PART XX:

THERAPEUTICAL APPROACH

TO FLOXED TENDONS

 

 

We refer here to the potential treatments for floxed tendons, ligaments and cartilages. In fact, nobody knows any therapy with proven eficcacy. So we only make a survey of different supportive measures that can be of some help in very specific cases only.

 

While it is true that tendinitis is among the group of permanent injuries caused by fluoroquinolones, it is also certain that most people do not take the doses needed to get severely hit and do recover, as it has been discused before.

 

 

145. SURGICAL APPROACH TO THE FLOXED TENDONS

 

We know of people that have been suffering from very debilitating quinolone-induced elbow epicondylitis for 7 years. It is a tendon for which quinolones show a predilection. Some doctors are for a surgical intervention. We believe than in severe cases there are so many tendons so much affected that surgery had to be performed on several tendons of almost every joint, rendering the method virtually inviable. The following report, as it corresponds to a french translation, uses the term "lesion" as a synonim of injury.

EPICONDYLITIS AFTER TREATMENT WITH FLUOROQUINOLONE ANTIBIOTICS

JC Le Huec, T Schaeverbeke, D Chauveaux, J Rivel, J Dehais, and A Le Rebeller

We report two cases of epicondylitis of the elbow occurring after treatment with fluoroquinolone antibiotics. Both patients had intense pain which appeared very shortly after the first dose of the drug and was not relieved by conservative treatment. Ultrasonography revealed extensive inflammatory lesions with pseudonecrotic areas. MRI confirmed the lesions and also showed a subclinical abnormality of the adjoining tendons. The persistent nature of the pain was the indication for surgical release of the extensor mechanism. After operation pain disappeared completely and the patients were able to return to their normal activities. Injuries of the tendo Achillis are a well-known side-effect of treatment with fluoroquinolone. Our two cases show that such lesions may occur elsewhere. They also indicate the need for caution when prescribing these antibiotics to patients at risk of tendon lesions, such as top-level sportsmen or patients on dialysis or steroid treatment.

 

 

146. NUTRITIONAL APPROACH TO FLOXED TENDONS AND CARTILAGES

 

There are some authors (Olzi and others), that have compiled proposals to approach the healing of the connective tissue of normal people through nutrition (foods and supplements).

 

For floxed persons things are different, because the damage is chemical and antinatural, but probably for mild reactions the following tips could constitute a program that would aid in healing. For severe floxed persons, none of the following advices has made any difference, and might even have a negative impact on symptoms.

 

146.1 Calories

 

Many studies demonstrate that collagen production is sensitive to changes in short and long-term food intake. Within 24 hours of fasting of some animal models, collagen synthesis in articular cartilage decreases to 50% of normal. Specific effects of malnutrition on connective tissue turnover are dependant on many factors such as exercise activities, injuries, and disease. Replacement of tissue pools of macronutrients requires weeks to months and certainly affects turnover rates of tissue components.

 

Calories provide the body with cellular energy for normal metabolism, building and repairing tissues and stimulate hormonal responses. Individuals with injuries or other trauma should avoid a decrease in calories below maintenance or slightly above, thereby providing the nutrients and energy needed for healing and repair.

 

146.2 Protein

 

Muscle tissue provides a steady source amino acids for general body needs. Connective tissue is the second source, which is reflective of the relative rate of turnover to muscle tissue. Many studies have demonstrated that a protein deficient diet results in a reduction of growth and development of the organism as well as delay in wound healing and repairs.

 

All of the essential aminoacids are required for synthesis of proteins and other components and growth factors in the extracellular matrix. Some studies show that supplementing certain individual aminoacids (methionine, lysine, arginine, and proline) to a protein deficient diet may inhibit prolongation of the inflammation phase of connective tissue healing and aid in fiber cross-linking mechanisms during repair.

 

Unfortunately, as it is discussed later, supplementation of floxed persons with arginine or lysine is controversial with at least as many negative reports as positive ones.

 

Although countless studies demonstrate that protein malnutrition is significantly detrimental to normal turnover and healing of connective tissues, floxed persons do not normally restrict protein intake, unless they are strictly vegetarian and consume incorrect proteins like the one derived from soy.

 

146.3 Carbohydrates

 

Aside from protein, carbohydrates are a major component of an athlete’s diet and supply quick energy for the body in the form of glucose. Although little information exits on the direct effects of glucose deficiencies on connective tissues, it is well known that glucose is an energy source for several components and growth mediators. Tissue cells such as fibroblasts and chondroblasts require glucose for synthesis of various macromolecules. Glucose is a building block of glycosaminoglycans and glycoproteins in the ground substance of the matrix. Arguably, hypoglycemia (abnormally low level of plasma glucose caused very frequently by quinolones) impairs normal cell function and delays wound healing. As well, production and release of several hormones, such as insulin and growth hormone, decline with low levels of plasma glucose further delaying tissue growth and repair. There is a suspicion that treating floxed persons with controlled combinations of growth hormone and anabolic steroids, could contribute to a quick healing process.

 

Conversely, high levels of plasma glucose (hyperglycemia, also caused frequenly by quinolones) may also be detrimental. Decreased insulin function may lead to hyperglycemia which also impairs wound healing. This is consistent with the high intolerance that many floxed persons develop to sugar and all kind of sweet foods.

 

High levels of plasma glucose reportedly may inhibit the stimulatory action of ascorbic acid on proteoglycan and collagen production. Furthermore, chronic high plasma and tissue glucose levels produce advanced glycation products that affect the physical, chemical and mechanical properties of collagen and elastin protein.

 

Diets low in carbohydrates typically cause body water loss. For athletes, the resultant dehydration may compromise integrity of connective tissues subject to mechanical loading. Considering that many connective tissues such as in articular joints require a relatively high water content for optimal functioning under stress, dehydration may increase incidence of injury or jeopardize healing and repair of injured tissue. Hence the importance for floxed persons of taking a lot of good quality water, but avoiding all sort of excesses in order to avoid the negative effects of too much water intake that for a floxed person can mean an increase in central nervous system symptoms, among other unwanted effects.

 

146.4 Fats

 

Saturated fats are commonly found in animal foods and in some vegetable plants and have little direct import in the physiology of connective tissue. However there are influences of polyunsaturated fatty acids on injured connective tissue.

 

The major polyunsaturated fatty acids are classified as two types: n-3 and n-6 polyunsaturated fatty acids. The n-6 family is the major polyunsaturated fatty acids in cell membranes and is derived from vegetable oils. Low levels of n-3 polyunsaturated fatty acids exist in most individual cell membranes because diets are generally low in fish oils which are the source of this polyunsaturated fatty acids family. Polyunsaturated fatty acids are precursors for a family of hormones called eicosanoids, which are released by macrophages and other cells and mediate many cellular functions. The major role of eicosanoids is in the inflammatory response; therefore, dietary polyunsaturated fatty acids may moderate the length of the inflammatory phase.

 

A relative excess of n-6 polyunsaturated fatty acids stimulates production of prostaglandin E2 which may prolong the inflammatory response. Although increasing intake of n-3 polyunsaturated fatty acids may not impact acute inflammation, such nutritional support quite possibly moderate long-term inflammation related to excessive prostaglandin E2 production and cytokine release from activated macrophages.

 

146.5 Vitamins

 

VITAMIN C (ascorbic acid)

Of all the vitamins, ascorbic acid probably has the most influence on connective tissue metabolism and has been the most studied.

 

In connective tissue, ascorbic acid is involved in several metabolic reactions. Iron is necessary for a variety of enzymatic reactions, and ascorbic acid protects iron from oxidation. Vitamin C preserves the enzyme-iron complex that catalyzes the reaction for intracellular assembly of collagen. Increased intake of dietary Vitamin C may prevent inhibition induced by high glucose (as seen in quinolone induced hyperglucemia) on collagen and proteoglycan synthesis.

In addition to collagen, the influence of Vitamin C extends to proteoglycans. The most commonly known role of Vitamin C is as an antioxidant. Vitamin C supplementation in surgical and non-surgical patients resulted in improved wound healing, reduced inflammation and improved recovery.

 

Always be aware of the toxic effects or large quantitites of any vitamin. In particular, Vitamin C excess can cause, among other disturbances, kidney stones, increased iron absortion leading to iron overload and liver problems, erosion of dental enamel, increased oxygen demand and pro-oxidant effects.

 

VITAMIN B COMPLEX

The B vitamin complex is a large group of compounds with different structure and biological activity. They are usually found within the same food sources. The primary role of the B vitamins is cellular energy metabolism. Any deficit in cellular energy will have adverse effects on cellular function. Therefore, the B vitamins are essential in connective tissue metabolism.

 

Many of the B complex serve as cofactors in process of collagen and elastin cross-linking. Deficiencies in several of the B vitamins influence expression of collagen genes and induce decreased mechanical strength of repaired and remodeled tissue.

 

Since most all B vitamins are found together in similar food groups, deficiencies of one singular vitamin is uncommon. However, deficiencies may exist if overall dietary intake is reduced. A mixture of all B vitamins should adequately provide for daily needs.

 

Always be aware of the toxic effects or large quantitites of any vitamin. In particular, Vitamin B1 excess can cause, among other disturbances. Niacin excess can be hepatotoxic (liver toxicity). Vitamin B6 excess causes NEUROPATHY. Vitamin B12 excess may cause insomnia, leukemia, kidney damage and also hypertiroidysm.

 

VITAMIN A

Retinoids are a group of compounds of which some have vitamin A activity and others do not. Vitamin A is often referred to as retinol in much of the literature and will be used interchangeably here. Although carotenoids are commonly mistaken for vitamin A, only a fraction of them have any vitamin A activity. b -Carotene is the most significant because in the body it can be broken down into two retinol molecules and therefore supply vitamin A when needed. Retinol is stored in the liver and distributed to peripheral tissues by strict regulatory mechanisms and metabolized in several pathways.

 

Retinol is converted to retinoic acid inside cells and both are potent regulators of specific genes, including expression of fibronectin and type I procollagen. Other metabolites of retinol regulate cell differentiation and are associated with glycosaminoglycan, glycoprotein and proteoglycan synthesis. Although still unclear, the role of vitamin A in proteoglycan synthesis may be involved in sulfation of glycosaminoglycan s. Tissue from animals deficient in vitamin A typically displays decreased synthesis of highly sulfated glycosaminoglycan.

 

Few in vivo studies exist documenting specific roles of retinoids in connective tissue, except for those studying wound healing in animal models. That rapidly growing tissues are sensitive to vitamin A deficiency is well known. Deficiency of other nutrients, such as zinc and protein, that assist in transport and metabolism of retinol may induce deficiency symptoms. Therefore, since retinol distribution from the liver is tightly regulated, functional deficiencies may result with normal vitamin A intake and stores. Additionally, extra-physiological doses of vitamin A may counteract the inhibitory effects of systemic corticosteroids on plasma retinol transport.

 

Because vitamin A is fat-soluble, toxicity is also a concern in connective tissue metabolism. High levels may inhibit collagen synthesis, as seen in the skin, and increase catabolism of cartilage. This may be concentration dependent since excessively high levels affect ascorbate induced lipid peroxidation, which in turn inhibits vitamin C-induced collagen synthesis.

 

Always be aware of the toxic effects or large quantitites of any vitamin. In particular, Vitamin A excess causes liver abnormalities and is teratogenic for the foetus. It also causes blurred vision, muscular incoordination, nervous system changes anb bone and skin abnormalities. In fact we recommend you to avoid any kind of supplementation with vitamin A above the daily recomendation of just one milligram (1 mg).

 

VITAMIN E

Vitamin E is a group of compounds comprising of two major classes: tocopherols and tocotrienols. The basic chemical structure in each class is similar with variations of substituents and confirmation resulting in different relative activity. We use the term vitamin E as a reference primarily to the tocopherols, as they have the greatest activity in the body.

 

Literature information on the role of vitamin E in connective tissue metabolism is controversial. The major function of vitamin E is as an antioxidant and in the maintenance of cell membrane integrity. Its role as an antioxidant is thought to require vitamin C and selenium. Although no specific disease of connective tissue can be attributed to vitamin E deficiency, it is no doubt needed for life and cell processes.

 

Animal model studies have shown that severe deficiency in vitamin E influence collagen cross-linking and an increase in susceptibility of insoluble collagen to degradation by proteinases. Conversely, excessive doses of vitamin E elicit effects similar to those of corticosteroids: inhibition of collagen synthesis and wound repair. Rats given supra-physiological doses of vitamin E exhibited less tensile strength in skin of healed wounds. Indeed, vitamin E may potentiate adverse effects of corticosteroids. We do not recommend to take supplemented vitamin E to treat a floxing because some floxed persons have reported increased hemorrhages probably due to