Design: Single-centre, three-arm, participant- and assessor-masked RCT
Population: 192 community adults with midportion Achilles tendinopathy
Primary outcome: VISA-A pain and disability at 52 weeks
Effect: Steroid vs sham −3.5 (98.33% CI −12.0 to 5.0); no-steroid vs sham 4.0 (−4.2 to 12.3)

The Inject trial, published in the BMJ, randomised 192 community adults with midportion Achilles tendinopathy in a single centre to sham injection (a small volume of local anaesthetic), high-volume injection of saline and bupivacaine, or the same with 25 mg hydrocortisone. Participants and assessors were masked, and everyone received the same exercise programme, education and load advice.

At 12 months, neither high-volume injection improved VISA-A pain and disability scores compared with sham. The steroid injection helped at six weeks but was worse than the non-steroid injection at 26 weeks. No serious trial-related adverse events occurred. An economic analysis suggested the steroid injection could save costs, but the authors conclude the clinical data do not support routine use.

For a family physician, the lesson is familiar from other tendinopathies: a steroid injection can buy short-term relief at the price of later outcomes, and graded loading remains the backbone of treatment.

Make a progressive loading exercise programme the first-line treatment for midportion Achilles tendinopathy.
Avoid routine high-volume or steroid injections for this condition.
Warn patients that any short-term relief from a steroid injection may be followed by poorer recovery.
Advise activity modification rather than complete rest, and allow some pain during exercise.
Refer to physiotherapy where adherence or progress is poor.

Why it matters

It removes the case for a popular injection and confirms that exercise carries most of the benefit.

The statistics, in plain English

The 98.33% confidence intervals adjust for three comparisons. Each 12-month interval crossed zero, so no injection showed a benefit over sham. The six-week steroid benefit was real but short-lived.