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8. Foot and Ankle MCQs

Practice Set 3 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 41

Topic: 8. Foot and Ankle

A 55-year-old male undergoes surgical debridement for severe insertional Achilles tendinopathy. After removing the calcific tendon portions and the Haglund's exostosis, 60% of the Achilles tendon insertion has been detached. What is the most appropriate next step in reconstruction?

. Primary repair using suture anchors alone
. V-Y fascial advancement of the gastrocnemius
. Flexor hallucis longus (FHL) tendon transfer
. Flexor digitorum longus (FDL) tendon transfer
. Gastrocnemius recession

Correct Answer & Explanation

. Flexor hallucis longus (FHL) tendon transfer

Explanation

If >50% of the Achilles tendon insertion requires detachment during debridement, augmentation with a tendon transfer (most commonly FHL) is recommended. This restores plantar flexion strength and brings highly vascularized tissue to the degenerative area.

Question 42

Topic: 8. Foot and Ankle

During harvest of the flexor hallucis longus (FHL) through a posterior single-incision approach for Achilles augmentation, which neurovascular structure is at greatest risk if dissection strays immediately medial to the FHL muscle belly?

. Sural nerve
. Deep peroneal nerve
. Posterior tibial artery and tibial nerve
. Peroneal artery
. Anterior tibial artery

Correct Answer & Explanation

. Posterior tibial artery and tibial nerve

Explanation

The posterior tibial neurovascular bundle lies immediately medial to the FHL muscle belly in the deep posterior compartment. Dissection must stay directly on the FHL tendon and muscle to avoid injuring these critical structures.

Question 43

Topic: 8. Foot and Ankle

A 62-year-old patient presents with a neglected Achilles tendon rupture from 4 months ago. Intraoperatively, after debridement of the necrotic ends, there is a 7 cm gap with the ankle in neutral. Which reconstructive option is most appropriate for a defect of this size?

. End-to-end repair with heavy nonabsorbable suture
. V-Y gastrocnemius fascial lengthening alone
. Turndown flap alone
. Primary repair augmented with an FDL transfer
. Achilles allograft reconstruction or free tissue transfer

Correct Answer & Explanation

. Achilles allograft reconstruction or free tissue transfer

Explanation

Tendon gaps greater than 6 cm typically cannot be bridged by local tissue like V-Y advancements or turndown flaps alone. They require bridging with an allograft (e.g., Achilles, hamstring) or synthetic mesh, often augmented with an FHL transfer.

Question 44

Topic: 8. Foot and Ankle

A 32-year-old runner has chronic posterior heel pain due to Haglund's deformity. If conservative measures fail, what is the biomechanical rationale for performing a Zadek (dorsal closing wedge) osteotomy of the calcaneus?

. It shifts the Achilles tendon insertion medially
. It completely excises the bony prominence through a direct posterior approach
. It pitches the posterosuperior tuberosity anteriorly to decompress the retrocalcaneal space
. It dynamically lengthens the Achilles tendon during heel strike
. It elevates the calcaneal pitch angle to stretch the plantar fascia

Correct Answer & Explanation

. It pitches the posterosuperior tuberosity anteriorly to decompress the retrocalcaneal space

Explanation

A dorsal closing wedge osteotomy (Zadek or Keck and Kelly) pitches the posterosuperior calcaneal tuberosity anteriorly. This effectively moves the bony prominence away from the Achilles tendon, decompressing the retrocalcaneal bursa.

Question 45

Topic: 8. Foot and Ankle

A patient with recalcitrant hindfoot pain is noted to have a lack of passive ankle dorsiflexion with the knee extended, but achieves 15 degrees of passive dorsiflexion with the knee flexed. Which surgical procedure targets the isolated pathology identified by this test?

. Tendo-Achilles lengthening (TAL)
. Proximal medial gastrocnemius recession
. Calcaneal osteotomy
. Flexor hallucis longus release
. Posterior tibial tendon tenosynovectomy

Correct Answer & Explanation

. Proximal medial gastrocnemius recession

Explanation

The Silfverskiold test differentiates isolated gastrocnemius contracture from an Achilles contracture. Improved dorsiflexion with knee flexion indicates isolated gastrocnemius tightness, properly treated with a gastrocnemius recession.

Question 46

Topic: 8. Foot and Ankle

A 19-year-old professional ballet dancer presents with posterior ankle pain exacerbated by the "en pointe" position. Nonoperative management has failed.

Surgical excision of the symptomatic Os trigonum is planned. This bony structure is located immediately lateral to which tendon?

. Achilles tendon
. Flexor hallucis longus
. Peroneus brevis
. Flexor digitorum longus
. Tibialis posterior

Correct Answer & Explanation

. Flexor hallucis longus

Explanation

The os trigonum is a secondary ossification center sitting at the posterolateral talus. It is located directly lateral to the flexor hallucis longus (FHL) tendon, which runs in the groove between the medial and lateral talar tubercles.

Question 47

Topic: 8. Foot and Ankle

The Achilles tendon is most vulnerable to rupture and non-insertional tendinopathy in its relative "watershed" area of decreased vascularity. This hypovascular zone is typically located:

. At the exact bony insertion on the posterior calcaneal tuberosity
. 2 to 6 cm proximal to the calcaneal insertion
. 8 to 10 cm proximal to the calcaneal insertion
. At the musculotendinous junction
. Within the deep fascial envelope of the soleus

Correct Answer & Explanation

. 2 to 6 cm proximal to the calcaneal insertion

Explanation

The watershed area of the Achilles tendon is relatively hypovascular due to the arrangement of its blood supply. It is located approximately 2 to 6 cm proximal to its insertion on the calcaneus.

Question 48

Topic: 8. Foot and Ankle

A 65-year-old patient on chronic systemic corticosteroids is prescribed a broad-spectrum antibiotic for a respiratory infection and subsequently suffers bilateral acute Achilles tendon ruptures. Which class of antibiotics is most strongly associated with this complication?

. Macrolides
. Aminoglycosides
. Fluoroquinolones
. Cephalosporins
. Tetracyclines

Correct Answer & Explanation

. Fluoroquinolones

Explanation

Fluoroquinolones carry a black-box warning for tendinopathy and tendon rupture. The risk is significantly amplified in older patients and those concurrently taking systemic corticosteroids.

Question 49

Topic: 8. Foot and Ankle

A 72-year-old diabetic female falls and complains of severe posterior heel pain. Radiographs reveal a displaced avulsion fracture of the posterior calcaneal tuberosity involving the Achilles tendon insertion. The overlying skin is severely blanched. What is the most appropriate management?

. Closed reduction and short leg cast in maximal plantar flexion
. Immobilization in a CAM boot and non-weight bearing for 6 weeks
. Urgent open reduction and internal fixation
. Delayed fixation after 10-14 days to allow soft tissue swelling to subside
. Excision of the bony fragment and primary soft tissue repair of the Achilles tendon

Correct Answer & Explanation

. Urgent open reduction and internal fixation

Explanation

A displaced calcaneal tuberosity avulsion fracture ("beak" fracture) causing skin blanching is an orthopedic emergency. Urgent open reduction and internal fixation is required to prevent rapid and devastating posterior skin necrosis.

Question 50

Topic: 8. Foot and Ankle

Following an acute open Achilles tendon repair, utilizing an accelerated functional rehabilitation protocol (early weight-bearing and controlled range of motion) rather than traditional prolonged cast immobilization has been shown to:

. Increase the risk of deep wound infections
. Decrease the time to return to work and sports activities
. Result in significant elongation of the tendon at 1 year
. Increase the overall rerupture rate
. Cause persistent loss of ankle dorsiflexion

Correct Answer & Explanation

. Decrease the time to return to work and sports activities

Explanation

Accelerated functional rehabilitation following Achilles repair reduces the time to return to work and sports. It does not increase the rerupture rate compared to traditional immobilization.

Question 51

Topic: 8. Foot and Ankle

When clinically evaluating a patient with a suspected acute Achilles tendon rupture, the Thompson test is considered highly reliable. A positive Thompson test is defined by:

. Vigorous plantar flexion upon squeezing the calf muscle
. Absence of ankle plantar flexion upon squeezing the calf muscle
. Severe pain over the Achilles insertion with resisted dorsiflexion
. Increased resting tension of the Achilles tendon in the prone position
. Palpable gap 10 cm proximal to the insertion point

Correct Answer & Explanation

. Absence of ankle plantar flexion upon squeezing the calf muscle

Explanation

A positive Thompson test signifies a complete discontinuity of the gastrosoleus complex. It is characterized by an absence of passive plantar flexion when the calf muscle is squeezed.

Question 52

Topic: 8. Foot and Ankle

Inversion injury of a plantarflexed foot results in disruption of the anterolateral capsuloligamentous structures in a sequential fashion. Which of the following is the order in which this disruption occurs:

. Anterolateral joint capsule, anterior talofibular ligament, calcaneofibular ligament
. Anterior talofibular ligament, anterolateral joint capsule, calcaneofibular ligament
. Anterolateral joint capsule, calcaneofibular ligament, anterior talofibular ligament
. Calcaneofibular ligament, anterior talofibular ligament, anterolateral joint capsule
. Calcaneofibular ligament, anterolateral joint capsule, anterior talofibular ligament

Correct Answer & Explanation

. Anterolateral joint capsule, anterior talofibular ligament, calcaneofibular ligament

Explanation

Inversion injury to the plantarflexed foot results in a predictable, sequential pattern of injury. Injury is initiated anteriorly with disruption of the anterolateral joint capsule and progresses posteriorly to the anterior talofibular ligament and ultimately to the calcaneofibular ligament.

Question 53

Topic: 8. Foot and Ankle

When treating recurrent inversion ankle sprains, physiotherapy should be directed at strengthening of which muscle or muscle group:

. Gastrosoleus
. Tibialis anterior
. Tibialis posterior
. Peroneals
. Flexor digitorum longus

Correct Answer & Explanation

. Peroneals

Explanation

The peroneals provide dynamic resistance to inversion of the ankle. Therapy programs designed for treating lateral ankle instability must attempt to maximize the function of these dynamic stabilizers.

Question 54

Topic: 8. Foot and Ankle

When comparing operative to nonoperative treatment of Achilles tendon ruptures, the major difference in outcome reported in the literature is:

. Return to full activity
. Plantarflexion strength
. Rerupture rate
. Ultimate range of motion
. There are no reported differences in results.

Correct Answer & Explanation

. Rerupture rate

Explanation

In a review of the literature, the rerupture rate after nonoperatively treated Achilles tendon ruptures was 13.4% compared to 1.4% for operative treatment. A prospective randomized study also substantiated these findings. Although the number of patients returning to full sporting activity and plantarflexion strength measurements was higher in the operative group, the differences were not as marked as the rerupture rate.

Question 55

Topic: 8. Foot and Ankle

A football player sustains an external rotation injury to his ankle. Which physical examination test is most specific for diagnosing a syndesmotic (high ankle) sprain?

. Anterior drawer test
. Talar tilt test
. External rotation stress test
. Thompson test
. Silfverskiold test

Correct Answer & Explanation

. External rotation stress test

Explanation

The external rotation stress test (Kleiger's test) effectively stresses the distal tibiofibular syndesmosis. Pain over the anterior inferior tibiofibular ligament during this test is highly specific for a syndesmotic injury.

Question 56

Topic: 8. Foot and Ankle

A college football running back sustains an acute hyperextension injury to his great toe while planting his foot on an artificial surface. He has exquisite tenderness over the plantar aspect of the 1st metatarsophalangeal (MTP) joint. What primary structure is injured in 'turf toe'?

. Extensor hallucis longus tendon
. Flexor hallucis longus tendon
. Plantar plate and capsuloligamentous complex
. Medial sesamoid bone
. Transverse metatarsal ligament

Correct Answer & Explanation

. Plantar plate and capsuloligamentous complex

Explanation

Turf toe is a severe sprain of the 1st MTP joint, specifically involving disruption or attenuation of the plantar plate and its capsuloligamentous structures due to an extreme hyperextension force.

Question 57

Topic: 8. Foot and Ankle

An athlete suffers an external rotation injury to the ankle and presents with a positive squeeze test and positive external rotation stress test. In a syndesmotic ankle sprain, which ligament is typically the first to be disrupted?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Interosseous membrane
. Anterior talofibular ligament (ATFL)
. Deltoid ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

In a high ankle (syndesmotic) sprain, external rotation forces sequentially tear the syndesmotic structures. The anterior inferior tibiofibular ligament (AITFL) is typically the first structure to fail.

Question 58

Topic: 8. Foot and Ankle

A 40-year-old 'weekend warrior' felt a sudden pop in his heel while playing tennis. The orthopedic surgeon performs a Thompson test, which is positive. What is the physiological mechanism behind a normal (negative) Thompson test?

. Squeezing the calf compresses the tibial nerve, eliciting a pain response
. Squeezing the calf manually shortens the gastroc-soleus complex, producing plantarflexion via an intact Achilles tendon
. Squeezing the calf stretches the anterior compartment, causing reflexive dorsiflexion
. Squeezing the calf tests the isolated integrity of the plantaris tendon
. Squeezing the calf displaces fluid in the retrocalcaneal bursa

Correct Answer & Explanation

. Squeezing the calf manually shortens the gastroc-soleus complex, producing plantarflexion via an intact Achilles tendon

Explanation

A normal Thompson test occurs when squeezing the calf muscle belly manually pulls the intact Achilles tendon, mechanically producing plantarflexion of the foot. Absence of this plantarflexion indicates a complete disruption of the Achilles tendon.

Question 59

Topic: 8. Foot and Ankle

Strain in the anterior talofibular ligament (ATFL) _ as the ankle moves from dorsiflexion to plantarflexion.

. Increases
. Decreases
. Remains unchanged
. Has not been evaluated
. Increases initially then decreases

Correct Answer & Explanation

. Increases

Explanation

The ATFL primarily functions to restrict internal rotation of the talus in the mortis Strain in the ATFL increases as the ankle moves from dorsiflexion and plantarflexion, and it is the primary restraint to anterior translation and adduction in this position.

Question 60

Topic: 8. Foot and Ankle

The most commonly injured ligament after inversion ankle sprains is the:

. Anterior tibiofibular ligament
. C alcaneofibular ligament
. Anterior talofibular ligament
. Posterior talofibular ligament
. Deltoid ligament

Correct Answer & Explanation

. Anterior talofibular ligament

Explanation

Isolated anterior talofibular ligament (ATFL) injuries are reported to occur in 67% of ankle sprains. The anterior talofibular ligament is the most commonly injured ligament after inversion ankle sprains.

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