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Fluoroquinolone-associated Achilles tendinopathy — MSRA MCQ

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ModerateAnkle and FootFluoroquinolone-associated Achilles tendinopathyMSRA

A 71-year-old man presents to general practice with a 2-day history of new left Achilles pain and swelling. Five days ago, he started ciprofloxacin 500 mg twice daily for a culture-confirmed complicated urinary tract infection; the isolate was resistant to first-line oral options. He is now afebrile and his urinary symptoms are improving. He has CKD G3b and takes prednisolone 7.5 mg daily for polymyalgia rheumatica. He reports no trauma, change in exercise or sudden "pop". There is focal tenderness and mild swelling 4 cm proximal to the calcaneal insertion. He can actively plantarflex the ankle; there is no palpable tendon gap and the calf-squeeze test is negative. He is systemically well. What is the most appropriate management today?

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

Reveal the answer and explanation

Correct answer: E — Stop ciprofloxacin immediately, advise rest and protection of the affected tendon, and obtain same-day antimicrobial advice about alternative treatment

Explanation lettering: E = shown as A · D = shown as B · A = shown as D · B = shown as E

This is probable fluoroquinolone-associated Achilles tendinopathy. The temporal association with ciprofloxacin, focal mid-portion Achilles pain and swelling, and absence of a traumatic mechanism are strongly suggestive. His age, renal impairment and concurrent systemic corticosteroid treatment further increase the risk of fluoroquinolone-related tendon injury. The negative calf-squeeze test, preserved plantarflexion and absence of a gap make complete rupture unlikely at present. MHRA advice is to stop a fluoroquinolone immediately at the first signs of serious tendon toxicity and seek clinical review; the affected area should be rested and protected. Because treatment remains necessary for a culture-confirmed complicated infection, alternative antimicrobial management should be discussed urgently with microbiology or an antimicrobial prescriber. A delays withdrawal despite a suspected serious adverse drug reaction. C inappropriately waits for imaging before stopping the causative medicine; imaging may be considered subsequently if diagnostic uncertainty or suspected rupture develops. D is inappropriate because corticosteroids may exacerbate fluoroquinolone-associated tendinitis and tendon rupture. E substitutes another fluoroquinolone, retaining the implicated drug class, and prematurely starts tendon loading rather than protecting the symptomatic tendon.

Reference: 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 Ciprofloxacin 250 mg film-coated tablets – Summary of Product Characteristics (June 2026) — https://www.medicines.org.uk/emc/product/7256/smpc