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8. Foot and Ankle MCQs

Practice Set 272 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 5421

Topic: 8. Foot and Ankle

Which of the following is the most important radiographic measurement for assessing the severity of hallux valgus?

. Intermetatarsal angle (IMA)
. Hallux valgus angle (HVA)
. Distal metatarsal articular angle (DMAA)
. Tibial sesamoid position
. Talar tilt

Correct Answer & Explanation

. Hallux valgus angle (HVA)

Explanation

The Hallux Valgus Angle (HVA) and the Intermetatarsal Angle (IMA) are the two most important radiographic measurements for assessing the severity of hallux valgus. The HVA specifically measures the degree of lateral deviation of the great toe, while the IMA measures the angle between the first and second metatarsals, reflecting the splayfoot deformity. DMAA assesses joint congruity. Tibial sesamoid position reflects subluxation of the sesamoids, which accompanies the deformity. Talar tilt is for ankle stability.

Question 5422

Topic: Midfoot & Hindfoot

Which of the following is the most common cause of painful pes planus (flatfoot) in an adult?

. Congenital pes planus
. Ligamentous laxity
. Posterior tibial tendon dysfunction (PTTD)
. Tarsal coalition
. Accessory navicular

Correct Answer & Explanation

. Posterior tibial tendon dysfunction (PTTD)

Explanation

Posterior tibial tendon dysfunction (PTTD), often progressing to adult acquired flatfoot deformity, is the most common cause of painful pes planus in adults. It results from a progressive attenuation and eventual failure of the posterior tibial tendon, leading to collapse of the medial longitudinal arch. While congenital pes planus, ligamentous laxity, tarsal coalition, and accessory navicular can cause flatfoot, PTTD is the predominant cause of adult-onset painful progressive flatfoot.

Question 5423

Topic: 8. Foot and Ankle

A 45-year-old "weekend warrior" hears a loud "pop" in his left ankle while playing tennis. He experiences sudden sharp pain and can no longer push off on his toes. On examination, a palpable gap is noted in the Achilles tendon, and he has a positive Thompson test. What is the MOST appropriate management for this acute injury in an active individual?

. Immobilization in a walking boot with early weight-bearing
. Open surgical repair of the Achilles tendon
. Physical therapy focusing on strengthening exercises
. Non-weight-bearing cast immobilization for 6 weeks
. Corticosteroid injection into the tendon rupture site

Correct Answer & Explanation

. Open surgical repair of the Achilles tendon

Explanation

Acute Achilles tendon rupture in an active individual is typically managed with surgical repair to restore strength and reduce the risk of re-rupture. While non-operative treatment can be considered for less active individuals or those with significant comorbidities, surgical repair offers better functional outcomes and a lower re-rupture rate in this demographic. Immobilization and PT alone are less effective for complete ruptures. Corticosteroid injections are contraindicated as they weaken tendons and increase rupture risk.

Question 5424

Topic: 8. Foot and Ankle

A 50-year-old female presents with a painful bunion deformity. Examination reveals a lateral deviation of the great toe and medial prominence of the first metatarsal head. What is the primary deformity that characterizes hallux valgus?

. Excessive pronation of the foot
. Splaying of the lesser toes
. Adduction of the first metatarsal and abduction of the hallux
. Rigid hammertoe deformity of the second toe
. Plantarflexion of the first metatarsal

Correct Answer & Explanation

. Adduction of the first metatarsal and abduction of the hallux

Explanation

Hallux valgus is primarily characterized by adduction (varus) of the first metatarsal and abduction (valgus) of the hallux (great toe) at the metatarsophalangeal (MTP) joint, leading to the prominent bunion deformity. While other foot deformities may coexist, these are the fundamental angular deformities. Excessive pronation can be associated, but it's not the primary deformity.

Question 5425

Topic: 8. Foot and Ankle

What is the primary goal of non-surgical management for Achilles tendon rupture?

. Immediate full return to activity
. Prevent re-rupture through surgical repair
. Allow tendon healing in a shortened position
. Allow tendon healing in a controlled, lengthened position
. Strengthen surrounding muscles to compensate for the rupture

Correct Answer & Explanation

. Allow tendon healing in a controlled, lengthened position

Explanation

The primary goal of non-surgical management for Achilles tendon rupture (often performed with functional bracing and early range of motion) is to allow the tendon to heal in a controlled, slightly lengthened position, which minimizes the risk of re-rupture and optimizes functional recovery. The tendon needs to heal, and a cast maintaining equinus initially, followed by gradual dorsiflexion, is often used. Immediate full return to activity is unsafe. Surgical repair is a different treatment modality. Allowing healing in a shortened position is not ideal for function.

Question 5426

Topic: 8. Foot and Ankle
A 45-year-old male, a keen recreational basketball player, complains of progressive pain, swelling, and instability in his ankle after multiple sprains. Radiographs show mild ankle degenerative changes and chronic lateral ankle instability. He has failed a comprehensive course of physical therapy. What is the most appropriate surgical management?
. Ankle arthrodesis (fusion)
. Ankle total joint arthroplasty
. Lateral ankle ligament reconstruction (e.g., Broström procedure)
. Arthroscopic ankle debridement
. Achilles tendon lengthening

Correct Answer & Explanation

. Lateral ankle ligament reconstruction (e.g., Broström procedure)

Explanation

Given the history of recurrent sprains, chronic lateral ankle instability, and failure of conservative treatment in an active, middle-aged individual with mild degenerative changes, lateral ankle ligament reconstruction (such as the Broström procedure or its modifications) is the most appropriate surgical management. This aims to restore stability and prevent further cartilage damage and progression of osteoarthritis. Ankle arthrodesis or arthroplasty are reserved for more severe, advanced osteoarthritis. Arthroscopic debridement might be adjunctive but does not address instability. Achilles lengthening is for equinus contracture.

Question 5427

Topic: 8. Foot and Ankle

Which ligament is most commonly injured in an inversion ankle sprain?

. Deltoid ligament
. Anterior talofibular ligament (ATFL)
. Posterior talofibular ligament (PTFL)
. Calcaneofibular ligament (CFL)
. Interosseous talocalcaneal ligament

Correct Answer & Explanation

. Anterior talofibular ligament (ATFL)

Explanation

The anterior talofibular ligament (ATFL) is the most commonly injured ligament in an inversion ankle sprain. It is the weakest of the lateral ankle ligaments and the first to be torn. Severe inversion injuries can also involve the calcaneofibular ligament (CFL). The deltoid ligament is on the medial side and is injured in eversion sprains. The PTFL is typically injured in very severe sprains and ankle dislocations.

Question 5428

Topic: 8. Foot and Ankle

A 40-year-old male presents with severe right foot pain following a fall from a ladder, landing on his heels. Radiographs reveal a comminuted fracture of the calcaneus, involving the posterior facet. What is the most appropriate initial management step (assuming no open wounds or neurovascular compromise)?

. Immediate surgical fixation
. Elevation, ice, non-weight bearing, and pain control
. Computed tomography (CT) scan of the foot
. Consultation with a spine surgeon
. Casting in a short leg walking boot

Correct Answer & Explanation

. Computed tomography (CT) scan of the foot

Explanation

Following a high-energy calcaneal fracture, especially one involving the posterior facet, a CT scan of the foot is essential. It provides detailed information regarding the fracture pattern, subtalar joint involvement, degree of displacement, and comminution, which are critical for surgical planning. Additionally, calcaneal fractures resulting from axial loading often have associated injuries, particularly to the lumbar spine (up to 10-15%), so a spine assessment is important but secondary to initial local evaluation. Initial management also involves elevation, ice, and pain control, but a CT is the crucial next diagnostic step before deciding on definitive treatment (surgical vs. non-surgical).

Question 5429

Topic: 8. Foot and Ankle

What is the primary function of the deltoid ligament complex of the ankle?

. Resist anterior translation of the talus
. Resist inversion forces
. Resist eversion forces
. Resist posterior translation of the talus
. Stabilize the distal tibiofibular syndesmosis

Correct Answer & Explanation

. Resist eversion forces

Explanation

The deltoid ligament complex, located on the medial side of the ankle, is a strong, multi-component ligament that primarily resists eversion forces. It stabilizes the ankle against outward rotation and abduction of the foot. In contrast, the lateral collateral ligaments (ATFL, CFL, PTFL) resist inversion forces.

Question 5430

Topic: 8. Foot and Ankle

A 58-year-old female experiences sudden, sharp pain in her calf during a tennis match, followed by difficulty weight-bearing. On examination, she has a palpable gap in her Achilles tendon and a positive Thompson test. What is the most appropriate management for a healthy, active individual seeking to return to high-level activity?

. Immobilization in a plantarflexed cast for 8 weeks
. Percutaneous repair of the Achilles tendon
. Open surgical repair of the Achilles tendon
. Physical therapy focusing on eccentric loading exercises
. Steroid injection around the tendon

Correct Answer & Explanation

. Open surgical repair of the Achilles tendon

Explanation

A palpable gap in the Achilles tendon and a positive Thompson test are diagnostic of an Achilles tendon rupture. For healthy, active individuals who desire to return to high-level sports, open surgical repair of the Achilles tendon is generally recommended. It provides the strongest repair, allows for anatomical reduction, and has been associated with a lower re-rupture rate compared to non-operative management or percutaneous techniques, especially in this population. Non-operative management or percutaneous repair might be considered for less active patients or those with comorbidities. Steroid injections are contraindicated due to the risk of further tendon degeneration and rupture.

Question 5431

Topic: Forefoot

What is the primary goal of surgical treatment for hallux valgus (bunion deformity)?

. Cosmetic correction of toe deformity
. Achieve a pain-free, functional foot
. Increase hallux range of motion
. Prevent recurrence of the deformity
. Reduce the intermetatarsal angle to zero

Correct Answer & Explanation

. Achieve a pain-free, functional foot

Explanation

The primary goal of surgical treatment for hallux valgus is to achieve a pain-free, functional foot with good alignment. While cosmetic correction and prevention of recurrence are important secondary goals, the overarching aim is to alleviate pain, improve shoe wear, and restore normal foot mechanics. Simply reducing the intermetatarsal angle to zero is not the goal, as a slightly divergent angle is normal. Increasing range of motion is desired but secondary to pain relief and function.

Question 5432

Topic: 8. Foot and Ankle

A 48-year-old male presents with chronic insidious bilateral heel pain, worse with the first steps in the morning and after periods of rest. Pain is localized to the plantar aspect of the heel. Physical examination reveals tenderness at the origin of the plantar fascia. What is the most likely diagnosis?

. Achilles tendinopathy
. Tarsal tunnel syndrome
. Stress fracture of the calcaneus
. Plantar fasciitis
. Fat pad atrophy

Correct Answer & Explanation

. Plantar fasciitis

Explanation

The classic presentation of plantar fasciitis involves chronic insidious heel pain, primarily on the plantar aspect, that is worse with the first steps in the morning ('first step pain') and after periods of rest, improving with activity. Tenderness at the medial plantar calcaneal tuberosity (origin of the plantar fascia) is a key diagnostic finding. Achilles tendinopathy causes posterior heel pain. Tarsal tunnel syndrome would present with nerve symptoms (numbness, tingling). Calcaneal stress fractures usually involve swelling and different pain patterns. Fat pad atrophy is common in older individuals but doesn't typically present with 'first step pain' as its primary symptom.

Question 5433

Topic: 8. Foot and Ankle

A 55-year-old male with a history of Charcot arthropathy of the foot presents with acute redness, swelling, and warmth, without an obvious break in the skin. Imaging shows joint disorganization and fragmentation typical of Charcot. What is a key management principle, especially in the acute phase, related to pressure?

. Aggressive weight-bearing to promote bone consolidation.
. Application of high-pressure compression bandages to reduce edema.
. Total contact casting (TCC) to offload the foot and evenly distribute pressure.
. Surgical debridement of inflamed tissue to reduce pressure.
. Prolonged immobilization without any weight-bearing.

Correct Answer & Explanation

. Total contact casting (TCC) to offload the foot and evenly distribute pressure.

Explanation

Total contact casting (TCC) is a cornerstone of acute Charcot arthropathy management. Its primary mechanism of action is to evenly distribute pressure across the entire plantar surface of the foot, effectively offloading areas of high pressure and reducing stress on fragile bones and joints. This minimizes further bone destruction and promotes healing. Aggressive weight-bearing is contraindicated. High-pressure compression bandages could exacerbate pressure points. Surgical debridement is not the initial management for acute Charcot without infection, and prolonged immobilization without specific offloading (like TCC) is less effective than TCC.

Question 5434

Topic: 8. Foot and Ankle

A patient with a chronic non-healing wound over the posterior heel, despite offloading, is found to have an ankle-brachial index (ABI) of 0.6. What does this pressure-related finding signify regarding wound healing?

. Normal arterial blood flow, indicating a venous etiology.
. Severe arterial insufficiency, making healing unlikely without revascularization.
. Mild arterial compromise, treatable with local wound care.
. Presence of a deep vein thrombosis.
. Neuropathic ulcer, unrelated to vascular pressure.

Correct Answer & Explanation

. Severe arterial insufficiency, making healing unlikely without revascularization.

Explanation

An Ankle-Brachial Index (ABI) of 0.6 signifies moderate to severe peripheral arterial disease (PAD). An ABI of 0.9-1.3 is normal; 0.7-0.9 indicates mild PAD; 0.4-0.7 indicates moderate PAD; and <0.4 indicates severe PAD. An ABI of 0.6 suggests significantly compromised arterial blood flow to the foot, which means insufficient perfusion pressure for wound healing. Without improving the arterial inflow (often through revascularization), wound healing is unlikely, and the risk of amputation is high.

Question 5435

Topic: 8. Foot and Ankle

A football player presents with a suspected MCL injury of the knee. What is the appropriate 'pressure-related' examination technique to assess the integrity of the MCL?

. Anterior drawer test with external rotation.
. Posterior drawer test in internal rotation.
. Valgus stress test at 0 and 30 degrees of knee flexion.
. Varus stress test at 0 and 30 degrees of knee flexion.
. Lachman test with neutral rotation.

Correct Answer & Explanation

. Valgus stress test at 0 and 30 degrees of knee flexion.

Explanation

The valgus stress test assesses the integrity of the medial collateral ligament (MCL). A valgus force (pushing the knee medially while stabilizing the ankle laterally) applies tensile stress (or 'pressure' in a directional sense) to the MCL. The test is performed at 0 degrees of flexion (to assess both MCL and posterior oblique ligament/capsule) and at 30 degrees of flexion (to isolate the MCL). Laxity or pain indicates MCL injury. Varus stress tests the LCL. Anterior/posterior drawer and Lachman tests assess cruciate ligaments.

Question 5436

Topic: 8. Foot and Ankle

A patient with a comminuted calcaneus fracture is managed non-operatively. What is a long-term pressure-related complication that needs to be anticipated and managed?

. Acute compartment syndrome of the foot.
. Charcot arthropathy of the ankle.
. Subtalar arthritis due to altered biomechanics and increased joint stress.
. Lisfranc injury due to midfoot instability.
. Achilles tendon rupture due to excessive load.

Correct Answer & Explanation

. Subtalar arthritis due to altered biomechanics and increased joint stress.

Explanation

Comminuted calcaneus fractures often lead to residual deformity, widening of the heel, and loss of heel height. These changes alter the biomechanics of the hindfoot, particularly the subtalar joint. The resulting incongruity and altered pressure distribution across the subtalar joint significantly increase the risk of post-traumatic subtalar arthritis, which is a common long-term complication causing chronic pain and disability. While acute compartment syndrome of the foot can be an early complication, subtalar arthritis is a key long-term, pressure-related (joint stress) issue. Charcot arthropathy is typically associated with neuropathy. Lisfranc and Achilles rupture are different injuries.

Question 5437

Topic: Midfoot & Hindfoot

A 40-year-old male presents with worsening right foot pain, particularly around the medial longitudinal arch, radiating to the heel. He describes a 'too many toes' sign on clinical examination. On weight-bearing radiographs, there is a collapse of the medial longitudinal arch, talonavicular sag, and forefoot abduction. What is the most likely diagnosis?

. Plantar fasciitis.
. Achilles tendinitis.
. Haglund's deformity.
. Adult acquired flatfoot deformity (AAFD) due to posterior tibial tendon dysfunction (PTTD).
. Stress fracture of the navicular.

Correct Answer & Explanation

. Adult acquired flatfoot deformity (AAFD) due to posterior tibial tendon dysfunction (PTTD).

Explanation

The patient's symptoms (medial arch pain, radiating to heel), clinical sign ('too many toes' indicating forefoot abduction), and radiographic findings (arch collapse, talonavicular sag) are classic for adult acquired flatfoot deformity (AAFD), most commonly caused by progressive posterior tibial tendon dysfunction (PTTD). Plantar fasciitis is typically heel pain. Achilles tendinitis is posterior heel/calf pain. Haglund's deformity is posterior heel pain with retrocalcaneal bursitis. Navicular stress fractures cause localized navicular pain and often edema.

Question 5438

Topic: 8. Foot and Ankle

A 25-year-old male sustains a traumatic rupture of the Achilles tendon during a recreational basketball game. Clinical examination reveals a palpable gap in the tendon, a positive Thompson test, and inability to perform a single heel raise. What is the most appropriate management, considering his age and activity level?

. Non-operative management with cast immobilization and gradual weight-bearing.
. Open surgical repair of the Achilles tendon.
. Percutaneous surgical repair of the Achilles tendon.
. Physical therapy focusing on strengthening and stretching.
. Platelet-rich plasma (PRP) injection and immobilization.

Correct Answer & Explanation

. Open surgical repair of the Achilles tendon.

Explanation

For a young, active individual with a complete Achilles tendon rupture, surgical repair (either open or percutaneous) is generally recommended to restore tendon length and tension, reduce the risk of re-rupture, and facilitate a quicker return to high-level activity. While non-operative treatment is an option, it is associated with higher rates of re-rupture, especially in active individuals. Open surgical repair allows for direct visualization of the tear and stronger repair. Percutaneous repair is a less invasive option with similar re-rupture rates to open repair but may have a higher risk of sural nerve injury. Physical therapy alone is insufficient for a complete rupture. PRP injections are investigational and not a standalone treatment for complete ruptures.

Question 5439

Topic: Ankle Trauma & Sports

Which specific ligament is most commonly injured in an isolated high ankle sprain (syndesmotic injury)?

. Anterior talofibular ligament (ATFL).
. Calcaneofibular ligament (CFL).
. Posterior talofibular ligament (PTFL).
. Anterior inferior tibiofibular ligament (AITFL).
. Deltoid ligament.

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL).

Explanation

In an isolated high ankle sprain, also known as a syndesmotic injury, the anterior inferior tibiofibular ligament (AITFL) is the most commonly injured ligament. The syndesmosis consists of the AITFL, posterior inferior tibiofibular ligament (PITFL), interosseous ligament, and transverse tibiofibular ligament. The ATFL, CFL, and PTFL are components of the lateral ankle collateral ligaments, typically injured in inversion ankle sprains. The deltoid ligament is on the medial side of the ankle.

Question 5440

Topic: 8. Foot and Ankle
In the setting of a calcaneal fracture (Böhler's angle < 20 degrees), what is the most significant long-term functional complication, even after surgical fixation?
. Achilles tendinitis.
. Ankle instability.
. Subtalar arthritis and pain.
. Plantar fasciitis.
. Toe deformities.

Correct Answer & Explanation

. Subtalar arthritis and pain.

Explanation

Subtalar arthritis and pain are the most significant and common long-term functional complications following intra-articular calcaneal fractures, even after optimal surgical fixation. The Böhler's angle (normal 20-40 degrees) is a measure of the posterior facet's inclination; a reduced angle indicates collapse and comminution of the subtalar joint. Despite anatomic reduction and fixation, residual articular incongruity, damage to the cartilage, and altered biomechanics often lead to post-traumatic subtalar arthritis, stiffness, and chronic pain. Achilles tendinitis, ankle instability, plantar fasciitis, and toe deformities are less common or less significant complications compared to subtalar joint issues.

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