descriptions of tendon damage

Ewood:

Multiple case reports of tendonitis (particularly Achilles tendonitis) and some reports of tendon rupture in patients receiving oral and parenteral fluoroquinolone treatment have confirmed a relationship between these agents and the development of tendinitis. Public Citizen successfully petitioned the FDA to add warnings regarding this to the drug inserts provided with fluoroquinolones in 1996.

The Food and Drug Administration has added a warning about the risk of tendinitis and tendon rupture on the label of fluoroquinolones marketed in the US.

Tendinopathy can occur within a few days or weeks or months following completion of a course of quinolones.

Tendon rupture can occur without a history of specific trauma.

Pathophysiology is unknown.

Unlike other etiologies, bilateral tendinitis is common.

Rotator cuff of the shoulder (supraspinatus, bicipital tendons)

Insertion of the wrist extensors (lateral epicondylitis or tennis elbow) and flexors (medial epicondylitis) at the elbow

Patellar and popliteal tendons, and iliotibial band at the knee

Insertion of the posterior tibial tendon in the leg (shin splints)

Achilles tendon at the heel

Pathologic changes consistent with chronic inflammation usually are seen. Tissue degeneration, characterized by cell atrophy, also may be seen. Calcium can deposit along the course of the tendon (calcific tendinitis) with the shoulder being the most common.

Mortality/Morbidity: Chronic tendonitis can lead to weakening of the tendon and subsequent rupture.

Lateral epicondylitis

Pain at the lateral aspect of elbow is present and becomes worse with grasping and twisting.

Medial epicondylitis

Pain is located at the medial aspect of the elbow.

Rotator cuff tendonitis

Deep ache in shoulder and painful range of motion are typical symptoms.

Patellar tendonitis

Insidious onset of well localized anterior knee pain.

Pain worsens when changing position from sitting to standing, or when walking or running uphill.

Popliteus tendonitis is associated with lateral knee pain

Iliotibial band syndrome

Lateral knee pain

Achilles tendonitis

Heel pain

Physical:

Lateral epicondylitis

Pain on palpation over the lateral epicondyle of the elbow

Pain at the elbow with resisted dorsiflexion of the wrist

Medial epicondylitis

Pain on palpation of the medial epicondyle of the elbow

Pain at the elbow with resisted flexion of the wrist

Supraspinatus tendonitis

Pain on palpation over the greater tuberosity where the supraspinatus tendon inserts

Pain with greater than 60 degrees of passive abduction and external rotation (tendon compressed by acromion)

Bicipital tendonitis

Pain to palpation over the anterior shoulder

Focal tenderness over groove on humerus between the greater and lesser tuberosities

Pain with biceps resistance test (shoulder flexion against resistance with elbow extended and forearm supinated)

Positive Yergason or Speed test - Pain with resisted supination of the wrist or with the elbow flexed at 90 degrees and the arm adducted against the body

Patellar tendonitis - Tenderness at patellar tendon insertion into lower pole of the patella

Popliteus tendonitis

Tenderness at the posterior-lateral joint line

The tendon is palpated most easily when the lateral ankle of the affected leg rests on the opposite knee.

The lateral collateral ligament is most prominent in this position and the popliteus is palpated just anterior to it and above the joint line.

Positive Webb test with patient supine, the knee flexed to 90 degrees, and the leg rotated internally; resisted external rotation elicits pain

Iliotibial band syndrome

Pain localized to lateral femoral condyle

With patient supine and knee flexed to 90 degrees, have patient extend knee while exerting pressure over the lateral femoral condyle.

At 30 degrees of flexion the patient will experience pain as the iliotibial band crosses the epicondyle.

Positive Renne test (Flexing knee while standing with weight on affected knee results in pain at about 30 degrees of flexion.)

Achilles tendonitis

Localized tenderness approximately 6 cm proximal to the Achilles insertion on the heel

Pain with resisted plantar flexion of the ankle

Crepitus may be palpable with severe cases.

In the 62nd meeting at the FDA testimony was offered which stated that MRI may not detect such damage. Testimony also stated that such injury may be irreversable and lead to further complications in the future. It was also stated at this meeting that the FDA was aware of these issues since 1989.