Achilles Tendon Injections Fail to Beat a Sham Shot in New BMJ Trial: What Runners Should Know

Achilles has a bad reputation in Greek myth. His mother dipped him in the river Styx to make him invulnerable but held him by the heel. That one dry spot became the most famous weak point in Western storytelling. Brad Pitt’s Achilles duly took an arrow there in Troy. If you have ever had real Achilles tendon pain, you know it looks nothing like cinema. It looks like limping down the stairs every morning for months.

Many people with stubborn Achilles pain eventually ask for an injection. A new randomized trial published in The BMJ this week suggests that, for the most common form of the problem, those injections may not deliver what you hope.

What the researchers tested

The trial, led by Monash University in Melbourne, enrolled 192 adults with midportion Achilles tendinopathy, a painful overuse condition of the tendon a few centimeters above the heel. Participants were 49 years old on average, 55 percent were men and they had lived with symptoms for a median of two years. They were recruited between December 2019 and July 2022, mostly through social media. Injections were given at a radiology clinic in Melbourne.

Everyone received the same foundation: an exercise program, education about the condition and advice on how to adjust activity. On top of that, participants were randomly assigned to one of three injections. One group got a sham injection. One got a high-volume injection, which delivers a larger amount of fluid made of saline and local anesthetic. The third got the same high-volume injection with a low dose of corticosteroid added.

The main yardstick was the VISA-A score after 52 weeks, a questionnaire from 0 to 100 that measures pain and function in the Achilles. At the start, participants averaged 48.7 points.

What they found

After a year, there was no clear difference between the sham group and either injection group. The two injection types did not clearly differ from each other either. Follow-up data at 12 months were available for 181 of the 192 participants.

The high-volume injection without steroid did not beat the sham at any point. The steroid version produced a small improvement at six weeks, which is exactly the kind of quick relief that makes cortisone shots popular. By 26 weeks, however, that group was doing worse than the group that had the injection without steroid. No serious trial-related adverse events were recorded.

The authors wrote that the evidence should prompt clinicians to “reconsider the rationale” for using these injections in Achilles tendinopathy. In a linked editorial, sports physician John Orchard of the University of Sydney stressed the trade-off between short-term relief and longer-term outcomes with corticosteroids. Patients, he argued, should never be told that a steroid will fix or cure tendinopathy.

Why the sham did so well

A sham injection is not nothing. It involves a needle, a clinic, a specialist plus the expectation of help. Expectation is a powerful force when it comes to pain. On top of that, every participant was doing the exercise program, which remains the recommended first approach for tendinopathy. A strong shared baseline makes it harder for any add-on to shine. This is our interpretation rather than a finding of the trial itself, but it helps explain why sham-controlled studies so often humble popular procedures.

One limit matters for anyone reading the headlines: the trial did not test platelet-rich plasma, the blood-derived injection that is popular in sports medicine. You cannot read this study as a verdict on every needle that has ever met a tendon. The authors also note that recruiting through social media may limit how far the results can be generalized and that the clinicians giving the injections could not be blinded.

Why so many people want the shot anyway

Achilles tendinopathy affects around 6 percent of people over their lifetime, according to Monash University. Exercise-based therapy is the standard treatment, yet up to 44 percent of patients do not recover with it. That gap is where the demand for injections comes from. Monash physiotherapist Professor Peter Malliaras acknowledged that some patients may get short-term relief from steroid injections. Temporary relief can matter, he noted, for example when pain stops someone from working. His advice is that clinicians discuss the potential benefits and limits openly with each patient.

Running culture adds its own pressure. Marathon season, run clubs that double as social scenes and a sneaker industry that sells performance as lifestyle all nudge people to get back on the road quickly. A quick fix is tempting when your training plan has a race date printed on it.

What this means for you

If your Achilles has been nagging you for weeks, this trial supports what sports medicine has been saying for years: guided, gradual loading exercise is the foundation, slow and unglamorous as it is. Injections may still have a place in specific situations, but the evidence here suggests they are not the shortcut many people hope for. If someone offers you a steroid shot, it is fair to ask what it is expected to do at six weeks and what it might mean at six months.

The tendon, it turns out, rewards patience more than needles. The original Achilles never got that option. You do.

This article is for general information only and does not replace advice from a doctor or physiotherapist. If you have persistent tendon pain, please seek a professional assessment.