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Midfoot & Hindfoot MCQs

Practice Set 1 of 39

This practice set contains high-yield board review questions covering key concepts in Midfoot & Hindfoot. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 1

Topic: Midfoot & Hindfoot

A 40-year-old female undergoes an endoscopic plantar fascia release for recalcitrant plantar fasciitis. Six months postoperatively, she complains of new-onset lateral midfoot pain. What is the most likely cause of her current symptoms?

. Sural nerve neuroma
. Recurrent plantar fasciitis
. Lateral column overload
. Medial calcaneal nerve entrapment
. Navicular stress fracture

Correct Answer & Explanation

. Lateral column overload

Explanation

A recognized complication of complete plantar fascia release is lateral column overload, which often leads to pain at the calcaneocuboid joint. The plantar fascia acts as an important dynamic stabilizer of the longitudinal arch.

Question 2

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with a painful, flexible flatfoot deformity. Examination reveals inability to perform a single-leg heel raise, and the 'too many toes' sign is positive. The subtalar joint remains mobile. Which of the following is the most appropriate surgical treatment?

. Isolated spring ligament repair
. Subtalar arthrodesis
. Flexor digitorum longus (FDL) transfer with medial displacement calcaneal osteotomy
. Triple arthrodesis
. Ankle arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer with medial displacement calcaneal osteotomy

Explanation

This is a Stage II adult acquired flatfoot deformity (flexible posterior tibial tendon dysfunction). The gold standard surgical management involves an FDL transfer to the navicular and a medial displacement calcaneal osteotomy to correct the valgus hindfoot axis.

Question 3

Topic: Midfoot & Hindfoot

Which of the following nerves is classically entrapped between the deep fascia of the abductor hallucis muscle and the medial aspect of the quadratus plantae, causing chronic heel pain?

. Medial plantar nerve
. First branch of the lateral plantar nerve
. Medial calcaneal nerve
. Sural nerve
. Deep peroneal nerve

Correct Answer & Explanation

. First branch of the lateral plantar nerve

Explanation

The first branch of the lateral plantar nerve (Baxter's nerve) can become entrapped between the abductor hallucis and quadratus plantae muscles. It provides sensory innervation to the calcaneal periosteum and motor innervation to the abductor digiti minimi.

Question 4

Topic: Midfoot & Hindfoot

An 11-year-old girl presents with bilateral painful flatfeet. A computed tomography image is shown (Slide). The most likely diagnosis is:

. Idiopathic planovalgus feet
. Talocalcaneal coalition
. Degenerative joint disease
. Osteoid osteoma
. Osteochondritis dissecans

Correct Answer & Explanation

. Talocalcaneal coalition

Explanation

This patient has evolving medial talocalcaneal facet coalition. The computed tomography is remarkable for obliquity of the medial facet, along with irregularity and narrowing of this facet, which is not evident on plain radiographs. Normally the medial subtalar facet should be parallel to the posterior facet. Treatment options for this patient include immobilization, resection, or subtalar fusion.

Question 5

Topic: Midfoot & Hindfoot

A mutation in the gene for peripheral myelin protein 22 causes which of the following disorders:

. Friedreich ataxia
. Charcot-Marie-Tooth disease
. Cerebral palsy
. Adrenoleukodystrophy
. Fragile X syndrome

Correct Answer & Explanation

. Charcot-Marie-Tooth disease

Explanation

Type I, or the hypertrophic demyelinating form, is the most common form of Charcot-Marie-Tooth disease. It is due to a mutation in the gene on chromosome 22, which encodes for peripheral myelin protein 22. Type I C harcot-Marie-Tooth disease has a prevalence of approximately 1 in 5,000 individuals.

Question 6

Topic: Midfoot & Hindfoot

Scapulothoracic fusion is most commonly indicated to help improve function in which of the following conditions:

. Duchenne muscular dystrophy
. Beckers muscular dystrophy
. Facioscapulohumeral dystrophy
. Charcot-Marie-Tooth disorder
. Congenital muscular dystrophy

Correct Answer & Explanation

. Facioscapulohumeral dystrophy

Explanation

Facioscapulohumeral dystrophy is a rare disorder inherited in an autosomal dominant fashion. Thirty percent of affected individuals have a new mutation. The genetic abnormality is found on chromosome 4, with a decreased number of D4Z4 tandem repeats, but this does not appear to code for a protein product. In this condition, selective weakness of the serratus anterior, trapezius, and rhomboid muscles is present. Therefore, the scapula is not effectively stabilized against the trunk during use. Although the deltoid is relatively spared, it cannot work well due to a hypermobile scapula. Fusion of the scapula to the thorax improves range of abduction in this condition.

Question 7

Topic: Midfoot & Hindfoot

A 12-year-old boy has bilateral cavovarus feet. A Coleman block test demonstrates a flexible hindfoot. In Charcot-Marie-Tooth disease, which primary muscle imbalance initiates the plantarflexed first ray?

. Strong tibialis anterior overriding a weak peroneus longus
. Strong peroneus longus overriding a weak tibialis anterior
. Strong tibialis posterior overriding a weak peroneus brevis
. Weak extensor hallucis longus with a strong flexor hallucis longus
. Weak gastrocnemius with a strong soleus

Correct Answer & Explanation

. Strong peroneus longus overriding a weak tibialis anterior

Explanation

In Charcot-Marie-Tooth disease, the typical muscle imbalance driving the cavus deformity is a strong peroneus longus overpowering a weak tibialis anterior, which severely plantarflexes the first ray.

Question 8

Topic: Midfoot & Hindfoot

A 4-year-old boy presents with bilateral flexible flatfeet. He has no pain, normal subtalar motion, and is able to perform a single-leg heel rise, during which the heel appropriately goes into varus. What is the most appropriate management?

. Custom rigid orthotics
. UCBL orthoses
. Bilateral subtalar arthroereisis
. Medial column lengthening
. Reassurance and observation

Correct Answer & Explanation

. Reassurance and observation

Explanation

Flexible, asymptomatic flatfeet in a young child represent a normal physiologic variant. Treatment is not indicated, and the best management is reassurance to the parents, as arch development continues up to age 10.

Question 9

Topic: Midfoot & Hindfoot

A 14-year-old male presents with deep posterior ankle pain during sports. Examination reveals decreased subtalar motion. Radiographs show a "C-sign" on the lateral view. Which anatomical structure is most commonly involved in this pathology?

. Anterior facet of the subtalar joint
. Middle facet of the subtalar joint
. Posterior facet of the subtalar joint
. Calcaneocuboid joint
. Talonavicular joint

Correct Answer & Explanation

. Middle facet of the subtalar joint

Explanation

The "C-sign" on a lateral radiograph is indicative of a talocalcaneal coalition. The middle facet of the subtalar joint is the most common anatomical site for this type of bony or cartilaginous bridge.

Question 10

Topic: Midfoot & Hindfoot

A 6-year-old boy presents with a limp and midfoot pain. Radiographs demonstrate sclerosis and flattening of the navicular bone without signs of infection. What is the most appropriate treatment?

. Core decompression of the navicular
. Excision of the navicular
. Short-leg walking cast for 4-6 weeks
. Intravenous antibiotics
. Talonavicular arthrodesis

Correct Answer & Explanation

. Short-leg walking cast for 4-6 weeks

Explanation

The diagnosis is Kohler disease, an idiopathic avascular necrosis of the navicular bone. It is a self-limiting condition; severe pain is best treated with a short-leg walking cast for symptomatic relief while awaiting spontaneous revascularization.

Question 11

Topic: Midfoot & Hindfoot

Which of the following findings is typical in patients with Marfan syndrome as opposed to patients with Ehlers-Danlos syndrome:

. Scoliosis
. Dural ectasia
. Pes planus
. Lens dislocation
. Joint pains

Correct Answer & Explanation

. Lens dislocation

Explanation

All of the findings presented, with the exception of lens dislocation, are seen in both syndromes at a frequency that exceeds the general population. Lens dislocation is common in patients with Marfan syndrome but not those with Ehlers-Danlos syndrome.

Question 12

Topic: Midfoot & Hindfoot

A diabetic patient presents with a swollen, erythematous, but painless foot. Radiographs show extensive bone fragmentation, subluxation, and joint debris without significant sclerosis. According to the Eichenholtz classification, what stage of Charcot arthropathy does this represent?

. Stage 0 (Inflammatory)
. Stage 1 (Development/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Consolidation/Reconstruction)
. Stage 4 (Ulceration)

Correct Answer & Explanation

. Stage 1 (Development/Fragmentation)

Explanation

Eichenholtz Stage 1 (Development) is characterized by acute inflammation, joint laxity, subluxation, bone fragmentation, and debris formation. Stage 2 (Coalescence) shows absorption of fine debris and early sclerosis.

Question 13

Topic: Midfoot & Hindfoot
According to the Eichenholtz classification of Charcot arthropathy, which of the following radiographic findings characterizes the Coalescence stage (Stage II)?
. Osteopenia and periarticular fragmentation
. Bone debris and subluxation
. Absorption of fine debris and fusion of large fragments
. Consolidation and remodeling of bone ends
. Normal radiographs with a clinically warm and swollen foot

Correct Answer & Explanation

. Absorption of fine debris and fusion of large fragments

Explanation

Stage II (Coalescence) is characterized by the absorption of fine bone debris, early fusion of larger fragments, and sclerosis. Stage I is fragmentation, and Stage III is consolidation and remodeling.

Question 14

Topic: Midfoot & Hindfoot
A 62-year-old patient with poorly controlled diabetes presents with a swollen, erythematous, and warm foot. Radiographs show fragmentation of the midfoot bones, joint subluxation, and periarticular debris. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?
. Stage 0
. Stage I (Developmental)
. Stage II (Coalescence)
. Stage III (Reconstruction)
. Stage IV (Consolidation)

Correct Answer & Explanation

. Stage I (Developmental)

Explanation

Eichenholtz Stage I (Developmental/Fragmentation) is characterized clinically by a red, hot, swollen foot and radiographically by bone fragmentation, joint subluxation, and debris. Stage II involves coalescence, and Stage III involves reconstruction and remodeling.

Question 15

Topic: Midfoot & Hindfoot

A 60-year-old diabetic patient presents with a warm, swollen, erythematous foot without ulceration. Radiographs show periarticular fragmentation, subluxation, and bony debris at the tarsometatarsal joints. According to the Eichenholtz classification, what is the appropriate initial management?

. Immediate open reduction and internal fixation
. Total contact casting and non-weight bearing
. Midfoot arthrodesis
. Below-knee amputation
. Intravenous antibiotics and I&D

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The patient is in the acute fragmentation phase (Eichenholtz Stage 1) of Charcot arthropathy. The mainstay of treatment is immobilization and offloading, typically utilizing a total contact cast, until the acute inflammation resolves.

Question 16

Topic: Midfoot & Hindfoot
A 55-year-old female presents with stage II adult acquired flatfoot deformity (posterior tibial tendon dysfunction). Which of the following physical examination findings differentiates stage II from stage III disease?
. Inability to perform a single heel rise
. Presence of a positive 'too many toes' sign
. Fixed, rigid hindfoot valgus
. Pain along the medial ankle
. Tenderness over the talonavicular joint

Correct Answer & Explanation

. Fixed, rigid hindfoot valgus

Explanation

Stage II posterior tibial tendon dysfunction is characterized by a flexible hindfoot valgus deformity. Progression to stage III is marked by the development of a fixed, rigid hindfoot deformity and subtalar arthritis.

Question 17

Topic: Midfoot & Hindfoot

Which of the following radiographic findings is the hallmark of Eichenholtz Stage 1 (developmental stage) Charcot arthropathy of the foot?

. Coalescence of bone fragments
. Subchondral osteopenia only
. Fragmentation and osseous debris
. Resolution of soft tissue swelling
. Osteophyte formation and sclerosis

Correct Answer & Explanation

. Fragmentation and osseous debris

Explanation

Eichenholtz Stage 1 is the fragmentation or developmental stage, characterized clinically by severe inflammation and radiographically by periarticular fragmentation, debris, and joint subluxation or dislocation. Stage 2 is coalescence, and Stage 3 is reconstruction/consolidation.

Question 18

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a swollen, erythematous, and warm foot with no systemic signs of infection. Radiographs show fragmentation, joint subluxation, and extensive osseous debris in the midfoot. According to the Eichenholtz classification, what is the most appropriate initial management?

. Immediate open reduction and internal fixation
. Total contact casting and strict non-weight bearing
. Intravenous antibiotics and surgical debridement
. Midfoot arthrodesis with robust hardware
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and strict non-weight bearing

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation) of Charcot arthropathy. The gold standard of initial management is immediate immobilization with a total contact cast and strict non-weight bearing until the active inflammatory phase subsides.

Question 19

Topic: Midfoot & Hindfoot
Which of the following disorders is due to a defect in anterior horn cells:
. Charcot-Marie-Tooth
. Duchenne dystrophy
. Friedreich's ataxia
. Spinal muscular atrophy
. Rett syndrome

Correct Answer & Explanation

. Spinal muscular atrophy

Explanation

Charcot-Marie-Tooth disease is due to a defect in peripheral nerves; Duchenne muscular dystrophy is due to a defect in dystrophin, affecting the muscle cell membrane; Friedreich ataxia is a degeneration of the spinocerebellar tracts. Rett syndrome is due to a defect in MECP-2 protein, affecting the brain. Only spinal muscular atrophy is due to a defect in anterior horn cells.

Question 20

Topic: Midfoot & Hindfoot
A 55-year-old patient with poorly controlled type 2 diabetes presents with a swollen, erythematous right foot. Radiographs show fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints. Which Eichenholtz stage describes these findings?
. Stage 0
. Stage I
. Stage II
. Stage III
. Stage IV

Correct Answer & Explanation

. Stage I

Explanation

Eichenholtz Stage I (Development/Fragmentation) of Charcot arthropathy is characterized by acute inflammation, bone fragmentation, joint subluxation, and debris. Stage II is coalescence, and Stage III is reconstruction.

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