A major clinical trial is challenging the effectiveness of commonly used injections for chronic Achilles tendon pain.
A widely used injection treatment for chronic Achilles tendon pain may offer little lasting relief, according to a clinical trial published in The BMJ. Researchers found that high-volume injections, including those containing corticosteroids, did not significantly improve pain or physical function compared with a sham procedure after one year. The findings challenge the routine use of injections for a condition that can persist for years and interfere with everyday movement.
Achilles tendinopathy causes pain, stiffness, and swelling in the tendon that connects the calf muscles to the heel. Approximately 6% of people experience the condition during their lifetime, and although exercise-based rehabilitation is the recommended treatment, up to 44% of patients do not recover. Many consequently explore other options, including injections intended to reduce pain and improve tendon function.
Testing Popular Injections Against a Placebo
To investigate whether these treatments provide meaningful benefits, researchers conducted a randomized clinical trial involving 192 adults with midportion Achilles tendinopathy in Melbourne, Australia, between December 2019 and July 2022. Participants were 49 years old on average, and their symptoms had persisted for a median of two years.
The researchers divided participants into three groups receiving either a sham injection (64), a high-volume injection without corticosteroid (63), or a high-volume injection containing corticosteroid (65). The active injections delivered saline and local anesthetic around the affected tendon, with corticosteroid added in one group. Everyone also received the same exercise program, education, and guidance on modifying physical activity.
The primary measure was pain and disability after 52 weeks, assessed using the Victoria Institute of Sport Assessment-Achilles scale (0-100, where 100 is no pain or disability). Participants began the trial with an average score of 48.7, indicating substantial symptoms and functional limitations.
Steroid Injections Provided Only Temporary Relief
At the one-year follow-up, researchers obtained results from 181 participants (94%). Neither high-volume injection treatment produced a clear improvement in pain or disability compared with the sham procedure. The two active injection approaches also showed no meaningful difference in their overall outcomes.
Injections without corticosteroid failed to outperform the placebo at any assessment point. Adding corticosteroid produced small improvements after six weeks, but these benefits were short-lived. By 26 weeks, participants who received corticosteroid had worse outcomes than those given high volume injections without the drug.
An economic analysis found that corticosteroid-containing injections were less costly and generated more quality-adjusted life-years than sham treatment. However, the overall clinical results did not justify their routine use. No serious adverse events related to the trial treatments were reported.
What the Findings Mean for Achilles Tendon Treatment
The researchers acknowledged several limitations. Many participants were recruited through social media, which could affect how well the findings apply to other patient populations. Clinicians administering the injections also knew which treatment they were providing, and some observed differences may have resulted from chance.
Despite these uncertainties, the authors concluded that the evidence “should prompt clinicians to reconsider the rationale for using these injections in people with Achilles tendinopathy.”
In a linked editorial, John Orchard of the University of Sydney cautioned that corticosteroids are neither universally beneficial nor inherently inappropriate. Their use should depend on the patient’s circumstances, particularly when immediate symptom relief takes priority over longer-term outcomes (where short-term needs predominate over longer-term needs). He emphasized that patients should never be told corticosteroid injections will fix or cure tendinopathy.
“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,” he concluded.
Reference: “Efficacy and cost effectiveness of high volume injections with and without corticosteroid compared with sham for midportion Achilles tendinopathy (Inject trial): randomised controlled trial” by Peter Malliaras, David Connell, Anders Ploug Boesen, Rebecca S Kearney, Hylton B Menz, Dylan Morrissey, Shannon E Munteanu, Karin Gravare Silbernagel, Martin Underwood, Andrew Forbes and Terry P Haines, 28 October 2026, BMJ.
DOI: 10.1136/bmj-2026-100807
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