Ciprofloxacin, a widely prescribed antibiotic, belongs to the fluoroquinolone class of drugs and is commonly used to treat bacterial infections such as urinary tract infections, respiratory infections, and skin infections. Other fluoroquinolones used in medicine include ofloxacin, levofloxacin, and Norfloxacin. While effective, fluoroquinolones have been linked to a severe and potentially life-altering side effect: tendon damage, particularly tendon rupture. So, what is the association between cipro and tendon rupture, why does it occur, and how can you treat it?  

What is Ciprofloxacin?

Ciprofloxacin is a broad-spectrum antibiotic that inhibits bacteria growth. Because it can destroy a broad spectrum of antibiotics, it is a preferred option for treating complex infections. However, fluoroquinolones like ciprofloxacin are known to cause multiple side effects, one of which is tendon damage. 

Cipro and Tendon Rupture: What We Know

One of the most well-known adverse effects of ciprofloxacin is its association with tendonitis and tendon rupture. The U.S. Food and Drug Administration (FDA) has issued warnings regarding fluoroquinolones, emphasising the increased risk of tendon rupture, especially in certain groups of people. 

Commonly Affected Tendons

While ciprofloxacin-induced tendonitis and rupture can occur in any tendon, the most frequently affected tendons include:

  • Achilles tendon
  • Rotator cuff (shoulder)
  • Biceps tendon
  • Quadriceps tendon

The Achilles tendon is the most vulnerable, and studies show that rupture typically occurs several days to weeks after treatment. Generally, people may experience pain, swelling, or stiffness before a rupture, though some ruptures happen without any prior warning. 

tendon rupture Achilles

Risk factors for tendon rupture

While tendon damage can occur in any patient, certain groups are more susceptible:

  • Older Adults (over 60): Tendons naturally weaken with age, and older patients are at significantly higher risk.
  • Patients on Corticosteroids: The combination of corticosteroid use and ciprofloxacin has increased the risk of tendon rupture due to corticosteroids’ impact on tendon weakening.
  • Kidney Disease Patients: Kidney disease affects the breakdown of drugs, leading to higher levels in the bloodstream and, consequently, a higher risk of side effects.
  • Active Individuals: Athletes or very active patients are more prone to tendon injuries while on ciprofloxacin.
  • History of Tendon Disease: Those with tendon issues are more likely to experience complications on ciprofloxacin. 
  • Higher dose of drug: Using a higher dose for longer increases the risk of tendon disease.  

Why does Cipro cause Tendon Rupture? 

We are not entirely sure why Ciprofloxacin causes tendon damage, but we have a few ideas: 

  1. Fluoroquinolones degrade collagen in tendons, weakening the tissue and increasing the risk of rupture.
  2. Ciprofloxacin may harm tendon cells called tenocytes, reducing collagen production and healing. 
  3. Ciprofloxacin has been found to increase the activity of enzymes that break down tendons, contributing to tendonitis and rupture.

Cipro and tendon rupture symptoms 

patient suffering from Achilles pain

Patients experiencing tendon damage from ciprofloxacin may report the following symptoms:

  • Sudden or gradual onset of tendon pain
  • Tenderness or swelling near the tendon
  • Stiffness or difficulty moving the affected area
  • A snapping or popping sensation, indicating a rupture

Generally, symptoms can occur immediately or after a few weeks for up to 30 days after antibiotics treatment. 

Cipro and Tendon rupture management 

If you develop tendon symptoms while taking fluoroquinolones, you must speak to a sports medicine doctor immediately: 

Discontinue Ciprofloxacin:

Ciprofloxacin should be stopped at the first sign of tendon discomfort to prevent further damage.

Rest and Immobilisation:

Tendons affected by ciprofloxacin should be given adequate time to heal. For example, for Achilles tendon pain, we use heel lifts or a walking boot to rest the tendon and prevent rupture. Depending on the severity of the symptoms, rest can last for days or weeks. 

GTN patches for tendonitis:

GTN patches contain Nitric Oxide, a critical metabolite in tendon healing. Recent studies show that applying GTN patches to the skin over a painful tendon can lower tendon pain. 

Generally, we use daily GTN patches for 1-2 months until the acute tendon pain settles.

NSAIDs

NSAIDs are anti-inflammatory medications that reduce inflammation. A typical NSAID used in medical practice is Ibuprofen, although we use other more potent NSAIDs such as Arcoxia or Diclofenac. These drugs are commonly used for overload tendon disease, such as tendonitis. However, we have concerns about using NSAIDs for Cipro-induced tendon disease, as we suspect they can cause worsening tendon damage. 

Slow and progressive rehab 

Once the acute pain settles, we recommend a slow and progressive rehab programme supervised by a physiotherapist.  Generally, we suggest starting slowly and progressing gradually to ensure you don’t go backwards. 

Surgery 

In cases of full tendon rupture, surgery to repair the tendon may be needed. 

Other frequently asked questions about Ciprofloxacin and tendon rupture? 

Do all fluoroquinolones have the potential to cause tendon damage? 

Yes. However, studies suggest that Ofloxacin has the highest risk of causing tendonitis and tendon rupture, whereas Ciprofloxacin has the least risk. 

What other musculoskeletal side effects occur with fluoroquinolones? 

Studies suggest that fluoroquinolone drugs can cause muscle aches, joint swelling, and tendon sheath swelling, also called tenosynovitis, in addition to tendonitis and tendon rupture. 

Does the intake of fluoroquinolones after a tendon surgery affect the chances of healing? 

Yes, we think so. One study found that taking fluoroquinolone antibiotics within 90 days of tendon surgery significantly increases the risk of failure requiring repeat surgery. This effect was seen in repair of rotator cuff, elbow and Achilles tendons. So, you should avoid using fluoroquinolones for at least three months after tendon surgery. 

Final word from Sportdoctorlondon about Cipro and Tendon Rupture

While ciprofloxacin remains an effective treatment for many bacterial infections, its association with tendon damage warrants caution. The risk of tendonitis and tendon rupture, especially in certain population groups, means we should limit its use only to severe infections. If you develop any musculoskeletal symptoms while taking these drugs, you should stop immediately and speak to a sports medicine doctor to discuss treatment. 

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