What Is the Risk of Tendonitis With Fluoroquinolone Use?

Michael Rudzinski, PA-C, RPh


November 20, 2001


After taking levofloxacin for pneumonia, we observed a patient who developed severe and long-lasting (about 8-10 weeks) Achilles tendinitis. What is the mechanism by which this occurs, how frequent is it, and is it a side effect with other quinolones such as ciprofloxacin?

David M. Jones, PA-C




Michael Rudzinski, PA-C, RPh 
Adjunct Faculty, Physician Assistant Program, D'Youville College PA Program, in Buffalo, New York, and a practicing PA in orthopaedics and pain management at the VA Medical Center in Buffalo.


Levofloxacin (Levaquin) is one of many fluoroquinolones. Other fluoroquinolones are ciprofloxacin (Cipro), enoxacin (Penetrex), gatifloxacin (Tequin), lomefloxacin (Maxaquin), moxifloxacin (Avelox), norfloxacin (Noroxin), ofloxacin (Floxin), sparfloxacin (Zagam), and trovafloxacin mesylate/alatrofloxacin mesylate (Trovan). Trovafloxacin has been associated with serious liver injury and its' use is reserved for use in in-patient healthcare facilities.

The fluoroquinolones are widely used antibiotics in the treatment of bacterial infections in adults. They are synthetic, broad-spectrum antibacterial agents that inhibit DNA gyrase and topoisomerase IV. DNA gyrase is an essential enzyme that is involved in the replication, transcription, and repair of bacterial DNA. Topoisomerase IV is an enzyme known to play a key role in the partitioning of the chromosomal DNA during bacterial cell division.

The levofloxacin package insert lists tendonitis as a potential adverse reaction, occurring at a rate of less than 1%. The patient information guide of levofloxacin states, "Ruptures of shoulder, hand or Achilles tendons have been reported in patients receiving quinolones, including Levaquin. If you develop swelling or rupture of a tendon, you should stop taking Levaquin and contact your health care professional."[1]

Since 1983, fluoroquinolones have been reported to be associated with tendon pathology. Tendon disorders associated with fluoroquinolones have been estimated to occur at a rate of 15-20 per 100,000 patients.[2] Fluoroquinolone-associated tendonitis most commonly involves the Achilles tendon, but the quadriceps, peroneus brevis, extensor pollicus longus, long head of the biceps, and rotator cuff tendons have also been reported.[3] According to reports from France, fluoroquinolones associated with tendon rupture include -- in descending order of frequency -- pefloxacin (not available in the United States), ofloxacin, norfloxacin, and ciprofloxacin. The risk of rupture associated with pefloxacin has been estimated to be 1 case per 23,130 treatment days, and for ciprofloxacin, 1 case per 79,600 treatment days.[4] The precise pathophysiologic mechanism of fluoroquinolone-associated tendon pathology remains unknown.

Patients at high risk for spontaneous rupture of tendons include those on steroid therapy or long-term dialysis; those with gout, rheumatoid arthritis, or advanced age; and those who have had renal transplantation.[4] Whether fluoroquinolones should be used in patients with a history of tendon problems or those with risk factors for development of tendon rupture depends on the seriousness of the infection and the alternatives available. High-risk patients require close surveillance.

Typically, fluoroquinolone-associated tendon symptoms occur within the first few weeks after therapy in started.[4] Fluoroquinolone treatment should be discontinued at the first sign of tendon inflammation so as to reduce the risk of subsequent rupture. If further investigation is warranted, magnetic resonance imaging (MRI) is useful in distinguishing between Achilles tendonitis and partial tendon rupture.[2]

In addition to prompt discontinuation of fluoroquinolone therapy, management of tendonitis consists of placing the tendons at rest, which may include the use of a cane, crutches, splinting, or casting.