What are the effects of oral corticosteroids (CS) on tendons?

From the Guidelines

Oral steroids should be avoided in patients with tendon issues due to their potential to weaken tendon structure and increase the risk of rupture or injury. The use of oral steroids can have detrimental effects on tendon health, as they inhibit collagen synthesis and tenocyte proliferation, which are crucial for maintaining tendon strength and elasticity 1. Additionally, steroids increase the activity of matrix metalloproteinases that break down tendon tissue, further compromising tendon integrity.

Key Points to Consider

• Oral steroids can affect tendon health within weeks of regular use, even at moderate doses
• The risk of tendon rupture or injury increases with higher doses, longer duration of use, and in older adults
• Patients taking oral steroids should be cautious with high-impact activities and heavy lifting, particularly if they have pre-existing tendon issues
• The Achilles tendon is particularly vulnerable to the effects of oral steroids
• Anyone experiencing tendon pain while on steroids should consult their healthcare provider immediately, as dose adjustment or alternative treatments may be necessary to prevent serious tendon damage

Alternative Treatment Options

• Relative rest and reduced activity can prevent further damage and promote healing and pain relief 1
• Cryotherapy and eccentric strengthening are effective treatments for tendinopathy and may reverse degenerative changes 1
• Topical NSAIDs and locally injected corticosteroids may be considered for short-term pain relief, but their long-term effects on tendon health are unclear 1

From the FDA Drug Label

Fluoroquinolones Post-marketing surveillance reports indicate that the risk of tendon rupture may be increased in patients receiving concomitant fluoroquinolones (e.g., ciprofloxacin, levofloxacin) and corticosteroids, especially in the elderly. Tendon rupture can occur during or after treatment with quinolones.

The use of oral steroids, such as prednisone, may increase the risk of tendon rupture when used concomitantly with fluoroquinolones, particularly in the elderly. Key points to consider:

• Tendon rupture can occur during or after treatment with quinolones.
• The risk is increased in elderly patients.
• Concomitant use of fluoroquinolones and corticosteroids should be approached with caution 2.

From the Research

Effects of Oral Steroids on Tendons

• There is limited direct evidence on the effects of oral steroids on tendons, as most studies focus on the comparison between platelet-rich plasma (PRP) and corticosteroid injections for tendinopathy treatment 3, 4, 5, 6.
• However, it is known that corticosteroid injections can have both positive and negative effects on tendons, with some studies showing improved pain relief and function in the short-term, but potential negative effects on tendon healing and long-term outcomes 3, 4.
• A systematic review and meta-analysis found that PRP injection can effectively improve pain and functional impairment in patients with tendinopathy, and its mid-term efficacy is superior to that of corticosteroids 3.
• Another study found that patients with rotator cuff tendinopathy or partial-thickness rotator cuff tears experienced clinical improvement in pain and patient-reported outcome scores after both ultrasound-guided corticosteroid and PRP injections, but PRP obtained superior improvement in pain and function at short-term follow-up (3 months) 4.
• A double-blind, randomized controlled trial found that a therapeutic regimen of standardized eccentric exercise and ultrasound-guided leukocyte-rich PRP injection with dry needling accelerates the recovery from patellar tendinopathy relative to exercise and ultrasound-guided dry needling alone, but the apparent benefit of PRP dissipates over time 5.
• A systematic review of the literature on the use of PRP as a treatment for tendinopathies found that patellar tendons seem to benefit from PRP injections, whereas in the Achilles tendon, PRP application is not indicated neither as a conservative approach nor as a surgical augmentation 6.