Efficacy and cost effectiveness of high volume injections with and without corticosteroid compared with sham for midportion Achilles tendinopathy (Inject trial): randomised controlled trial
BMJ · 28 Oct 2026
† Impact is the editorial-priority score. All scores are out of 100. Clinical is a stored clinical-importance score from the earlier method; it has not been recalculated.
Why it matters
High volume injections are increasingly offered for stubborn Achilles tendinopathy, and this sham-controlled trial suggests they add no lasting benefit to exercise, with steroid offering only brief relief and possible later harm.
The evidence
This single-centre, three-arm trial randomised 192 adults with chronic midportion Achilles tendinopathy to an ultrasound-guided high volume injection (50 mL) with corticosteroid, the same injection without corticosteroid, or a sham injection, with all groups also doing a 12-week exercise programme. At 12 months, neither injection improved VISA-A pain and disability compared with sham (with steroid vs sham -3.5 points; without steroid vs sham +4.0 points). The steroid injection gave a small benefit over sham at 6 weeks (about 9 points) but did worse than the non-steroid injection at 26 weeks (-8.6 points).
Pain and disability at 52 weeks: Mean difference -3.5 (95% CI unavailable; VISA-A).
Why this rigour score?
Sham-controlled RCTDesign starting point: 68.6
Raised the score
- Sham / placebo control+11.9
- Blinded outcome assessment+6.8
Lowered the score
- 12-month follow-up−0
Methods at a glance
Recorded assessment- Outcome assessors blindedMet
- Allocation concealedMet
- Random sequence generatedMet
- Intention-to-treat analysisMet
- Adequate statistical powerMet
- Prospective registrationMet
Not reported does not mean not done. Checks have different weights; this is not a count of boxes ticked.
See the full score breakdown
- Study design starting point
- 68.6
- Concealed allocation
- +5.1
- Random sequence generation
- +2.5
- Sham-controlled
- +6.8
- Placebo or sham control
- +5.1
- Blinded outcome assessment
- +6.8
- Intention-to-treat analysis
- +3.4
- 12-month follow-up
- −0
- 0% loss to follow-up
- +1.7
- Adequately powered
- +6
- Prospectively registered
- +5.1
- Study design ceiling
- −11.1
- Final rigour score rounded
- 100 / 100
Study design sets the starting point and a ceiling of 100. Recorded methods then adjust the score. Points are shown to one decimal place; the final score uses unrounded values.
Checklist from the stored appraisal. “Not met” describes the recorded criterion; it does not always produce a deduction. This overview supports reading the full study.
For journal club
1.For a patient with Achilles tendinopathy that has not improved despite loading exercises, how would you counsel them about a high volume corticosteroid injection, given that it may help at 6 weeks but appears worse at 6 months?
2.Are there patients, such as a self-employed worker who needs short-term pain relief to keep working, for whom the brief benefit of a corticosteroid-containing injection might justify its use, and how should follow-up be planned for them?
Original publication title
Efficacy and cost effectiveness of high volume injections with and without corticosteroid compared with sham for midportion Achilles tendinopathy (Inject trial): randomised controlled trial