T Nation

Antibiotics and Tendon Ruptures

ANTIBIOTICS AND TENDON RUPTURE
BY NICHOLAS S. LIATSOS, PT, CSCS, CISSN

You know the warning labels that come with the antibiotics youâ??ve been prescribed over the years? You should read them. And so should your doctor.

Unfortunately, many patients and physicians are unaware of the potentially devastating side effects of antibiotics, like fluoroquinolones.

Fluoroquinolones are broad-spectrum antibiotics that are routinely used for respiratory infections, urinary tract infections, and skin infections. The most common fluoroquinolones are Cipro, Levaquin, and Avelox.

Antibiotics and Tendon Ruptures

Under normal circumstances, tendon ruptures are rare. They usually occur spontaneously as a result of sports injuries. Studies estimate an annual rate of 6 to 37 cases per 100,000 people. However, reports show that the likelihood of a rupture increases by three to four times that rate with the use of fluoroquinolones. And these ruptures have been reported with little or no inciting event.

Fluoroquinolones can cause tears or ruptures in the Achilles, shoulder, hand, patella, or quadriceps tendon. The Achilles tendon seems to be the most vulnerable to injury during weight-bearing activities, such as walking or running. But it is important to note that use of these antibiotics may also weaken tendons and set you up for ruptures down the road. Tendon pain, swelling, or inflammation (tendonitis) can lead to degenerative changes in the tendon, or tendinosis, which may cause a ruptureâ??even one year after discontinuing the antibiotic.

The link between fluoroquinolones and tendinopathy and tendon rupture is not completely understood. Researchers believe the drugsâ?? toxic effects somehow alter the structure and biomechanical properties of the connective tissue.

Risk Factors

People over 60 years old are at a greater risk of developing tendon disorders with the use of this class of drugs. Other contributing factors include, but are not limited to, corticosteroid use, chronic renal disease, diabetes, rheumatoid arthritis, and other musculoskeletal disorders.

Red Flag

In 1995, the Food and Drug Administration (FDA) updated the warning label for this class of antibiotics to include a warning about tendinopathy and tendon rupture. The label recommended that patients discontinue taking the drug and refrain from exercise at the first sign of tendon pain or inflammation.

This red flag, however, did not do enough to bring awareness to the problem. Reports of tendon injuries associated with fluoroquinolones continued. So, in 2006, Public Citizen, a Washington, D.C.-based watchdog group, and Illinois Attorney General Lisa Madigan petitioned the FDA for a more prominent boxed warning about these tendon risks.

A boxed warning, sometimes referred to as a black-box warning, is the strongest warning issued by the FDA. It signifies that medical studies show a significant risk of serious or life-threatening side effects.

Besides the black-box warning, the petition also requested that the FDA require a medication guide for patients and a letter from the manufacturers to the doctors detailing the tendon risks.

In 2008, the FDA finally agreed to require boxed warnings and a medication guide for patients. But they did not require the drug makers to include a letter to doctors detailing the risks.

Awareness

Despite the black-box warning, many practitioners are still unaware of these adverse effects and continue to prescribe fluoroquinolones without determining whether the patient is at risk of developing tendinopathy or rupture.

Patients who are over 60 or have other risk factors listed on the warning label should consult with their healthcare provider about being prescribed a non-fluoroquinolone antimicrobial drug. But I think we need to go one step further. For athletes and exercise enthusiasts, this class of antibiotics should also be considered off limits.

Tendinopathy and tendon rupture are serious and debilitating. It takes the average person months, or even a year, to recover from a complete rupture that requires surgical repair. For athletes, a rupture can be a career-ending injury. It is not worth the risk, especially considering there are alternative treatment options.

Empowered Autonomy

â??The link between fluoroquinolones and tendon disorders has been known for nearly 20 years. But awareness remains an issue. It is up to you to ask about the risks and read the warning labels. If your doctor prescribes fluoroquinolones, like Cipro, ask for an alternative!

â??
Sources:

Greene, B. (2002, December). Physical Therapist Management of Fluoroquinolone-Induced Achilles Tendinopathy. Journal of American Physical Therapy Association. Retrieved December 19, 2013, from http://ptjournal.apta.org/content/82/12/1224.full

Kim, G. et al. (2010, April). The Risk of Fluoroquinolone-induced Tendinopathy and Tendon Rupture. The Journal of Clinical and Aesthetic Dermatology, 3(4); 49â??54.

Landers, S. (2008, July 28). FDA requires black-box warnings for fluorquinolones. American Medical News. Retrieved December 19, 2013, from http://www.amednews.com/article/20080728/health/307289979/7/

Miller, K. (2013, August 27). Some Antibiotics Linked to Serious Nerve Damage. WebMD. Retrieved December 19, 2013, from http://www.webmd.com/brain/news/20130826/fda-strengthens-fluoroquinolone-warning

â??Postmarket Drug Safety Information (2008) U.S. Food and Drug Administration. Retrieved December 19, 2013, from http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm126085.htm

Actually there are bigger risks to quinolines then tendon rupture alone, they have been shown to create long lasting neurological and behavioral issues for a lot of patients.

They actually have since put a black label warning on prescriptions for this adverse side effects.

[quote]cstratton2 wrote:
Actually there are bigger risks to quinolines then tendon rupture alone, they have been shown to create long lasting neurological and behavioral issues for a lot of patients.
[/quote]

Wow thats insane and thank you for the response!

This thread brought me out of a good 5+ year lurk. I fell victim to one of these antibiotics before the black box warning took effect. I took Levaquin for a skin infection acquired from grappling. Within days, I began breaking out in hives and rashes. Soon thereafter, I began experiencing horrible pain in my heels and wrists. The following week, (after stopping the medicine after only about 3 days) I started to experience painful migratory poly-arthritis. I would wake up in the morning not being able to move my left arm, go to bed and wake the following day unable to walk. This went on for about three months in total.

Trips to specialists; rheumatologists, infectious disease doctors, emergency room visits yielded no conclusions as all tests came back negative, despite presenting all of the aforementioned symptoms. Finally, after being falsely diagnosed with rheumatoid arthritis, I was put on a medrol dose-pack and the arthritis-like symptoms dissipated. This was almost 6 years ago, and I have not had a single occurrence of joint pain, tendon discomfort, etc. despite heavy weightlifting, grappling, running, etc.

No doctor would come to a concrete conclusion as to the cause of my condition, but it is my belief that the Levaquin is to blame.

Good topic- thanks for bringing it up, as more people should know about the potential “side effects” of these commonly prescribed drugs.

@ Waterman that’s brutal… glad to hear your better.

We’re taught that quinolones are in theory associated with tendon rupture, but in reality the studies initially showing that were in dogs. There have also been some isolated case studies. But on the whole there hasn’t been a whole lot of conclusive evidence showing quinolones put healthy populations at risk of tendon injury. Apparently there is some association with levaquin, but again there’s not a whole lot of conclusiveness to the studies.

Waterman’s case sounds a lot like an autoimmune reaction, which can sporadically happen with pretty much any medication. It’s also worth mentioning that these antibiotics are normally held for more serious infections and they do have a significant side effect profile like cardiac arrhythmias. If your doctor is reaching for cipro, moxi or levaquin, it’s not for your average sore throat. Mostly they’re used for hospital acquired pneumonia or urinary tract infections from indwelling catheters. The risk profile of the drugs I’d say is worth it considering the infections they are normally used to treat.

[quote]XiaoNio wrote:
We’re taught that quinolones are in theory associated with tendon rupture, but in reality the studies initially showing that were in dogs. There have also been some isolated case studies. But on the whole there hasn’t been a whole lot of conclusive evidence showing quinolones put healthy populations at risk of tendon injury. Apparently there is some association with levaquin, but again there’s not a whole lot of conclusiveness to the studies.

Waterman’s case sounds a lot like an autoimmune reaction, which can sporadically happen with pretty much any medication. It’s also worth mentioning that these antibiotics are normally held for more serious infections and they do have a significant side effect profile like cardiac arrhythmias. If your doctor is reaching for cipro, moxi or levaquin, it’s not for your average sore throat. Mostly they’re used for hospital acquired pneumonia or urinary tract infections from indwelling catheters. The risk profile of the drugs I’d say is worth it considering the infections they are normally used to treat.[/quote]

Interesting to think I wonder if these sporatic cases with the medications were all issues of auto immune disease pre disposition triggered by the medication.

Sorry to hear about all that Waterman, glad you feel better!

Yeah unfortunately I also took levaquin before the black box warning…out of the blue while cleaning and pressing a strongman log( had 285 on it which I had hit for 4 reps12 days earlier) blew both patellar tendons out on first rep…quite the gruesome injury,6 days in hospital/12 days in rehab facility/8 weeks in immobilizing braces( had surgery 24 hrs after injury).

Was 6 months before I could walk without limp/ cane/braces…devasting injury that to this day bothers me…ended my completive career in highland games and strongman

Cipro (for a very serious sinus infection that would not go away after multiple rounds of other antibiotics) and deadlifting when I suddenly no longer felt like hell made me limp around with swollen and bulging Achilles tendon for over two years.

Just dodged a rupture, I think.

Basically, if you are on this stuff, stop anything but very, very, very light work for a solid month during and after.

I get a bad sinus infection every 1 to 2 years. Tried other antibiotics but Levaquin is the magic bullet every time. However, I have noted decreased flexibility in my achilles tendon along with tightness and pain when doing things like walking up steps, playing basketball, or doing calf raises. It’s always in the back of my head that it could blow which is a real nightmare since it takes about a year to heal an achilles rupture.

[quote]XLR8MyLife wrote:
I get a bad sinus infection every 1 to 2 years. Tried other antibiotics but Levaquin is the magic bullet every time. However, I have noted decreased flexibility in my achilles tendon along with tightness and pain when doing things like walking up steps, playing basketball, or doing calf raises. It’s always in the back of my head that it could blow which is a real nightmare since it takes about a year to heal an achilles rupture.[/quote]

I also get frequent sinus infections. Levaquin and Cipro are my “magic bullets” as well. The one alternative that also seems to work, although it is very hard on your stomach, so be wary of that, is Clindamycin. May be something you want to check on.

[quote]jbpick86 wrote:

[quote]XLR8MyLife wrote:
I get a bad sinus infection every 1 to 2 years. Tried other antibiotics but Levaquin is the magic bullet every time. However, I have noted decreased flexibility in my achilles tendon along with tightness and pain when doing things like walking up steps, playing basketball, or doing calf raises. It’s always in the back of my head that it could blow which is a real nightmare since it takes about a year to heal an achilles rupture.[/quote]

I also get frequent sinus infections. Levaquin and Cipro are my “magic bullets” as well. The one alternative that also seems to work, although it is very hard on your stomach, so be wary of that, is Clindamycin. May be something you want to check on.[/quote]

For me as well, only things like Levaquin will knock out a sinus infection. My doctor warned me about heavy lifting with it, so I took it easy while I was on it and for 2 weeks after. I have experienced no bad effects at all. She also said the tendon problem is worse in older people, 60 and up.

Rob

[quote]beachguy498 wrote:

[quote]jbpick86 wrote:

[quote]XLR8MyLife wrote:
I get a bad sinus infection every 1 to 2 years. Tried other antibiotics but Levaquin is the magic bullet every time. However, I have noted decreased flexibility in my achilles tendon along with tightness and pain when doing things like walking up steps, playing basketball, or doing calf raises. It’s always in the back of my head that it could blow which is a real nightmare since it takes about a year to heal an achilles rupture.[/quote]

I also get frequent sinus infections. Levaquin and Cipro are my “magic bullets” as well. The one alternative that also seems to work, although it is very hard on your stomach, so be wary of that, is Clindamycin. May be something you want to check on.[/quote]

For me as well, only things like Levaquin will knock out a sinus infection. My doctor warned me about heavy lifting with it, so I took it easy while I was on it and for 2 weeks after. I have experienced no bad effects at all. She also said the tendon problem is worse in older people, 60 and up.

Rob[/quote]

I have always tried to avoid levaquin if possible after I had some serious joint pain while on it. Cipro doesn’t seem to do this and works just as well for me so that is usually my go to.

[quote]XiaoNio wrote:
We’re taught that quinolones are in theory associated with tendon rupture, but in reality the studies initially showing that were in dogs. There have also been some isolated case studies. But on the whole there hasn’t been a whole lot of conclusive evidence showing quinolones put healthy populations at risk of tendon injury. Apparently there is some association with levaquin, but again there’s not a whole lot of conclusiveness to the studies.

Waterman’s case sounds a lot like an autoimmune reaction, which can sporadically happen with pretty much any medication. It’s also worth mentioning that these antibiotics are normally held for more serious infections and they do have a significant side effect profile like cardiac arrhythmias. If your doctor is reaching for cipro, moxi or levaquin, it’s not for your average sore throat. Mostly they’re used for hospital acquired pneumonia or urinary tract infections from indwelling catheters. The risk profile of the drugs I’d say is worth it considering the infections they are normally used to treat.[/quote]
This

I’ve taken cipro and never had any issues and I’m pushing 60. glad for the info. went to www.peoplespharmacy.com and found all kinds of issues being listed about fluoroquinolones. over 3400 lawsuites involving levofloxacin.

as soon as I got to the site saw this one on statins, which I take.

[quote]silverblood wrote:
I’ve taken cipro and never had any issues and I’m pushing 60. glad for the info. went to www.peoplespharmacy.com and found all kinds of issues being listed about fluoroquinolones. over 3400 lawsuites involving levofloxacin.

as soon as I got to the site saw this one on statins, which I take.

www.peoplespharmacy.com/2014/02/17/statin-ruined-his-bodybuilding-career/[/quote]

Statins can do massive muscle damage when mixed with certain supplements… Can’t remember too much info about it but I know grape fruit seed extract with it can cause issues.

Mercola has an article about some of this I think…

http://articles.mercola.com/sites/articles/archive/2009/08/06/statins-cause-muscle-damage.aspx