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Fluoroquinolone-associated Achilles tendinopathy — MSRA MCQ

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HardAnkle and FootFluoroquinolone-associated Achilles tendinopathyMSRA

A 74-year-old woman contacts her GP on day 6 of a 14-day culture-directed course of oral ciprofloxacin for a complicated urinary tract infection. Her urinary symptoms have resolved. She takes prednisolone 5 mg daily for polymyalgia rheumatica and has stable CKD G3b (eGFR 36 mL/min/1.73 m²). This morning, while walking indoors, she developed abrupt pain and swelling 4 cm proximal to the left Achilles insertion. There has been no trauma. Examination shows focal Achilles tenderness and mild swelling, with no palpable gap. The calf-squeeze test is negative and she can weight-bear with discomfort. There is no calf swelling, chest pain or breathlessness. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Stop ciprofloxacin, obtain same-day advice on an appropriate non-fluoroquinolone antimicrobial plan, and rest or immobilise the affected ankle

This presentation is most consistent with fluoroquinolone-associated Achilles tendinopathy. The abrupt focal Achilles pain and swelling developed during ciprofloxacin treatment, and tendon injury may occur within 48 hours of starting a fluoroquinolone. Her age, renal impairment and concurrent systemic corticosteroid therapy are each recognised risk factors for fluoroquinolone-associated tendon injury and rupture. The absence of a palpable gap and a negative calf-squeeze test make complete rupture less likely, but do not alter the immediate drug-safety action. Ciprofloxacin should be stopped at the first sign of tendinitis, the limb protected with rest or immobilisation, and alternative antimicrobial treatment considered. As the original treatment was culture-directed for a complicated infection, selection of an alternative should be reviewed urgently with the original prescriber or microbiology using the susceptibility result and clinical response. A and D inappropriately continue ciprofloxacin despite suspected tendon toxicity. Ultrasound may subsequently be indicated if partial or complete rupture is suspected, but imaging must not delay discontinuation. B recognises the need to stop ciprofloxacin but escalating corticosteroids is inappropriate: corticosteroids can exacerbate fluoroquinolone-related tendinitis and rupture. E avoids ciprofloxacin specifically but retains class exposure, as levofloxacin is also a fluoroquinolone.

Reference: Ciprofloxacin 250 mg film-coated tablets - Summary of Product Characteristics, section 4.4 (29 May 2026) — https://www.medicines.org.uk/emc/product/7256/smpc Fluoroquinolone antibiotics: must now only be prescribed when other commonly recommended antibiotics are inappropriate (22 January 2024) — https://www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-must-now-only-be-prescribed-when-other-commonly-recommended-antibiotics-are-inappropriate?es_c=4D8E57EB7462CC94BCC96A821