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High Volume Injections as treatment for Achilles tendinopathy

Updated: Jun 2, 2022



Having a high volume injections is one of the treatment options available for patients with mid-portion Achilles tendinopathy. In this article I take a look at how they are thought to work and if the research shows that they are useful.

In this article:

  • How do High Volume Injections work?

  • What does the research say – do they actually work?

How do High Volume Injections work?

The main objective for using a high volume injection is to decrease pain which then allows a patient to move and exercise more. It is usually used for patients whose pain levels are preventing them from progressing with their rehab. Remember, pain does not equal damage so it is OK to use adjunct treatments to decrease your pain and allow you to get on with the rehab that will make your tendon strong again.

It’s not seen as a standalone “cure” for Achilles tendinopathy and is usually used in conjunction with a well-structured progressive rehab programme. When you have Achilles tendinopathy, you lose some of the strength in your tendon and the rehab programme is important, because it’s the only way to get your tendon back to its pre-injury strength. If you jump back into full sport without doing your rehab first, you’ll likely just flare your pain up again.

When they do a high volume injection, they inject a high volume of normal saline (sterile water) into the tendon. It should be done under ultrasound guidance so that they can target the area in the tendon where they can see the main area of injury and ingrowth of new blood vessels. They also inject a small amount of anaesthetic so that the injection isn’t painful. Lastly they sometimes include a small amount of corticosteroid and other times they don’t.

You can consult us online for an assessment of your Achilles injury and a tailored treatment plan. Follow the link to learn more.

We’re not quite sure about how exactly these injections manage to decrease the pain. One theory is that the high volume of fluid and the movement of the needle has a local mechanical effect on the tendon and also collapses the small blood vessels that you usually find in the injured tendon. These blood vessels aren’t found in healthy tendons. Each blood vessel has a little nerve that grows with it and these nerves are thought to cause some of the pain that you feel when you have a tendinopathy. When the blood vessels collapse, it also gets rid of the little nerves which is then thought to be the reason why your pain decreases.

We know that corticosteroids act as a very good pain killer in the short term and another school of thought is that it’s actually the steroids that is behind the drop in pain. However, there are studies that have shown that high volume injections can be effective even if the corticosteroid is left out.

Nobody has so far investigated the effect that the anaesthetic has on how well these injections work. We know that the pain created by ongoing injuries can become disproportionately high and it may very well be that the anaesthetic just resets the pain system back to normal.

What does the research say – do they actually work?

There’s really not a lot of high quality research available yet, but the current studies do seem to suggest that high volume injections can be useful when combined with a structured rehab programme. If you’re struggling to progress with your rehab and your pain levels remain high despite doing all the right things, having a high volume injection may be a treatment option worth considering.

Let me know if you have any questions. Need more help with your Achilles injury? You’re welcome to consult us online via video call for an assessment of your injury and a tailored treatment plan.

Best wishes


About the Author:

Maryke Louw is a chartered physiotherapist and holds an MSc in Sports Injury Management. You can follow her on LinkedIn, Facebook, Twitter or Instagram.


  1. Abdulhussein, H., et al. (2017). "High Volume Image Guided Injections with or without steroid for mid-portion Achilles Tendinopathy: A Pilot Study." Clinical Research on Foot & Ankle 5(3): 249.

  2. Boesen, A. P., et al. (2017). "Effect of high-volume injection, platelet-rich plasma, and sham treatment in chronic midportion Achilles tendinopathy: a randomized double-blinded prospective study." The American Journal of Sports Medicine 45(9): 2034-2043.

  3. Boesen, A. P., et al. (2019). "High volume injection with and without corticosteroid in chronic midportion achilles tendinopathy." Scandinavian Journal of Medicine & Science in Sports 29(8): 1223-1231.

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