Musculoskeletal Complications of Fluoroquinolones: Guidelines and Precautions for Usage in the Athletic Population

Abstract

Fluoroquinolone antibiotics are associated with a wide spectrum of musculoskeletal complications that involve not only tendon but also cartilage, bone, and muscle. Insights into the pathoetiology of fluoroquinolone toxicity on musculoskeletal tissues have been evolving over recent years. Although the pathoetiology is certainly multifactorial, alterations in cell signaling proteins and direct toxic effects on musculoskeletal tissues have been strongly implicated. Increasing age and concomitant systemic corticosteroid use appear to significantly increase the risk of adverse events. The purpose of this article is to review the musculoskeletal complications associated with use of fluoroquinolone antibiotics by adults; identify risk factors associated with fluoroquinolone toxicity; explore the possible pathoetiology of fluoroquinolone toxicity on tendon, cartilage, bone, and muscle; and offer recommendations regarding evaluation and treatment of fluoroquinolone-associated musculoskeletal complications. In addition, this review will provide recommendations regarding fluoroquinolone use in athletes and return to play after fluoroquinolone exposure.

Fluoroquinolone-induced Achilles tendinitis

“…Other risk factors like age, repeated trauma due to sports activities, or steroid therapy may impair the repair process of the tendon, thus, increasing the risk of tendinopathy in this group of patients. 6,14 The tendinopathy usually presents with acute or subacute onset of pain and swelling over the tendon. Together with a history of recent consumption of fluoroquinolones and absence of other obvious causes of the tendinopathy, the diagnosis can be established.…”

“…Athletes who are prescribed with fluoroquinolones should be advised to alter their training regimen (reduction in high-intensity and ballistic activities, decrease in total training volume) during the course of the antibiotics. 14 …”

Achilles Tendinopathy After Treatment with Ophthalmic Moxifloxacin

“…On histologic examination, fluoroquinolone-associated tendinopathy is similar to that observed following athletic overuse injury and is characterized by abnormal fiber structure, hypercellularity, fibrotic areas, increased extracellular matrix, and neovascularization 3,4 . Proposed mechanisms include direct effects of fluoroquinolones on fibroblasts 5 , induction of increased matrix metalloproteinase-3 expression 6 , and oxidative stress 7 .…”

Healing of subcutaneous tendons: Influence of the mechanical environment at the suture line on the healing process

“…Degenerative changes of the tendon have been linked to genetic abnormalities of the collagen tissues [68] , chronic diseases or metabolic disorders [69] and neurological conditions [70] . Fluoroquinolones and locally or systemically administered corticosteroids have been implicated in the etiology of tendon rupture [71][72][73][74] . In the literature, there are four basic types of tendon degeneration: hypoxic, mucoid degeneration, lipomatosis and calcification of the tendon.…”