Achilles Tendon Injury with WARNING

[jchamilt]

A short history of my recent tennis injury and questions about diagnosis with a WARNING at the end.

December 29th, 2009, 9:30 PM -- While playing in a tennis tournament heard a snap and fell down with a pain just below the bulge of the right calf muscle (gastroc). Could not put any pressure on the ball of the right foot due to pain in the calf. Was helped off the court and to my car and drove to the ER.

December 29th, 2009, 10:30 PM -- ER examination by MD and she was not sure if injury was to the Achilles or gastroc. Lateral and AP X-rays were taken of right lower leg. Reading by radiologist indicated, “ … xrays were normal.” I felt the Achilles tendon and there was some tendon there, but it felt thin to me.

December 30th, 2009 4 PM – saw orthopedic surgeon and he thought there was a partial tear of the Achilles tendon, ordered an MRI of the lower leg. He was surprised at the force I could exert when pointing my toes. I had complete ranged of motion in my right foot without pain in the tendon, but minor pain in the lower gastroc.

December 31st, 2009 1:30 AM got MRI

December 31st, 2009 noon radiology report arrived. “There is a full-thickness transection of the Achilles tendon 4-5 cm from distal attachment.”

When I palpated the tendon in the ER there was no pain associated with the tendon. Pain was in the lower gastroc. As mentioned above there was something there, which I though was tendon in the area of the supposed transection and without a depression or bulge often associated with a complete rupture. Also, although xrays are not good at showing soft tissues, I have seen the outline of the Achilles on a radiograph I had of my left lower leg and am wondering how a full-thickness transection of the Achilles tendon with 3 cm between the ends could be missed when that is the question everyone is and should be asking. The radiologist who read the MRI didn’t see the xrays or details of the physical exam.

In talking with a physician who had tendon surgery, he mentioned that he had two radiologists read the MRI and one came up with complete rupture and the other said no rupture. At surgery there was 50% of the tendon left.

Will get a second opinion and second reading of the xrays and MRI and keep you posted. What is possibly frustrating and you can add you own words is I feel fine with minimal pain mainly in the lower gastroc area and I can walk in small steps without any pain. If I do need surgery, I wish I felt worse and not better everyday.

********* WARNING **********

I got back from the Far East on December 20th, and was taking a five day course of Cipro for diarrhea and stopped on December 21st. Cipro and antibiotics of that class ARE associated with tendon rupture. I didn’t know that when I took it.

 

[chess9]

http://www.univgraph.com/bayer/inserts/ciprotab.pdf

Thanks to ETBrit for bringing this to my attention. Note that other tendons can be involved. I wouldn't advise tennis players to take Cipro unless absolutely necessary.

-Robert

 

[larry10s]

http://emedicine.medscape.com/article/85024-overview
soleus rupture is another injury in the calf thay does not have as severe a prognosis. get another mri at a different location imho. if you tore yor achilles you shoulkd not be able to get on your tippy toes on that side .imho.
levaquin is another antibiotc that achilles tendon rupture is mentioned as a side effect

 

[scotus]

So for what duration are these antibiotics known to pose threat to tendons, only while you are on them, or for days, weeks, or months afterward?

 

[chess9]

Months! Up to 4 months after taking them!!

-Robert

 

[Bud]

A short history of my recent tennis injury and questions about diagnosis with a WARNING at the end.

December 29th, 2009, 9:30 PM -- While playing in a tennis tournament heard a snap and fell down with a pain just below the bulge of the right calf muscle (gastroc). Could not put any pressure on the ball of the right foot due to pain in the calf. Was helped off the court and to my car and drove to the ER.

December 29th, 2009, 10:30 PM -- ER examination by MD and she was not sure if injury was to the Achilles or gastroc. Lateral and AP X-rays were taken of right lower leg. Reading by radiologist indicated, “ … xrays were normal.” I felt the Achilles tendon and there was some tendon there, but it felt thin to me.

December 30th, 2009 4 PM – saw orthopedic surgeon and he thought there was a partial tear of the Achilles tendon, ordered an MRI of the lower leg. He was surprised at the force I could exert when pointing my toes. I had complete ranged of motion in my right foot without pain in the tendon, but minor pain in the lower gastroc.

December 31st, 2009 1:30 AM got MRI

December 31st, 2009 noon radiology report arrived. “There is a full-thickness transection of the Achilles tendon 4-5 cm from distal attachment.”

When I palpated the tendon in the ER there was no pain associated with the tendon. Pain was in the lower gastroc. As mentioned above there was something there, which I though was tendon in the area of the supposed transection and without a depression or bulge often associated with a complete rupture. Also, although xrays are not good at showing soft tissues, I have seen the outline of the Achilles on a radiograph I had of my left lower leg and am wondering how a full-thickness transection of the Achilles tendon with 3 cm between the ends could be missed when that is the question everyone is and should be asking. The radiologist who read the MRI didn’t see the xrays or details of the physical exam.

In talking with a physician who had tendon surgery, he mentioned that he had two radiologists read the MRI and one came up with complete rupture and the other said no rupture. At surgery there was 50% of the tendon left.

Will get a second opinion and second reading of the xrays and MRI and keep you posted. What is possibly frustrating and you can add you own words is I feel fine with minimal pain mainly in the lower gastroc area and I can walk in small steps without any pain. If I do need surgery, I wish I felt worse and not better everyday.

********* WARNING **********

I got back from the Far East on December 20th, and was taking a five day course of Cipro for diarrhea and stopped on December 21st. Cipro and antibiotics of that class ARE associated with tendon rupture. I didn’t know that when I took it.

They should have know there was some sort of detachment when you explained to them about the 'snap' you heard/felt at the time of injury. It seems they also should have been able to palpate the area in question as well... feeling something was amiss (like you did).

Thanks for the Cipro warning as well... as it's a pretty common antibiotic.

These types of threads are exactly the reason why anyone/everyone should relate their experiences to others... especially concerning injuries. Doctors are not infallible and you should always give your intuition, concerning your body, much credit.

BTW, would it be possible to display partial X-rays/MRI of the area so we can see what the doctors missed?

Good luck with your rehabilitation

 

[scotus]

How about Omnicef and Levaquin? Are those dangerous, too?

 

[larry10s]

http://emedicine.medscape.com/article/85024-overview
soleus rupture is another injury in the calf thay does not have as severe a prognosis. get another mri at a different location imho. if you tore yor achilles you shoulkd not be able to get on your tippy toes on that side .imho.
levaquin is another antibiotc that achilles tendon rupture is mentioned as a side effect

lavoquin yes .dont know about omnicef

 

[scotus]

lavoquin yes .dont know about omnicef

Thank you. Anyone have any info on Omnicef?

 

[charliefedererer]

Thank you. Anyone have any info on Omnicef?

Omnicef is a cephalosporin, and as such is in a different class of antibiotics than Cipro and Levoquin which are both quinalones.

While quinalones have an association with tendon rupture, cephalosporins such as Omnicef do not have an association with tendon rupture.

 

[charliefedererer]

There is another reason, other than tendon rupture, for athletes to avoid Levoquin and Cipro. These drugs apparently cause joint inflammation, with some changes potentially permanent:

"Levofloxacin and other quinolones have been shown to cause arthropathy [joint inflammation and damage] in immature
animals of most species tested. (See WARNINGS.) In immature dogs (4-5 months
old), oral doses of 10 mg/kg/day for 7 days and intravenous doses of 4 mg/kg/day for
14 days of levofloxacin resulted in arthropathic lesions. Administration at oral doses
of 300 mg/kg/day for 7 days and intravenous doses of 60 mg/kg/day for 4 weeks
produced arthropathy in juvenile rats. Three-month old beagle dogs dosed orally with
levofloxacin for 8 or 9 consecutive days, with an 18-week recovery period, exhibited musculoskeletal clinical signs by the final dose at dose levels ≥ 2.5 mg/kg
(approximately 0.27 >0.2-fold the potential therapeutic dose (500 mg q24h) based
upon plasma AUC comparisons). Synovitis and articular cartilage lesions were
observed at the 10 and 40 mg/kg dose levels (equivalent to and 3-fold greater than the
potential therapeutic dose, respectively). All musculoskeletal signs were resolved by
week 5 of recovery; synovitis was resolved by the end of the 18-week recovery
period; whereas, articular cartilage erosions and chondropathy persisted."
http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2004/20635s037,20634s036ltr.pdf

"The results of these pediatric trials indicated that arthropathy occurred more frequently in patients who received ciprofloxacin (within these studies). The affected joints included the knees, elbows, ankles, hips, wrists, and shoulders of the pediatric patients. In one study at six weeks arthropathy was seen in 9.3% of ciprofloxacin patients. These rates increased significantly after one year to 13.7% of the ciprofloxacin patients. Such arthropathy occurred more frequently in patients treated with ciprofloxacin than any other control drug, regardless of whether they received IV ciprofloxacin or the oral version of the drug."
http://en.wikipedia.org/wiki/Quinolone#cite_note-pmid17559736-23

 

[charliefedererer]

Tendon rupture with Cipro or Levoquin apparently happens "relatively infrequently", except in the elderly, and/or those also taking steroids (steroids have a known association with tendon rupture). The following was the first large report that indicated how frequently the tendon ruptures occurred.

"Increased risk of achilles tendon rupture with quinolone antibacterial use, especially in elderly patients taking oral corticosteroids.
van der Linden PD, Sturkenboom MC, Herings RM, Leufkens HM, Rowlands S, Stricker BH.

Pharmacoepidemiology Unit, Department of Epidemiology & Biostatistics and Internal Medicine, Erasmus Medical Centre Rotterdam, Rotterdam, the Netherlands.

Comment in:

Arch Intern Med. 2004 Mar 22;164(6):678.

BACKGROUND: In several case reports, the occurrence of Achilles tendon rupture has been attributed to the use of quinolones, but the epidemiologic evidence for this association is scanty. METHODS: We conducted a population-based case-control study in the General Practice Research Database in the United Kingdom during the period 1988 through 1998. Cases were defined as all persons who had a first-time recording of an Achilles tendon rupture, and who had at least 18 months of valid history before the index date. As a control group, we randomly sampled 50 000 patients with at least 18 months of valid history who were assigned a random date as index date. RESULTS: We identified 1367 cases that met the inclusion criteria. The adjusted odds ratio (OR) for Achilles tendon rupture was 4.3 (95% confidence interval [CI], 2.4-7.8) for current exposure to quinolones, 2.4 (95% CI, 1.5-3.7) for recent exposure, and 1.4 (95% CI, 0.9-2.1) for past exposure. The OR of Achilles tendon rupture was 6.4 (95% CI, 3.0-13.7) in patients aged 60 to 79 years and 20.4 (95% CI, 4.6-90.1) in patients aged 80 years or older. In persons aged 60 years and older, the OR was 28.4 (95% CI, 7.0-115.3) for current exposure to ofloxacin, while the ORs were 3.6 (95% CI, 1.4-9.1) and 14.2 (95% CI, 1.6-128.6) for ciprofloxacin and norfloxacin, respectively. Approximately 2% to 6% of all Achilles tendon ruptures in people older than 60 years can be attributed to quinolones. CONCLUSIONS: Current exposure to quinolones increased the risk of Achilles tendon rupture. The risk is highest among elderly patients who were concomitantly treated with corticosteroids."
http://www.ncbi.nlm.nih.gov/pubmed/12912715

 

[scotus]

Omnicef is a cephalosporin, and as such is in a different class of antibiotics than Cipro and Levoquin which are both quinalones.

While quinalones have an association with tendon rupture, cephalosporins such as Omnicef do not have an association with tendon rupture.

Thank you very much.

I have taken both omnicef and levoquin. I think I will stick to omnicef from now if needs be.

 

[DANMAN]

Fluoroquinolones are the class of abx that cause tendon rupture. This includes Ciprofloxacin (Levaquin) and Moxifloxacin (Avelox). I've taken both and have had no issues and play serious tennis (5.0 level). Tendon rupture occurs in a small minority of patients. Although there are other abx for use, sometimes the fluoroquinolones are best. Using the same abx over and over will cause organisms that plague you to become resistant.

 

[charliefedererer]

Fluoroquinolones are the class of abx that cause tendon rupture. This includes Ciprofloxacin (Levaquin) and Moxifloxacin (Avelox). I've taken both and have had no issues and play serious tennis (5.0 level). Tendon rupture occurs in a small minority of patients. Although there are other abx for use, sometimes the fluoroquinolones are best. Using the same abx over and over will cause organisms that plague you to become resistant.

You make a good point that Cipro, Avelox, and Levoquin may be the best antibiotics to treat some infections, and the with the risk of tendon rupture in young, healthy adults being small, the benefits may far outweigh the risks.

But the FDA only mandated the warning on tendon rupture be included in fluoroquinone packaging in 2008, and I'll bet many primary care and specialists who only occasionally use fluoroquinones may not be aware of the risk, or don't realize their patient is a tennis, basketball or soccer player. Therefore it would not be unreasonable to mention this to your prescribing doctor, and see if there is another antiobiotic in a non-fluoruoquinone category that they could take.

So I'm basically agreeing with you, but if done in a non-threatening way, I'm sure the physician wouldn't mind at least reconsidering the antibiotic choice.

 

[DANMAN]

You make a good point that Cipro, Avelox, and Levoquin may be the best antibiotics to treat some infections, and the with the risk of tendon rupture in young, healthy adults being small, the benefits may far outweigh the risks.

But the FDA only mandated the warning on tendon rupture be included in fluoroquinone packaging in 2008, and I'll bet many primary care and specialists who only occasionally use fluoroquinones may not be aware of the risk, or don't realize their patient is a tennis, basketball or soccer player. Therefore it would not be unreasonable to mention this to your prescribing doctor, and see if there is another antiobiotic in a non-fluoruoquinone category that they could take.

So I'm basically agreeing with you, but if done in a non-threatening way, I'm sure the physician wouldn't mind at least reconsidering the antibiotic choice.

Absolutely excellent point...

I am a medical student, 5.0 tennis player, and competitive basketball player. I also play flag football leagues. Being a med student, you learn all the side effects and immediately worry it will happen to you. I took Avelox (moxifloxacin) for a sinus infection after having previously been on both Doxycycline and Trimethoprim-sulfamethoxazole (Bactrim). The doctor assured me that being in good physical shape that the chances of tendon rupture was minimal and that the fluoroquinolone would be better for the sinus infection that has lingered. I asked respectfully since I knew of the side effects and didn't want him to think I was being a know it all. He totally understood my position, and this little conversation made me feel much better. Just wanted to encourage the sort of behavior charlie federer suggests.

 

[not_too_shabby]

Just bumping this thread to give it visibility again regarding the effect of Ciprofloxacin on tendons. I took Cipro about 2.5 weeks ago, only for 3 days. About 5 days after I finished the course, my calves and achilles were stiff and painful. I went on a trip last weekend and had to have a wheelchair take me through the airport. I am 49, healthy, play tennis 5 days/week, lift weights, run, swim and now I can barely walk. The tendon pain has bounced all over my body but has continued to effect my Achilles tendons. I took Cipro about 15 years ago for prostatitis for at least 4 weeks, probably a lower dose 250mg, and didn't have any issues. I read there can be a cumulative effect of taking this medication multiple times. I am starting to improve, but it will likely be months before I am confident enough to try and put any strain on my tendons. From what I have read this medication can effect permanently how your body produces collagen, and what it does produce may be mechanically inferior. It anybody has some positive outcomes of recovering from this antibiotic, I would love to hear it. The internet is full of horror stories. I went to my primary care doctor and she basically acted like she has given Cipro out like candy until about 4 years ago and never had an issue. There doesn't appear to be any definitive remedy to counteract the effect, just a lot of suggestions for a wide range of supplements to detox the body and support cell regeneration. Don't be fooled that this antibiotic will only cause tendon issues in old people with a lot of other conditions. You may get away with it a few times, or the first time can cause an issue. Not worth the risk unless your life depends on it.