Inject trial: high-volume injections for Achilles tendinopathy no better than sham at a year

Design

Single-centre, participant- and assessor-masked, three-arm randomised trial

Population

192 adults with midportion Achilles tendinopathy

Primary outcome

VISA-A pain and disability at 12 months

Effect

Steroid vs sham -3.5 (98.3% CI -12.0 to 5.0); no steroid vs sham 4.0 (-4.2 to 12.3)

The Inject trial, published in the BMJ on 28 October 2026, randomised 192 adults with midportion Achilles tendinopathy in one Australian community centre to sham injection, high-volume injection of saline and local anaesthetic, or the same with 25 mg hydrocortisone. Everyone received the same exercise programme and advice, and participants and assessors were masked.

At 12 months there was no clear difference in VISA-A pain and disability between sham and either injection. The steroid injection helped at six weeks (9.2 points better than sham), but at 26 weeks it did worse than the steroid-free injection (-8.6 points). A cost analysis favoured the steroid injection, but the authors judged that the longer-term clinical picture does not support routine use.

For anyone who sees tendon pain, the message is that injections do not replace loading exercise, and a short-term steroid gain may cost later recovery.

• Make progressive loading exercise the first treatment for midportion Achilles tendinopathy.
• Avoid routine high-volume injections, with or without steroid, for this condition.
• If a patient asks for an injection for quick relief, explain the early gain was offset by worse outcomes at six months.
• Set expectations that recovery takes months, not weeks.

Why it matters

A quick steroid benefit that turns into worse recovery later is exactly the trade patients are not usually told about.

Don't overread it

A single-centre trial of 192 people; it tested high-volume injection, not every injection technique.

The statistics, in plain English

The trial used 98.3% confidence intervals to allow for three comparisons. All 12-month intervals crossed zero, so no injection clearly beat sham. The six-week and 26-week differences were secondary and should be read as signals.

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