ABIM Concept Review: Achilles Tendon

Ankle injuries are an important concept to understand and one you should have a firm grasp on if you are preparing for the Internal medicine board (ABIM) exam. Let’s review achilles tendon through a recent story in the news.


“With the thirteenth pick in the 1996 NBA draft, the Charlotte Hornets select Kobe Bryant from Lower Merion High School,” announced NBA commissioner David Stern. Immediately after being selected by the Hornets, seventeen-year-old Kobe Bryant was traded to the Los Angeles Lakers, marking the start of an illustrious basketball career.


Five NBA championships, 2 finals MVP, and over 54,000 minutes of playing time later, on April 12, 2013, the fourth leading scorer in NBA had perhaps the biggest scare of his life. In the fourth quarter of a late-season game against the Golden State Warriors, he drove to the basket as he has done countless times over his career. But this time, he dropped to the floor in excruciating pain before reaching the hoop. He asked one of his teammates if he accidentally kicked him in his ankle. When his teammate replied “No”, Bryant fearfully knew what injury he had suffered: Achilles tendon tear.


The Achilles tendon is the thickest and also the most commonly injured tendon in the body. It connects the gastrocnemius, soleus, and plantaris muscles to the calcaneus bone. The main aggravating motion leading to an Achilles tendon rupture is sudden plantar flexion or dorsiflexion of the ankle. Risk factors for Achilles tendon rupture are high intensity workout or sports, old Achilles tendon injuries, advanced age, prolonged use of fluoroquinolone antibiotics (e.g. ciprofloxacin, levofloxacin, and moxifloxacin), or corticosteroid injections in the setting of Achilles tendonitis.


Diagnosis of this condition is made by clinical history and usually an MRI to detect the degree of tear. Individuals usually feel the sensation of being kicked in the ankle, like Bryant experienced. They also have difficulty bearing weight on the affected ankle and cannot walk on their tiptoes. Swelling of the tendon is usually present.


Normally, when healthy individuals lay prone (face down), squeezing the calf muscle will result in passive movement (plantar flexion of the foot). Individuals with Achilles tendon tears do not display this passive movement—a finding known as a positive Thompson’s test.


Treatment for Achilles tendon rupture is usually surgery, which can be done using either an open or percutaneous approach. Patients who undergo percutaneous surgical repair have a lower chance of re-rupture than those pursuing nonoperative treatment. The surgeon makes the decision based on the degree of injury and the severity of the tear. After surgery, there is a lengthy rehab process that is involved to strengthen the tendon to prevent re-injury. Bryant’s percutaneous repair took place on April 13.


Throughout his spectacular NBA career, he has displayed extreme mental toughness that has allowed him to have an edge over his competitors. Now he possibly faces the toughest physical challenge of his professional career. With his advanced age of 35 years (in the world of sports), will he be able to perform at the same pinnacle level that he has displayed over his entire NBA career once he returns? Usually athletes who suffer such debilitating injuries are at high risk of ending their professional careers. Only time will tell whether the injury proves to be Bryant’s “Achilles’ heel” or if he’ll successfully return to the basketball court in the six to nine months his doctors estimate.


While it is unlikely that Kobe Bryant will show up in your actual ABIM exam, it’s quite possible that a quite about ankle injuries will. You can view the likely Internal Medicine Board Certification exam topics by looking at the ABIM blueprint.

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