According to MedPage Today coverage of a randomized trial featured in The BMJ, high-volume injections designed to alleviate disability and pain for individuals with Achilles tendinopathy failed to show a significant advantage over sham procedures. Led by Peter Malliaras, PhD, of Monash University in Melbourne, Australia, researchers found that 192 patients assigned to three different treatment arms experienced similar levels of improvement after 12 months, regardless of whether they received a steroid combination or a sham treatment.
Trial Evaluates Three Interventions Incorporating Saline
The trial evaluated three distinct interventions, all incorporating saline. Participants received either bupivacaine plus hydrocortisone, bupivacaine alone, or bupivacaine delivered to a site not expected to yield any therapeutic benefit. At baseline, patients averaged about 50 on the Victorian Institute of Sport Assessment-Achilles (VISA-A) instrument, a 100-point scale evaluating pain and disability where lower values indicate worse severity.
Active injections were administered at the junction of the Achilles tendon and Kager’s fat pad. Meanwhile, sham injections were delivered at least 10 mm anterior to that junction. Researchers utilized a sleeve over the Achilles region so participants receiving high-volume injections could not see the temporary bulge.
Short-Term Relief Versus Long-Term Outcomes
While the bupivacaine-steroid combination provided significantly greater relief at 6 weeks compared with the other two arms, that advantage vanished by week 12. By week 26, pain and disability appeared worse with the combination. Conversely, researchers noted no differences between sham injections and bupivacaine alone at any time point during the study.
“Although high-volume injections with corticosteroid showed short-term clinical benefit and potential reduction in healthcare costs over a year, they were associated with worse longer-term clinical outcomes,” Malliaras and colleagues concluded. They added that clinical data do not support routine use for midportion Achilles tendinopathy.
Expert Commentary on Corticosteroid Trade-Offs
In an accompanying editorial, John W. Orchard, MBBS, MD, PhD, a sports medicine expert at the University of Sydney and chief medical officer for Australian cricket associations, commented that short-term benefits with hydrocortisone come with a significant cost. He characterized the treatment as borrowing from the future to finance the present.
“The short-term improvement is impressive, but the benefits are a loan not a gift,” Orchard wrote. He emphasized that clinicians recommending or performing these injections need to understand the trade-off and explain the broader overview to patients during informed consent.
Common Questions About Achilles Tendinopathy Injections
Why did high-volume injections become popular without rigorous evidence?
Like many orthopedic procedures, injections of saline, analgesics, and steroids grew popular for treating tendon injuries without rigorous supporting evidence. To bypass controversial longer-term adverse effects seen in tennis elbow, clinicians developed a workaround for Achilles tendinopathy by using large volumes of saline, such as 50 mL per treatment.
What specific measurements were used to track patient progress?
Researchers used the VISA-A instrument to evaluate pain and disability on a 100-point scale. Changes in VISA-A scores at week 52 served as the primary outcome measure, averaging about 25 to 30 points across all three arms without reaching statistical significance.
Did the treatment impact overall healthcare costs?
Yes, including the steroid did reduce overall healthcare costs during the year-long study period. Based on an economic evaluation, the active regimen was found to be cost-effective with greater than 90% certainty at willingness-to-pay thresholds ranging from AUS$50,000 to $100,000.