Menu

8. Foot and Ankle MCQs

Practice Set 1 of 353

This practice set contains high-yield board review questions covering key concepts in 8. Foot and Ankle. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 1

Topic: 8. Foot and Ankle

Histology of chronic Achilles tendinosis DOES NOT reveal which of the following:

. Abnormal fiber structure
. Focal hypercellularity
. Vascular proliferation
. Abundant inflammatory cells
. All of the above are noted

Correct Answer & Explanation

. All of the above are noted

Explanation

Histological analysis of Achilles tedinosis has revealed abnormal fiber structure, focal hypercellularity, and vascular proliferation. Inflammatory cells are not present in patients with chronic Achilles tendinosis.

Question 2

Topic: 8. Foot and Ankle
Initial management of a symptomatic Haglund's deformity in a runner consists of:
. Intratendinous steroid injection
. Debridement of the tendon
. Excision of the posterosuperior calcaneal prominence
. Heel lift and soft shoe counter
. A firm heel counter and medial heel wedge

Correct Answer & Explanation

. Heel lift and soft shoe counter

Explanation

Haglund's deformity is characterized by a prominence about the posterosuperior calcaneus that can lead to retrocalcaneal bursitis and Achilles tendon injury just proximal to its insertion. The initial treatment involves relieving pressure from the affected area with a heel lift and soft heel counter. Resistant cases may benefit from excision of the prominence and debridement of the bursa and tendon.

Question 3

Topic: 8. Foot and Ankle

Which of the following is not consistent with a complete rupture of the Achilles tendon:

. A palpable defect 3 cm to 4 cm proximal to the Achilles insertion
. Ability to plantarflex the foot against gravity
. Sensation of being kicked in the calf
. Plantarflexion of the foot with the Thompson test
. No previous symptoms of Achilles related pain

Correct Answer & Explanation

. Sensation of being kicked in the calf

Explanation

Patients who sustain an Achilles tendon rupture will often feel as if they were kicked in the back of the leg. They experience the sudden onset of pain and may present with a palpable defect. The patients may note plantarflexion weakness but may demonstrate active plantarflexion of the foot as a result of other muscles that cross posterior to the ankle such as the flexor hallucis longus and tibialis posterior muscles. The Thompson test (midcalf squeeze) will typically illicit no plantarflexion of the foot.

Question 4

Topic: 8. Foot and Ankle

Which of the following physical examination tests is considered the most sensitive for diagnosing an acute Achilles tendon rupture?

. Thompson test
. Matles test
. O'Brien needle test
. Copeland test
. Silfverskiold test

Correct Answer & Explanation

. Matles test

Explanation

The Matles test, which involves observing the resting ankle position with the patient prone and knees flexed to 90 degrees, has been shown to be the most sensitive test for acute Achilles ruptures. The affected ankle will rest in neutral or dorsiflexion, losing its normal resting equinus.

Question 5

Topic: 8. Foot and Ankle

The blood supply to the Achilles tendon is most precarious in its 'watershed' region, predisposing it to tendinosis and rupture. Where is this hypovascular region typically located relative to the calcaneal insertion?

. At the exact calcaneal insertion
. 2 to 6 cm proximal to the insertion
. 8 to 10 cm proximal to the insertion
. At the musculotendinous junction
. It is uniformly vascularized throughout

Correct Answer & Explanation

. 2 to 6 cm proximal to the insertion

Explanation

The Achilles tendon has a hypovascular 'watershed' region located roughly 2 to 6 cm proximal to its insertion on the calcaneus. This area is supplied primarily by the paratenon, making it uniquely susceptible to degeneration.

Question 6

Topic: 8. Foot and Ankle

A 40-year-old man undergoes percutaneous repair of an acute Achilles tendon rupture using a specific jig system. Postoperatively, he complains of numbness along the lateral aspect of his foot. Which nerve was most likely injured during the procedure, and where does it typically cross the lateral border of the Achilles tendon?

. Sural nerve; 10 cm proximal to the insertion
. Sural nerve; 2 cm proximal to the insertion
. Superficial peroneal nerve; 10 cm proximal to the insertion
. Medial calcaneal nerve; 5 cm proximal to the insertion
. Tibial nerve; at the musculotendinous junction

Correct Answer & Explanation

. Sural nerve; 10 cm proximal to the insertion

Explanation

The sural nerve is at high risk during percutaneous Achilles repair. It typically crosses the lateral border of the Achilles tendon approximately 10 cm (range 9-12 cm) proximal to its calcaneal insertion.

Question 7

Topic: 8. Foot and Ankle

A 32-year-old active patient with an acute Achilles tendon rupture is discussing nonoperative versus operative management. Based on modern high-level evidence utilizing early functional rehabilitation protocols, which of the following is true regarding clinical outcomes?

. Operative treatment has a significantly lower re-rupture rate when functional rehabilitation is used in both groups.
. Nonoperative treatment with functional bracing has a similar re-rupture rate to operative management.
. Operative treatment results in significantly greater plantarflexion strength at 2 years.
. Nonoperative treatment has a higher rate of deep infection and sural neuritis.
. Nonoperative treatment requires rigid non-weight-bearing cast immobilization for at least 8 weeks.

Correct Answer & Explanation

. Nonoperative treatment with functional bracing has a similar re-rupture rate to operative management.

Explanation

Recent randomized controlled trials have shown that when early functional rehabilitation protocols are employed, the re-rupture rates between nonoperative and operative management of Achilles ruptures are essentially similar. Operative treatment, however, carries higher risks of wound complications.

Question 8

Topic: 8. Foot and Ankle
A 48-year-old patient presents with chronic Achilles tendinosis. Histological evaluation of the diseased tendon would most likely demonstrate which of the following findings when compared to a healthy, normal tendon?
. Increased ratio of Type I to Type III collagen
. Abundant inflammatory cells with prominent neutrophils
. Decreased ground substance and mucopolysaccharides
. Disorganized collagen bundles, neovascularization, and increased Type III collagen
. Uniformly aligned parallel collagen fibers with increased tenocyte apoptosis

Correct Answer & Explanation

. Disorganized collagen bundles, neovascularization, and increased Type III collagen

Explanation

Achilles tendinosis is characterized as a degenerative, non-inflammatory process. Histology shows disorganized collagen fibers, mucoid degeneration, neovascularization, hypercellularity, and a higher ratio of Type III to Type I collagen.

Question 9

Topic: 8. Foot and Ankle

A patient with severe insertional Achilles tendinopathy is scheduled for debridement and FHL transfer. If the surgeon harvests the FHL at the level of the midfoot, they must identify the Master Knot of Henry. Which of the following accurately describes this anatomic landmark?

. The crossing of the FHL dorsal (deep) to the FDL
. The crossing of the FDL dorsal (deep) to the FHL
. The bifurcation of the tibial nerve into medial and lateral plantar nerves
. The crossing of the posterior tibial tendon dorsal to the FDL
. The point where the sural nerve crosses the Achilles tendon

Correct Answer & Explanation

. The crossing of the FHL dorsal (deep) to the FDL

Explanation

The Master Knot of Henry is located in the plantar midfoot where the Flexor Hallucis Longus (FHL) tendon crosses dorsal (deep) to the Flexor Digitorum Longus (FDL) tendon. Fibrous slip connections between the two tendons are routinely found here.

Question 10

Topic: 8. Foot and Ankle

A 35-year-old weekend warrior sustains an acute injury resulting in severe posterior heel pain.

To confirm an Achilles tendon rupture, the O'Brien needle test is performed. A needle is inserted 10 cm proximal to the calcaneal insertion. What is the expected movement of the needle hub during passive dorsiflexion of the foot if the tendon is completely ruptured distal to the needle?

. It tilts proximally
. It tilts distally
. It rotates medially
. It rotates laterally
. It does not move significantly

Correct Answer & Explanation

. It does not move significantly

Explanation

In the O'Brien needle test, a needle is placed in the tendon proximal to the suspected rupture. If the tendon is completely ruptured distal to the needle, passive dorsiflexion fails to pull the proximal stump, and the needle hub will not move significantly.

Question 11

Topic: 8. Foot and Ankle

Which of the following classes of antibiotics is a well-established risk factor for spontaneous Achilles tendon rupture, especially when used concurrently with oral corticosteroids?

. Amoxicillin
. Fluoroquinolones
. Tetracyclines
. Macrolides
. Aminoglycosides

Correct Answer & Explanation

. Fluoroquinolones

Explanation

Fluoroquinolones (such as ciprofloxacin and levofloxacin) are known to increase the risk of Achilles tendinopathy and spontaneous rupture. This risk is compounded in older adults and those concurrently taking systemic corticosteroids.

Question 12

Topic: 8. Foot and Ankle

A 60-year-old male presents with a neglected Achilles tendon rupture that occurred 3 months ago. MRI demonstrates a 6 cm gap between the tendon ends. What is the most appropriate surgical management for a defect of this size?

. End-to-end repair with heavy non-absorbable suture
. Percutaneous repair with a jig system
. V-Y tendon advancement of the gastrocnemius aponeurosis combined with FHL transfer
. Isolated gastrocnemius recession
. Excision of the proximal stump and primary repair to the calcaneus

Correct Answer & Explanation

. V-Y tendon advancement of the gastrocnemius aponeurosis combined with FHL transfer

Explanation

Chronic Achilles ruptures with large gaps (typically >5 cm) cannot be approximated with primary repair alone. They require a combination of V-Y advancement (or turndown flaps) and structural augmentation, typically using the FHL tendon.

Question 13

Topic: 8. Foot and Ankle

A 55-year-old active man presents with chronic insertional Achilles tendinopathy refractory to 6 months of conservative care. Intraoperatively, extensive calcific tendinosis is noted, and thorough debridement requires excision of 60% of the tendon insertion. What is the most appropriate next step in management?

. Primary repair with suture anchors alone
. Flexor hallucis longus (FHL) tendon transfer
. Flexor digitorum longus (FDL) tendon transfer
. Peroneus brevis tendon transfer
. V-Y tendon lengthening

Correct Answer & Explanation

. Flexor hallucis longus (FHL) tendon transfer

Explanation

When debridement of the Achilles tendon requires excision of greater than 50% of its insertion, augmentation with a tendon transfer (typically the FHL) is recommended to restore plantarflexion strength and prevent rupture.

Question 14

Topic: 8. Foot and Ankle
Which of the following best describes the histologic findings characteristically seen in chronic non-insertional Achilles tendinosis?
. Predominance of type I collagen fibers
. Presence of acute inflammatory cells and neutrophils
. Disorientation of collagen fibers with mucoid degeneration
. Abundant synovial tissue hypertrophy
. Granulomatous inflammation with multinucleated giant cells

Correct Answer & Explanation

. Disorientation of collagen fibers with mucoid degeneration

Explanation

Tendinosis is a degenerative, non-inflammatory process characterized by disorganized collagen fibers, mucoid/myxoid degeneration, increased neovascularization, and a shift from type I to type III collagen.

Question 15

Topic: 8. Foot and Ankle

During a percutaneous or minimally invasive repair of an acute Achilles tendon rupture, the sural nerve is most at risk of iatrogenic injury at which location relative to the tendon insertion?

. Medial to the tendon at the level of the insertion
. Lateral to the tendon 10 cm proximal to the insertion
. Directly anterior to the tendon within Kager's fat pad
. Crossing from medial to lateral 5 cm proximal to the insertion
. Running midline within the superficial paratenon

Correct Answer & Explanation

. Lateral to the tendon 10 cm proximal to the insertion

Explanation

The sural nerve courses distally along the posterolateral aspect of the calf, typically crossing the lateral border of the Achilles tendon approximately 10 cm proximal to its calcaneal insertion.

Question 16

Topic: 8. Foot and Ankle

A 60-year-old patient sustains an Achilles tendon rupture while taking levofloxacin for pneumonia. What is the proposed mechanism by which fluoroquinolones increase the risk of tendon rupture?

. Direct inhibition of tenocyte DNA gyrase causing cell lysis
. Inhibition of type I collagen cross-linking by lysyl oxidase
. Upregulation of matrix metalloproteinases (MMPs) leading to accelerated collagen degradation
. Ischemic necrosis secondary to drug-induced microvascular thrombosis
. Intracellular urate crystal deposition within the paratenon

Correct Answer & Explanation

. Upregulation of matrix metalloproteinases (MMPs) leading to accelerated collagen degradation

Explanation

Fluoroquinolones are highly toxic to tenocytes and are thought to cause tendinopathy by upregulating matrix metalloproteinases (MMPs) and inducing apoptosis, leading to rapid degradation of the tendon matrix.

Question 17

Topic: 8. Foot and Ankle

A 42-year-old recreational basketball player complains of chronic pain 4 cm proximal to the Achilles tendon insertion. This specific "watershed" zone is predisposed to tendinopathy primarily due to poor blood supply originating from which vessel?

. Posterior tibial artery
. Peroneal artery
. Anterior tibial artery
. Sural artery
. Medial plantar artery

Correct Answer & Explanation

. Peroneal artery

Explanation

The watershed area 2 to 6 cm proximal to the Achilles insertion has a precarious blood supply. The predominant extrinsic blood supply to the paratenon in this region is derived from the peroneal artery.

Question 18

Topic: 8. Foot and Ankle

A 28-year-old female runner presents with posterior heel pain and a palpable bony prominence lateral to the Achilles insertion. She has failed 3 weeks of rest. What is the most appropriate next step in the conservative management of her suspected Haglund's syndrome?

. Corticosteroid injection directly into the Achilles tendon
. Surgical excision of the posterosuperior calcaneal tuberosity
. Open retrocalcaneal bursectomy
. Heel lift, physical therapy, and open-backed shoes
. Extracorporeal shockwave therapy directly over the calcaneus

Correct Answer & Explanation

. Heel lift, physical therapy, and open-backed shoes

Explanation

Initial conservative management of Haglund's deformity includes shoe wear modification (open-backed shoes), heel lifts to decrease tendon tension, and physical therapy. Direct intratendinous corticosteroid injections are contraindicated due to the high risk of rupture.

Question 19

Topic: 8. Foot and Ankle

A 45-year-old man presents with sudden posterior ankle pain after lunging for a tennis ball. Clinical examination reveals a positive Thompson test. A lateral radiograph is obtained.

Which radiographic sign on a lateral ankle X-ray is most indicative of an acute Achilles tendon rupture?

. Obliteration of Kager's fat pad triangle
. Decreased Bohler's angle
. Increased lateral clear space
. Presence of a prominent os trigonum
. Calcification of the plantar fascia origin

Correct Answer & Explanation

. Obliteration of Kager's fat pad triangle

Explanation

Obliteration or increased radiodensity within Kager's fat pad triangle on a lateral radiograph strongly suggests an Achilles tendon rupture or severe hemorrhage and edema in the retrocalcaneal space.

Question 20

Topic: 8. Foot and Ankle

A 10-year-old boy who plays competitive soccer presents with bilateral posterior heel pain that worsens after practice. Examination reveals point tenderness over the calcaneal apophysis but no swelling or erythema. The Achilles tendon is intact. What is the most appropriate initial management?

. Short leg cast immobilization for 6 weeks
. Surgical excision of the unfused apophysis
. Activity modification, heel cups, and calf stretching
. MRI of the ankle to rule out osteomyelitis
. Corticosteroid injection of the retrocalcaneal bursa

Correct Answer & Explanation

. Activity modification, heel cups, and calf stretching

Explanation

Calcaneal apophysitis (Sever's disease) is a self-limiting traction apophysitis in active children. First-line treatment consists of activity modification, heel cushions/cups, and stretching of the gastrocnemius-soleus complex.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page