Achilles tendinopathy injections no better than sham

Clinical takeaway: Hold off on recommending high volume injections for Achilles tendinopathy and keep exercise therapy as the foundation. If a patient still asks for a steroid version, counsel that it is a short-term option, not a solution. 

Exercise therapy is the first-line treatment for Achilles tendinopathy, yet up to 44% of patients don’t recover with it. Many of them pursue additional treatments such as injections. High volume injection, which floods the space between the tendon and Kager’s fat pad with saline, local anesthetic, and typically a corticosteroid, has spread on the basis of little evidence. 

Early work suggested the steroid version helped for up to 26 weeks. Later trials of the steroid-free version found no short-term benefit. No trial had tested either version for a full year. Whether the steroid does harm over the long run was also uncertain. This randomized trial tested whether either version beats a sham injection at 12 months. 

At 12 months, neither injection beat sham on pain and disability. The corticosteroid injection scored slightly below sham, and the steroid-free injection scored slightly above. Neither gap was statistically distinguishable from sham. 

The corticosteroid injection did lead sham at six weeks, by a small margin. By 26 weeks it trailed the injection without steroid by a similar margin, and the gap held at about the same size at 12 months, though that estimate was no longer statistically distinguishable. Without steroid, the injection never separated from sham at any timepoint. 

The trial randomized 192 adults with midportion Achilles tendinopathy at a single clinic in Melbourne, Australia, to a sham injection, a high volume injection without corticosteroid, or a high volume injection with corticosteroid. All groups followed the same exercise program. At 12 months, 94% completed the primary measure. 

High volume injections have been thought to follow a different course than a plain corticosteroid injection because of the added saline. But the trial found a familiar pattern: the steroid version showed the same short-lived relief seen with corticosteroid injections alone. Early benefit was followed by worse outcomes than the steroid-free injection. 

“All clinicians recommending or performing corticosteroid injections for tendinopathy need to understand this trade-off and make every effort to explain the broader overview to the patient as part of the informed consent process,” concludes John Orchard, adjunct professor at the University of Sydney, in a linked editorial.

Source: Malliaras P, et al. (2026 Oct 28) BMJ. Efficacy and cost effectiveness of high volume injections with and without corticosteroid compared with sham for midportion Achilles tendinopathy (Inject trial): randomised controlled trial