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8. Foot and Ankle MCQs

Practice Set 2 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 21

Topic: 8. Foot and Ankle

Unlike many flexor tendons in the hand and wrist, the Achilles tendon lacks a true synovial sheath. Instead, it is enveloped by a layer of loose connective tissue. What is the primary function of this structure?

. To secrete synovial fluid for frictionless lubrication
. To provide the primary extrinsic vascular supply to the tendon
. To anchor the tendon firmly to the underlying bone
. To prevent medial-lateral tendon subluxation
. To produce type I collagen during the inflammatory phase of repair

Correct Answer & Explanation

. To provide the primary extrinsic vascular supply to the tendon

Explanation

The Achilles tendon is covered by a paratenon, a highly vascularized layer of loose connective tissue that stretches with tendon movement and provides its primary extrinsic blood supply.

Question 22

Topic: 8. Foot and Ankle

A patient presents with chronic insertional Achilles pain. The examiner passively dorsiflexes the ankle with the knee extended, noting 0 degrees of dorsiflexion. When the knee is flexed to 90 degrees, ankle dorsiflexion increases to 15 degrees. What does this physical examination finding indicate?

. Isolated soleus contracture
. Combined gastrocnemius and soleus contracture
. Isolated gastrocnemius contracture
. Anterior ankle bony impingement
. Tibialis posterior tendon dysfunction

Correct Answer & Explanation

. Isolated gastrocnemius contracture

Explanation

The Silfverskiold test differentiates isolated gastrocnemius contracture from combined gastrosoleus contracture. Improvement of ankle dorsiflexion with knee flexion indicates an isolated gastrocnemius contracture since the gastrocnemius crosses the knee joint.

Question 23

Topic: 8. Foot and Ankle

A 35-year-old male presents with bilateral, painless, nodular swelling of the Achilles tendons. He has a strong family history of premature coronary artery disease. A core biopsy of the mass would most likely reveal which of the following?

. Urate crystals with negative birefringence
. Lipid-laden macrophages and cholesterol clefts
. Calcium hydroxyapatite deposition
. Amyloid fibrils with apple-green birefringence under polarized light
. Granulation tissue with caseating granulomas

Correct Answer & Explanation

. Lipid-laden macrophages and cholesterol clefts

Explanation

Achilles tendon xanthomas are painless nodular lesions highly associated with familial hypercholesterolemia. Histology typically demonstrates cholesterol clefts and lipid-laden macrophages (foam cells).

Question 24

Topic: 8. Foot and Ankle

A 50-year-old patient presents with a neglected Achilles tendon rupture sustained 4 months ago. MRI reveals a defect of 7 cm between the retracted tendon ends. Which of the following is the most appropriate surgical reconstruction option?

. Direct end-to-end repair with heavy non-absorbable suture
. V-Y tendinous flap lengthening of the gastrocnemius aponeurosis alone
. FHL tendon transfer with or without a fascial turndown flap
. Isolated gastrocnemius recession
. Bone-patellar tendon-bone allograft reconstruction

Correct Answer & Explanation

. FHL tendon transfer with or without a fascial turndown flap

Explanation

Chronic Achilles ruptures with large gaps (greater than 5-6 cm) cannot be closed primarily or with simple V-Y advancement alone. They require a V-Y advancement combined with a turndown flap or a tendon transfer (such as the FHL) for adequate bridging and functional strength.

Question 25

Topic: 8. Foot and Ankle

When performing an FHL tendon transfer for a massive Achilles tendon defect, harvesting the FHL requires careful dissection to avoid injury to which closely associated structure at the level of the master knot of Henry?

. Medial plantar nerve
. Flexor digitorum longus (FDL) tendon
. Posterior tibial artery
. Tibialis anterior tendon
. Sural nerve

Correct Answer & Explanation

. Flexor digitorum longus (FDL) tendon

Explanation

The master knot of Henry is located in the plantar midfoot where the FHL crosses dorsal to the FDL tendon. Careful dissection and separation at this decussation are needed to harvest the FHL without inadvertently cutting the FDL.

Question 26

Topic: 8. Foot and Ankle

Which of the following anatomic and pathologic triads correctly defines Haglund's syndrome?

. Insertional Achilles tendinopathy, retrocalcaneal bursitis, and a prominent posterosuperior calcaneal tuberosity
. Non-insertional Achilles tendinopathy, plantar fasciitis, and an inferior calcaneal heel spur
. Sever's disease, retroachilles bursitis, and a symptomatic os trigonum
. Paratenonitis, mucoid degeneration of the tendon, and sural neuritis
. Subtalar arthritis, retrocalcaneal bursitis, and an acute Achilles rupture

Correct Answer & Explanation

. Insertional Achilles tendinopathy, retrocalcaneal bursitis, and a prominent posterosuperior calcaneal tuberosity

Explanation

Haglund's syndrome is classically characterized by the triad of a prominent posterosuperior calcaneal tuberosity (Haglund's deformity), retrocalcaneal bursitis, and insertional Achilles tendinopathy.

Question 27

Topic: 8. Foot and Ankle

A 45-year-old male undergoes percutaneous repair of an acute Achilles tendon rupture. Postoperatively, he complains of numbness and tingling along the lateral border of his foot. Which of the following nerves was most likely injured during the procedure?

. Sural nerve
. Superficial peroneal nerve
. Deep peroneal nerve
. Medial plantar nerve
. Saphenous nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve crosses the lateral border of the Achilles tendon approximately 10 cm proximal to its insertion. It is at highest risk of iatrogenic injury during percutaneous Achilles tendon repair.

Question 28

Topic: 8. Foot and Ankle

A 55-year-old patient with chronic insertional Achilles tendinosis undergoes surgical debridement. During the procedure, the surgeon notes that 60% of the tendon must be excised to remove all degenerative tissue. What is the most appropriate next step in management?

. Primary repair with side-to-side suturing
. Tendon transfer using the flexor digitorum longus
. Tendon transfer using the flexor hallucis longus
. Gastrocnemius recession alone
. V-Y tendon advancement

Correct Answer & Explanation

. Tendon transfer using the flexor hallucis longus

Explanation

When more than 50% of the Achilles tendon is debrided at its insertion, augmentation is recommended to restore plantarflexion strength. Flexor hallucis longus (FHL) transfer is the gold standard due to its strength, axis of pull, and anatomical proximity.

Question 29

Topic: 8. Foot and Ankle

Non-insertional Achilles tendinopathy typically occurs in a poorly vascularized 'watershed' region. This region is located approximately how far proximal to the calcaneal insertion?

. 0 to 1 cm
. 2 to 6 cm
. 7 to 10 cm
. 10 to 15 cm
. At the musculotendinous junction

Correct Answer & Explanation

. 2 to 6 cm

Explanation

The watershed area of the Achilles tendon is located 2 to 6 cm proximal to the calcaneal insertion. This relative hypovascularity contributes to the pathogenesis of non-insertional tendinosis and increases the risk of rupture.

Question 30

Topic: 8. Foot and Ankle

A 35-year-old male runner presents with acute posterior heel pain and weakness following a sudden push-off mechanism. The clinical examination finding shown in the image is expected to be positive. Which of the following is true regarding conservative management of this condition?

. It is contraindicated in patients older than 30 years.
. It involves immediate rigid immobilization in maximal dorsiflexion.
. Early functional rehabilitation protocols result in re-rupture rates comparable to surgical repair.
. It carries a significantly higher risk of sural nerve injury than percutaneous repair.
. It always results in severe long-term plantarflexion weakness compared to surgery.

Correct Answer & Explanation

. Early functional rehabilitation protocols result in re-rupture rates comparable to surgical repair.

Explanation

The condition is an acute Achilles tendon rupture. Recent literature demonstrates that non-operative management utilizing an early functional rehabilitation protocol has re-rupture rates and functional outcomes similar to operative repair, while avoiding wound complications.

Question 31

Topic: 8. Foot and Ankle

During physical examination for equinus contracture, a patient demonstrates 0 degrees of ankle dorsiflexion with the knee extended, and 15 degrees of dorsiflexion with the knee flexed to 90 degrees. What is the most appropriate surgical intervention if conservative measures fail?

. Tendo-Achilles lengthening (TAL)
. Gastrocnemius recession
. Anterior tibial tendon transfer
. Soleus aponeurosis release
. Tibialis posterior lengthening

Correct Answer & Explanation

. Gastrocnemius recession

Explanation

The Silfverskiold test differentiates isolated gastrocnemius contracture from a combined gastrosoleus contracture. Improvement in dorsiflexion with knee flexion indicates an isolated gastrocnemius contracture, which is best treated with a gastrocnemius recession.

Question 32

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 33

Topic: 8. Foot and Ankle

A 25-year-old skier sustains an acute dorsiflexion and eversion injury to the ankle, resulting in posterolateral ankle pain and a snapping sensation behind the lateral malleolus. Disruption of which of the following structures is most likely responsible for these symptoms?

. Inferior extensor retinaculum
. Superior peroneal retinaculum
. Calcaneofibular ligament
. Posterior talofibular ligament
. Flexor retinaculum

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

The superior peroneal retinaculum (SPR) stabilizes the peroneal tendons in the retromalleolar groove. Disruption of the SPR due to forced dorsiflexion and eversion leads to peroneal tendon subluxation.

Question 34

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 35

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 36

Topic: 8. Foot and Ankle

A 22-year-old professional ballet dancer complains of posterior ankle pain when assuming the 'en pointe' position. Physical examination reveals tenderness posteromedially and triggering of the great toe during active range of motion. What is the most likely diagnosis?

. Posterior tibial tendinitis
. Achilles tendinopathy
. Flexor hallucis longus (FHL) tendinitis
. Peroneal tendon subluxation
. Tarsal tunnel syndrome

Correct Answer & Explanation

. Flexor hallucis longus (FHL) tendinitis

Explanation

FHL tendinitis (often termed 'dancer's tendinitis') classically presents with posteromedial ankle pain, especially in extreme plantarflexion (en pointe). Stenosing tenosynovitis of the FHL behind the medial malleolus can cause triggering of the hallux.

Question 37

Topic: 8. Foot and Ankle

A patient with a chronic Achilles tendon rupture presents with a palpable gap of 6 cm. What is the most appropriate reconstructive option?

. End-to-end repair with heavy non-absorbable sutures
. V-Y tendon advancement of the gastrocnemius aponeurosis
. Flexor hallucis longus (FHL) transfer with or without V-Y advancement
. Percutaneous Achilles tendon repair
. Gastrocnemius recession

Correct Answer & Explanation

. Flexor hallucis longus (FHL) transfer with or without V-Y advancement

Explanation

For chronic Achilles tendon defects >5 cm, primary repair or simple V-Y advancement is usually insufficient. An FHL tendon transfer is indicated to bridge the gap and restore plantarflexion strength, often combined with a turndown flap or V-Y advancement.

Question 38

Topic: 8. Foot and Ankle

A 60-year-old male is diagnosed with an acute Achilles tendon rupture. He has a history of a recent respiratory infection treated with an antibiotic. Which class of antibiotics is most strongly associated with an increased risk of Achilles tendon rupture?

. Macrolides
. Cephalosporins
. Fluoroquinolones
. Aminoglycosides
. Tetracyclines

Correct Answer & Explanation

. Fluoroquinolones

Explanation

Fluoroquinolones (e.g., ciprofloxacin) are heavily associated with tendinopathy and tendon rupture, particularly in the Achilles tendon. The risk is significantly increased in older patients and those concurrently taking corticosteroids.

Question 39

Topic: 8. Foot and Ankle

In the surgical management of Haglund's syndrome, a Zadek osteotomy is sometimes performed. What is the primary anatomical alteration achieved by this procedure?

. Medialization of the calcaneal tuberosity
. Plantarflexion of the first metatarsal
. Dorsal closing wedge of the calcaneus to anteriorly tilt the tuberosity
. Lateral displacement of the calcaneus
. Excision of the os trigonum

Correct Answer & Explanation

. Dorsal closing wedge of the calcaneus to anteriorly tilt the tuberosity

Explanation

A Zadek (or Keck and Kelly) osteotomy is a dorsal closing-wedge osteotomy of the calcaneus. It anteriorly tilts the posterosuperior tuberosity, relieving pressure on the Achilles tendon insertion without requiring direct detachment of the tendon.

Question 40

Topic: 8. Foot and Ankle

When performing a minimally invasive or percutaneous Achilles tendon repair, the sural nerve is at greatest risk of iatrogenic injury. At what approximate distance proximal to the calcaneal insertion does the sural nerve typically cross the lateral border of the Achilles tendon?

. 2 to 3 cm
. 5 to 6 cm
. 9 to 10 cm
. 12 to 14 cm
. 15 to 16 cm

Correct Answer & Explanation

. 9 to 10 cm

Explanation

The sural nerve typically crosses the lateral border of the Achilles tendon approximately 9.8 cm proximal to its calcaneal insertion. Care must be taken during percutaneous repairs to avoid nerve entrapment or transection in this region.

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