Tag Archives: tendon ruptures

Case Study: Death by Levaquin

9 Oct

I’d like to bring attention to a study done by Doctors Andrew W Gottschalk and John W Bachman of the Mayo Clinic Department of Family Medicine. The case study involves an elderly man given Levaquin for a presumed brochitis who developed complete tendon ruptures of both of his Achilles heels. This drug’s side-effect was directly responsible for his subsequent physical and psychologic decline and unfortunate death.
   

The doctors found that with Achilles tendon rupture, as with hip fracture in the elderly, ‘the best offense is a good defense’. Steroid co-medication is a known risk factor for tendinopathy, and thus should be avoided when placing a patient on levofloxacin, or indeed on any fluoroquinolone. Patients currently on corticosteroid treatment should receive trials with other antibiotics before levofloxacin is considered. Doses should be adjusted accordingly in patients with decreased creatinine clearance. All patients should be educated as to possible side-effects of treatment. The development of tendonitis is an indication for discontinuing therapy, and informing patients of the possibility of tendon distress may prevent severe complications. Levofloxacin is an expensive, commonly used antibiotic. Although this fluoroquinolone is often appropriate therapy under certain circumstances, their case reminds us that levofloxacin therapy has associated risks, which in their patient catalyzed a downward spiral resulting in death.

The following is a brief summary, or read the case study in full here:
 
An active senior, a farmer, came to the Mayo Clinic because his “feet [weren’t] working”. One month earlier, the patient was diagnosed with bronchitis at an outside clinic and was treated with a seven-day course of levofloxacin 500 mg by mouth, taken once a day. His heel pain began over the first four days of fluoroquinolone treatment. On the seventh day of treatment, upon dismounting his tractor, he noticed sudden, severe pain in both of his heels and a compromised ability to get around independently.
 
He had no history of tendinopathy. But MRIs of his ankles showed complete rupture of both Achilles tendons. He was fitted with casts for his heels and discharged from the hospital one day after admission. Five weeks after hospital admission, the patient’s casts were removed and he was fitted with controlled ankle motion (CAM) boots. Nine weeks after hospitalization, the patient was instructed to stop wearing the CAM boots and began wearing his own tennis shoes.
 
At his initial presentation to the outpatient care center on the day of admission, the patient’s primary care physician noted, “History of depression and anxiety: He is not anxious and depression is currently not a problem. He looks much brighter.” However, at the meeting with his orthopedic surgeon nine weeks after hospital discharge, both the patient and family members noted decreased energy levels and general lack of enthusiasm. There was concern that these symptoms were fueled by his immobility.
 
Ten weeks after diagnosis, the patient presented to the Emergency Department with a 22-pound weight loss over the prior two months as well as generalized lethargy. He was hospitalized for evaluation where he was hydrated and his antihypertensive regimen was modified. He was discharged with blood pressures well within the normal range and with close follow-up with his primary care physician. The patient was readmitted for inpatient care the following day with hospital-acquired pneumonia. He subsequently developed kidney failure, sepsis, heart failure, and a myocardial infarction. After consultation with the patient and his family, care was withdrawn and comfort care measures were initiated until the patient passed away 11 weeks after the initial diagnosis of bilateral complete Achilles tendon rupture.
 
In the study, the doctors show that tendon rupture can be deadly. Physiologically, their patient could not perform the farm chores his body had become accustomed to and could no longer actively prepare his own meals. Psychologically, his mobility had allowed him to interact with his family, friends, and coworkers on the farm. Immobility led to social isolation which led to a recurrence of his depression. This, coupled with his rapid deconditioning, resulted in disaster. 

 

Source: Journal of Medical Case Reports, Death following bilateral complete Achilles tendon rupture in a patient on fluoroquinolone therapy, by Drs. Andrew W Gottschalk and John W Bachman, available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2631494

As always, we at LevaquinBlog hope you educate yourself before taking any medicine, especially one with serious known risks such as Levaquin.

Sports Injuries: All About Achilles’ Tendon Injuries

5 Oct

Here is an informative interview with Jim Barnett, former team physician for the NBA’s Orlando Magic, that discusses the basic causes of Achilles tendon injuries and recommends preventative measures:

What does the Achilles tendon do?

Dr. Barnett: The Achilles tendon is a thick band of tissue that attaches the muscles of the calf to the heel bone and is the key to the foot’s ability to flex. The Achilles tendon enables the athlete to push off of the foot when walking or running.

Achilles TendonAchilles Tendon

What causes the Achilles tendon to rupture?

Dr. Barnett: There can be a number of factors that cause the tendon to tear. There is no question that patients with certain systemic disease processes can have a predisposition to tendon ruptures in all areas of the body. These include people who have taken steroids for a long time, as immuno-suppression tends to weaken connective tissue. We define these as pathologic ruptures where there is a pre-existing problem with the stability of the tendon itself.

The most common cause of Achilles tendon tears is related to a problem called tendinosis — a painless degenerative condition with the tendon due to old age or overuse. With this condition, the tendon is not as strong in any one part of its length as it should be, and some type of trauma causes it to rupture.

We see this commonly in the weekend athlete who doesn’t exercise on a regular basis or does not properly stretch before an activity. In the professional arena, most Achilles injuries seem to occur in the quick acceleration/jumping-type sports like basketball or racquetball. 

What accounts for the number of non-contact Achilles tendon tears?

 Dr. Barnett: There is a situation we refer to called an eccentric load, when a load or stress is applied to a tendon that’s already being stretched. An example of this would be an athlete running backwards. This is the opposite of a concentric load, in which you are applying a load to a muscle that’s being shortened, such as when you are doing toe raises and walking up a flight of stairs.

What we think happens in a number of ruptures of the stop-and-start variety or the backward-to-forward transition, is that the tendon has a concentric load applied to it followed quickly by an eccentric load or vice versa. Think of a quarterback dropping back to pass and then stepping up into the pocket, or a tennis player that rushes the net and then retreats for a lob over his head.

 Are aging athletes more susceptible to Achilles tendon injuries?

Dr. Barnett: We see a lot of tendinitis in the Achilles region in younger athletes as a result of overuse but probably the most common group affected by Achilles tendon ruptures are the older, weekend warrior-type athletes. Characteristically, the tendon tears a certain distance from its insertion in the heel bone, where it has the least amount of blood supply. There seems to be direct correlation to aging where the older athlete, in general, has less blood flow to this region.

How is a rupture diagnosed?

Dr. Barnett: The patient will usually relate that it feels that someone or something has hit him in the calf. He normally doesn’t have the sensation that something actually has torn. There is a good amount of swelling and pain and a little bit of weakness when he walks. We’ll perform something called the Thompson’s test if we suspect Achilles damage. The patient lies face down on a table and the physician squeezes the calf muscle. If the tendon is intact, the foot will point down, which shows tendon integrity and means that there is not a complete tear. However, if you squeeze the calf and the foot remains motionless, this signals that the tendon is ruptured.

How is an Achilles tendon rupture treated?

Dr. Barnett: Most young, healthy athletes on the high school, college or professional level recover more quickly and require less rehabilitation when their Achilles is repaired surgically. The two ends of the tendon are sewn together and the foot and lower leg are placed in a cast with the foot pointed down to lessen the tension on the repaired tendon. In older, less active individuals, we favor a more conservative approach, which involves casting and a lengthy period of immobilization. Regardless of the treatment, you’re looking at a six- to 12-week recovery period. It is almost always a season-ending injury for the athlete because of the tenuous situation with the blood supply to the area. Complete healing needs to take place or there is a possibility of recurrence.

How can ruptures be prevented?

 Dr. Barnett: The best advice we give to people to lessen their chances of injuring the Achilles area is to practice proper stretching before beginning an activity. Loosen up by breaking a light sweat and then do gentle calf stretches. This is especially true if you are older or not well-conditioned. Be aware of any pain in the Achilles tendon and make sure to treat any sign of tendinitis with RICE — rest, ice, compression and elevation.

Source: ESPN.com

Antibiotics and Injuries: Which Class of Antibiotics Can Bring Your Lifting Career to a Screeching Halt?

3 Oct

Here’s a story (and some advice) from Ball Quick Athletics concerning the special risks weightlifters face when prescribed Levaquin:

Antibiotics and Injuries: Which Class of Antibiotics Can Bring Your Lifting Career to a Screeching Halt?

It’s almost that time of the year. Football season is just beginning, my lawnmower is getting less and less use, and the temperature is fluctuating more than the stock market. And the season wouldn’t be complete without an endless stream of antibiotics coming from the doctors’ offices. But before you go begging your doctor for an antibiotic for that runny nose, there’s one class of antibiotics that you better be particularly concerned about, especially if you lift heavy weights.

And that class is…. Fluoroquinolones (i.e. Cipro, Levaquin,etc)

Introduced in the 1980s, this class antibiotics is becoming increasingly popular with each passing year primarily due to the increase in antibiotic-resistant infections. Used most commonly to treat pneumonia and bronchitis, nowadays doctors are using them to treat just about everything. In fact at my pharmacy, they’re quickly creeping up the list of most popular antibiotics dispensed, right behind amoxicillin, azithromycin, and bactrim ds.

And why should you care… Tendon ruptures (those things that connect your bones to your muscles)

99 out of 100 doctors aren’t going to ask you if you lift weights. In fact, 99 out of 100 doctors are probably going to tell you squatting 300 pounds is extremely dangerous:-) So it’s your responsibility to be aware of potential tendon problems associated with fluoroquinolone use.

Even though they’re rare (most experts agree the odds are probably 1 in 100,000), the results can be extremely devastating, especially to an athlete or weekend warrior. In fact, in 2008 the FDA required that all fluoroquinolones carry a black box warning indicating potential tendon problems associated with their use (the equivalent of wearing the scarlet letter). And what is even more concerning to you and I, we’re already at a higher risk because a potential risk factor for tendon rupture is participation in sports, which includes weightlifting. In addition, you’re even further at risk if you’re taking corticosteroids like prednisone. Even inhaled corticosteroids for allergies (Nasonex, Flonase, Nasacort) put you at a higher risk.

Another important fact: Just because you finished your 10 day course of Cipro without any pain, don’t think you’re out of the woods just yet. There’s been documented cases of tendon ruptures 6 months AFTER using a flouroquinolone.

How will you know? Snap, crackle, pop.

The most commonly affected tendon is the Achilles tendon. However, they can affected virtually any tendon in your body. Symptoms range from stiffness and redness surrounding the tendon to complete inability to move the affected joint. Usually the pain is quick and intense.

I saw firsthand what Levaquin can do. My mother began a 5 day course of Levaquin, and had to stop after 3 days because of the tendon pain. It was so bad she couldn’t even walk up and down the stairs. And the worst part: it took 3 weeks for the pain to subside. And this is a lady who has passed 2 kidney stones without any pain medication stronger than Tylenol.

So what’s your options? Ask

Ask for a different antibiotic. Tell the doctor you lift weights, and you don’t want to risk injury. If you have pneumonia and are relatively healthy, ask for a z-pack. It’s considered first line anyways (plus it’s also a lot cheaper). With antibiotics, there is usually always alternatives. With so many of them out today, there’s almost always overlapping coverage for different types of bacterial infections, unless of course you have something truly funky going on.

More questions?

Here’s the best review I’ve found regarding fluoroquinolone-induced tendon ruptures: “Fluoroquinolone-associated tendinopathy: a critical review of the literature.”

Source: http://ballquickathletics.com/blog/?p=204