Achilles tendonitis is common in middle-aged runners and elite and amateur sportspeople. The most common cause is too much load on the tendon. However, obesity, diabetes, and high cholesterol increase the risk. Moreover, some antibiotics can trigger tendon damage, while others can be helpful. So, are antibiotics and Achilles tendons harmful or helpful?
Antibiotics and Achilles tendons: which are harmful?
Since the 1980s, doctors have noticed a link between people taking antibiotics and Achilles tendonitis and rupture. The first antibiotic linked to tendonitis is the group known as fluoroquinolones. Some of the common antibiotic names in this group include ciprofloxacin and levofloxacin. Other antibiotics known to increase the risk of tendonitis include clindamycin or azithromycin. Since the first reports many years ago, there have been over 100 cases reported in the medical community.
Why do people take these potentially harmful antibiotics?
These antibiotics treat severe lung, bone, and kidney infections. However, in some cases, these powerful antibiotics have also been prescribed for relatively mild illnesses, such as bronchitis. Recently, there has been an effort to make people aware of this possible link between antibiotics and tendonitis.
Antibiotics and Achilles tendons: why do they cause tendonitis?
We are still determining the answer. However, we think certain antibiotics cause inflammation, leading to a build-up of potent toxins. These toxins directly damage the tendon, causing tendonitis and rupture. Again, however, we are still determining the exact reason and need to do more research into the link. We also know that tendon damage is more significant in people with a history of tendonitis. Moreover, other factors that increase the risk of tendon damage with fluoroquinolone use include the elderly, chronic diseases such as diabetes and the recent use of cortisone tablets or injections.
Also, recent research suggests that certain fluoroquinolones increase the risk of tendonitis and tendon rupture. One study found that ofloxacin and norfloxacin had the most significant risk of tendon rupture, while another found that levofloxacin was potentially the most harmful.
Antibiotics and Achilles tendon rupture
Generally, the same antibiotics that cause tendonitis increase the risk of complete rupture.
How do you know whether you have antibiotic-induced tendonitis?
Knowing whether antibiotics are causing tendon damage can be challenging. Often, people report sudden pain and swelling in the tendon. Sometimes, pain starts within a few hours of taking the antibiotics. In other cases, a reaction can occur six months after stopping antibiotics. Overall, doctors should be more aware of these reactions. In addition, we should only use these types of antibiotics for serious hospital infections.
What do you do if you think you’ve developed a reaction?
Firstly, you must stop the antibiotics and see your doctor immediately. After that, you may need to change to another antibiotic.
Secondly, diagnostic ultrasound helps confirm the state of inflammation in the tendon. Sometimes, blood tests help with ruling out other causes.
Unfortunately, the treatment of antibiotic tendonitis is not easy. We know that recovery from tendon damage takes longer to heal. Initially, it would be best if you rested the tendon to allow the tendon to heal. A heel raise in your shoes can help. A walking boot may be needed for several weeks in moderate to severe cases. Once the severe pain settles, we suggest a slow strengthening program directed by a physiotherapist. In some cases, walking and calf exercises in a pool might help. Overall, the recovery is slow and can take many months.
What other treatments are available?
Sometimes, we consider options to reduce pain and help with physiotherapy in people who struggle.
GTN patches are helpful. These patches contain a substance called nitric oxide that helps heal collagen. However, it would help if you spoke to your doctor about side effects and how to use the patches correctly. Generally, we use patches for 2-3 months, depending on symptom severity.
Other options, such as shockwave therapy, injections, and surgery, are generally not recommended for antibiotic tendon damage. Finally, cortisone tablets or injections should be avoided due to the risk of tendon rupture.
Antibiotics and Achilles tendons: Which are helpful?
One type of antibiotic, doxycycline, lowers the levels of an enzyme in the body called MMP. Lowering this enzyme reduces inflammation in tendonitis. This type of antibiotic could help with pain from acute tendonitis. Some of us use this antibiotic for cases of acute tendon pain.
Other commonly asked questions about antibiotics and Achilles tendonitis:
Why does recovery take so long after antibiotic-induced tendonitis?
We suspect certain antibiotics trigger necrosis of the collagen fibres, leading to severe tendonitis and, in some cases, tendon rupture. Generally, recovery is much longer than overload-induced tendonitis, averaging 6-12 months.
Can fluoroquinolones cause other musculoskeletal problems in addition to tendonitis?
According to the Medicines and Healthcare Products Regulatory Agency (MHRA) in the UK, fluoroquinolones can cause other symptoms such as joint pain or swelling in shoulders, arms, or legs, abnormal pain or sensations such as persistent pins and needles, tingling, tickling, numbness, or burning, weakness or difficulty walking, changes in vision, taste, smell, or hearing. If you develop any of these symptoms, you should stop the medication immediately and seek medical attention. MHRA suggests restricting fluoroquinolones to treat severe infections only where other antibiotics are ineffective or inappropriate.
Do certain types of fluoroquinolones increase the risk of tendonitis or tendon rupture?
Yes, we think so.
One study found that ofloxacin and norfloxacin had the most significant risk of tendon rupture, while another found that levofloxacin was potentially the most harmful.
Final word from Sportdoctorlondon about antibiotic tendon damage
Antibiotic-induced tendonitis can be a devastating injury. You should see your doctor immediately if you think you’ve developed a reaction. Healing can take months to years and requires an expert to guide recovery. Generally, people should avoid these antibiotics unless they have severe hospital infections.
Thank you very much Dr. Masci for the info.
This is exactly what happened to me two months ago. (17/10/2021) About 1 week after my Cipro treatment (10 days, 3 pills per day, with no sign of any side effects at first), I started to get rashes on my chest and stomach. First very lightly then heavily. After about 3 weeks the rashes moved down to my legs in full force. I started to feel more significant pain in my knees, neck and shoulders around the beginning of December. As of today (23/12/2021), my ankles are swollen, my calves constantly feel like I just got a cramp, and quite painful when I walk. Neither can I extend my arms due to the pain in my shoulders.
Your blog helped me understand the cause of my problems better, Thank you!
I was certain that all my recent physical problems was caused by Cipro but had no proof for it!
Hi Noa, Thank you for the comment. I hope you get well soon.
Thank you Dr. Masci!
Happy Holidays to you & yours!
🙏🎄🙏
I used Z-pack 2treatments back to back. I’m having a hug flair in my elbow and shoulder pain.
Can it be the antibiotics.
I’ve don’t nothing else.
Thanks!
I’ve heard from colleagues of reports of acute tendinitis after taking Zithromax – but I haven’t seen this myself.
Thank you for acknowledging the existence of this problem. I am 5 months experiencing tendinitis in my wrists and Achilles, my right Achilles is 24/7 painful. Little or no treatment offered. I’ve aged 20 years
antibiotic drip due to body feeling inflamed and high temp, after 2nd dose I got erythema nodosum
And my Achilles were absolutely killing me to the extent I couldn’t walk. My body was already in agony – I’ve had Achilles issues for years but this was excruciating. Rheumatologist thinks on top of the virus I was admitted with I took an averse reaction to the antibiotic.
Age 65 2014. Given 1000mg cipro for 10
Days. Now 73. Still suffering. Neck shoulders Prussia hands. Wish you were in the states
I had clindamycin three times a day for 8 days, and am now suffering from achilles tendinitis above my left ankle. I tried not running for over a week and it improved dramatically. I was doing swimming instead which did not cause any problems. However, now even after a shorter run it comes back straight away, and I am now limping again when I walk. This is annoying as I love to run. I am considering bike riding for a while to see how that goes until I can run again. I am 51 and have been running most days since I was 17, so I am desperate to get back into my routine. I also try to keep my runs to no more than an 13 kms, so I don’t think over exertion is the problem.
See my blog for advice on treatment. This blog also has further advice on the treatment of Achilles tendonitis:
https://sportdoctorlondon.com/achilles-tendon-pain/
You should see a physical therapist to supervise a rehab programme.
I was given a Levofloxacin prescription by a hospital consultant on discharge after treatment for a chest infection and
was to take Two tablets a day for 7 days.
I Took only four tablets of the course and my Achilles tendonitis had started.
I have rested as mush as possible with legs elevated , used regular ice packs and this seems to be working .
My right ankle is more or less clear but not my right thigh which appears to have also been affected..
The left ankle still has a away to go .
I will be seeing a physiotherapist next week , the first appointment possible . So am hoping for great things.
I feel rather cross about this Achilles tendonitis , the literature states should be given with caution
To the over 60’s … I am fast heading for 80 yrs.