Popular high-volume injections for Achilles tendon pain did no better than sham at one year, BMJ trial finds

High-volume injections — about 50 mL of saline plus local anaesthetic, often with a corticosteroid, delivered next to the Achilles tendon — are increasingly used worldwide for stubborn midportion Achilles tendinopathy. The randomised Inject trial, published in The BMJ on 28 October 2026, tested whether they work over a full year.

The study

• Design: single-centre (Melbourne, Australia), participant- and assessor-masked, three-arm randomised controlled trial with an economic evaluation.
• Participants: 192 adults (mean age 48.7; median symptom duration two years) who had not responded to prior treatment, randomised to sham (small anaesthetic injection placed away from the target), high-volume injection without steroid, or high-volume injection with 25 mg hydrocortisone. Everyone received the same exercise programme and advice.
• Primary outcome: pain and disability on the VISA-A scale (0–100) at 52 weeks; 94% provided data.

Results

• At 12 months, neither injection beat sham: with steroid −3.5 points (98.33% CI −12.0 to 5.0), without steroid +4.0 (−4.2 to 12.3).
• The steroid injection gave a small benefit at six weeks (+9.2 vs sham, below the 10-point target) but worse outcomes than the steroid-free injection at 26 weeks (−8.6).
• In the economic analysis the steroid injection was cheaper than sham with similar quality-adjusted life years, largely through less time off work early on; the authors urge caution because the health gain was negligible.
• No tendon ruptures and no serious trial-related adverse events.

The authors conclude the clinical data “do not support routine use” of high-volume steroid injections for this condition.

Limitations

Single centre with participants mainly recruited via social media, so they may differ from hospital patients; the injecting radiologist and nurse could not be masked; only one of four recommended core outcome instruments was used; economic data had growing gaps; and with many outcomes and time points some differences may be due to chance. Discuss treatment options with your doctor or physiotherapist.