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8. Foot and Ankle MCQs

Practice Set 27 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 521

Topic: 8. Foot and Ankle

Many materials are used in the production of orthotic arch supports. Plastizote is a material commonly used either alone or in combination. The problem with this material is:

. It cannot be used in patients with neuropathy.
. It is too hard a material for use with arthritis.
. It is extremely expensive.
. It increases sweating in the foot and is not well tolerated.
. It softens and loses resilience quickly.

Correct Answer & Explanation

. It softens and loses resilience quickly.

Explanation

Plastizote is a remarkably forgiving material and accommodates well to the foot shape. It is soft, and it loses resilience or sponginess after 6 months. Therefore, plastizote is commonly used in combination with other materials for orthotic support, particularly for the patient with neuropathy.

Question 522

Topic: 8. Foot and Ankle

A 35-year-old man has experienced ankle pain for 7 years. It is associated with giving way and progressive deformity of the foot. He notices that the foot is rolling inward and is becoming flatter. The cause of his condition is:

. Tarsal coalition
. Subtalar arthritis
. Talonavicular arthritis
. Recurrent ankle sprains
. Rupture spring ligament

Correct Answer & Explanation

. Tarsal coalition

Explanation

This patient presents with ankle instability and progressively worsening flatfoot, with the hindfoot in valgus. Although a rare condition, this is caused by a talonavicular tarsal coalition, with increasing stress on the ankle likely.

Question 523

Topic: 8. Foot and Ankle

A 14-year-old boy presents for treatment of a painful foot, which has been present for 2 years. He has limited his athletic activities. He has similar symptoms in the opposite foot, although not as severe. On clinical examination, the alignment and appearance of the foot are normal; motion of the foot and ankle is good; and some discomfort is present in the sinus tarsi. Standard radiographs, of which the lateral view is presented, include anteroposterior, lateral, and oblique views. Because the diagnosis is unclear, more imaging studies are required. The next study to obtain is:

. External oblique views of the foot
. Axial views of the subtalar joint (Harris)
. Oblique views of the subtalar joint (Broden)
. Internal oblique views of the midfoot
. Inclined views of the talonavicular joint (C anale)

Correct Answer & Explanation

. Axial views of the subtalar joint (Harris)

Explanation

The radiograph demonstrates changes in the subtalar joint suggestive of a middle facet coalition. Note the sclerosis of the joint surface. Although a computed axial tomography scan may be helpful, standard axial views of the subtalar joint (Harris) taken in the plane of the joint are usually diagnostic of tarsal coalition. Motion of the subtalar joint may be normal in the adolescent with a tarsal coalition.

Question 524

Topic: 8. Foot and Ankle

The radiograph of a 22-year-old woman with ankle pain and instability is presented. She has noted this problem for 10 years, and it appears to be worsening. The opposite ankle is not symptomatic. She has not had any previous treatment for foot or ankle problems. The cause of this ankle deformity is most likely to be associated with which of the following conditions:

. Recurrent ankle instability
. C ongenital bimalleolar dysplasia
. Subtalar fusion
. Talar growth arrest
. Fibular hemimelic syndrome

Correct Answer & Explanation

. Fibular hemimelic syndrome

Explanation

This patient has a ball and socket ankle, which results from limited motion of the hindfoot during early childhood, either from extensive tarsal coalition, premature hindfoot arthrodesis, or trauma. The condition most commonly associated with a ball and socket ankle is a form of hemimelia of the fibula with lateral ray deficiencies and associated tarsal coalition of which the latter is usually extensive.

Question 525

Topic: 8. Foot and Ankle

The sustentaculum tali is the anatomic roof of which tendon:

. Posterior tibial
. Flexor digitorum longus
. Flexor digitorum brevis
. Anterior tibial
. Flexor hallucis longus

Correct Answer & Explanation

. Flexor hallucis longus

Explanation

The sustentaculum tali forms an arch under which the flexor hallucis longus passes. This is of anatomic significance when resecting middle facet tarsal coalition and performing subtalar arthrodesis.

Question 526

Topic: 8. Foot and Ankle

The nerve most likely to be at risk during surgical exposure when performing a triple arthrodesis is the:

. Sural
. Lateral cutaneous branch superficial peroneal
. Intermediate cutaneous branch superficial peroneal
. Lateral plantar
. Dorsalis pedis

Correct Answer & Explanation

. Sural

Explanation

The sural nerve has a variable path in the distal leg, but lies immediately adjacent to the peroneal tendons on the lateral side of the foot. The lateral incision used to expose the subtalar and calcaneocuboid joints is adjacent to this nerve.

Question 527

Topic: 8. Foot and Ankle

A 55-year-old man presents for treatment of pain in the Achilles tendon. This has been present for 2 years, but has suddenly become much worse. The pain is approximately 6 cm proximal to the insertion. He is unable to push off during walking and has pain when ascending stairs. C linical examination reveals thickening of the tendon, weakness of the gastrocnemius-soleus, and pain upon squeezing the Achilles tendon. The magnetic resonance image is shown. The diagnosis is:

. Xanthoma
. Degenerative tendinosis
. C hronic paratendinitis
. Acute rupture
. C hronic rupture

Correct Answer & Explanation

. Degenerative tendinosis

Explanation

The widening and thickening over a length of the tendon noted clinically and on magnetic resonance image (MRI) is diagnostic of chronic degenerative tendinosis. While paratendinitis may be present simultaneously, limited MRI changes are noted in this condition. Rupture of the tendon may occur and patients with chronic tendinosis should recognize the potential for tendon rupture.

Question 528

Topic: 8. Foot and Ankle

A patient presents for surgical correction of a ruptured Achilles tendon. He recalls injuring his ankle 1 year previously, but did not seek any medical treatment at that time. You plan to repair the tendon, and at surgery, a gap between the tendon ends is noted (Slide). The following procedure is not consistent with an acceptable outcome:

. V-Y advancement
. Flexor hallucis tendon transfer
. End-to-end repair with the foot positioned in slight equinus
. Flexor digitorum longus tendon transfer
. Fascial turn down flap from musculotendinous junction

Correct Answer & Explanation

. Fascial turn down flap from musculotendinous junction

Explanation

End-to-end repair of a chronic rupture of the Achilles tendon may not be considered if the gap is greater than 2 cm. Equinus positioning is never acceptable. Although each of the other alternatives above may be considered, each has its proponents and potential disadvantages.

Question 529

Topic: 8. Foot and Ankle

You are commencing a repair of an acute rupture of the Achilles tendon that occurred 8 days previously in a 32-year-old recreational tennis player. Fibrillation of the tendon ends is noted. The following is most important to maximize the ultimate outcome of the repair:

. Resection of the frayed tendon end, and end-to-end apposition
. Incorporation of the plantaris tendon in the repair
. Repair of the tendon with the foot in slight equinus
. Augmentation of the repair with a facial turn down flap
. Repair with the tendon ends at normal resting tension

Correct Answer & Explanation

. Repair with the tendon ends at normal resting tension

Explanation

Repair of the Achilles tendon at its normal resting length is critical. The frayed tendon ends should not be excised, since this will force a repair with the foot in equinus. The resting tension of the repair can be compared with the position of the opposite limb that should be prepared into the operative field.

Question 530

Topic: 8. Foot and Ankle

A 17-year-old patient presents for evaluation and treatment of pain in the back of her ankle. She is a ballet dancer and has noticed that for the past year, she is unable to assume the pointe position without pain. Upon clinical examination she has full range of motion, excellent strength, normal toe function, and pain with pressure in the posterior ankle. The cause of her pain is:

. Flexor hallucis longus tendonitis
. Osteochondral defect of the talus
. Anterior tibial tendonitis
. Peroneus longus tendonitis
. Os trigonum syndrome

Correct Answer & Explanation

. Os trigonum syndrome

Explanation

Posterior ankle impingement is common in ballet dancers. When in the pointe position, maximum plantar flexion of the ankle is present, and pain may occur from impingement in the posterior ankle. Flexor hallucis tendonitis may cause posterior ankle pain, but there is no evidence for this condition here.

Question 531

Topic: 8. Foot and Ankle

The structure that lies immediately medial to the bone prominence in the posterior ankle shown is the:

. Tibial nerve
. Peroneus longus
. Peroneus brevis
. Posterior tibiofibular ligament
. Flexor hallucis longus

Correct Answer & Explanation

. Flexor hallucis longus

Explanation

The os trigonum presented in the radiograph may be the cause of posterior ankle impingement. The flexor hallucis longus lies immediately medial to the os and must be protected during excision of this bone.

Question 532

Topic: 8. Foot and Ankle

A 43-year-old construction worker sustained a work-related injury to his foot 7 months ago. He was initially treated with cast immobilization and limited weight bearing. He has lateral foot pain and inability to walk comfortably. He has limited walking endurance. Upon examination, pain is present laterally along the course of the peroneal tendons, and no motion of the subtalar joint is present. The recommendation is:

. Physical therapy followed by job modification
. Shoe modification and orthotic support
. Nonsteroidal medication, and ankle foot orthoses
. Injection of the peroneal tendons with cortisone
. Subtalar arthrodesis

Correct Answer & Explanation

. Subtalar arthrodesis

Explanation

A worker who sustains a calcaneus fracture must be returned to the work force as soon as possible. Although these alternatives for treatment may be considered in the patient with limited activity and low demands, the longer the time from injury to salvage surgery with arthrodesis, the less likely it is that the injured worker will ever return to gainful employment. Therefore, subtalar arthrodesis should be performed.

Question 533

Topic: Forefoot

The structure on the side of the metatarsophalangeal joint of the second toe which is marked by the pointer is the:

. Lumbrical tendon
. Volar plate ligament
. C ollateral ligament
. Interosseous tendon
. Lateral joint capsule

Correct Answer & Explanation

. Volar plate ligament

Explanation

The structure is the volar plate ligament. This ligament may assume a pathologic role in claw toe deformity and instability of the metatarsophalangeal joint.

Question 534

Topic: 8. Foot and Ankle

A 21-year-old man presents for evaluation of high arches, which have been present his entire life. C urrently, he is experiencing some discomfort with running activities. His brother and mother have high arches. He does not recall any trauma as a child, or any other pertinent childhood musculoskeletal problems. C linical examination reveals a rigid deformity bilaterally. What structure is responsible for plantarflexion of the first metatarsal:

. Peroneus longus tendon
. Anterior tibial tendon
. Plantar fascia
. Flexor hallucis longus
. Flexor hallucis brevis

Correct Answer & Explanation

. Peroneus longus tendon

Explanation

The peroneus longus passes under the cuboid to function as a plantar flexor of the first metatarsal. It is a primary deforming force in the development of the cavus foot.

Question 535

Topic: 8. Foot and Ankle

A 22-year-old patient presents for treatment of a painful foot deformity. On examination, a flexible cavovarus deformity is present. The patient has good dorsiflexion foot strength, and eversion strength is weak. A possible tendon transfer that can be used to correct this deformity is:

. Anterior tibial to middle cuneiform
. Posterior tibial to peroneus longus
. Peroneus longus to peroneus brevis
. Flexor digitorum to posterior tibial
. Posterior tibial to lateral cuneiform

Correct Answer & Explanation

. Peroneus longus to peroneus brevis

Explanation

Transfer of the strong peroneus longus to the weak peroneus brevis tendon can be considered to improve function and strength of the cavus foot. Posterior tibial tendon transfer is not indicated because dorsiflexion strength is good. Transfer of the anterior tibial tendon is not indicated, although it is contributing to the midfoot varus.

Question 536

Topic: 8. Foot and Ankle

A 56-year-old man presents for treatment of chronic ankle pain. He has noted long-standing pain associated with activities since early adulthood. He does not have any other pertinent musculoskeletal history. C linical and radiographic examinations reveal ankle arthritis. A probable cause for this arthritis and deformity is:

. Recurrent ankle instability
. Idiopathic osteoarthritis
. Rheumatoid arthritis
. Post traumatic arthritis
. Anterior ankle impingement syndrome

Correct Answer & Explanation

. Recurrent ankle instability

Explanation

The varus ankle deformity indicates either a chronic hindfoot varus and hindfoot cavus, or chronic recurrent instability of the ankle. If associated with rotatory instability, anterior impingement and eventual arthritis will occur.

Question 537

Topic: 8. Foot and Ankle

This muscle group demonstrates electrical activity at the time of heel strike:

. Anterior compartment
. Intrinsic foot muscles
. Lateral compartment
. Deep posterior compartment
. Medial compartment

Correct Answer & Explanation

. Anterior compartment

Explanation

The anterior muscle compartment, in particular, the anterior tibialis, is active during heel strike, to maintain foot dorsiflexion, and prevent foot drop during heel strike.

Question 538

Topic: 8. Foot and Ankle

A 7-year-old boy presents with bilateral high arches. His parents report that they are having difficulty finding shoes that comfortably fit him. The patient denies any foot pain. The father had similar problems with his feet and was diagnosed with a mild neurologic condition. On exam, the child has bilateral pes cavus with a supple hindfoot. Treatment of the feet at this time should consist of:

. Soft tissue procedures alone
. Soft tissue procedures and calcaneal osteotomy
. Triple arthrodesis
. Bracing
. Observation

Correct Answer & Explanation

. Soft tissue procedures alone

Explanation

The child has a supple deformity secondary to C harcot-Marie-Tooth disease that will progress if untreated. Soft tissue procedures, which may consist of claw toe correction, plantar release, and possibly tendon transfer, are recommended for children younger than 8 years old who have a supple hindfoot. The calcaneal osteotomy is reserved for patients with a rigid hindfoot. Triple arthrodesis is a salvage procedure reserved for a fixed, painful foot in older children. Bracing and observation are not preferred options due to the progressive nature of the disease, and the lack of ability to apply corrective forces to the foot in cavus.

Question 539

Topic: 8. Foot and Ankle
A 50-year-old woman presents with pain in the second toe. She describes this as burning and notes swelling of the toe for the past month. Upon examination, there appears to be instability of the toe with a positive dorsal subluxation stress test. The anatomic structure which is responsible for this patient's symptoms is:
. The deep transverse metatarsal ligament
. The second common digital nerve
. The medial collateral ligament of the second metatarsophalangeal joint
. The plantar plate
. The flexor digitorum brevis

Correct Answer & Explanation

. The plantar plate

Explanation

This patient describes swelling of the toe, which is not associated with an interdigital neuroma. The pain, swelling, and clinical findings suggest a rupture of the plantar plate with early instability and second metatarsophalangeal synovitis.

Question 540

Topic: 8. Foot and Ankle
A 15-year-old boy presents with a 2-year history of pain in the foot associated with a sense of stiffness and of giving way of the ankle. Upon examination, pain in the sinus tarsi, slightly decreased subtalar motion, and normal ankle motion with no apparent instability are noted. A lateral foot radiograph is presented. The next radiograph to obtain is:
. Anteroposterior view of the ankle
. Inversion stress view of the ankle
. Axial view of the hindfoot
. 30° internal oblique view of the foot
. Anteroposterior view of the foot

Correct Answer & Explanation

. Axial view of the hindfoot

Explanation

This child presents with symptoms suggestive of a tarsal coalition. There is stiffness, and symptoms of ankle discomfort or instability. On the lateral radiograph, there is consolidation of trabeculation under the posterior facet in the shape of a 'C', a typical finding of a middle facet coalition, which should be investigated further with an axial view of the subtalar joint (Harris).

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