Shoulder pain affects about 18 million Americans per year. Many of these people have rotator cuff tears and live with impaired function. They may be unable to lift their arms or hold onto larger objects, or struggle to get clothing on and off. Recent information offers game changing understanding for conservative management and highlights shocking risks of antibiotics and steroid shots.

The rotator cuff is a group of four muscles and their tendons that surround the ball and socket joint of the shoulder. A rotator cuff tear is a partial or complete tear of one or more of these tendons. Medical treatment may consist of conservative treatment with pain medication, cortisone shots, rest, ice, and physical therapy. When conservative treatment fails, then surgical repair of the torn tendons is recommended. Many times, repeat surgical revisions take place. In severe cases, shoulder replacement may be recommended. Often there is a chronic progression and loss of function with the shoulder.

Scientists have been looking at the pathology of why the rotator cuff breaks down. There are a number factors associated with rotator cuff disorders. Common factors include physical trauma (sports, motor vehicle collisions, etc.), chronic heavy workloads, chronic vibration (construction workers, truck drivers, etc.), chronic joint structure challenges, smoking, diabetes, and infection. In a first-of-its-kind clinical report, scientists identified a relationship with thyroid problems and non-traumatic rotator cuff tears. Women who had thyroid problems were more prone to develop rotator cuff tears. The reasons are yet to be determined. There are two other factors that you need to be aware of and are related to medical treatments.

Antibiotic Use and Tendons

Drug reactions can cause sudden onset of rotator cuff problems. This is indeed the case for fluoroquinolone antibiotics like Cipro/Ciprofloxacin, Levaquin/Levofloxacin, and others. These antibiotics have a black box warning on them that indicates increased risk for tendon injury. In fact, tendons may partially or completely rupture during the use of the medication. The risk persists for several months after the use of these antibiotics. Each person responds differently to these antibiotics. Some experience severe reactions that occur within hours of using the medication resulting in permanent damage, while others have minor irritation that goes away after a few days after stopping the medication.

A recent animal study in the American Journal of Sports Medicine looked at how these types of antibiotics disrupted tendon health. Each animal group treated with different amounts fluoroquinolone antibiotics showed measurable disrupted tendon health as opposed to those that were untreated. When the scientists looked at the tendons under a microscope, the tendons were friable and had atrophied. In essence they were ragged, shredded, and shrunken. The researchers measured inflammatory markers matrix metalloproteinase MMP-3 andMMP-13 and tissue inhibitor of metalloproteinase TIMP-1 before and after the antibiotic use. The MMP-3 increased 30 times, MMP-13 increased 7 times, and TIMP increased 4 times. The results showed that tendon tissue had less fibrous cartilage and lost its healthy structure.

MMPs and TIMPs are types of enzymes that play essential roles in tendon development and normal remodeling after injury. The body needs some activity of these enzymes to keep up with normal wear and tear. Too much activity of these enzymes leads to weakening, damage, and degeneration of these tendons i.e. a disease state of the rotator cuff. This animal study with antibiotics showed dangerous increased activity levels of these enzymes leading to the disintegration of the tendons and development of rotator cuff disease. The antibiotic reactions caused the MMP enzymes to go from responsible clean-up to en masse destruction and tissue shredding.

Those who struggle with poor healing rotator cuff issues not due to Levaquin also face concerns with too much MMP and TIMP activity. There are other enzymes as well like Cox-1, Cox-2, and 5-Lox that cause tendon breakdown. The tendons atrophy, develop fatty deposits and become more friable. These same enzymes are also involved with other joint and cartilage breakdown. The COX enzymes are common drug targets seen on many pain relief drug commercials.

Glutamate, Cortisone, and Joint Damage

On a different facet, research published in the American Journal of Sports Medicine in May 2014, shows that patients with rotator cuff tears have very high levels of glutamate within the tendon tears. Just like in the brain, glutamate is dynamically involved with pain and metabolic pathways in the body. Glutamate is a stimulatory neurotransmitter in the brain. We need some to be awake, productive, and alert. Too much glutamate in the brain is a problem and is associated with damage and dysfunction. How it plays a role in the rotator cuff disease process is yet to be determined, but an interesting finding has transpired.

A British Journal of Sports Medicine December 2014 report studied patients who had rotator cuff problems and had received treatment through surgery or through steroid injections. Biopsies were taken before and after treatment with steroid injections and compared to those who had surgical repair. The patients who underwent surgery showed a healthy healing response, whereas the steroid injection group had a different change. Those who received the shoulder steroid injections had an increase in the ion-channel glutamate receptor (NMDAR1) activity. This means that there was high glutamate in the tendons after the cortisone injection creating high risk and presence of excitotoxic chemicals. The authors in this study strongly questioned the standard treatment protocol and efficacy of steroid injections because of the newly identified excitotoxic glutamate response. The authors’ conclusion was that this standard treatment raises the potential for more tissue damage, ultimately causing deleterious effects on the tendon health.

There is no doubt that steroid injections reduce pain, but at what cost? Many who are on the standard medical track receive a series of injections and may repeat the process a year or two later because their pain and disability worsened. This is a similar progression pattern that is often seen with patients with other types of joint and cartilage problems. The finding of this study opens the door for some much needed re-evaluation and other treatment options for joint tissue health.

Patients who have rotator cuff problems struggle with sometimes the simplest of activities. Raising the arm to brush teeth, comb hair or even lifting utensils to eat can be a challenge. Targeting these enzymes and excitotoxic chemicals mentioned earlier may help provide another route of support for health and healing.

Researchers have recently identified that too much leptin or leptin resistance also elevates MMP enzymes activity, i.e. MMP-3 and -13, etc to cause tissue breakdown and degenerative joint disease. This certainly gives anyone with joint problems added incentive to improve their leptin resistance and follow The Leptin Diet.

Patients with new or chronic rotator cuff problems need to be proactive with their care. Lack of timely treatment can lead to further breakdown of the joint and problems with frozen shoulder or adhesive capsulitis. Patients who undergo fluoroquinolone antibiotic treatments with simultaneous or adjacent steroid shots may potentially find themselves susceptible to dangerous MMPs enzyme elevations and glutamate toxicity. This can lead to a terrible degenerative quandary with permanent tissue destruction. Higher levels of stress and inflammation, and age contribute to this potential risk. If you or your loved one is facing any of these situations with a bad shoulder, consider the risks and benefits.

Follow healthy eating patterns to support the hormone leptin and keep the repair enzymes in a healthy balance rather than destruction. Find a combination of nutrients to help support healthy tissue and use that in conjunction with your physical therapy, chiropractic, and/or other conservative medical care. These tools may also be used if you need further support after shoulder surgery. There are many levels of breakdown and healing with rotator cuff disease. If one or more tendons are permanently damaged, work on protecting and supporting the other tissues in the area, because they will get the brunt of the work. Several options and resources exist in managing bad shoulders. Don’t ignore the problem or minimize the need for support. Use these resources to take charge of your health today!