Antibiotics, Steroids and Fascia
By Bernie Clark, December 18, 2023
Athletes and yogis both should be aware that some antibiotics and injections of corticosteroids can affect your fascia, and especially your tendons. This is rare, but for people who are experiencing tendonitis, it is something to know because your pain may be due in part to other treatments you are undergoing.
Health is a balance
Maintaining health requires a balance between degrading and recycling older, worn-out tissues and growing new healthy tissue. These processes are referred to as catabolism (degradation) and anabolism (growth). Certain cells in our bodies can secrete enzymes that assist in the catabolism of tissues.
Ready for a tongue twister? Say this five times fast, “matrix metalloproteinases”. Ok, let’s just call them MMPs. The first MMP discovered was collagenase. The “ase” at the end of a word usually indicates that we are referring to an enzyme, and this enzyme helps to degrade the protein being named. In this case, collagenase is an enzyme that degrades collagen, and collagen is the primary protein found in our fascial tissues, such as tendons, ligaments and joint capsules, but also in our bones and the fascial wrappers around and within our organs. Collagen is the most abundant protein in our bodies. Cells like fibroblasts, tenocytes, and osteoblasts (which create fibers, tendons and bones) secrete collagen which then forms a scaffold into which other substances like calcium are held in place.
Athletes and yogis, through their exercises and practices, place load or stress on their tissues, which can cause microscopic damage. The collagen that is injured needs to be removed and then the body needs to produce more collagen and other proteins to replace and improve the damaged tissue. This replace and improve cycle involves the anabolic and catabolic processes described above. MMPs are the enzymes released to break down and recycle the damaged collagen.
So far, so good. We rely upon exercise to stimulate the recycling and upgrading of our tissues. Unfortunately, there are some medications, including a class of antibiotics called fluoroquinolones which include ciprofloxacin, levofloxacin, pefloxacin, and norfloxacin, that can stimulate catabolism. Fluoroquinolones are very effective antibiotics, but unfortunately, for a small portion of the population, these antibiotics stimulate production of MMPs, which in turn weaken collagen.
The most commonly reported fascial problems from fluoroquinolones are tendonitis and complete rupturing of the Achilles tendon, but problems have also been reported in the knees, hips, shoulders and hands. Symptoms include acute inflammation along with its commensurate pain and swelling, but many cases do not display any symptoms at all before a sudden and surprising rupture of the tendon occurs. Symptoms can arise very quickly after beginning antibiotic treatment, within as little as 2 hours, but the average appearance of symptoms is about six days. Unfortunately, symptoms may be delayed for as long as six months after treatment has ended. Many people using fluoroquinolones may be weakening their collagen without ever knowing it because they are not active enough for full-blown tendinopathy to arise.
This is rare!
Athletes and yogis are naturally stressing and loading their fascial tissues, which leads to catabolism of their collagen, and of course, anabolism. This is good. But, when exercise is combined with the use of a fluoroquinolones-based antibiotic, the degradation of the collagen may be enhanced. Our fascia weakens faster than our body can rebuild it, which can lead to tendinopathy which can include tendonitis and even rupture. Fortunately, all this is rare. In one large study of the use of this family of antibiotics only 2.4 cases of tendinitis and 1.2 cases of tendon rupture occurred for every 10,000 prescriptions. That is only 0.024%! This is not something you necessarily have to worry about.1
In order to quickly get back to their sport, athletes are twice as likely to use antibiotics than non-athletes.2 Thus, although the risk of fascial problems from antibiotic use is already very low, it is higher for athletes. For yoga students who already have a genetic predisposition to weaker collagen, such as students with Ehler Danlos syndrome, their fascia may become even more prone to damage with the use of these antibiotics. Very few doctors are aware of the effect on fascia of fluoroquinolones. If you already have some form of tendinopathy, or if you are an active athlete or a very flexible yoga student, and you need an antibiotic, you should consider asking your doctor to prescribe one that is not a fluoroquinolone.
Corticosteroids can make matters worse
A side effect of living long and prospering is the reality that our tissues change. Our fascia gets weaker and stiffer with age. We become brittle. Also, the older we get, the more likely we are at some point to be prescribed a corticosteroid to help us deal with asthma, a chronic inflammation or osteoarthritis in a joint. Athletes are also likely during their career to have a course or two of corticosteroid injections to deal with injuries. Unfortunately, if this happens at the same time that we are given a fluoroquinolone-based antibiotic, the deleterious effect of the two combined is considerably worse than either alone. A 2006 study found a 46-fold increase in the incidence of Achilles tendon rupture compared to a control group that took neither the antibiotic or steroid.” 3 One conclusion reported in a 2014 systematic review of the literature is
“Fluoroquinolones are effective antimicrobials but have very potent cytotoxic effects on human connective tissue…Athletes should not be prescribed fluoroquinolones and should be given alternative antibiotics when possible, particularly if … risk factors are present. [F]luoroquinolone use by athletes who require corticosteroid treatment for asthma could be hazardous.”4
A separate investigation found that corticosteroid injections to help with debilitating osteoarthritis did help manage pain in the affected joint, but at a cost of increasing the rate of arthritic degeneration. Alternatively, injections of hyaluronic acid both decreased pain and swelling as effectively as the steroid injection but lead to a slowing down of the progression of osteoarthritis.5 Thus, we find two big reasons to approach corticosteroids with an abundance of caution: they can make arthritis worse and they can weaken our collagen.
Prognosis and treatment
One standard form of treating tendinopathies, like tendonitis, is a gradual loading of the tendon which will help to rebuild its strength while improving its extensibility.6 If someone is also taking a fluoroquinolone-based antibiotic, or has taken one during the last six months, then loading of the tendon should be delayed to a second phase of recovery.7 For yoga students, the advice would be similar to that for athletes. Avoid strong loads on the affected tendon. Bracing the area may be the preferred first phase of treatment to avoid further damage to the fascia. If someone has an existing tendinopathy and requires an antibiotic, any attending physician should be advised to not prescribe a fluoroquinolone-based antibiotic. Similarly, corticosteroid injections might be best avoided, with perhaps a different intervention used instead, such as hyaluronic acid injection.
Again, these are rare situations and most of us will thankfully never have to worry about any of this. But, for the active athlete and yogis who work at the extreme limits of their body’s capability, it is useful to have this information tucked away in case the day comes when a fascial issue arises at the same time that a need for an antibiotic or steroid injection occurs. Even without worrying about a tendinopathy, any suggestion of a corticosteroid injection should be considered carefully and alternatives examined. It is always wise to consult your health care professional, but don’t be afraid to ask questions and raise these issues. As a team, you can determine the best way forward.
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[1] Lewis T, Cook J. Fluoroquinolones and tendinopathy: a guide for athletes and sports clinicians and a systematic review of the literature. J Athl Train. 2014 May-Jun;49(3):422-7. doi: 10.4085/1062-6050-49.2.09. Epub 2014 Apr 24. PMID: 24762232; PMCID: PMC4080593.
[2] Puccini V. Antibiotic Therapy and Athletes: Is the Mitochondrial Dysfunction the Real Achilles’ Heel? Sports (Basel). 2022 Aug 31;10(9):131. doi: 10.3390/sports10090131. PMID: 36136386; PMCID: PMC9504712.
[3] Corrao G, Zambon A, Bertù L, Mauri A, Paleari V, Rossi C, Venegoni M. Evidence of tendinitis provoked by fluoroquinolone treatment: a case-control study. Drug Saf. 2006;29(10):889-96. doi: 10.2165/00002018-200629100-00006. PMID: 16970512.
[4] Lewis T et al.
[5] “While both corticosteroid and hyaluronic acid injections are reported to help with symptomatic pain relief for knee osteoarthritis, our results conclusively show that corticosteroids are associated with significant progression of knee osteoarthritis up to two years post-injection and must be administered with caution,” Dr. Upadhyay Bharadwaj said. “Hyaluronic acid, on the other hand, may slow down progression of knee osteoarthritis and alleviate long term effects while offering symptomatic relief.” Steroid injections worsen knee arthritis, according to two new studies in Radiological Society of North America, November29, 2022. https://medicalxpress.com/news/2022-11-steroid-worsen-knee-arthritis.html
[6] Khan KM, Cook JL, Maffulli N, Kannus P. Where is the pain coming from in tendinopathy? It may be biochemical, not only structural, in origin. Br J Sports Med. 2000 Apr;34(2):81-3. doi: 10.1136/bjsm.34.2.81. Erratum in: Br J Sports Med 2000 Aug;34(4):318. PMID: 10786860; PMCID: PMC1724184.
[7] Greene BL. Physical therapist management of fluoroquinolone-induced Achilles tendinopathy. Phys Ther. 2002 Dec;82(12):1224-31. PMID: 12444881.