How to treat antibiotics induced Achilles tendonitis

Antibiotics induced tendonitis is usually much more painful and lasts longer than tendonitis or tendinopathy caused by sport or daily activities. We often receive emails and messages from people who worry that they will never get better because their mobility is so severely affected. But you can recover from antibiotics induced tendonitis – it just requires patience and a gentler approach than regular Achilles rehab. Remember, if you need more help with an Achilles injury, you're welcome to consult one of our team via video call.

The terms tendinitis, tendonitis, tendinosis, and tendinopathy mean the same thing for all practical purposes, and we use these interchangeably in our articles.

We’ve previously discussed how and why fluoroquinolone antibiotics (like Cipro) can cause Achilles tendonitis and even tendon ruptures. In this article, we’ll focus on how to treat antibiotics induced tendonitis or tendinopathy by looking at the following issues:

1. Act immediately

2. Anti-inflammatory medication

3. Shoes and heel lift inserts

4. Load management

5. Exercises for antibiotic induced tendonitis

6. Supplements

7. How we can help

We've also made a video about this:

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Act immediately

If you experience any of the side effects linked to fluoroquinolone antibiotics – and tendon pain is one of them – speak to your doctor immediately so that they can switch you to a different type of antibiotic. The advice from the current research is that a patient should immediately be taken off fluoroquinolone antibiotics as soon as they start experiencing side effect symptoms.

Anti-inflammatory medication

In contrast with tendonitis caused by overuse of the Achilles tendon, where you don’t really find much inflammation, antibiotic induced tendonitis often goes hand in hand with severe inflammation that tends to be quite painful.

If this is the case, you may benefit from a short course of NSAIDS (anti-inflammatory medication) to help reduce the acute pain and get you moving. If you want to stay away from drugs, you can also use ice to help reduce pain and inflammation.

Shoes and heel lift inserts

People often assume that bare feet or flat shoes would be best for an Achilles injury, but in most cases, this makes things much worse. You can help your Achilles pain calm down more quickly by wearing shoes with slightly raised heels or by placing heel lift inserts into your shoes.

Why does this help? When we walk, our Achilles tendons naturally stretch as we propel ourselves forward. An injured Achilles tendon usually does not like being stretched. By wearing shoes where the heel is higher than the toes (regular running shoes often work well), you reduce the amount of stretch in the Achilles tendon, and it helps it to calm down and the pain to settle.

Our patients get the best results during the early stages of their rehab if they wear heeled shoes most of the time, even in the house. As their tendon pain settles down and they progress in their rehab, they can then slowly transition back to their normal shoes.

You can get some heel raising inserts for your shoes below:

Load management

Once injured, the Achilles tendon loses some of its capacity (strength and endurance) to handle the loads or forces created during activities. As a result, it can no longer tolerate the normal volume of walking and other things you usually do. Often, antibiotic induced tendonitis is so painful that you can do very little during those early stages.

If you try and just push through the pain and continue with things as normal, it usually only increases the pain. To help your tendon calm down and restore its capacity for work, the following approach is better.

1. Don’t rest completely; just reduce your activities to a level that does not cause your pain to increase significantly. A slight increase in pain above your normal daily levels (up to 3/10) is usually okay, as long as it settles back down within 24 hours after the activity.

2. Then, as your tendon recovers, you slowly increase your activities, always keeping an eye on how your tendon reacts to the increases. Tendons often only start to hurt more several hours after you’ve done an activity.

3. Avoid sudden increases in the volume of your activities. For instance, if your tendon has been relatively happy with you walking slowly around the house, then it may be time to start building its endurance by doing short continuous 5- to 10-minute walks. However, if you immediately try a 20- or 30-minute walk, it will likely flare your pain up because the increase is too drastic, and your tendon has not been prepared for it.

4. Avoid sudden increases in intensity. The faster you walk, the harder your tendon has to work. If you’ve only been doing slow walks, then trying to do a power walk can often really flare things up if you haven’t prepared your tendon for it.

5. For very painful tendons, little recovery breaks during the day can often help, e.g. doing some tasks for an hour or two and then spending an hour with your feet up, resting on the couch, before you move on to the next thing.

Exercises for antibiotic induced tendonitis

Doing specific exercises for your Achilles tendon can help to reduce your pain and also restore your tendon’s strength and function. The main differences between exercises for antibiotic induced tendonitis and those for regular tendonitis or tendinopathy are:

• The exercises should start with very low loads and volumes. Typically, heel raises while sitting (with no extra weight) can help to get the circulation going and are tolerated well. These can then be progressed to standing heel raises. Your physio will help you decide what is best in your case.

The rehab exercises during the early stages of recovering from Antibiotic induced tendonitis are aimed at reducing pain and improving circulation.

• Avoid stretch positions in the early stages. So, do your heel raises only to floor level (not over the side of a step) and while wearing heeled shoes (like running shoes).

• Progress more slowly to heavier loads, e.g. using extra weight, than you would for overuse tendinopathy.

Start with calf raises done on floor level and only later progress to over a step.

• The antibiotics affect your body’s ability to produce and repair collagen (the main building block of tendons), so it may be useful to increase the recovery time between exercise sessions, e.g. two or three days rather than one, when you’re doing higher load strength training.

• Postpone plyometric exercises or explosive activities (jumping, hopping, running, etc.) for six months or until your therapist is satisfied that you have built the appropriate level of strength required for this. Fluoroquinolone antibiotics increase your risk of rupturing your Achilles tendon, so it is very important that you build up to doing heavy strength training for several months before adding these activities.

Only start plyometric exercises after six months and if you've built up to heavy strength training.

Supplements

There is research that suggests that supplementing with antioxidants may improve recovery from tendinopathy and specifically antibiotic induced tendon injuries. The strongest evidence so far seems to be for Vitamin C, but Vitamin E has also been indicated. More research needs to be done before we can say for certain that these substances help or what doses are required.

If you do decide to take supplements, be careful not to overdose. Speak to your doctor to find out what is considered a safe dose.

How we can help

Need more help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master's Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.

References:

1. Noriega-González, D. C., et al. (2022). "Effect of Vitamin C on Tendinopathy Recovery: A Scoping Review." Nutrients 14(13): 2663.

2. Puccini, V. (2022). "Antibiotic Therapy and Athletes: Is the Mitochondrial Dysfunction the Real Achilles’ Heel?" Sports 10(9): 131.

3. Pietruszyński, R., et al. (2020). "Antioxidant therapy in the management of fluoroquinolone-associated disability." Archives of Medical Science 16(6): 1483-1486.

4. Michalak, K., et al. (2017). "Treatment of the fluoroquinolone-associated disability: the pathobiochemical implications." Oxidative Medicine and Cellular Longevity 2017.

5. Lewis, T. and J. Cook (2014). "Fluoroquinolones and tendinopathy: a guide for athletes and sports clinicians and a systematic review of the literature." Journal of Athletic Training 49(3): 422-427.