A randomized trial led by Peter Malliaras and published in The BMJ reveals that high-volume injections for Achilles tendinopathy offer no long-term benefit over sham treatment at 52 weeks among 192 participants. While corticosteroid injections deliver temporary relief at six weeks and lower healthcare costs, symptom improvements disappear by week 12 and lead to worse outcomes at 26 weeks. University of Sydney expert John W. Orchard notes that corticosteroids borrow from the future, warning against routine clinical use.
Trial design and primary outcomes
- ▪At 52 weeks, the Inject clinical trial recorded no statistically significant difference in pain and disability scores among participants receiving sham injections or high-volume injections with or without corticosteroid.
- ▪In a randomized trial published in October 2026 led by Peter Malliaras, 192 adults with midportion Achilles tendinopathy received sham injections, high-volume injections without corticosteroid, or high-volume injections with corticosteroid.
- ▪The BMJ clinical trial evaluated self-reported pain and disability at 52 weeks using the Victorian Institute of Sport Assessment-Achilles scale, where 100 represents no pain or disability.
High-volume injections without corticosteroid
- ▪In the 2026 clinical trial, 16% of participants receiving high-volume injections without corticosteroid experienced aggravated Achilles pain.
- ▪In the clinical trial published in October 2026, high-volume injections without corticosteroid demonstrated no clinical benefit over sham injections at any measured time point up to 52 weeks.
Short-term benefits of corticosteroid injections
- ▪At 52 weeks, the Inject clinical trial recorded no statistically significant difference in pain and disability scores among participants receiving sham injections or high-volume injections with or without corticosteroid.
- ▪John W. Orchard noted that corticosteroid high-volume injections allowed patients with Achilles tendinopathy to avoid the lowest functional scores more rapidly in the short term.
- ▪Corticosteroid high-volume injections reduced missed days from work and required fewer total health visits in the short term compared to sham injections.
Worsening corticosteroid outcomes over time
- ▪By week 12 of the Inject clinical trial, the initial functional advantage provided by corticosteroid high-volume injections over sham and active non-steroid injections had completely disappeared.
- ▪At 26 weeks post-treatment, participants receiving high-volume injections with corticosteroid reported significantly worse pain and disability outcomes than those receiving high-volume injections without corticosteroid.
- ▪John W. Orchard reported that corticosteroid high-volume injections yielded inferior 52-week functional outcomes compared to sham treatment for Achilles tendinopathy.
Cost-effectiveness of corticosteroid injections
- ▪High-volume injections with corticosteroid achieved greater quality-adjusted life-years gained and lower overall healthcare costs over one year compared to sham injections.
- ▪Researchers found a greater than 90% probability that corticosteroid high-volume injections were cost-effective at willingness-to-pay thresholds between AUS$50,000 and $100,000 per quality-adjusted life-year.
Clinical guidance on corticosteroid use
- ▪John W. Orchard urged clinicians to inform patients that corticosteroid injections do not fix or cure tendinopathy and to explain long-term trade-offs during informed consent.
- ▪John W. Orchard advised that corticosteroid injections should only be used when short-term functional demands predominate over long-term outcomes, such as within six weeks of major athletic competition.
Trial conclusions and limitations
- ▪Peter Malliaras and colleagues acknowledged study limitations, including recruiting participants primarily through social media and being unable to mask injection providers.
- ▪Peter Malliaras and colleagues concluded that trial findings do not support the routine use of high-volume injections for midportion Achilles tendinopathy.
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