In a Melbourne radiology clinic, over a span of several years, 192 adults living with stiff, aching Achilles tendons agreed to be part of a quiet test of an old hope: that a needle placed near a stubborn tendon might succeed where exercise and patience had not. A year later, the verdict published in The BMJ is humbling. The injections, whether they contained a corticosteroid or not, did no meaningfully better than a sham, and the apparent early comfort of steroid faded into something worse. It is a reminder that the body's slow repairs cannot always be hurried, and that relief felt in the firs
Achilles Tendon Injections Show No Meaningful Benefit Over Sham Treatment, Trial Finds
The real injections did no meaningfully better than the fake one.
Mark
So what did the trial actually find?
Mimi
That at 12 months, pain and disability scores were not clearly different between sham injections and either kind of real injection, with or without corticosteroid.
Mark
Did the steroid do anything at all?
Mimi
Small gains over sham at six weeks. But by 26 weeks it did worse than the injection without steroid.
Luke
Worth noting that the six-week gain is described as small. The source gives no figures for it, so I wouldn't read much into its size.
Mark
The steroid injection was also cheaper and more effective by the QALY measure. Doesn't that favor it?
Mimi
On that economic measure, yes. But the authors still say the overall clinical findings don't support routine use.
Luke
And we aren't told how that cost advantage was calculated, so I'd hold it loosely. The authors themselves say some effects may be chance.
Mark
What limits the study?
Mimi
Recruitment mostly through social media, and providers who couldn't be masked to the injection they gave.
Luke
Also a single radiology clinic in Melbourne. Whether the results hold elsewhere isn't something this trial can answer.
Mark
So what does the editorial add?
Mimi
John Orchard says steroids have a place when short-term relief matters most, but patients should never be told they cure a tendinopathy.
Il Polso
- A common, stubborn tendon condition leaves many people unable to walk comfortably, and up to 44% do not recover with exercise alone.
- Patients turn toward injections in search of faster relief, but the trial's sham-controlled design now places that hope under hard scrutiny.
- Steroid injections offered a brief lift at six weeks, only to fall behind the non-steroid group by 26 weeks, unsettling the case for quick fixes.
- The authors urge clinicians to reconsider routine use, while an accompanying editorial insists patients must never be promised a cure and must weigh short-term gains against long-term costs.
- Limits remain: social-media recruitment, unmasked providers, and possible chance effects mean the field is still in motion, not settled.
In a Melbourne radiology clinic, over a span of several years, 192 adults living with stiff, aching Achilles tendons agreed to be part of a quiet test of an old hope: that a needle placed near a stubborn tendon might succeed where exercise and patience had not. A year later, the verdict published in The BMJ is humbling. The injections, whether they contained a corticosteroid or not, did no meaningfully better than a sham, and the apparent early comfort of steroid faded into something worse. It is a reminder that the body's slow repairs cannot always be hurried, and that relief felt in the first weeks may not be the relief that lasts.
In a radiology clinic in Melbourne, between late 2019 and mid-2022, 192 adults with sore, swollen Achilles tendons were each given one of three treatments. Some received a sham. Others received a high-volume injection of saline and local anesthetic, with or without a low dose of corticosteroid, placed around the tendon. A year later, the results published in The BMJ show that the real injections did no meaningfully better than the fake one.
The condition, midportion Achilles tendinopathy, affects around 6% of people at some point and can make ordinary walking painful. Exercise is the recommended treatment, yet as many as 44% of patients do not recover with it, so many go searching for alternatives. Injections had seemed promising, and earlier data hinted that steroids might ease symptoms in the short term, though their longer effects remained unclear.
Everyone in the trial followed the same exercise program and received the same advice on adjusting their activity. The average participant was 49 and more than half were men, most having suffered for about two years. The main measure, a pain and function score at 52 weeks, showed no clear difference between sham and either injection, or between the two injections themselves.
The timeline tells a more nuanced story. The non-steroid injection never outperformed the sham. The steroid injection brought small gains at six weeks, but by 26 weeks it had fallen behind the non-steroid group. Its cost-effectiveness looked favorable, yet the authors concluded that the clinical evidence does not justify routine use. No serious trial-related adverse events were recorded.
The researchers acknowledged real limits: most participants were recruited through social media, the providers could not be blinded, and some effects may be chance. Still, they argue clinicians should rethink why they offer these injections. In an accompanying editorial, John Orchard of the University of Sydney adds a measured warning: corticosteroids are neither wholly good nor wholly bad, and patients must never be told they will cure a tendon problem.
In a radiology clinic in Melbourne, Australia, between December 2019 and July 2022, 192 adults with sore, stiff, swollen Achilles tendons were given one of three injections. Some got a real treatment. Some got a sham. A trial published in The BMJ now reports that, a year later, the real injections did no meaningfully better than the fake one.
The condition is midportion Achilles tendinopathy, a leading cause of persistent lower-limb pain that affects around 6% of people at some point in their lives and gets in the way of everyday activities such as walking. Exercise-based therapy is the recommended treatment, but up to 44% of patients do not recover with it, and many go looking for alternatives, injections among them.
The injections tested were high-volume: saline, local anesthetic and sometimes a low dose of corticosteroid delivered around the tendon. Earlier data suggested corticosteroid-containing injections might ease symptoms in the short term, but their longer-term effects and cost-effectiveness were unclear.
The participants had an average age of 49, and 55% were men. They were randomly divided into three groups: 64 received a sham injection, 63 received a high-volume injection without corticosteroid, and 65 received a high-volume injection with corticosteroid. Everyone also followed the same exercise program and received the same education and advice on modifying their activity. At the start, they reported moderate to high pain and disability, with a mean score of 48.7 on the VISA-A scale, which runs from 0 to 100, where 100 means no pain or disability. The median duration of symptoms was two years.
The main measure was the VISA-A score at 52 weeks. Data were available for 181 of the 192 participants, or 94%. They showed no clear differences between sham and either injection, or between the two injections themselves.
The timeline is more detailed than that headline result. The injection without corticosteroid showed no benefit over sham at any point. The one with corticosteroid gave small, short-term improvements over sham at six weeks, but by 26 weeks its outcomes were worse than those of the injection without corticosteroid. The researchers also assessed cost per quality-adjusted life-year, a combined measure of length and quality of life. On that measure, the corticosteroid injection was more effective and less costly than sham, yet the authors conclude that the clinical findings do not support routine use. No serious adverse events related to the trial were recorded.
The authors list limitations: participants were recruited mainly through social media, which may limit how far the results generalize; the providers giving the injections could not be masked to which treatment they were delivering; and some effects may reflect chance rather than true treatment effects. Even so, they say 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 offers a more nuanced view of corticosteroids: neither all good nor all bad, and appropriate only where short-term needs outweigh longer-term ones. He stresses that patients should never be told a corticosteroid will fix or cure a tendinopathy, and says clinicians must explain this trade-off as part of informed consent.
Citazioni salienti
The evidence should prompt clinicians to reconsider the rationale for using these injections in people with Achilles tendinopathy.— Trial authors, The BMJ
Clinicians must explain the trade-off of corticosteroid injections to patients as part of informed consent.— John Orchard, University of Sydney (linked editorial, paraphrased)
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