As a sports physical therapist, I’ve treated several clients who suffered from Fluoroquinolone associated debilitating tendon pain. I welcomed Tom Goom, PT’s insight on this very important topic, and I am going to share brief summary to create awareness and suggest steps to address this.
Fluoroquinolone associated tendon pain is a very important topic because it can significantly impact peoples’ lives. It is under-recognized condition but with the right treatment can do very well.
Fluoroquiniolones are widely used class of antibiotics and can have quite wide impact of the individual’s lives. They can affect multiple tissue types such as tendons, bones, muscles and nerves. Some of the effects include tendinopathy and development of tendon rupture, joint pain and swelling, muscle pain and weakness, and nerve damage to name a few.
Fluoroquinolone can also reduce bone healing and have also psychological effect with fatigue, panic attacks, memory issues, and depression (Hall et al. 2011, Lewis and Cook 2014).
Raising people’s awareness is an important step in prevention of these effect.
Here are some of the medications to watch for, many of them have ‘floxacin’ in the name:
- Ciprofloxacin
- Levofloxacin
- Pefloxacin
- Ofloxacin
We as medical providers need to watch for these in patients’ history and if you are a patient, make sure that your physical therapist or medical doctor knows about them.
One of the most common complications is tendinopathy (0.5-2% of people who took Fluoroquinolone develop tendinopathy). Achilles tendon is affected in approximately 90% of these cases and often bilaterally. Symptoms can be acute, within about 1 week after starting the antibiotic but also the symptoms can be delayed up to 6 months after stopping the medication (Scott et al. 2015).
There are factors that influence how someone develops tendon problems – age is a big factor (people over 60 develop tendon problems more likely), sports participation, and use of systemic corticosteroids. So, an older athlete who is physically active and uses corticosteroid (for asthma for example) is a person prone to tendon problems, especially if he had tendon problems in the past.
Management
It is very important to recognize this situation and take appropriate steps, as it can do well with care. Many times, the biggest problem is that this condition goes unrecognized and the pain is often times dismissed.
When we recognize that Fluoroquinolone associated disorder may be an issue, a referral to appropriate health care provider is important to get the support our clients need. This issue requires multidisciplinary approach (Millar et al. 2019):
- Physical therapist for musculoskeletal management and progression to function/return to sports
- Rheumatologist if multiple joint pain is present
- Orthopedic surgeon if someone actually progresses to tendon rupture
- Neurologist is there is nerve damage associated
- Radiologist to perform the appropriate imaging
- Nutritionist to improve healing potential of the tissues
Physical therapists have an important role in management of Fluoroquinolone associated pain and musculoskeletal disorders. It is important to recognize the symptoms and know how to progress through the stages of healing. In acute stage, the painful tissue/tendon needs to be offloaded and the client should take some time off sports and higher impact activities to let it settle. A treatment of choice may be a heel lift in shoes to offload Achilles tendon, Kinesiotape, or crutches if needed. Then we can plan slow return to sports and monitor the response. Flareups can be common and the progress will likely be slower than normal.
At the beginning, we have to establish what is manageable activity monitor the load on the tendon, and slowly progress from there. How do we determine that? Start with known level of non-irritable activity and slowly build from there. Tendon pain from overuse likely surfaces the next day, so leading a training log or an activity log is important.
To progress, change one thing at time:
- Frequency/reps
- Time under tension
- Speed
- Surface
- Range of motion
- Load
- Type of loading (walking, running, plyometrics)
An important thing to realize is that rest and passive treatments are poor choice of treatment. The tendon needs to be loaded! Ice, heat, massage, electrotherapy and other modalities show poor effect on the healing of the tendon.
If the progression is guided and gradual, the tendon adapts. If we offload for long periods and rest, the tendon gets deconditioned and return to activities and loading is difficult. We have to find the golden middle that provides enough load stimulation but not producing flareups. We have to set goals, expectations, and timeframe. This is not a quick fix, it can take anytime from 12-18 months to be able to fully return top sports and activities.
Physical therapists are skilled in recognizing musculoskeletal issues such as joint, tendon and muscle issues and are able to progress activities appropriately. They also have tools to decrease pain so progress is made.
Take-away points:
- If you’ve taken an antibiotic ending in ‘-floxacin’ or are on long term asthma medications (corticosteroids) and have tendon pain, there is a connection… talk to your physical therapist!
- If #1 is the case, you will likely progress slower than a person who has not taken the medications.
- The key is to offload the painful tendon and SLOWLY build it back up. This will take time, there is no quick fix.
- Overall, it responds very well to gradual, guided loading…talk to your physical therapist!
Very important!….a message that is echoed throughout SportsPhysioAK; this site is not designed to replace medical assessment and advice. With injury – if in doubt get it checked out!
Source: Tom Goom, PT www.RunningPhysio.com
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Zuzana Rogers PT, ScD, SCS, COMT
www.SportsPhysioAK.com
Helping recreational and elite runners of all ages to return to running safely and pain free…for life.