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A randomized trial of 192 adults with midportion Achilles tendinopathy found no significant difference in symptoms at 12 months between high-volume injections with hydrocortisone, injections without it, and a sham procedure. The steroid-containing injection improved scores more at six weeks, but the gap disappeared by week 12 and outcomes were worse at week 26 on some comparisons.
A randomized trial of 192 adults found that high-volume injections for midportion Achilles tendinopathy did not significantly improve pain and disability more than a sham injection at 12 months. The steroid-containing injection produced greater improvement at six weeks, but the advantage had disappeared by week 12, raising questions about the lasting value of a treatment used for tendon pain.
The study, reported in The BMJ by Peter Malliaras of Monash University in Melbourne and colleagues, assigned adults with gradual-onset Achilles tendon pain to one of three groups. Participants had symptoms for at least three months, and ultrasound was used to confirm the condition. The trial compared bupivacaine and saline, the same injection with 25 milligrams of hydrocortisone, and a sham procedure.
Both high-volume active injections contained 10 milliliters of 0.5% bupivacaine and 40 milliliters of saline; the steroid group also received hydrocortisone. The sham involved a smaller amount of bupivacaine injected at a site not expected to affect tendon pain or swelling. Researchers used a sleeve to conceal the temporary bulge associated with the larger injections and help maintain blinding.
The primary outcome was change in the VISA-A score, a 100-point scale measuring Achilles-related pain and disability, with lower scores indicating more severe problems. At 52 weeks, average improvement was roughly 25 to 30 points across all groups, with no statistically significant difference. Eleven participants lacked week-52 scores, but the researchers said analyses limited to participants who completed the protocol produced similar findings.
The Steroid Benefit Faded Over Time
The results challenge the expectation that a procedure can provide durable relief simply because it is widely used. The trial found no significant long-term advantage for either active injection over sham, while the temporary improvement in the hydrocortisone group may matter to patients seeking short-term symptom relief.
That short-term change needs to be weighed against the later pattern. At six weeks, the steroid group had roughly a 10-point greater improvement on the VISA-A scale than the other groups. The difference was gone by week 12. By week 26, scores in the steroid group were worse numerically than sham and significantly worse than the bupivacaine-only group; the gap narrowed later and was not statistically significant at the final assessment.
The authors said the findings do not support routine use of these injections for midportion Achilles tendinopathy. Their conclusion is specific to the treatment and patient group studied, rather than proof that every injection approach or tendon condition has the same outcome. For patients and clinicians, the study highlights the importance of discussing how long a possible benefit may last, as well as uncertainty about longer-term outcomes.
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Why Researchers Tested High-Volume Injections
Injections containing saline, local anesthetics or corticosteroids have become a treatment option for tendon problems, although the MedPage Today report said their popularity developed without strong rigorous evidence. For Achilles tendinopathy, a high-volume saline approach has been used in an effort to relieve pain and disability. Earlier trials had produced mixed findings, leaving its benefit compared with placebo uncertain.
The trial focused on adults with midportion tendinopathy, a condition involving the central portion of the Achilles tendon, rather than tendon pain at the heel attachment. Participants averaged about 50 years old, and their baseline VISA-A scores were around 50 in all three groups. The year-long follow-up allowed investigators to compare early symptom changes with later outcomes.
Concerns about longer-term effects of corticosteroids in tendon conditions have also informed debate about their use. In an accompanying editorial, John W. Orchard of the University of Sydney described the possible short-term relief as a trade-off against later outcomes. The editorial drew an analogy to reports involving other tendon conditions, but the trial itself tested Achilles injections and should be read on that basis.
“The clinical data do not support routine use for midportion Achilles tendinopathy.”
— Peter Malliaras and colleagues, the trial authors
How Durable Is the Early Relief?
The study does not establish why the steroid group’s early advantage faded, or whether particular patients might experience a different balance of short- and longer-term effects. The 12-month comparison showed no statistically significant group differences, but that finding does not prove that the treatments are identical for every patient. Week-52 data were unavailable for 11 participants, although the reported per-protocol analysis was similar.
The source report also notes that the steroid-containing regimen reduced overall healthcare costs during the study year, with the analysis favoring it over sham and more than 90% certainty that the active regimen was cost-effective. That economic result does not establish a lasting clinical advantage. The supplied report does not provide the cost amounts or enough detail to assess how the analysis treated specific healthcare use, and the trial does not resolve whether results apply to other injection techniques, tendon problems or patient groups.
How Clinicians May Apply the Findings
The trial report supplies a year of follow-up, but it does not announce a new treatment guideline or a required change in care. The immediate next step for patients considering an injection is a discussion with a qualified clinician about the evidence, the possibility that relief could be temporary, and other suitable management options for their individual circumstances.
Further research could test whether specific patient characteristics or injection methods change the balance of outcomes, and could report the economic findings in greater detail. Until then, the authors’ stated conclusion is that the clinical data do not support routine use of high-volume injections for the midportion Achilles condition studied. The findings leave open questions about individual responses and other forms of Achilles tendinopathy.
Key Questions
Did the injections work better than the sham treatment?
At 12 months, the trial found no statistically significant difference in improvement among the steroid injection, bupivacaine-only injection and sham groups.
Did the steroid injection provide any benefit?
The hydrocortisone group improved more at six weeks, by roughly 10 VISA-A points compared with the other groups. That advantage had disappeared by week 12.
What happened to outcomes later in the study?
At week 26, the steroid group’s results were numerically worse than sham and significantly worse than bupivacaine alone. The difference later narrowed, and no significant difference remained at 12 months.
Who was included in the trial?
The 192 participants were adults with gradual-onset, ultrasound-confirmed midportion Achilles tendinopathy lasting at least three months. The findings do not automatically apply to every type of Achilles tendon problem.
Does the study mean no patient should receive an injection?
No. The authors said the data do not support routine use for the condition studied. Individual treatment decisions should be discussed with a clinician, including the potential for short-term relief and the uncertainty about longer-term outcomes.
Source: medpagetoday.com
