Statin-induced and fluoroquinolone-induced ligament and tendon injuries
We see many patients who have joint pain and are on medications for other health challenges. Among these other health challenges are high cholesterol. High Cholesterol and statin medication use has been implicated in some studies as presenting a challenge to soft tissue healing in damaged joints. Among these soft tissues are the tendons that connect muscles to bones. The benefits, side-effects, and even the worthiness of taking statins have been under constant attack in recent years. We will not tackle the great statin debate in this article. What we will look at is if you are trying to repair a damaged tendon, will statin usage present a problem.
In our clinics, we use simple dextrose Prolotherapy injections as a healing stimulant in damaged joints and spine. The simple injection is a “reset” or “reboot,” to help a stalled healing process. One of the rests Prolotherapy helps with is tendon healing. If tendons do not heal or are compromised, muscles weaken, muscles atrophy, you lose strength and function.
Over the past few years, there has been a concern in the medical research community that statin usage, as prescribed for high cholesterol, may cause tendon damage. We do get emails about tendon damaged induced by medications and people asking us what we can do to help them. Our answer is to rebuild the problem tendon with Prolotherapy injections. But what if you are currently taking statins, will this cause of problems in getting the most benefit out of regenerative medicine injections? Likely no. But let’s explore the research.
Statins, Fluoroquinolones, and the Achilles tendon
In late 2018, researchers in the Czech Republic reported these observations in the Czech journal Internal Medicine: (1)
“Tendon injury belongs to the less known side effects of some drugs, reported until recently only for glucocorticoids (steroid) and fluoroquinolones (antibiotics). To date, some other classes of drugs such as statins, aromatase inhibitors, anabolic steroids, potentially causing tendon injury, have been added to the list.
(In regard to tendon injury) most often, the Achilles tendon is affected, however, nearly every tendon of the entire body may be affected.
Tendon rupture or drug-induced tendinopathy should be strongly considered in those who have a tendon injury and have recently taken these drugs.
- So there is some connection between statin use and tendon injury and it affects some people, not all people.
University researchers in Turkey writing in the medical journal Knee surgery, sports traumatology, arthroscopy, (2) discuss the accumulating clinical evidence indicating the risk of tendinopathy and spontaneous and/or simultaneous tendon ruptures associated with statin use.
In their experimental study, the researchers designed a plan to evaluate and compare the biomechanical and histopathological (tissue damaging) effects of the three most commonly prescribed statins (simvastatin, atorvastatin and rosuvastatin) on the Achilles tendon in rats.
Statins were given to the rats at daily doses of 20 and 40 mg/kg for 3 weeks. One week later, the Achilles tendons were dissected and their biomechanical properties, including ultimate tensile force, yield force and elastic modulus, were determined.
- All the statins caused deterioration of the biomechanical parameters of the Achilles tendon. Histopathological (tissue damage) analysis demonstrated foci of dystrophic calcification (the calcification of dead and dying soft tissue) in the statin-treated groups.
They concluded that all the statins tested are associated with calcific tendinopathy risk of which full awareness is required during everyday medical practice. The benefit? Statin-associated improvement of bone biomechanical properties is a favorable feature which may add to their beneficial effects in atherosclerotic cardiovascular disease, especially in the elderly.
So there are risks and this should be discussed with patients currently taking statins and seeking regenerative medicine injections.
HOWEVER, researchers at the Vancouver Coastal Health Research Institute and University of British Columbia suggest that their study published in the journal Public Library of Science one (3) did not identify any influence of statin use on Achilles tendon cross-sectional area or collagen organization (The statins did not interfere with tendon healing or remodeling).
The researchers concluded: “These results are encouraging for health professionals working in cardiovascular rehabilitation who may wish to prescribe load-bearing exercise as part of a multidisciplinary intervention for people with hypercholesterolemia.”
Statins and the Patellar tendon and Finger Tendons
University hospital researchers in Brazil writing in the Canadian journal of physiology and pharmacology (3) also discussed rising numbers of cases of tendon injuries associated with statin therapy reported over the past few years.
In this study, this study the researchers assessed whether statins can affect the extracellular matrix (ECM) of the deep digital flexor tendon (finger tendons in humans) and the patellar tendon.
- Wistar rats were assigned to groups treated with atorvastatin (A20, A80), treated with simvastatin (S20, S80), and control.
Both the statins provoked marked changes in both tendons.
Findings: Both the statins provoked marked changes in both tendons. All these changes may make the tendons more prone to microdamage and ruptures. Therefore, a better understanding of the behavior of the tendon ECM components under statin therapy may provide important insights into the mechanisms behind statin-induced tendon injuries.
Confusion and surprising findings – Do statins make tendons stronger? Weaker? No effect?
Researcher Pernilla Eliasson who is affiliated with the University of Copenhagen, Linköping University, Sweden, and the University of Rochester in New York lead a team of researchers looking at the complexity of Simvastatin and atorvastatin and its relationship with tendon damage.
The research appearing in the on-line medical journal PLOS examined the theory that Simvastatin and atorvastatin may have different potential for negative effects on tendons. Atorvastatin has been pointed out as one of the most harmful statins for tendon tissue while simvastatin has appeared with mixed findings.
- Some studies indicate that simvastatin has a negative impact on tendon tissue, while other studies suggest that simvastatin might even have a positive effect.
- Both atorvastatin and simvastatin had a negative effect on the tendon constructs in our study, however, the effect of simvastatin was in fact stronger and more pronounced.
- This indicates that simvastatin indeed is harmful for tendon tissue and its extracellular matrix. However, high dose atorvastatin treatment was the only treatment which had an effect on collagen content, and this was reduced by 22% compared to controls.
- Simvastatin had no effect on the collagen content to the researcher’s surprise. This indicates that there might be some differences in the mechanism of action on human tendon cells and extracellular matrix between these two statins. The range of the dosage of the two statins in clinical settings is similar, though the average dose for atorvastatin is slightly lower than the average dose for simvastatin.
Higher doses of either of these two statins are toxic for tendon fibroblasts
The researchers concluded that normal statin treatment of just seven days had such a detrimental effect upon tendon tissue indicates that also long term adaptations may occur. The more you take the statins, the worse the tendon damage.3 Please see my article high cholesterol and joint pain to continue this discussion.
If you have questions about Statin-induced tendon injuries, you can get help and information from our Caring Medical Staff.
1 Alušík Š, Paluch Z. Drug induced tendon injury. Vnitrni lekarstvi. 2018;63(12):967-71. [Google Scholar]
2 Kaleağasıoğlu F, Olcay E, Olgaç V. Statin-induced calcific Achilles tendinopathy in rats: comparison of biomechanical and histopathological effects of simvastatin, atorvastatin and rosuvastatin. Knee Surgery, Sports Traumatology, Arthroscopy. 2017 Jun 1;25(6):1884-91. [Google Scholar]
3 Oliveira LP, Vieira CP, Marques PP, Pimentel ER. Do different tendons exhibit the same response following chronic exposure to statins?. Canadian journal of physiology and pharmacology. 2016 Oct 4;95(4):333-9. [Google Scholar]
4 Eliasson P, Svensson RB, Giannopoulos A, Eismark C, Kjær M, Schjerling P, Heinemeier KM. Simvastatin and atorvastatin reduce the mechanical properties of tendon constructs in vitro and introduce catabolic changes in the gene expression pattern. PloS one. 2017 Mar 6;12(3):e0172797. [Google Scholar]