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8. Foot and Ankle MCQs

Practice Set 303 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 6041

Topic: Forefoot

A 25-year-old professional football player sustains an acute hyperdorsiflexion injury to his first metatarsophalangeal (MTP) joint, resulting in a 'turf toe'. Magnetic resonance imaging confirms a complete tear of the plantar plate with 4 mm of proximal sesamoid retraction. What is the most appropriate management?

. Immediate full weight-bearing in a stiff-soled shoe
. Short leg cast in plantarflexion for 6 weeks
. Surgical repair of the plantar plate and capsuloligamentous complex
. Closed reduction and percutaneous pinning of the MTP joint
. Excision of the sesamoid bones

Correct Answer & Explanation

. Surgical repair of the plantar plate and capsuloligamentous complex

Explanation

A complete tear of the plantar plate (Grade 3 turf toe injury) with significant sesamoid retraction (typically >3 mm), vertical instability, intra-articular fracture, or traumatic hallux valgus are indications for surgical repair in high-level athletes to restore the push-off strength and joint stability.

Question 6042

Topic: 8. Foot and Ankle

During surgical management of severe insertional Achilles tendinopathy, extensive debridement of the Achilles tendon is performed. At what threshold of Achilles tendon detachment/debridement is a Flexor Hallucis Longus (FHL) tendon transfer classically indicated?

. Greater than 20% of the tendon
. Greater than 30% of the tendon
. Greater than 50% of the tendon
. Only if the calcaneal tuberosity is fully excised
. Only in the setting of a complete acute traumatic rupture

Correct Answer & Explanation

. Greater than 50% of the tendon

Explanation

If more than 50% of the Achilles tendon insertion requires detachment or debridement during surgery for insertional Achilles tendinopathy, the remaining tendon is generally considered insufficient, and an FHL tendon transfer is indicated to provide adequate plantarflexion strength.

Question 6043

Topic: Forefoot

A patient undergoes an isolated surgical excision of the fibular (lateral) sesamoid due to a chronic, non-healing fracture. Which of the following deformities is the most recognized complication of this specific procedure?

. Hallux valgus
. Hallux varus
. Claw toe deformity of the first ray
. Dorsal subluxation of the first MTP joint
. Hammer toe deformity of the first ray

Correct Answer & Explanation

. Hallux varus

Explanation

Excision of the fibular (lateral) sesamoid compromises the insertion of the adductor hallucis and the lateral head of the flexor hallucis brevis. This creates an imbalance of dynamic forces at the MTP joint, with unopposed pull from the abductor hallucis leading to a hallux varus deformity. Conversely, medial sesamoid excision risks hallux valgus.

Question 6044

Topic: 8. Foot and Ankle

A 55-year-old female undergoes a Weil osteotomy for intractable central metatarsalgia. Postoperatively, she complains that her toe does not touch the ground when she stands barefoot. What is the pathomechanism of this specific complication?

. Iatrogenic transaction of the extensor digitorum longus tendon
. Plantar displacement of the interosseous intrinsic muscles dorsal to the MTP joint axis
. Dorsal shift of the interosseous intrinsic muscles relative to the MTP joint axis
. Over-lengthening of the metatarsal shaft
. Avulsion of the plantar plate

Correct Answer & Explanation

. Dorsal shift of the interosseous intrinsic muscles relative to the MTP joint axis

Explanation

The most common complication of a Weil osteotomy (distal oblique sliding osteotomy of the metatarsal neck) is a 'floating toe'. This occurs because the plantar translation of the metatarsal head during the osteotomy relatively shifts the axis of the interosseous muscles dorsal to the center of rotation of the MTP joint. As a result, the intrinsics act as extensors rather than flexors of the MTP joint.

Question 6045

Topic: 8. Foot and Ankle

A 14-year-old female gymnast presents with progressive forefoot pain. Radiographs reveal flattening, sclerosis, and fragmentation of the second metatarsal head.

Based on the most likely diagnosis, what is the initial appropriate management?

. Metatarsal osteotomy (e.g., dorsal closing wedge)
. Excision of the metatarsal head
. Activity modification, metatarsal pad, and a stiff-soled shoe
. Corticosteroid injection into the second MTP joint
. Core decompression of the metatarsal head

Correct Answer & Explanation

. Activity modification, metatarsal pad, and a stiff-soled shoe

Explanation

The clinical and radiographic presentation is classic for Freiberg's infraction, an osteochondrosis (avascular necrosis) most commonly affecting the second metatarsal head. Initial management is nonoperative, focusing on offloading the joint with activity modification, a metatarsal pad, and rigid-soled shoes or a walking boot. Surgical intervention is reserved for refractory cases.

Question 6046

Topic: 8. Foot and Ankle

During dorsal surgical excision of a Morton's neuroma in the third webspace, which anatomic structure must be incised to adequately expose and mobilize the neuroma?

. Plantar fascia
. Deep transverse metatarsal ligament
. Plantar plate
. Lumbrical tendon
. Flexor digitorum brevis tendon

Correct Answer & Explanation

. Deep transverse metatarsal ligament

Explanation

Morton's neuroma is a compressive neuropathy of the common digital nerve. The nerve lies plantar to the deep transverse metatarsal ligament. When approached dorsally, the deep transverse metatarsal ligament must be transected to decompress the area and gain adequate exposure to resect the nerve proximally.

Question 6047

Topic: 8. Foot and Ankle

When performing a surgical release for Tarsal Tunnel Syndrome, the flexor retinaculum is divided. Which of the following structures lies most posterior and lateral within the tarsal tunnel?

. Tibialis posterior tendon
. Flexor digitorum longus tendon
. Posterior tibial artery
. Tibial nerve
. Flexor hallucis longus tendon

Correct Answer & Explanation

. Flexor hallucis longus tendon

Explanation

The contents of the tarsal tunnel from anterior/medial to posterior/lateral are: Tibialis posterior tendon, Flexor digitorum longus tendon, posterior tibial Artery, posterior tibial Vein, tibial Nerve, and Flexor hallucis longus tendon (FHL). This is remembered by the mnemonic 'Tom, Dick, AND Very Nervous Harry'. The FHL is the most posterior/lateral structure.

Question 6048

Topic: 8. Foot and Ankle

A 22-year-old skier presents with lateral ankle pain and a popping sensation behind the lateral malleolus when actively dorsiflexing and everting the foot against resistance. Which structure is the primary restraint to this specific pathomechanism?

. Anterior talofibular ligament (ATFL)
. Calcaneofibular ligament (CFL)
. Inferior peroneal retinaculum (IPR)
. Superior peroneal retinaculum (SPR)
. Peroneus brevis tendon

Correct Answer & Explanation

. Superior peroneal retinaculum (SPR)

Explanation

The patient has recurrent peroneal tendon subluxation. The primary restraint to the subluxation of the peroneal tendons out of the retromalleolar groove is the Superior Peroneal Retinaculum (SPR). Treatment for chronic subluxation typically involves SPR repair/reconstruction, often combined with groove deepening.

Question 6049

Topic: 8. Foot and Ankle

A 68-year-old man presents with a painless "slapping gait" and weakness in ankle dorsiflexion. On examination, he compensates by hyperextending his big toe during the swing phase, and his ability to evert the foot is preserved. Which tendon is most likely ruptured?

. Tibialis posterior
. Tibialis anterior
. Extensor hallucis longus
. Peroneus longus
. Achilles tendon

Correct Answer & Explanation

. Tibialis anterior

Explanation

A spontaneous rupture of the tibialis anterior tendon classically presents in older males with a painless 'foot drop' or slapping gait. Because the extensor hallucis longus (EHL) is intact, the patient will recruit the EHL to assist with dorsiflexion, leading to clawing of the hallux. Eversion is preserved because the peroneal tendons are unaffected.

Question 6050

Topic: 8. Foot and Ankle

A 20-year-old classical ballet dancer complains of posterior ankle pain that is exacerbated when dancing 'en pointe'. Physical examination reveals tenderness posteromedially and triggering of the hallux with active plantarflexion. Which of the following conditions is most likely responsible?

. Achilles tendinopathy
. Flexor hallucis longus tendinopathy
. Peroneal tendon subluxation
. Posterior tibial tendon insufficiency
. Tarsal tunnel syndrome

Correct Answer & Explanation

. Flexor hallucis longus tendinopathy

Explanation

Flexor hallucis longus (FHL) tendinopathy, also known as 'dancer's tendinitis', occurs due to repetitive extreme plantarflexion (en pointe). It often presents with posteromedial ankle pain and triggering of the FHL tendon as it passes through the fibro-osseous tunnel posterior to the medial malleolus, often exacerbated by an os trigonum.

Question 6051

Topic: 8. Foot and Ankle

A 58-year-old poorly controlled diabetic patient presents with a swollen, warm, erythematous foot but denies any pain. Pulses are palpable. Radiographs are obtained.

The image demonstrates extensive periarticular bone debris, joint subluxation, and fragmentation of the midfoot. According to the modified Eichenholtz classification, what stage of Charcot neuroarthropathy does this represent?

. Stage 0 (Acute inflammatory)
. Stage 1 (Developmental/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Consolidation)
. Stage 4 (Remodeling)

Correct Answer & Explanation

. Stage 1 (Developmental/Fragmentation)

Explanation

The clinical and radiographic description corresponds to Eichenholtz Stage 1 (Developmental/Fragmentation). Characteristics include joint effusion, soft tissue swelling, osteopenia, fragmentation of articular cartilage and subchondral bone, and debris formation. Stage 0 is clinical inflammation with normal radiographs. Stage 2 shows absorption of debris and early fusion. Stage 3 shows bone remodeling and consolidation.

Question 6052

Topic: 8. Foot and Ankle

When evaluating a patient with a cavovarus foot deformity, a Coleman block test is performed. The patient's heel is placed on a block while the first ray is allowed to drop off the medial edge. During this maneuver, the hindfoot varus deformity completely corrects to a neutral alignment. What does this physical examination finding dictate?

. The deformity is primarily driven by a rigid, contracted Achilles tendon
. The hindfoot deformity is fixed, requiring a calcaneal osteotomy
. The deformity is flexible and entirely driven by a plantarflexed first ray
. The subtalar joint is fused and requires an arthrodesis
. The tibialis posterior tendon is ruptured

Correct Answer & Explanation

. The deformity is flexible and entirely driven by a plantarflexed first ray

Explanation

The Coleman block test is used to evaluate hindfoot flexibility in a cavovarus foot. By allowing the first ray to hang off the block, it eliminates the contribution of a plantarflexed first ray to the hindfoot alignment. If the hindfoot varus corrects to neutral, the varus is flexible and driven by the forefoot (plantarflexed 1st ray). Treatment can then primarily target the forefoot (e.g., dorsiflexion osteotomy of the 1st metatarsal) without necessarily requiring corrective bony hindfoot surgery.

Question 6053

Topic: 8. Foot and Ankle

During the extensile lateral approach to the calcaneus for open reduction and internal fixation of a joint-depressed calcaneus fracture, a full-thickness soft tissue flap is elevated. Which of the following arteries provides the primary vascular supply to the apex of this specific flap?

. Medial calcaneal artery
. Lateral tarsal artery
. Lateral calcaneal artery
. Dorsalis pedis artery
. Sural artery

Correct Answer & Explanation

. Lateral calcaneal artery

Explanation

The viability of the full-thickness flap used in the extensile lateral approach to the calcaneus is primarily dependent on the lateral calcaneal artery, a terminal branch of the peroneal artery. The horizontal limb of the incision must be placed carefully, usually in line with the base of the 5th metatarsal, to preserve the vascularity of the corner.

Question 6054

Topic: 8. Foot and Ankle

Based on recent Level 1 evidence, when comparing surgical repair with modern functional non-operative management (early weight-bearing and functional bracing) for acute Achilles tendon ruptures, which of the following outcomes is true?

. Surgical repair results in significantly lower re-rupture rates than modern functional non-operative management
. Functional non-operative management has an equivalent re-rupture rate but lower complication rates compared to surgery
. Functional non-operative management results in significantly greater permanent plantarflexion weakness
. Surgical repair is mandatory for ruptures in the watershed area to prevent chronic tendinopathy
. There is no difference in wound complications between the two groups

Correct Answer & Explanation

. Functional non-operative management has an equivalent re-rupture rate but lower complication rates compared to surgery

Explanation

Recent Level 1 evidence (e.g., Willits et al., Soroceanu et al.) demonstrates that when modern functional rehabilitation protocols (early weight-bearing and ROM) are employed, the re-rupture rates between non-operative and operative management are statistically equivalent. However, operative management carries a higher risk of soft-tissue and wound complications.

Question 6055

Topic: 8. Foot and Ankle

A 12-year-old boy presents with recurrent ankle sprains and a rigid, painful flatfoot. Oblique radiographs demonstrate an osseous connection between the anterior process of the calcaneus and the navicular.

Which classic radiographic sign would most likely be visible on the lateral radiograph in this specific condition?

. C-sign
. Talar beak sign
. Anteater nose sign
. Fleck sign
. Double density sign

Correct Answer & Explanation

. Anteater nose sign

Explanation

The clinical scenario and images describe a calcaneonavicular coalition. On a lateral radiograph, the classic finding is the 'anteater nose sign', which represents the elongated anterior process of the calcaneus attempting to bridge to the navicular. The 'C-sign' and 'talar beak' are classically associated with talocalcaneal (subtalar) coalitions.

Question 6056

Topic: Midfoot & Hindfoot

A 45-year-old runner with chronic heel pain is diagnosed with recalcitrant plantar fasciitis. MRI reveals edema not only at the plantar fascia origin but also within the abductor digiti minimi muscle, suggesting entrapment of Baxter's nerve. Baxter's nerve is a branch of which of the following?

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

Correct Answer & Explanation

. Lateral plantar nerve

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve. It courses between the abductor hallucis and the quadratus plantae, then turns laterally to innervate the abductor digiti minimi. Entrapment can mimic or occur concomitantly with chronic plantar fasciitis.

Question 6057

Topic: 8. Foot and Ankle
During clinical examination of a patient with an acquired flatfoot deformity, the examiner evaluates ankle dorsiflexion. With the knee fully extended, ankle dorsiflexion is limited to 0 degrees. When the knee is flexed to 90 degrees, ankle dorsiflexion improves to 15 degrees. What does this test indicate?
. Combined gastrocnemius-soleus complex contracture
. Isolated soleus contracture
. Isolated gastrocnemius contracture
. Tibialis posterior tendon rupture
. Anterior ankle bony impingement

Correct Answer & Explanation

. Isolated gastrocnemius contracture

Explanation

This is the Silfverskiรถld test. The gastrocnemius muscle crosses both the knee and the ankle joints, while the soleus only crosses the ankle. If ankle dorsiflexion improves when the knee is flexed (relaxing the gastrocnemius), the contracture is isolated to the gastrocnemius. If dorsiflexion does not improve with knee flexion, the contracture involves the combined gastrocnemius-soleus complex.

Question 6058

Topic: 8. Foot and Ankle

A 24-year-old professional rugby player sustains a twisting injury to his midfoot. Radiographs are negative for fractures, but weight-bearing views show a 3 mm diastasis between the bases of the 1st and 2nd metatarsals. An MRI confirms a purely ligamentous Lisfranc injury. What is the most appropriate surgical management to maximize his functional outcome and return to play?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation (ORIF) with transarticular screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Dorsal bridge plating without joint violation
. Conservative management with a non-weight-bearing cast for 6 weeks

Correct Answer & Explanation

. Primary arthrodesis of the first, second, and third tarsometatarsal joints

Explanation

Current evidence suggests that primary arthrodesis yields superior functional outcomes and lower reoperation rates compared to ORIF for purely ligamentous Lisfranc injuries. ORIF is generally preferred for purely bony variants.

Question 6059

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a progressive flatfoot deformity, lateral hindfoot pain, and inability to perform a single-leg heel raise. Weight-bearing radiographs show talonavicular uncoverage of 45%. Clinical exam reveals severe forefoot abduction (too-many-toes sign) and a flexible hindfoot (Stage IIb Adult Acquired Flatfoot). Which of the following surgical combinations is most appropriate?

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy (MDCO) only
. FDL transfer, MDCO, and lateral column lengthening
. Isolated triple arthrodesis
. Talonavicular arthrodesis and Spring ligament repair
. Gastrocnemius recession and orthotic management

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction (PTTD) is characterized by significant forefoot abduction (>30-40% talonavicular uncoverage). This requires a lateral column lengthening (e.g., Evans osteotomy) in addition to FDL transfer and MDCO to correct the triplanar deformity.

Question 6060

Topic: Forefoot

A 62-year-old man presents with severe pain and stiffness in his right great toe. On exam, he has pain throughout the entire range of motion of the 1st metatarsophalangeal (MTP) joint, including the mid-arc. Radiographs reveal near-complete joint space loss, prominent dorsal osteophytes, and subchondral sclerosis. Based on the Coughlin and Shurnas classification, what is the gold standard surgical treatment?

. Dorsal cheilectomy
. Moberg osteotomy
. First MTP joint arthrodesis
. Silicone implant arthroplasty
. Keller resection arthroplasty

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

This patient has Grade 4 hallux rigidus, defined by pain throughout the range of motion including the mid-arc. First MTP joint arthrodesis is the gold standard for end-stage hallux rigidus, providing reliable pain relief and functional improvement.

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