What is the treatment for Achilles tendon tendinopathy associated with fluoroquinolones (Fluoroquinolone antibiotics)?

Treatment of Fluoroquinolone-Associated Achilles Tendon Tendinopathy

The primary treatment for fluoroquinolone-associated Achilles tendinopathy includes immediate discontinuation of the fluoroquinolone antibiotic, rest, non-steroidal anti-inflammatory drugs, physical modalities, and a progressive rehabilitation program with eccentric strengthening exercises. 1

Immediate Management

• Discontinue fluoroquinolone use immediately at the first sign of tendon inflammation to reduce the risk of progression to tendon rupture 1, 2
• Rest and reduce stress on the tendon through the use of assistive devices such as crutches during the acute phase 3
• Consider orthoses or bracing to offload the affected tendon during the initial healing phase 3
• Use non-steroidal anti-inflammatory drugs (NSAIDs) for pain management during the acute inflammatory phase 1

Antioxidant Supplementation

• Consider magnesium supplementation during the treatment course if no contraindications exist, as recommended by the American College of Physical Medicine and Rehabilitation 4
• Antioxidant supplementation with vitamin E or coenzyme Q10 may be beneficial based on preliminary data showing protective effects against fluoroquinolone-induced tendon damage 5
• Mitochondrial-targeted ubiquinone (MitoQ) has demonstrated larger protective effects than untargeted ubiquinone in human Achilles tendon cells exposed to fluoroquinolones 5

Rehabilitation Protocol

• Implement a two-phase rehabilitation approach based on connective tissue remodeling principles 3:

  • Phase 1 (Protection Phase): Reduce stress on the tendon through rest, assistive devices, and orthoses 3
  • Phase 2 (Progressive Loading Phase): Gradually increase tendon loading through controlled exercise and functional activities 3

• Incorporate eccentric strengthening exercises as the cornerstone of rehabilitation once the acute phase has resolved 1

• Gradually progress physical activity based on pain response and functional improvement 3

Monitoring and Follow-up

• Monitor for symptom improvement - most patients report recovery within 2 months of discontinuing the fluoroquinolone antibiotic, though 26% may still report pain and disability at follow-up 5
• Consider MRI imaging to distinguish between tendinitis and partial tendon rupture if symptoms persist or worsen despite appropriate management 2
• Refer for surgical consultation if tendon rupture occurs or is suspected 1, 6

Special Considerations and Risk Factors

• Higher vigilance is needed for patients over 60 years who have 4 times higher risk of Achilles tendon rupture compared to the general population 7
• Concomitant corticosteroid use dramatically increases risk (odds ratio 43.2 for Achilles tendon rupture) and may require more aggressive management 7, 4
• Athletes and physically active individuals require special attention as 50% of fluoroquinolone-associated tendon disorders occur during sports participation 5
• Bilateral involvement is common, occurring in more than half of cases, necessitating comprehensive assessment of both Achilles tendons 5

Pitfalls and Caveats

• Do not delay discontinuation of the fluoroquinolone - symptoms can occur as early as 2 hours after initial exposure or as late as 6 months after discontinuation 5, 7
• Avoid corticosteroid injections which may further increase the risk of tendon rupture 7
• Do not rush return to full activity as premature loading may lead to tendon rupture 3
• Be aware that other tendons may be affected beyond the Achilles, including patellar tendon, rotator cuff, and various hand and foot tendons 5, 7