2 Cases of Achilles Tendinitis

-AdvanceWeb

BY GREGORY CLOUD, MHA, PA-C, CHAIM ROGOZINSKI, MD, AND ABRAHAM ROGOZINSKI, MD

05/26/2009 - PAs in family practice, emergency medicine and other specialties are likely to encounter quinolone-associated tendinitis and/or tendon rupture at some time, making it important to recognize the signs of and be aware of the risk factors for the condition.

In a recent six-week span, two patients presented to our orthopedic clinic with fluoroquinolone-associated Achilles tendinitis.

Case 1

A 54-year-old woman presented with a complaint of severe bilateral pain in the calf and shin. The patient, an intensive-care nurse, described her general health as good and reported that she ran regularly and performed yoga workouts. She had developed upper respiratory symptoms following exposure to spray painting and had kept a log of her subsequent symptoms and medical treatments.

Her primary care physician had started her on levofloxacin 750 mg for seven days; when her symptoms did not improve immediately, a pulmonologist had initiated a course of prednisone. By the fourth day of antibiotic treatment, the patient began to experience bilateral calf and shin soreness.

Despite having discontinued the antibiotic after the fourth dose, her leg pain had progressed, becoming aching and sharp and increasing in intensity at times to 10+ on a 0-to-10 pain scale. By day 5, she had developed a bilateral lower-extremity edematous petechial rash that had progressed to the groin. She became unable to walk or drive because of severe lower-leg pain; at this point, she returned to her primary care physician.

Although her primary care physician had been unaware that rash and tendinitis were potential side effects of levofloxacin, the patient quickly educated him with an in-office Internet search. The patient was started immediately on high-dose rapidly tapered prednisone.

This patient came to our attention serendipitously when she was observed hobbling at work. Physical examination revealed lower-extremity rash, edema and marked ankle and gastrocnemius tenderness. Thompson's test for Achilles rupture was negative. She was unable to stand on her toes because of ankle pain, and she demonstrated a markedly antalgic gait.

At six-week follow-up, this patient was symptom free and had resumed her usual work and workout activities, including running.

Case 2

A 52-year-old painter presented to our orthopedic clinic with a four-month history of progressive bilateral heel pain and right-posterior thigh pain. His symptoms had begun without any associated sports activity or trauma, and he could not recall any discrete precipitating event. He had been to three separate podiatrists; treatment with various shoes, orthotics, nonsteroidal anti-inflammatory drugs and hydrocodone had failed to relieve or even improve his symptoms.

When seen in the clinic, the patient reported unremitting sharp aching pain that was a 7 on a 0-to-10 pain scale. Walking, transitioning from sitting to standing, climbing ladders or stairs, squatting and standing exacerbated his symptoms. Ankle and heel pain curtailed ambulation. The patient denied back pain or symptoms consistent with vascular claudication; after 45 minutes of walking, pain occurred only in the back of the heels.

As for past medical history, the patient reported that about eight or nine months ago he had been treated for "blood clots" and renal failure that had necessitated six months of concurrent treatment with warfarin, corticosteroids and ciprofloxacin. He had since discontinued the steroids and ciprofloxacin, and he had been able to return to work about four months ago, at which point he began to experience progressive ankle and heel pain. In a phone consultation, the patient's nephrologist described a severe nephrotic syndrome that had been controlled only after 12 months of intensive treatment.

Physical exam was significant for exquisite bilateral Achilles tenderness without tenderness of the lateral or medial malleolus, peroneal tendon or posterior tibial tendon. The patient was unable to toe walk or heel walk because of the pain. Nerve root tension signs were present on the right (positive straight-leg raising). Otherwise, the neurologic examination was unremarkable, as was the vascular exam.

Film review of a right-ankle MRI study that had been performed 4.5 months before the patient's clinic presentation revealed an Achilles tendon tear and retrocalcaneal bursitis. No MRI had been performed on the left despite the patient's bilateral complaints. Right and left foot X-rays performed at the initial orthopedic visit demonstrated diffuse degenerative changes without fracture or dislocation, as well as calcaneal spurring.

The patient was placed into bilateral short-leg orthoses to immobilize the ankles while permitting ambulation and was started on a 12-day steroid dose-pack. After completing the dose-pack, and with nephrology and hematology concurrence, the patient began celecoxib 200 mg twice a day with close monitoring.

At his follow-up visit eight weeks after initial presentation, the patient's bilateral Achilles pain had resolved. His physical examination was unremarkable, and, fortunately, he had not progressed to complete Achilles rupture. He has resumed his usual work activities without apparent sequelae.

Discussion

Fluoroquinolone use has increased worldwide. Since 1995, fluoroquinolones have become the most commonly prescribed antibiotic class to adults in the United States, increasing from 7 million visits in 1995 to 22 million visits in 2002.1 During this period, fluoroquinolone prescriptions as a percentage of all antibiotic prescriptions increased from 10% to 24%; 42% of these prescriptions were for non-approved diagnoses.1

The increase in fluoroquinolone prescribing has resulted in an increase in the number of reported cases of tendinitis and tendon rupture during or immediately following fluroroquinolone use. Increasing reports of tendinopathy beginning in the 1980s prompted the FDA to issue an adverse events report in 1996.2 All fluoroquinolones' prescribing information now warn of adverse tendon effects, including "ruptures of the shoulder, hand, Achilles tendon or other tendons that required surgical repair or prolonged disability."3,4

Patient factors such as age, concomitant steroid use and the presence of comorbid illness increase the relative risk of quinolone-associated tendinitis and/or tendon rupture. One study showed a relative risk for Achilles tendon disorders (i.e., tendinitis and rupture) of 1.9 with current fluoroquinolone use, increasing to 3.2 for people 60 and older. Concurrent steroid use in those 60 and older increased the risk to 6.2.5

Another study found that current use of fluoroquinolones significantly increased the risk of tendon disorders as a whole, along with tendon rupture and rupture of the Achilles tendon in specific.6 The risk increased even further in patients on concomitant corticosteroids and patients older than 60. The authors estimated that, overall, one case of Achilles tendon rupture would occur in every 5,958 persons treated with fluoroquinolones.6

Diagnosis and Treatment

Quinolone-associated tendinitis and/or tendon rupture should be in the differential diagnosis when a patient presents with any of these red flags: a history of abrupt onset of severe tendon or joint pain, resulting in restricted mobility, that increases with movement and/or direct palpation, without a history of trauma or other discrete precipitating event, and recent or current fluoroquinolone use with or without concurrent steroid treatment; an age of 60 or older; and the presence of comorbidities.

Treatment includes discontinuing the fluoroquinolone immediately; restricting movement of, use of or stress to the tendon, which may require bracing or immobilization; judicious use of rapidly tapered oral steroids; and referral for possible surgical repair in cases of complete tendon rupture. Avoid tendon steroid injection, which might provoke rupture.

Gregory Cloud is a PA at Rogozinski Orthopedic Clinic (ROC) in Jacksonville, Fla. Chaim Rogozinski is an orthopedic spinal surgeon, a diplomate of the American Board of Orthopedic Surgeons (ABOS) and the medical director for ROC. Abraham Rogozinski is an orthopedic spinal surgeon for ROC and is a diplomate of the ABOS.

References

1. Linder JA, Huang ES, Steinman MA, Gonzales R, Stafford RS. Fluoroquinolone prescribing in the United States: 1995 to 2002. Am J Med. 2005;118:259-268.

2. Gold L, Igra H. Levofloxacin-induced tendon rupture: a case report and review of the literature. J Am Board Fam Pract. 2003;16:458-460.

3. Cipro XR [package insert]. West Haven, Conn: Bayer Pharmaceuticals Corp; 2007.

4. Levaquin [package insert]. Raritan, NJ: Ortho-McNeil Pharmaceutical Inc; 2007.

5. van der Linden PD, Sturkenboom MC, Herings RM, Leufkens HG, Stricker BH. Fluoroquinolones and risk of Achilles tendon disorders: case-control study. BMJ. 2002;324:1306-1307.

6. Corrao G, Zambon A, Bert L, et al. Evidence of tendinitis provoked by fluoroquinolone treatment: a case-control study. Drug Saf. 2006;29;889-896.

If you or a loved one have experienced serious side effects or injury as a result of Fluoroquinolone antibiotics such as tendonitis, torn ligament, or ruptured tendons, you may be entitled to compensation. Contact one of our Fluoroquinolone lawyers today for more information regarding your legal rights. For more information about a potential Fluoroquinolone lawsuit, or Fluoroquinolone side effects, fill out our free case evaluation form or call the toll-free number listed below.