Randomized trial shows no significant improvement in pain from treatment for Achilles tendinopathy — Evidence Review

A new randomized trial finds that commonly used high-volume and corticosteroid injections for chronic Achilles tendon pain are no more effective than placebo after one year. Related studies generally support the limited long-term benefit of such injections, emphasizing exercise-based rehabilitation as the most consistently effective approach for chronic tendinopathy, as detailed in the original publication.

• Multiple systematic reviews and meta-analyses have found that while corticosteroid injections may offer short-term pain relief for tendinopathy, they do not provide sustained improvement and may even be contraindicated for long-term management 3 11 14.
• Eccentric exercise programs remain the most robustly supported intervention for improving pain and function in chronic tendon injuries, with alternatives like shockwave therapy and platelet-rich plasma (PRP) demonstrating inconsistent or limited benefit 3 4 14.
• Some studies suggest PRP or high-volume injections may provide short-term gains when combined with exercise, but these effects are not reliably superior to exercise alone over the long term, and evidence for their routine use remains inconclusive 1 2 5.

Study Overview and Key Findings

This study addresses a critical gap in the management of chronic Achilles tendinopathy, a condition that affects up to 6% of the population and often persists for years, interfering with daily activities. Although high-volume and corticosteroid injections are widely offered when exercise-based rehabilitation fails, their true efficacy has remained uncertain due to limited high-quality trials with long-term follow-up. By directly comparing these popular interventions to a sham procedure and tracking outcomes over a full year, this research provides robust evidence to inform clinical decision-making and patient consent.

Property	Value
Study Year	2026
Organization	University of Sydney
Journal Name	BMJ
Authors	Peter Malliaras, David Connell, Anders Ploug Boesen, Rebecca S Kearney, Hylton B Menz, Dylan Morrissey, Shannon E Munteanu, Karin Gravare Silbernagel, Martin Underwood, Andrew Forbes, Terry P Haines
Population	Adults with midportion Achilles tendinopathy
Sample Size	192 participants
Methods	Randomized Controlled Trial (RCT)
Outcome	Pain and disability after 52 weeks
Results	No significant improvement in pain or disability from injections

Literature Review: Related Studies

To place these findings in a broader context, we searched the Consensus database of over 200 million research papers using the following queries:

1. chronic tendon pain treatment effectiveness
2. injections chronic pain outcomes
3. tendon pain management alternatives

Literature Review Table

Topic	Key Findings
What are the long-term effects of injection therapies for tendinopathy?	• Corticosteroid injections offer short-term pain relief but lack sustained benefit and may be ineffective or contraindicated for long-term management 3 11 14. • High-volume and PRP injections may provide temporary improvement, but evidence for lasting benefit is inconsistent 2 5.
How effective are exercise-based and physical therapy interventions?	• Eccentric exercise programs are consistently effective for improving pain and function in chronic tendinopathy 3 14. • Other modalities, such as shockwave therapy and low-level laser therapy, show modest or inconclusive effects 3 4 14.
What is the comparative effectiveness of emerging or adjunctive treatments?	• PRP injections may offer functional improvement and pain reduction in some cases, but superiority over placebo or exercise alone remains unproven, especially at longer follow-up 1 2 5 13. • Topical glyceryl trinitrate, hyaluronic acid injections, and dry needling are promising but require more evidence before recommendation 12 13.
Are corticosteroid injections beneficial for other chronic pain syndromes?	• Epidural steroid injections may provide moderate short-term relief in chronic spinal pain, but long-term benefit is limited, with similar patterns observed for other chronic pain conditions 6 7 8 9 10.

What are the long-term effects of injection therapies for tendinopathy?

The literature consistently shows that while corticosteroid injections and high-volume saline injections can provide short-term pain relief for tendinopathy, these effects do not persist in the long term. The recent study's finding that neither high-volume nor corticosteroid injections produce sustained improvement at one year aligns with systematic reviews and meta-analyses that highlight a lack of durable benefit and potential long-term ineffectiveness, especially when compared to active rehabilitation.

• Systematic reviews indicate corticosteroid injections are effective for short-term pain relief but offer little or no long-term benefit, and may be contraindicated for chronic tendinopathy 3 11 14.
• High-volume and PRP injections may yield temporary improvements in symptoms, but their effects generally diminish over time and are not reliably superior to placebo or exercise alone 2 5.
• These findings reinforce the need for caution in using injections as a standard long-term therapy for chronic tendon pain.
• Economic analyses, as in the new study, occasionally suggest cost-effectiveness for certain injections, but the lack of clinical benefit limits their routine use 3.

How effective are exercise-based and physical therapy interventions?

Exercise-based interventions, particularly eccentric strengthening programs, have the most robust evidence supporting their use for chronic tendinopathy, both for pain reduction and functional improvement. The new study confirms this by providing all participants with an exercise regimen, emphasizing its central role in management and indicating that adjunctive injections do not confer additional long-term benefit.

• Eccentric exercises are consistently recommended as first-line therapy due to their effectiveness across multiple tendinopathies 3 14.
• Other modalities, such as low-level laser therapy and extracorporeal shockwave therapy, offer moderate or inconclusive benefits, with some recent studies suggesting negligible effects for Achilles tendinopathy specifically 3 4 14.
• Evidence supports reserving other physical therapy modalities for patients who do not respond to exercise-based protocols 3 4.
• The superiority of exercise interventions over injections is now further substantiated by well-powered, long-term randomized trials 3.

What is the comparative effectiveness of emerging or adjunctive treatments?

Newer and adjunctive therapies, including PRP, dry needling, and topical agents, are being explored for chronic tendinopathy. While some studies report short-term improvements, particularly with PRP, the magnitude and duration of these effects relative to established exercise therapy remain uncertain. The new findings caution against routine use of injections, echoing the call for more high-quality trials of emerging treatments.

• PRP injections may lead to short-term reductions in pain and improvements in function, but network meta-analyses and randomized trials have not demonstrated consistent or substantial long-term superiority over placebo or exercise 1 2 5 13.
• Adjunctive treatments like topical glyceryl trinitrate and hyaluronic acid injections show promise but currently lack robust evidence from large, high-quality randomized trials 12 13.
• Comparative studies highlight that the choice of adjunctive intervention should be individualized and based on patient response and preference, pending further research 1 12.
• The need for more head-to-head trials is clear to establish the optimal role of these interventions 12 13.

Are corticosteroid injections beneficial for other chronic pain syndromes?

Research on corticosteroid injections for other chronic pain conditions, such as chronic spinal pain, reveals similar patterns—moderate short-term relief but limited or inconsistent long-term improvement. This parallels the findings in chronic Achilles tendinopathy, suggesting a broader pattern of limited long-term efficacy for corticosteroid injections in chronic musculoskeletal pain.

• Systematic reviews of epidural steroid injections for chronic spinal pain show moderate evidence for short-term relief but limited support for sustained benefit 6 9.
• The effectiveness of corticosteroid injections varies by pain condition and injection technique, but evidence for long-term functional improvement is generally weak 6 7 8 9 10.
• These patterns reinforce the importance of setting realistic expectations for patients considering injection therapies 11.
• Across chronic pain syndromes, rehabilitation and exercise-based approaches often yield more reliable long-term results 3 6.

Future Research Questions

While the current study significantly advances understanding of injection therapies for chronic Achilles tendinopathy, several important questions remain. Future research should aim to clarify the role of alternative interventions, optimize rehabilitation protocols, and identify patient subgroups who may benefit from tailored approaches.

Research Question	Relevance
What is the optimal exercise-based rehabilitation protocol for chronic Achilles tendinopathy?	Determining the most effective type, intensity, and duration of exercise could further improve outcomes beyond standard protocols 3 14.
Do any patient subgroups benefit from injection therapies for tendinopathy?	Identifying characteristics (e.g., symptom duration, age, activity level) that predict response to injections could individualize treatment 1 2 13.
What are the long-term effects and safety profiles of emerging treatments like PRP and dry needling?	Long-term comparative studies are needed to fully assess benefits and risks of newer interventions compared to standard care 1 5 13.
How can patient education and shared decision-making be optimized for tendinopathy management?	Effective communication about the risks, benefits, and expectations for each treatment option is essential, as highlighted by recent editorials 11 14.
Are combination therapies (multi-modal) more effective than single modalities for chronic tendinopathy?	Studying whether combining exercise with adjunctive treatments (e.g., PRP, shockwave) results in better outcomes could refine management strategies 2 12.