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A randomized trial of 192 adults with midportion Achilles tendinopathy found that high-volume injections did not significantly improve pain and disability more than sham treatment at 12 months. Hydrocortisone injections offered greater improvement at six weeks, but the difference faded by week 12 and scores were worse at week 26 than with bupivacaine alone.
A randomized trial of 192 adults with midportion Achilles tendinopathy found that high-volume injections containing saline and bupivacaine, with or without hydrocortisone, did not significantly improve pain and disability more than a sham injection after 12 months. The steroid combination provided greater relief at six weeks, but that advantage had disappeared by week 12, according to the study reported in The BMJ.
Researchers led by Peter Malliaras of Monash University assigned participants to one of three groups: a high-volume injection of bupivacaine and saline with 25 mg of hydrocortisone; the same high-volume mixture without the steroid; or a sham procedure using a smaller amount of bupivacaine delivered away from the tendon area expected to affect symptoms. The sham was designed to maintain blinding while avoiding the active injection placement.
The primary outcome was change in the VISA-A score at week 52, a 100-point measure of Achilles-related pain and disability, with lower scores reflecting worse symptoms. Average improvement was about 25 to 30 points across the groups, and the differences at 12 months were not statistically significant. Eleven participants did not provide week-52 scores; the researchers said analyses of participants who completed the protocol produced similar findings.
The hydrocortisone group improved by roughly 10 points more at six weeks than the other groups. That separation was gone by week 12. By week 26, scores in the steroid group were numerically worse than sham and significantly worse than the bupivacaine-only group; the difference narrowed later and was no longer statistically significant at the final assessment. No significant benefit from bupivacaine alone over sham was found at any measured time, according to the report.
The Trade-Off in Steroid Relief
The findings challenge the routine use of these high-volume injections for midportion Achilles tendinopathy, a condition often associated with gradual-onset pain and activity limits. The study did not show a durable advantage over sham, while the temporary improvement with hydrocortisone came alongside worse scores at a midterm assessment. That pattern matters to patients and clinicians weighing short-term symptom relief against longer-term outcomes.
The researchers also reported that the steroid-containing regimen reduced healthcare costs over the study year compared with sham, though the supplied report does not provide the amount or full cost breakdown. Cost results do not change the clinical finding: the groups had similar average outcomes at 12 months. They may, however, be part of a treatment discussion alongside the timing and uncertain durability of symptom effects.
In an accompanying editorial, sports medicine physician John W. Orchard of the University of Sydney said patients should be told that the short-term gain may come with a trade-off. His comments are an interpretation of the findings, rather than a separate result from the trial.
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How the Trial Tested Injections
Achilles tendinopathy injections using saline, local anesthetics or corticosteroids have been used despite limited rigorous evidence, according to the MedPage Today report. One approach has been to inject a large volume of saline around the tendon. Previous trials had produced mixed findings, leaving uncertainty about whether the procedure offers benefits beyond placebo effects or other aspects of care.
The trial enrolled adults with gradual-onset symptoms lasting at least three months, confirmed by ultrasound. Participants were about 50 years old on average, and just under half were women. Their average baseline VISA-A scores were around 50 in each group. The active injections were placed near the junction of the Achilles tendon and Kager’s fat pad; the sham was delivered at least 10 millimeters away from that junction. A sleeve obscured the area so participants would not see the temporary bulge associated with the larger injections.
“The clinical data do not support routine use for midportion Achilles tendinopathy.”
— Peter Malliaras and colleagues, as reported in The BMJ
What the Results Cannot Resolve
The trial does not establish whether different injection techniques, doses, patient groups or treatment schedules would produce different results. Its findings apply to the studied group: adults with ultrasound-confirmed, gradual-onset midportion Achilles tendinopathy lasting at least three months. They should not automatically be extended to other tendon conditions or other forms of Achilles injury.
The report says the steroid group’s scores were worse at week 26 than the bupivacaine-only group, but the difference later became statistically insignificant. The supplied information does not give the exact score differences, detailed adverse-event counts or the full healthcare-cost estimates. It also does not establish why the steroid group’s relative scores changed over time. Those limits make it difficult to quantify the size and cause of the possible longer-term trade-off.
How Clinicians May Apply the Findings
The study authors concluded that the clinical data do not support routine use of high-volume injections for midportion Achilles tendinopathy. The report does not identify a further trial or a planned change to treatment guidance, so any next research steps remain unclear. Clinicians and patients can use the results as evidence when discussing the expected duration of relief, the lack of a demonstrated 12-month advantage and the observed score pattern after steroid treatment.
Further research would be needed to clarify whether any subgroup gains lasting benefit, how the trial’s cost findings compare with other care, and whether the week-26 difference reflects a reproducible effect. Until then, the central result is that none of the injection groups showed a significant advantage over sham at one year.
Key Questions
What did the randomized trial find?
Among 192 adults with midportion Achilles tendinopathy, high-volume injections with bupivacaine, with or without hydrocortisone, did not significantly outperform sham treatment on pain and disability at 12 months.
Did the steroid injection help at all?
The hydrocortisone group had greater improvement at six weeks, by roughly 10 VISA-A points compared with the other groups. The difference had disappeared by week 12, and the group had worse scores at week 26 than the bupivacaine-only group.
What does the sham injection mean in this study?
The sham used a small amount of bupivacaine placed at least 10 millimeters away from the tendon junction, at a site not expected to provide a therapeutic effect. It was designed to help keep participants unaware of which procedure they received.
Does this trial apply to every Achilles injury?
No. Participants had gradual-onset, ultrasound-confirmed midportion tendinopathy lasting at least three months. The results do not establish what would happen with other Achilles conditions, injuries or injection approaches.
What remains unknown about the findings?
The supplied report does not provide detailed adverse-event counts or the full cost estimates, and it does not explain why scores in the steroid group were worse at week 26. Whether different patients or injection methods could produce lasting benefit also remains uncertain.
Source: medpagetoday.com
