TL;DR
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A randomized trial of 192 adults with midportion Achilles tendinopathy found no significant difference in pain and disability among high-volume injections with bupivacaine, injections with bupivacaine and hydrocortisone, and a sham procedure after 12 months. The steroid combination showed a short-term benefit at six weeks, but it had faded by week 12 and outcomes were worse at week 26 than with bupivacaine alone.
A randomized trial of 192 adults found that high-volume injections for midportion Achilles tendinopathy were no better than sham treatment after 12 months, while adding hydrocortisone produced a short-lived improvement and worse results than bupivacaine alone at 26 weeks. The findings, reported in The BMJ, challenge routine use of the injections for this condition.
Participants were assigned to one of three groups: a high-volume injection containing bupivacaine and saline, the same mixture with 25 milligrams of hydrocortisone, or a sham injection. The active treatments were delivered near the junction of the Achilles tendon and Kager’s fat pad. The sham used a smaller amount of bupivacaine and was placed at a nearby site not expected to treat tendon pain, but was designed to preserve blinding.
The main outcome was change at 52 weeks on the VISA-A scale, which measures Achilles-related pain and disability on a 100-point scale, with lower scores indicating worse symptoms. Average scores improved by about 25 to 30 points across the groups, but the differences between them were not statistically significant. Eleven participants did not provide week-52 scores; the researchers said analyses limited to participants who completed the protocol showed similar results.
The steroid-containing injection performed better at six weeks, with about a 10-point greater improvement than the other groups. That difference was gone by week 12. At week 26, pain and disability appeared worse in the steroid group than in the sham group and were significantly worse than in the bupivacaine-only group. The gap later narrowed and was not statistically significant by the end of the year.
A Brief Gain With a Later Trade-Off
The findings matter to patients and clinicians weighing a procedure that has been used despite limited rigorous evidence. In this trial, neither active injection improved one-year outcomes over sham. The short-term result with hydrocortisone may still matter to some patients, but it did not persist and came alongside a period when outcomes were worse than with bupivacaine alone.
The authors also assessed healthcare costs over the year. Their analysis favored the steroid-containing regimen over sham, with more than 90% certainty that it was cost-effective, according to the report. That economic result does not establish better long-term symptom relief: cost estimates and clinical outcomes address different questions. Patients and clinicians may weigh temporary relief, later symptoms, and cost differently, but the trial does not support treating the injections as a proven long-term solution.
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How the Trial Tested the Injections
The study enrolled adults with gradual-onset, ultrasound-confirmed midportion Achilles tendinopathy lasting at least three months. The condition often affects people who run or take part in other physical activities. At the start, participants’ average VISA-A scores were about 50 in each group, indicating substantial symptoms. Their average age was around 50, and just under half were women.
High-volume saline injections have been proposed as a way to relieve pain and disability, sometimes with anesthetic or corticosteroid added. But earlier trials had produced mixed results, according to the report. The researchers designed the sham procedure to account for the injection experience: it included a numbing agent and was placed close to the treatment area, while a sleeve concealed the temporary bulge caused by the larger-volume injections.
“The clinical data do not support routine use for midportion Achilles tendinopathy.”
— Peter Malliaras and colleagues, the trial authors
Limits of the Evidence
The trial’s results concern adults with chronic, midportion Achilles tendinopathy; they do not establish whether the same findings apply to other tendon problems or different patient groups. The report also does not show that every individual patient would experience the average result. Although the study tracked outcomes for a year, longer-term effects beyond that period remain unknown.
The cost analysis favored the steroid-containing treatment over sham, but the supplied report does not provide the full cost figures or the assumptions behind the analysis. The report also does not establish why scores in the steroid group were worse at week 26. The temporary improvement was observed in the trial, but its duration and trade-offs may not be the same for every patient.
How Clinicians May Apply the Results
The study authors say the clinical evidence does not support routine use of these injections for midportion Achilles tendinopathy. The accompanying editorial called for clinicians who recommend or perform corticosteroid injections to explain the potential trade-off during informed consent, including the short-term relief and later outcome uncertainty.
The report does not announce a change to clinical guidelines or a new treatment recommendation beyond the authors’ conclusion. Further research would be needed to clarify which patients, if any, might benefit from the temporary improvement and whether outcomes differ over periods longer than 12 months. For now, patients considering an injection can ask their clinician how the trial’s findings apply to their diagnosis and treatment options.
Key Questions
Did the injections work better than the sham treatment?
Not at 12 months. The trial found no statistically significant difference in the main pain and disability outcome between the two active injection groups and the sham group.
Did hydrocortisone provide any benefit?
The hydrocortisone combination showed greater improvement at six weeks, but the advantage had disappeared by week 12. At week 26, outcomes were significantly worse than with bupivacaine alone; that difference was not significant at 52 weeks.
Who took part in the trial?
The study included 192 adults with gradual-onset, ultrasound-confirmed midportion Achilles tendinopathy lasting at least three months. The groups received bupivacaine with saline, the same mixture with hydrocortisone, or a sham injection.
Does this mean no patient should receive an injection?
The trial authors said the evidence does not support routine use for midportion Achilles tendinopathy. The study does not determine what is right for every individual; patients should discuss the evidence and their circumstances with a qualified clinician.
Source: medpagetoday.com
