the steroid combination, but the available report does not provide enough detail to assess the size or assumptions behind that economic finding.
How Clinicians May Use the Findings
The published trial and its editorial give clinicians evidence to weigh when discussing high-volume injections with patients who have midportion Achilles tendinopathy. The researchers’ stated conclusion is against routine use of the tested injections; the editorial says patients considering corticosteroids should be told that the short-term benefit may not last and may come with a longer-term trade-off.
The source report does not describe a planned follow-up study or a change to clinical guidelines. Further research would be needed to clarify which patients, if any, might benefit from injections, whether different regimens produce different results, and how the clinical outcomes compare with treatment alternatives over longer periods.
Key Questions
Did the injections work better than sham treatment?
Not at 12 months. The trial found similar improvement in pain and disability across the steroid, bupivacaine-only and sham groups.
Did hydrocortisone provide any benefit?
The hydrocortisone group had greater improvement at six weeks, by roughly 10 points on the VISA-A scale. The advantage was gone by week 12, and outcomes appeared worse at week 26 on some comparisons.
Who took part in the study?
The study enrolled 192 adults with gradual-onset, ultrasound-confirmed midportion Achilles tendinopathy lasting at least three months. Their average age was about 50, and just under half were women.
Does this trial rule out injections for every Achilles problem?
No. The results concern the specific injection regimens and adults with chronic, midportion tendinopathy studied. They do not establish outcomes for every Achilles condition or injection approach.
Source: medpagetoday.com
