The Fluoroquinolone Toxicity Research Foundation

 
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Tendon Damage Research                  See downloads for: Adobe Files



Background: Tendonitis is an inflammatory condition characterized by pain at tendinous insertions into bone. Common sites of tendonitis include the following:

Rotator cuff of the shoulder (ie, supraspinatus, bicipital tendons)
Insertion of the wrist extensors (ie, lateral epicondylitis, tennis elbow) and flexors (ie, medial epicondylitis) at the elbow
Patellar and popliteal tendons and iliotibial band at the knee
Insertion of the posterior tibial tendon in the leg (ie, shin splints)
Achilles tendon at the heel
Pathophysiology: Tendonitis most commonly is caused by overuse. Pathologic changes consistent with chronic inflammation usually are observed. Tissue degeneration, characterized by cell atrophy, also may be observed. Calcium can deposit along the course of the tendon (ie, calcific tendinitis), with the shoulder being the most common site.

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

Age: Middle-aged adults are most susceptible to the development of tendonitis.

History:

Lateral epicondylitis
Pain at the lateral aspect of elbow is present and becomes worse with grasping and twisting.
A history of playing racquet sports or manual labor is common.
Medial epicondylitis
Medial epicondylitis is common in Little League pitchers, golfers, and bowlers.
Pain is located at the medial aspect of the elbow.
Rotator cuff tendonitis
This is associated with a history of participating in overhead activities such as painting.
Deep ache in shoulder and painful range of motion are typical symptoms.
Patellar tendonitis
This is associated with insidious onset of well-localized anterior knee pain. Patellar tendonitis is common in those who participate in jumping sports (eg, basketball, volleyball, high jumping) and running.
Pain worsens when changing position from sitting to standing or when walking or running uphill.
Popliteus tendonitis
This type of tendonitis is associated with lateral knee pain.
Running downhill is a risk factor.
Iliotibial band syndrome
Lateral knee pain occurs in iliotibial band syndrome.
This syndrome may be observed in cyclists, dancers, long-distance runners, football players, and military recruits.
Shin splints
Pain is located at the anteromedial aspect of the lower leg.
Runners running on hard surfaces without proper footwear are predisposed to this condition.
Achilles tendonitis
Heel pain is evidence of Achilles tendonitis.
Runners running uphill or on hard surfaces are predisposed to this condition.
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° of passive abduction and external rotation (ie, 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 (ie, shoulder flexion against resistance with elbow extended and forearm supinated)
Positive Yergason or Speed test (ie, pain with resisted supination of the wrist or with the elbow flexed at 90° 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
Tendon palpated most easily when lateral ankle of the affected leg rests on the opposite knee
Lateral collateral ligament most prominent in this position; the popliteus is palpated just anterior to it and above the joint line
Positive Webb test with patient supine, the knee flexed to 90°, 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°, have patient extend knee while exerting pressure over the lateral femoral condyle.
At 30° of flexion the patient experiences pain as the iliotibial band crosses the epicondyle.
Positive Renne test finding (ie, flexing knee while standing with weight on affected knee resulting in pain at approximately 30° of flexion)
Shin splints - Pain referred to anteromedial aspect of lower leg
Achilles tendonitis
Localized tenderness approximately 6 cm proximal to the Achilles insertion on the heel
Pain with resisted plantar flexion of the ankle
Crepitus possibly palpable with severe cases
Causes: Overuse is the most common etiology.

Physical work-related factors
Intense, repeated, and sustained exertion
Awkward, sustained, or extreme postures
Insufficient recovery time between activities
Vibration
Cold temperatures
Psychosocial work-related factors
Monotonous work
Time pressure
High work load
Lack of peer support
Poor supervisor-employee relationship
Oral and parenteral fluoroquinolone treatment
Multiple case reports of tendonitis (particularly Achilles tendonitis) and some reports of tendon rupture in patients receiving oral and parenteral fluoroquinolone treatment have suggested a relationship between these agents and the development of tendinitis.
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 United States.
Tendinopathy can occur within a few days, weeks, or months following completion of a course of quinolones.
Tendon rupture can occur without a history of specific trauma.
Pathophysiology is unknown.
Unlike with other etiologies, bilateral tendinitis is common.

Other Problems to be Considered:

Osteoarthritis

Imaging Studies:

Radiographs may be indicated if a history of trauma is present, but findings usually are negative with tendonitis.
Occasionally a fleck of bone may be visualized, suggesting an avulsion fracture at the site of tendinous insertion.
A roughened appearance of the bone at the site of tendinous insertion may suggest periostitis.
Calcium deposits along the tendon may be visualized with calcific tendonitis.
Magnetic resonance imaging (MRI) and ultrasonography have proven useful in making the diagnosis of tendonitis but still are considered experimental diagnostic studies.