Could there be a link between that course of antibiotics you took 6 weeks or even 6 months ago – And the Tennis or Golfer’s Elbow (or other tendon pain) you’re suffering now?
Yes, as strange as it sounds, there’s a class of antibiotics called ‘Fluoroquinolones’ that have been know for decades to cause various forms of tendon damage – (Cipro being the most well-known and commonly prescribed.)
“Tendinitis and tendon ruptures induced by fluoroquinolones, while uncommon, have been documented in the literature since 1983” [Ref: PubMed]
The official medical websites, pharma sources and research literature seem to downplay this link, while at the same time the FDA requires “Black Box” label warnings on these drugs. (The most stringent caution level.)
AND the FDA also now advises Doctors NOT to prescribe systemic Fluoroquinolones to patients unless there are no other options for their serious infection, (including certain Acute Bacterial Sinusitis, Bacterial Bronchitis and urinary tract infection cases)…
Because the risks of these tendon-damaging effects (and other side effects we’ll get to) otherwise outweigh the benefits. [Source: FDA updates]
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The Fluoroquinolone Antibiotics That Cause Tendon Damage
“As of July 2008, the FDA mandated that all FQ products have a black-box warning indicating an increased risk in adverse events including tendon rupture.”
“The FQ [Fluoroquinolone] products affected by the labeling changes include:”
- Ciprofloxacin (Cipro)
- Extended-release Ciprofloxacin (Cipro XR, Bayer; Proquin XR, Depomed)
- Gemifloxacin (Factive, Oscient)
- Levofloxacin (Levaquin, Ortho McNeil)
- Moxifloxacin (Avelox, Bayer)
- Norfloxacin (Noroxin, Merck)
- Ofloxacin (Floxin, Ortho McNeil, and generic)
The Risk of Fluoroquinolone-induced Tendinopathy and Tendon Rupture
J Clin Aesthet Dermatol. 2010 Apr; 3(4): 49–54
(This list above may not be conclusive. There are first, second, third AND fourth-generation versions of this class of drugs.)
Other Nervous / Musculoskeletal Symptoms
The side effects of these drugs are not limited to kidney and tendon damage – but are also linked to other musculoskeletal, nervous system and, even Psychiatric Disorders:
Muscular symptoms: Myalgia (muscle pain), muscular tension, rigidity and weakness
Joint symptoms: Arthralgia / Arthromyalgia (joint pain)
Nervous system symptoms: Tremors, dizziness, headaches and Paraesthesia (“pins and needles”)
Psychiatric symptoms: Insomnia, hallucinations, depression, anxiety Temporospatial Disorientation (mental confusion)
(If you are still on any of these antibiotics and are experiencing any of these symptoms, be sure to contact your Doctor right away!)
In the most severe cases, tendon ruptures (massive tendon tearing of the majority of the tendon) can occur, (most often in the Achilles Tendon) – Which certainly won’t go unnoticed.
“The majority (>85%) of FQ-associated tendinopathies occur within a month of initial FQ therapy, with a 3-fold higher chance of tendon rupture within the first 90 days of exposure.”
“In rare cases of patients with pre-existing musculoskeletal disorders, FQ therapy has been linked to tendinopathy as early as a few hours after administration to as late as 6 months after discontinuing medication”
Nonantibiotic Effects of Fluoroquinolones in Mammalian Cells
J Biol Chem. 2015 Sep 4; 290(36): 22287–22297
These side effects are said to be “uncommon” even “rare” – but by what measure?
After all, how many “lessor” cases must surely exist where someone develops a case of Tennis Elbow, Golfer’s Elbow, a Rotator Cuff injury or other tendon disorder while taking – OR, more to the point, some time AFTER taking these drugs?…
Cases where neither the person nor their doctor makes any connection between their tendon pain and their recent course of Antibiotics?
The paper refers to “rare” cases of people who have “pre-existing musculoskeletal disorders”
Yet, musculoskeletal disorders, which include everything from back pain to shin splints to Tennis Elbow, are so common and mundane they’re practically the norm in modern society.
Almost everyone you know has some kind of “pre-existing” musculoskeletal disorder. (And chances are, you do, as well, if you’re here reading this!)
And when their knee, elbow or shoulder suddenly starts hurting a lot worse, who is going to think:
“Ah! This must be from the antibiotics I was taking earlier – I’d better see my Doctor right away!”
Yes, the majority (85%) reported the onset of their tendon pain within only a month of taking the drug…
But how many people “fall through the cracks” if they start experiencing mild to moderate tendon pain SIX months after taking these antibiotics!?
I’ve worked with tendon pain sufferers for over 20 years now, and, for what it’s worth, most Tennis and Golfer’s Elbow sufferers don’t bother even seeing their doctor about their injury, so how would they be assessed and “counted” as an antibiotic-injured case?
How Do These Drugs Damage Tendons?
First off, sadly, there can be other ‘Soft Tissues’ affected by these drugs along with tendons.
Ligaments and joints can also be damaged (and muscle pain is a less-serious – but still potentially disruptive symptom.)
When you have chronic (long term / persistent) damage to tendons (which connect muscles to bones) and ligaments (which connect the bones of a joint) you eventually get ‘Joint Instability,’ as well.
Meaning: When you have a persistent, non-healing breakdown of these tissues that move and support your joints – Then your joints themselves will start hurting and wearing out a lot faster.
The mechanism of Fluoroquinolone Antibiotic damage, according to the following study, will likely be too technically dense for anyone to follow – without the proper level of chemical / biological science training.
in the simplest of terms,
“Fluoroquinolones (FQ) are powerful broad-spectrum antibiotics whose side effects include renal damage and, strangely, tendinopathies. The pathological mechanisms underlying these toxicities are poorly understood.”
“inhibition of proline hydroxylation in collagen, respectively. These effects may explain FQ-induced nephrotoxicity and tendinopathy.”
Nonantibiotic Effects of Fluoroquinolones in Mammalian Cells
J Biol Chem. 2015 Sep 4; 290(36): 22287–22297
In short: These drugs can damage the Collagen your tendons are made of, causing pain, tearing and possibly full-blown rupture…
Especially in weight-bearing joints and their tendons and ligaments, which include the ankles, knees and hips.
The Achilles Tendon being the most common site of ruptures, according to the literature.
(And let’s not forget the risk of poisoning and damaging your kidneys ‘Nephrotoxicity.’)
Proposed Mechanism [of Damage]
“Fluoroquinolones have been hypothesized to compromise tendon function and increase risk of injury… These medications may cause direct tissue injury, including necrosis or exposure-dependent cellular apoptosis.”
“They may also induce toxicity indirectly by stimulating local release of tissue-damaging substances… that degrade collagen.”
Sakaan SA, Self TH. Minimizing the risk of tendon injury associated with fluoroquinolone use
The two key terms to focus on are: ‘Necrosis’ (tissue decay) and ‘Apoptosis’ (which refers to cellular death.)
If you haven’t already heard it on social media, online forums or YouTube, there’s a special lay term for these Antibiotic-induced collagen injuries often and used by their sufferers:
“FLOXED” (Slang term, meaning injured by Fluoroquinolone toxicity – Derived from the ‘floxacin’ in these drugs names.)
How Does This Differ From A “Typical” Tendon Injury? (Tendinopathy)
In the “typical” injury process that leads to Tennis Elbow, Golfer’s Elbow, Achilles Tendon pain and similar tendon injuries, a tendon will fail to heal and regenerate properly in response to the stresses (mechanical loads) placed on it…
And your tendon gradually breaks down to the point where it starts to become weak and painful.
(Although exactly WHY this happens isn’t well understood either!)
Later, if allowed to progress, this can result in a tear because the tendon becomes too weak to handle the load on it and fails.
If you already know you have a tear, here’s my detailed article on the big question of:
This a gradual biological failure on a microscopic level (often referred to as a form of ‘Micro Tearing’ but more accurately as ‘Tendinosis.’)
Tendinosis being a slow, degenerative “rot.” (Dry Rot would be a crude way to characterize it if we were talking about wood.)
The antibiotic-driven “FLOX Rot” seems to be a very rapid chemically-induced biological failure…
One that begins on a microscopic, chemical level but which can very quickly escalate to the “macro” / big-damage level and result in a moderate-sized tear – or even a full-blow rupture!
Whereas, it would normally take many months – if not several years for the progression of the Tendinosis to weaken a tendon to the point where it tears.
All of these connective tissues; tendons, ligaments and joint capsules, are composed mainly of Collagen, the most common protein in the body.
And the essence of the problem is the breakdown / degeneration / damage to the Collagen in these connective tissues.
Whether it comes from mechanical stress (what’s often called “overuse”) Repetitive Strain Injury, Tendonitis, Tendinopathy, Tendinosis, etc.
Or whether it’s driven by the chemically-induced “side effects” of these antibiotics…
OR, possibly a combination of BOTH of these factors.
I would hazard a guess that for many sufferers who are mildly to moderately “Floxed” / suffering from an Antibiotic-Induced Collagen Injury…
There is an overlap – Or one factor has already “pre-weakened” a tendon or tendons and the other factor pushes it over the edge…
Such as months or years of playing tennis weakens the lateral elbow tendons (Common Extensor Tendon Origin) and the antibiotics cause further damage – compounding it to the point where it becomes a chronic, (persistent) painful injury.
Or the inverse, where the antibiotic damage sets one up for the sports injury or repetitive strain-type injury from some other activity.
How Do You Recover From An Antibiotic-Induced Tendon Injury?
Well, as I alluded to earlier, I don’t claim to have the answer! (At least, not a confident, comprehensive answer.)
But I do believe (or assume) it has to be much the same way you recover from a naturally-occurring tendon injury.
My focus, in my practice, is on tendon problems of the upper extremity – Tennis and Golfer’s Elbow – the Rotator Cuff, and some wrist, thumb and finger problems.
Whereas the majority of the focus in medically-based Physical Therapy (from what I can see online)…
Seems to be on the incredibly traumatic Achilles Tendon rupture cases. They’re sudden, dramatic – extremely painful and debilitating injuries.
And since these injuries require immediate medical care they’re not slipping under the radar.
But I certainly hope that’s not what you’re facing and instead have Tennis Elbow or something similar.
Again, that’s my focus – It’s what I have the most confidence in being able to outline a treatment strategy for.
Although, I’m not a Doctor – I’m just a Neuromuscular Therapist, which is basically just a Massage Therapist with extra training…
And this is just my opinion and not medical advice.
Whether your tendon is damaged by a drug, it’s caused by a sport or repetitive activity – OR due to some combination of the two…
The essence of the problem is a degradation and breakdown of the Collagen protein structure of your tendon.
It’s not that tendons simply don’t recover when injured. Tendons are perfectly capable of healing, regenerating and getting stronger.
It’s just that they have this mysterious tendency NOT to. Like a two-year old who has discovered the word NO! No, I don’t FEEL like healing.
WHY tendons often don’t heal like they’re supposed to is a question that has still not been properly answered by decades of medical research.
(Maybe they’re not looking in the right place.)
Again, I’m not a Doctor or even a PT, but based on my understanding of the biology and of the pathology of damaged tendons…
The word that sums up the whole picture…
The degenerative collagen breakdown – The failed healing state – The rot at the root of the problem:
Like a stagnant body of water that doesn’t have enough movement or oxygen and is collecting waste.
It seems we need to increase the activity in the tendon – To stimulate it in a way that encourages healing.
To break the vicious cycle of stagnation and degeneration by strategically nudging it with physical manipulation.
And increasing the circulation to some extent seems to be beneficial.
And, yes, at the extreme end of the medical spectrum of options, you have treatments like Prolotherapy, and PRP injections.
The goal of which is to stimulate healing by causing new trauma, bleeding and a subsequent inflammation response.
Because that’s the first stage of healing and without inflammation there is no healing.
I don’t think that’s necessary, however, except in severe cases where there’s a tear, or similar major damage.
I believe you can take a hands on approach to stimulating your tendons – as well as releasing tension and adhesions in your muscles, which seem to be a significant contributing cause.
Now, I can’t say I’ve personally worked with antibiotic-injured people.
(At least not knowingly – Again who knows how many people are unknowingly damaged by these drugs.)
I can say I’ve helped countless people recover from “naturally occurring” tendon disorders, both in person and through my courses here.
But I don’t have enough data – enough people with these drug-induced tendon injuries to go on.
The one thing I’m certain of, though, is that you have to be proactive.
There isn’t going to be a pill that fixes the damage from the other pills.
If you’re unfortunate to have suffered a tendon rupture, then I don’t think there’s an alternative to surgery.
(Sometimes lessor tears can heal without full, open surgery but sometimes you still need some kind of minimally-invasive procedure.)
And you’ll still need to work very diligently on your rehab exercises either way.
It’s just that there’s something missing from the standard treatment approach in Physical or Physio-Therapy.
It’s the manual therapy. The hands-on manipulation part.
Fortunately when it comes to Tennis and Golfer’s elbow, it’s possible to work on the muscles and tendons involved yourself.
I can’t make any promises but if that’s where your injury lies, then my programs might make sense for you.
But be prepared to work long and hard on yourself.
And that’s not to say there aren’t other treatments – medical or alternative out there that may aid in recovery.
I believe one of the most promising is Class 4 cold laser.
Chances are, you will need to find a Doctor to get that treatment. Some Chiropractors offer it.
Don’t waste your money on some cheap garbage claiming to be a cold laser on the Internet.
It’s probably just an infra-red device and even if it is a cold laser it won’t be a Class 4 device because they cost 10 to 30 thousand dollars.
Shockwave therapy is another possibility. I have very little confidence in that, though, to be honest with you.
But I think I need to toss it out there because it is a treatment that can stimulate tendon healing.
I still believe it’s more important to learn how to work on your own muscles and tendons.
That’s something you can do every day and you’re not limited by any budget concerns – or the need to schedule appointments.
Now, if you have an injury to a larger tendon – Especially a lower-body, weight-bearing tendon like your Achilles that’s more challenging to work on yourself.
If you have good insurance or can simply afford to get the help you need you may want to see if you can find a practitioner with a Class 4 laser and/or Shockwave Therapy.
Again, I’m wish I had more to offer solution-wise but I hope this at least helps you better understand the nature of the problem.
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