TL;DR
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A randomized trial of 192 adults with midportion Achilles tendinopathy found no significant difference in pain and disability improvement between high-volume injections and a sham procedure at 12 months. Hydrocortisone added to the injection was linked to greater improvement at six weeks, but that benefit faded, and scores were worse at week 26 than with bupivacaine alone.
A randomized trial of 192 adults found that high-volume injections for midportion Achilles tendinopathy did not improve pain and disability significantly more than a sham procedure after 12 months. The hydrocortisone-containing injection offered greater relief at six weeks, but the difference had disappeared by week 12, and outcomes later favored the steroid-free injection at one assessment.
Peter Malliaras of Monash University in Melbourne and colleagues assigned participants to one of three groups: a high-volume injection of bupivacaine and saline, the same mixture with 25 milligrams of hydrocortisone, or a sham injection. The active injections contained 10 milliliters of 0.5% bupivacaine and 40 milliliters of saline. The sham used a smaller volume of bupivacaine, placed at a site not expected to affect tendon pain or swelling.
The study enrolled adults with gradual-onset, ultrasound-confirmed midportion Achilles tendinopathy and symptoms lasting at least three months. The main outcome was change in the VISA-A score, a 100-point measure of Achilles-related pain and disability; lower scores indicate worse symptoms. Average baseline scores were about 50. At week 52, scores had improved by roughly 25 to 30 points across all three groups, with no statistically significant between-group difference. Eleven participants did not provide week-52 scores; analyses limited to participants who completed the study produced similar results.
The steroid group showed about a 10-point greater improvement at week six than the other groups. By week 12, that advantage was no longer present. At week 26, scores in the steroid group were worse numerically than in the sham group and significantly worse than in the bupivacaine-only group; the gap narrowed later and was not statistically significant at the final assessment. The researchers also reported that the steroid-containing treatment reduced overall healthcare costs during the study year, though the supplied report does not give the cost figures.
The Trade-Off After Early Relief
The findings challenge the use of high-volume injections as a routine treatment for midportion Achilles tendinopathy: the trial did not show a significant 12-month advantage over sham. For patients and clinicians, the results also distinguish the short-term response to hydrocortisone from longer-term outcomes. The early improvement may matter to some people, but it was not sustained in the trial and came with worse scores than bupivacaine alone at week 26.
In an accompanying editorial, sports medicine specialist John W. Orchard of the University of Sydney argued that the short-term benefit should be weighed against the possibility of poorer later outcomes. He wrote that corticosteroid treatment can be “borrowing from the future to finance the present,” and said clinicians should explain the trade-off during informed consent. That is an editorial interpretation of the results, not a separate finding from the randomized comparison.
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How the Injection Trial Was Designed
High-volume injections combining saline with local anesthetic, sometimes with corticosteroids, have been used for tendon problems despite a history of limited rigorous evidence. For Achilles tendinopathy, the proposed approach uses a large saline volume around the tendon region. Earlier trials had produced mixed findings, according to the report, leaving uncertainty about whether the procedure helps beyond placebo effects or other aspects of care.
To make the comparison more credible, the trial used a sham injection placed at least 10 millimeters away from the junction of the Achilles tendon and Kager’s fat pad, where a therapeutic effect was not expected. The sham still contained a small amount of bupivacaine to produce a numbing effect, and participants wore a sleeve so they could not see the temporary bulge caused by the larger-volume injections. The study therefore compared both the injection mixtures and the effects of receiving a procedure under blinded conditions.
“The clinical data do not support routine use for midportion Achilles tendinopathy.”
— Peter Malliaras and colleagues, the trial authors
Limits of the 12-Month Findings
The trial does not establish why the steroid group’s scores were worse than those of the bupivacaine-only group at week 26, or whether that pattern would recur in other patient populations. The supplied report also does not provide detailed cost amounts, so the size and practical importance of the reported healthcare savings cannot be assessed here. Although 11 participants lacked week-52 scores, the researchers said per-protocol analyses gave similar results.
The findings apply to adults with gradual-onset, midportion disease confirmed by ultrasound, not necessarily to other Achilles conditions, acute injuries, or different injection methods. The study compared specific doses, volumes and injection locations; it does not settle the effectiveness of every type of injection or other treatment approach. The trial authors’ conclusion concerns routine use for midportion Achilles tendinopathy.
How Clinicians May Apply the Results
The report provides no announced follow-up study or change to clinical guidance. For now, the main development is evidence that this particular high-volume injection approach did not outperform sham on the trial’s primary 12-month outcome. Clinicians and patients considering a hydrocortisone-containing injection can discuss the observed six-week improvement alongside its disappearance by week 12 and the less favorable week-26 comparison.
Further research would be needed to clarify which patients, if any, might gain meaningful benefit, how the cost finding holds up in other settings, and whether the later difference associated with steroid treatment is reproducible. Until more evidence is available, the study supports caution about treating short-term relief as proof of lasting benefit.
Key Questions
Did the injections work better than sham treatment?
Not at 12 months. The trial found similar improvement across the high-volume injection groups and sham, with no statistically significant difference in the primary outcome.
Did hydrocortisone provide any benefit?
The hydrocortisone group had about 10 points more improvement at six weeks, but the advantage was gone by week 12. At week 26, scores were significantly worse than with bupivacaine alone.
Who took part in the trial?
The 192 participants were adults with gradual-onset, ultrasound-confirmed midportion Achilles tendinopathy and symptoms lasting at least three months.
Does the study rule out all injections for Achilles pain?
No. It tested specific high-volume injection regimens in a defined group of patients. The findings do not settle the effectiveness of every injection type, dose, or treatment approach.
Source: medpagetoday.com
