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8. Foot and Ankle MCQs

Practice Set 267 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 5321

Topic: 8. Foot and Ankle

A diabetic patient with established peripheral neuropathy develops claw toe deformities and progressive thinning of the plantar fat pad beneath the metatarsal heads. This biomechanical alteration is primarily driven by the dysfunction of which of the following?

. Intrinsic foot musculature
. Extensor digitorum longus
. Tibialis anterior
. Achilles tendon
. Flexor hallucis longus

Correct Answer & Explanation

. Intrinsic foot musculature

Explanation

Diabetic motor neuropathy typically affects the intrinsic foot muscles first, leading to an intrinsic-minus foot. This results in unopposed action of the long extensors and flexors, causing claw toe deformities and distal migration of the plantar fat pad.

Question 5322

Topic: 8. Foot and Ankle

According to the International Working Group on the Diabetic Foot (IWGDF), a patient with loss of protective sensation (LOPS) and a history of a previous diabetic foot ulcer should undergo routine foot screening at which of the following intervals?

. Once every 1 to 2 years
. Once every 6 to 12 months
. Once every 3 to 6 months
. Once every 1 to 3 months
. Weekly

Correct Answer & Explanation

. Once every 1 to 3 months

Explanation

A history of a previous ulcer places a diabetic patient in IWGDF Risk Group 3. These high-risk patients require frequent screening and preventative care every 1 to 3 months.

Question 5323

Topic: 8. Foot and Ankle

When screening for diabetic sensorimotor polyneuropathy, which of the following deep tendon reflexes is typically diminished or absent earliest in the disease process?

. Patellar reflex
. Achilles reflex
. Babinski reflex
. Hamstring reflex
. Tibialis posterior reflex

Correct Answer & Explanation

. Achilles reflex

Explanation

Diabetic peripheral neuropathy progresses in a distal-to-proximal, length-dependent manner. The Achilles reflex (ankle jerk) is typically the earliest deep tendon reflex to be lost.

Question 5324

Topic: 8. Foot and Ankle

Which of the following instruments is the recommended standard for clinical screening of vibratory sensation in the diabetic foot?

. 64 Hz tuning fork
. 128 Hz tuning fork
. 256 Hz tuning fork
. 512 Hz tuning fork
. 1024 Hz tuning fork

Correct Answer & Explanation

. 128 Hz tuning fork

Explanation

The 128 Hz tuning fork is the standard clinical tool for assessing vibratory sensation in diabetic foot screening. It is conventionally applied to the bony prominence of the distal hallux.

Question 5325

Topic: 8. Foot and Ankle

When screening for loss of protective sensation (LOPS) using the 10-g Semmes-Weinstein monofilament at the 10 standard testing sites on each foot, what is the minimum number of insensate sites required to formally diagnose LOPS?

. 1
. 3
. 4
. 5
. 10

Correct Answer & Explanation

. 10

Explanation

According to standard screening guidelines, the inability to perceive the 10-g monofilament at even a single site on the foot is considered an abnormal test indicative of Loss of Protective Sensation (LOPS).

Question 5326

Topic: 8. Foot and Ankle

A 55-year-old diabetic male develops a chronic ulcer under the first metatarsal head. He has intact pulses but loss of protective sensation. Physical exam reveals restricted ankle dorsiflexion. Which of the following interventions is most effective at reducing forefoot plantar pressures to heal this ulcer?

. First metatarsophalangeal joint arthrodesis
. Tendo-Achilles lengthening
. Flexor tenotomy
. Sympathectomy
. Tibialis anterior tendon transfer

Correct Answer & Explanation

. Tendo-Achilles lengthening

Explanation

Gastrocnemius-soleus contracture (equinus) is common in diabetics due to motor neuropathy and glycation of the Achilles tendon, significantly increasing forefoot pressures. Tendo-Achilles lengthening reduces these pressures and is highly effective in promoting forefoot ulcer healing.

Question 5327

Topic: 8. Foot and Ankle

A diabetic foot ulcer is evaluated and found to be penetrating into the joint capsule. There are no clinical signs of infection, but non-invasive vascular testing reveals severe ischemia. According to the University of Texas Wound Classification System, what is the correct grade and stage for this ulcer?

. Grade 1, Stage B
. Grade 2, Stage C
. Grade 2, Stage D
. Grade 3, Stage C
. Grade 3, Stage D

Correct Answer & Explanation

. Grade 2, Stage C

Explanation

In the University of Texas system, Grade 2 indicates penetration to tendon or capsule. Stage C signifies the presence of ischemia without infection, making this a Grade 2, Stage C ulcer.

Question 5328

Topic: 8. Foot and Ankle

Current guidelines for comprehensive diabetic foot screening recommend using the 10-g monofilament test in conjunction with another modality to maximize sensitivity for detecting at-risk feet. Which of the following is most commonly recommended as the second screening modality?

. Electromyography (EMG)
. Nerve conduction velocities (NCV)
. 128 Hz tuning fork
. Sural nerve biopsy
. Magnetic resonance neurography

Correct Answer & Explanation

. 128 Hz tuning fork

Explanation

Guidelines strongly recommend combining the 10-g monofilament test with the assessment of vibration perception (using a 128 Hz tuning fork), ankle reflexes, or pinprick sensation to achieve greater sensitivity for detecting neuropathy.

Question 5329

Topic: 8. Foot and Ankle

A 58-year-old diabetic patient has normal monofilament testing but complains of burning foot pain at night. Which nerve fibers are most likely affected early in this disease process, causing these symptoms?

. Large myelinated A-beta fibers
. Small unmyelinated C fibers and A-delta fibers
. Parasympathetic postganglionic fibers
. Large myelinated A-alpha motor fibers
. Preganglionic sympathetic fibers

Correct Answer & Explanation

. Small unmyelinated C fibers and A-delta fibers

Explanation

Small-fiber neuropathy often precedes large-fiber involvement and typically presents with burning, tingling, or shooting pain, especially at night. Protective sensation, mediated by large A-beta fibers, may remain intact early in the disease.

Question 5330

Topic: 8. Foot and Ankle

Which of the following screening tools is most appropriate for evaluating large-fiber neuropathy and proprioceptive pathways in the diabetic foot?

. 128 Hz tuning fork
. Pinprick sensation test
. Hot and cold test tubes
. Ankle-brachial index
. Ipswich Touch Test

Correct Answer & Explanation

. 128 Hz tuning fork

Explanation

A 128 Hz tuning fork is the standard tool used to test vibratory sensation, which is a marker of large-fiber neuropathy. It is typically applied at the bony prominence of the dorsum of the first toe.

Question 5331

Topic: 8. Foot and Ankle

During routine screening, a diabetic patient is noted to have severe claw toe deformities. This intrinsic-minus foot presentation is primarily a consequence of which of the following?

. Autonomic sudomotor dysfunction
. Ischemic contracture of the long flexors
. Motor neuropathy affecting intrinsic foot muscles
. Loss of protective sensation (large fiber neuropathy)
. Charcot neuroarthropathy of the midfoot

Correct Answer & Explanation

. Motor neuropathy affecting intrinsic foot muscles

Explanation

Motor neuropathy causes atrophy of the intrinsic foot muscles (lumbricals and interossei), overpowering them by the extrinsic muscles. This leads to an intrinsic-minus foot characterized by claw toe deformities and increased plantar forefoot pressures.

Question 5332

Topic: 8. Foot and Ankle
A 65-year-old diabetic patient undergoes vascular screening. The ankle-brachial index (ABI) is calculated to be 1.45. What is the most appropriate next step in evaluating this patient's peripheral perfusion?
. Reassure the patient of excellent vascular flow
. Refer immediately for below-knee amputation
. Perform a Toe-Brachial Index (TBI)
. Initiate high-dose corticosteroid therapy
. Order a venous duplex ultrasound

Correct Answer & Explanation

. Perform a Toe-Brachial Index (TBI)

Explanation

An ABI greater than 1.3 in a diabetic patient typically indicates non-compressible, calcified vessels due to Mรถnckeberg's medial calcific sclerosis. A Toe-Brachial Index (TBI) should be obtained as digital arteries are less prone to calcification.

Question 5333

Topic: 8. Foot and Ankle

According to the International Working Group on the Diabetic Foot (IWGDF) risk stratification system, how frequently should a patient with a history of a previous diabetic foot ulcer (Risk Category 3) undergo professional foot screening?

. Once every 2 years
. Annually
. Every 6 to 12 months
. Every 1 to 3 months
. Only when symptoms arise

Correct Answer & Explanation

. Every 1 to 3 months

Explanation

Patients with a history of a diabetic foot ulcer or lower extremity amputation are at the highest risk for recurrence (IWGDF Risk Category 3). Guidelines strongly recommend professional screening every 1 to 3 months for this high-risk group.

Question 5334

Topic: 8. Foot and Ankle

A diabetic patient with documented LOPS presents for orthotic management. They have a rigid claw toe deformity but no active ulceration. What is the best footwear recommendation?

. Standard commercial athletic shoes
. Extra-depth shoes with custom accommodative orthotics
. Total contact cast
. Barefoot ambulation to toughen the plantar skin
. Rigid carbon-fiber ankle-foot orthosis

Correct Answer & Explanation

. Extra-depth shoes with custom accommodative orthotics

Explanation

Patients with LOPS and structural foot deformities require extra-depth footwear to accommodate the deformity. Custom-molded, accommodative orthotics are essential to redistribute peak plantar pressures and prevent tissue breakdown.

Question 5335

Topic: 8. Foot and Ankle
Infrared dermal thermometry is increasingly used in diabetic foot screening. A temperature differential of >2 degrees Celsius between homologous foot sites is most indicative of which impending condition?
. Deep vein thrombosis
. Peripheral arterial occlusion
. Localized inflammation predisposing to ulceration or Charcot event
. Small fiber peripheral neuropathy
. Venous insufficiency

Correct Answer & Explanation

. Localized inflammation predisposing to ulceration or Charcot event

Explanation

Infrared dermal thermometry detects localized temperature increases, typically defining risk as a >2 degree Celsius difference compared to the contralateral foot. This indicates impending ulceration or acute Charcot neuroarthropathy, prompting immediate activity modification.

Question 5336

Topic: 8. Foot and Ankle

Which of the following plantar sites is NOT routinely recommended as a standard target location for 10g monofilament screening?

. Plantar surface of the hallux
. First metatarsal head
. Third metatarsal head
. Fifth metatarsal head
. Base of the fifth metatarsal

Correct Answer & Explanation

. Base of the fifth metatarsal

Explanation

Routine monofilament testing sites typically include the plantar aspect of the hallux and the 1st, 3rd, and 5th metatarsal heads due to their high sub-metatarsal peak pressures. The base of the 5th metatarsal is not a primary screening site.

Question 5337

Topic: 8. Foot and Ankle

A patient with profound LOPS presents with a red, swollen, and warm right foot without any open wounds. To differentiate between an acute Charcot neuroarthropathy and a deep soft tissue infection, what simple clinical test should be performed?

. Repeat monofilament testing
. Assess deep tendon reflexes
. Elevate the affected foot for 5 to 10 minutes
. Perform a Romberg test
. Calculate the Ankle-Brachial Index

Correct Answer & Explanation

. Elevate the affected foot for 5 to 10 minutes

Explanation

Elevating the foot for 5-10 minutes usually leads to a significant decrease in erythema in acute Charcot neuroarthropathy. In contrast, erythema caused by cellulitis or deep infection typically persists despite elevation.

Question 5338

Topic: 8. Foot and Ankle

A diabetic foot screening reveals a Wagner Grade 1 ulcer under the first metatarsal head. Which biomechanical factor is most commonly responsible for shifting plantar pressures distally to the forefoot in these patients?

. Excessive subtalar pronation
. Gastrocnemius-soleus equinus contracture
. Metatarsus adductus
. Tibialis posterior tendon dysfunction
. Cavovarus deformity

Correct Answer & Explanation

. Gastrocnemius-soleus equinus contracture

Explanation

An equinus contracture (tight Achilles or gastrocnemius complex) limits ankle dorsiflexion, shifting weight-bearing forces anteriorly. This significantly increases peak plantar pressures under the metatarsal heads, directly predisposing to forefoot ulceration.

Question 5339

Topic: 8. Foot and Ankle

Transcutaneous oxygen pressure (TcPO2) is measured during a comprehensive diabetic foot assessment to predict wound healing. What TcPO2 threshold strongly indicates severe hypoxia and a high likelihood of wound healing failure?

. < 100 mmHg
. < 80 mmHg
. < 60 mmHg
. < 30 mmHg
. > 50 mmHg

Correct Answer & Explanation

. < 30 mmHg

Explanation

A TcPO2 level below 30-40 mmHg indicates severe local tissue hypoxia and is heavily associated with failure of diabetic foot ulcers to heal. Levels above 40 mmHg generally suggest sufficient perfusion for healing.

Question 5340

Topic: 8. Foot and Ankle

A patient with diabetes has documented loss of protective sensation (LOPS) but lacks peripheral arterial disease, foot deformity, and any history of foot ulceration. According to the International Working Group on the Diabetic Foot (IWGDF) risk classification, how frequently should this patient undergo a comprehensive foot examination?

. Every 1 to 3 months
. Every 3 to 6 months
. Every 6 to 12 months
. Annually
. Every 2 years

Correct Answer & Explanation

. Every 6 to 12 months

Explanation

According to IWGDF guidelines, Risk 1 (LOPS without deformity or PAD) warrants screening every 6-12 months. Risk 2 (LOPS with deformity or PAD) requires screening every 3-6 months, and Risk 3 (history of ulcer/amputation) requires screening every 1-3 months.

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