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8. Foot and Ankle MCQs

Practice Set 312 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 6221

Topic: 8. Foot and Ankle
A 16-year-old presents with a progressive cavus foot. Nerve conduction studies (NCS) reveal uniformly slowed conduction velocities in both motor and sensory nerves. This finding is characteristic of:
. CMT type 2 (axonal neuropathy).
. Hereditary neuropathic amyotrophy.
. CMT type 1 (demyelinating neuropathy).
. Guillain-Barrรฉ syndrome.
. Peripheral nerve entrapment.

Correct Answer & Explanation

. CMT type 1 (demyelinating neuropathy).

Explanation

Charcot-Marie-Tooth (CMT) disease is broadly classified into demyelinating (CMT1) and axonal (CMT2) forms. CMT type 1, the most common form, is characterized by a primary defect in myelin, which results in uniformly slowed nerve conduction velocities in both motor and sensory nerves. CMT type 2, in contrast, involves primary axonal degeneration and typically shows normal or mildly reduced conduction velocities but reduced compound muscle action potential (CMAP) amplitudes.

Question 6222

Topic: 8. Foot and Ankle

Which of the following describes the most appropriate use of a plantar fascia release in the surgical correction of a cavus foot?

. As a stand-alone procedure for rigid cavus foot.
. Primarily to correct a fixed ankle equinus.
. To address pain from plantar fasciitis and contribute to forefoot flexibility, often combined with other procedures.
. To prevent recurrence of lateral ankle sprains.
. To correct a rigid hindfoot varus deformity.

Correct Answer & Explanation

. To address pain from plantar fasciitis and contribute to forefoot flexibility, often combined with other procedures.

Explanation

A plantar fascia release is a common soft tissue component of cavus foot surgery. It is performed to relieve tension in the tight plantar fascia, which contributes to the high arch and can be a source of pain (plantar fasciitis). By lengthening the plantar fascia, it can also improve the flexibility of the forefoot. However, it is rarely a stand-alone procedure for a significant cavus deformity and is almost always combined with other soft tissue or bony corrections (e.g., tendon transfers, osteotomies) to achieve comprehensive correction. It does not directly correct ankle equinus or hindfoot varus.

Question 6223

Topic: 8. Foot and Ankle

What is the common term for the deformity where the calcaneus is dorsiflexed relative to the ankle, leading to a high arch with a negative calcaneal pitch angle?

. Pes planus.
. Cavovarus foot.
. Pes calcaneocavus.
. Forefoot equinus.
. Tarsal coalition.

Correct Answer & Explanation

. Pes calcaneocavus.

Explanation

Pes calcaneocavus (or calcaneocavus foot) is a specific type of cavus deformity where the calcaneus is dorsiflexed or in relative calcaneus, causing the heel to strike first and leading to a loss of the heel rocker. Radiographically, this is characterized by a normal or even reduced (negative) calcaneal pitch angle, despite a high arch. This differs from the more common cavovarus foot, where the calcaneus is typically plantarflexed (increased calcaneal pitch) and in varus.

Question 6224

Topic: 8. Foot and Ankle

The Steindler stripping procedure, historically used for cavus foot, primarily addresses which component of the deformity?

. Forefoot adduction.
. Hindfoot varus.
. Plantar fascia contracture and intrinsic muscle tightness.
. Ankle equinus.
. Claw toe deformity.

Correct Answer & Explanation

. Plantar fascia contracture and intrinsic muscle tightness.

Explanation

The Steindler stripping procedure (also known as Steindler release) is a historical soft tissue procedure for flexible cavus feet. It involves releasing the plantar fascia and the origin of the intrinsic foot muscles (abductor hallucis, flexor digitorum brevis, abductor digiti minimi) from the calcaneus. The primary goal is to lengthen these contracted plantar structures, thereby reducing the tension and contributing to a lowering of the arch and improving flexibility. It does not directly address fixed bony deformities, ankle equinus, or hindfoot varus.

Question 6225

Topic: Midfoot & Hindfoot

Which of the following is an effective method to assess the flexibility of the forefoot adduction/abduction component in a cavus foot?

. Gait analysis on a treadmill.
. Passive inversion and eversion of the subtalar joint.
. Plantar pressure mapping.
. Talar head palpation test (Hubscher maneuver) while passively correcting the forefoot.
. Passive pronation and supination of the Chopart joint.

Correct Answer & Explanation

. Passive pronation and supination of the Chopart joint.

Explanation

To assess the flexibility of the forefoot relative to the hindfoot (which includes pronation/supination, abduction/adduction), passively manipulating the Chopart (midtarsal) joint is key. This joint allows the forefoot to be moved independently of the hindfoot. Assessing its range of motion and reducibility helps determine if forefoot abduction/adduction or pronation/supination components are flexible or rigid, which is crucial for surgical planning.

Question 6226

Topic: 8. Foot and Ankle

What is the most common reason for pain in the midfoot and hindfoot in a patient with a long-standing cavus foot?

. Achilles tendonitis.
. Tibialis anterior tendinopathy.
. Stress fractures due to altered weight bearing.
. Plantar fasciitis and degenerative changes in the midfoot/subtalar joints.
. Morton's neuroma.

Correct Answer & Explanation

. Plantar fasciitis and degenerative changes in the midfoot/subtalar joints.

Explanation

Long-standing cavus feet are subject to abnormal biomechanical stresses. The rigid, high arch places excessive tension on the plantar fascia, leading to plantar fasciitis (pain at the heel/arch). The altered alignment also leads to increased load across the midfoot and subtalar joints, predisposing them to early degenerative changes and arthritis, which become a significant source of chronic pain in older patients. While stress fractures can occur, and Achilles tendonitis is possible, plantar fasciitis and degenerative arthritis are the most prevalent causes of midfoot/hindfoot pain.

Question 6227

Topic: 8. Foot and Ankle

When a cavus foot is associated with a tight Achilles tendon (equinus deformity), what is the potential consequence if the equinus is not corrected during surgical intervention?

. Increased risk of hallux valgus development.
. Development of a flexible flatfoot.
. Recurrence of the cavus deformity and metatarsalgia.
. Increased ankle dorsiflexion post-operatively.
. Development of a Charcot joint in the midfoot.

Correct Answer & Explanation

. Recurrence of the cavus deformity and metatarsalgia.

Explanation

Failure to address an associated ankle equinus (tight Achilles tendon) during cavus foot correction is a common cause of recurrence of the deformity and continued symptoms, particularly metatarsalgia. If the ankle cannot dorsiflex adequately, the foot will compensate by creating a forefoot equinus or increasing the plantarflexion of the first ray to bring the heel to the ground. This pushes the metatarsal heads down, leading to increased pressure and pain (metatarsalgia), and can drive the recurrence of the cavus and claw toe deformities. Achilles tendon lengthening is often a necessary component of comprehensive cavus foot correction.

Question 6228

Topic: 8. Foot and Ankle

In a patient with a flexible cavus foot and isolated weakness of the tibialis anterior muscle, which tendon transfer is often considered to restore dorsiflexion and balance?

. Peroneus brevis to medial cuneiform.
. Tibialis posterior to lateral cuneiform.
. Flexor digitorum longus to metatarsal necks.
. Peroneus longus to dorsum of the midfoot.
. Tibialis posterior through interosseous membrane to dorsum of midfoot.

Correct Answer & Explanation

. Tibialis posterior through interosseous membrane to dorsum of midfoot.

Explanation

Isolated tibialis anterior weakness is a key contributor to forefoot equinus and cavus foot. The tibialis posterior tendon, being a strong invertor and plantarflexor, can be transferred through the interosseous membrane to the dorsum of the midfoot (e.g., to the cuneiforms or navicular) to convert it into a dorsiflexor. This transfer helps to restore active dorsiflexion and rebalance the foot, countering the plantarflexion tendency. This is a common tendon transfer used in neuromuscular cavus feet with tibialis anterior weakness.

Question 6229

Topic: 8. Foot and Ankle

What specific type of gait pattern is often observed in patients with a cavus foot, particularly those with neuromuscular causes?

. Steppage gait.
. Antalgic gait.
. Scissoring gait.
. Waddling gait.
. Ataxic gait.

Correct Answer & Explanation

. Steppage gait.

Explanation

Patients with significant cavus foot, especially those with underlying neuromuscular conditions like CMT causing weakness of ankle dorsiflexors (e.g., tibialis anterior), often develop a 'steppage gait.' This involves excessively lifting the knee and hip to clear the foot off the ground during the swing phase, preventing the toes from dragging due to the foot drop. While an antalgic gait (painful limp) is common due to pain, steppage gait is directly related to the muscle imbalance and foot drop component.

Question 6230

Topic: 8. Foot and Ankle

Which clinical maneuver would you perform to specifically assess for ankle joint equinus (fixed plantarflexion deformity of the ankle)?

. Coleman Block Test.
. Grasping the hindfoot and gently inverting and everting it.
. Palpating the medial longitudinal arch.
. Placing the subtalar joint in neutral and maximally dorsiflexing the ankle.
. Assessing the range of motion of the first MTP joint.

Correct Answer & Explanation

. Placing the subtalar joint in neutral and maximally dorsiflexing the ankle.

Explanation

To accurately assess true ankle joint equinus, the subtalar joint must first be placed in a neutral position to eliminate any compensatory motion. Once the subtalar joint is neutralized, the ankle is then maximally dorsiflexed. The inability to achieve at least 10 degrees of dorsiflexion past neutral indicates an ankle equinus deformity. The Coleman Block Test assesses hindfoot varus and forefoot flexibility. Other options assess different components of the foot.

Question 6231

Topic: 8. Foot and Ankle

In a flexible cavovarus foot with a flexible plantarflexed first ray and an intact Achilles tendon, what is the most common combination of soft tissue and bony procedures considered?

. Triple arthrodesis.
. Dwyer calcaneal osteotomy and plantar fascia release.
. Plantar fascia release, first metatarsal dorsiflexion osteotomy, and potentially a lateralizing calcaneal osteotomy if residual varus.
. Posterior tibial tendon transfer and Achilles lengthening.
. Isolated flexor-to-extensor transfer of the lesser toes.

Correct Answer & Explanation

. Plantar fascia release, first metatarsal dorsiflexion osteotomy, and potentially a lateralizing calcaneal osteotomy if residual varus.

Explanation

For a flexible cavovarus foot, the primary deformity is often a plantarflexed first ray, leading to compensatory hindfoot varus. The standard surgical approach often involves a plantar fascia release to address tension and a dorsiflexion osteotomy of the first metatarsal (e.g., closing wedge) to correct the primary forefoot deformity. If a significant, flexible hindfoot varus persists after forefoot correction (or is deemed a major component), a lateralizing calcaneal osteotomy can be added to realign the hindfoot. Achilles lengthening is not needed if the tendon is not tight. Triple arthrodesis is for rigid, arthritic feet.

Question 6232

Topic: 8. Foot and Ankle

What is the primary role of a 'tarsal osteotomy' (e.g., a Girdlestone-Taylor tarsectomy or a V-osteotomy of the midfoot) in the management of a cavus foot?

. To correct severe, rigid midfoot collapse (flatfoot deformity).
. To address flexible forefoot supination.
. To shorten the foot for cosmetic reasons.
. To provide multiplanar correction for severe, rigid cavus deformities, particularly those with a midfoot apex.
. To improve blood supply to the forefoot.

Correct Answer & Explanation

. To provide multiplanar correction for severe, rigid cavus deformities, particularly those with a midfoot apex.

Explanation

Tarsal osteotomies (like a dorsal closing wedge osteotomy of the midfoot, a V-osteotomy, or a Girdlestone-Taylor tarsectomy) are reserved for severe, rigid cavus deformities, especially those with a significant apex in the midfoot (tarsal cavus). These procedures allow for multiplanar correction of the rigid arch deformity, enabling a more plantigrade foot by effectively 'breaking' and realigning the midfoot. They are more extensive than simple metatarsal or calcaneal osteotomies and are used when the deformity is not amenable to more limited procedures.

Question 6233

Topic: 8. Foot and Ankle

Which of the following describes the 'Lesser's sign' (or 'Helbing's sign') when inspecting the hindfoot in a cavovarus foot?

. Prominent medial malleolus.
. Lateral deviation of the Achilles tendon with respect to the calcaneal tuberosity.
. Medial deviation of the Achilles tendon with respect to the calcaneal tuberosity.
. Visibility of the posterior heel pad from the anterior aspect of the foot.
. Increased creasing in the skin of the medial arch.

Correct Answer & Explanation

. Medial deviation of the Achilles tendon with respect to the calcaneal tuberosity.

Explanation

Lesser's sign, also known as Helbing's sign, describes the medial bowing or deviation of the Achilles tendon when viewed from behind in a hindfoot varus deformity (which is typical of a cavovarus foot). As the calcaneus inverts, the Achilles tendon, which inserts into the posterior calcaneus, is pulled medially, creating a C-shaped curve or medial bow. This is in contrast to a flatfoot with hindfoot valgus, where the Achilles tendon would bow laterally.

Question 6234

Topic: 8. Foot and Ankle

A patient with a cavovarus foot experiences chronic pain at the base of the 5th metatarsal and recurrent inversion ankle sprains. This presentation suggests:

. A primary problem with the tibialis anterior tendon.
. Tightness of the Achilles tendon.
. Excessive loading of the lateral column due to hindfoot varus and forefoot adduction.
. A fixed forefoot valgus deformity.
. Generalized hypermobility of the foot.

Correct Answer & Explanation

. Excessive loading of the lateral column due to hindfoot varus and forefoot adduction.

Explanation

In a cavovarus foot, the hindfoot is in varus and the forefoot is often adducted. This leads to altered weight-bearing mechanics, concentrating pressure along the lateral border of the foot, particularly at the base of the fifth metatarsal. This increased stress can cause chronic pain (lateral foot pain, e.g., peroneus brevis tendinopathy or cuboid syndrome) and makes the foot highly susceptible to inversion ankle sprains due to chronic loading and instability on the lateral aspect. This pattern of pain and instability is highly characteristic of a cavovarus foot.

Question 6235

Topic: 8. Foot and Ankle

When assessing the relative contribution of intrinsic foot muscle weakness to claw toe deformity in a cavus foot, which test is most appropriate?

. Gastrocnemius and soleus strength test.
. Peroneus longus strength test.
. Manual muscle test of the interossei and lumbricals (e.g., ability to hold paper between toes).
. Tibialis anterior strength test.
. Flexor hallucis longus strength test.

Correct Answer & Explanation

. Manual muscle test of the interossei and lumbricals (e.g., ability to hold paper between toes).

Explanation

Claw toe deformities are strongly linked to intrinsic foot muscle weakness. The interossei and lumbricals are intrinsic muscles responsible for MTP joint flexion and PIP/DIP extension. Testing their strength, such as by asking the patient to hold a piece of paper between their toes or to actively flex their MTP joints against resistance while keeping the IP joints extended, directly assesses their function and helps quantify the degree of intrinsic muscle weakness.

Question 6236

Topic: 8. Foot and Ankle

Which of the following is considered a radiographic sign of a fixed plantarflexed first ray in a cavus foot?

. Increased calcaneal pitch angle.
. Dorsiflexed first metatarsal relative to the lesser metatarsals on an AP view.
. The first metatarsal head lies significantly plantar to the lesser metatarsal heads on a lateral view.
. Lateral subluxation of the navicular on the talus.
. Reduced talonavicular coverage angle.

Correct Answer & Explanation

. The first metatarsal head lies significantly plantar to the lesser metatarsal heads on a lateral view.

Explanation

A fixed plantarflexed first ray means the first metatarsal is abnormally angled downwards. On a lateral weight-bearing radiograph, this manifests as the first metatarsal head lying significantly more plantar (lower) than the heads of the second and third metatarsals. This causes the apex of the arch to be at the first metatarsal cuneiform joint and drives the compensatory hindfoot varus. An increased calcaneal pitch angle reflects hindfoot plantarflexion, not specifically the first ray.

Question 6237

Topic: 8. Foot and Ankle

A 5-year-old presents with a flexible cavus foot. The parents report a family history of 'high arches.' What is the most appropriate initial management strategy?

. Immediate surgical correction with multiple osteotomies.
. Custom orthotics, physical therapy focusing on stretching and strengthening, and observation.
. Referral for triple arthrodesis.
. Strict bed rest to prevent progression.
. Prescription of pain medication and activity restriction.

Correct Answer & Explanation

. Custom orthotics, physical therapy focusing on stretching and strengthening, and observation.

Explanation

For a flexible cavus foot, especially in a young child, conservative management is always the first line. This typically involves custom orthotics to support the arch and balance weight-bearing, along with physical therapy to stretch tight structures (e.g., Achilles tendon, plantar fascia) and strengthen weak muscles (e.g., tibialis anterior, intrinsic muscles). Regular observation is crucial to monitor for progression of the deformity or rigidity. Surgical intervention is reserved for progressive, painful, or rigid deformities that fail conservative measures.

Question 6238

Topic: 8. Foot and Ankle

What is the primary objective of a V-osteotomy of the first metatarsal base in cavus foot correction?

. To lengthen the first metatarsal.
. To correct fixed forefoot adduction.
. To allow for multiplanar correction of a plantarflexed and adducted first ray.
. To decompress the first metatarsophalangeal joint.
. To increase the stability of the medial column.

Correct Answer & Explanation

. To allow for multiplanar correction of a plantarflexed and adducted first ray.

Explanation

A V-osteotomy at the base of the first metatarsal is a versatile procedure used to correct a plantarflexed and often adducted first ray in a cavus foot. The V-cut allows for translation and rotation of the metatarsal head fragment, enabling correction in multiple planes (dorsiflexion for plantarflexion correction and abduction for adduction correction) without shortening the metatarsal as much as a simple closing wedge osteotomy might. It is particularly useful for achieving precise realignment of the first ray.

Question 6239

Topic: 8. Foot and Ankle

Which specific finding on a physical exam would alert you to a possible underlying spasticity contributing to a cavus foot deformity?

. Flaccid paralysis of ankle dorsiflexors.
. Absent deep tendon reflexes.
. Clonus and exaggerated deep tendon reflexes.
. Stocking-glove sensory loss.
. Significant intrinsic muscle atrophy.

Correct Answer & Explanation

. Clonus and exaggerated deep tendon reflexes.

Explanation

Spasticity (increased muscle tone, velocity-dependent resistance to stretch) is a hallmark of upper motor neuron lesions (e.g., cerebral palsy, spinal cord injury/tumor). In a cavus foot, spasticity of calf muscles or tibialis posterior can contribute to the deformity. Clinical signs of spasticity include clonus (rhythmic, involuntary muscle contractions in response to sustained stretch) and exaggerated deep tendon reflexes. Flaccid paralysis, absent reflexes, and stocking-glove sensory loss are characteristic of lower motor neuron or peripheral nerve pathology.

Question 6240

Topic: 8. Foot and Ankle

A cavus foot deformity where the primary problem is a dorsiflexed calcaneus, leading to increased weight-bearing on the heel and forefoot, and a relatively horizontal talus, is described as:

. Equinocavus.
. Forefoot cavus.
. Pes calcaneocavus.
. Tarsal cavus.
. Idiopathic cavovarus.

Correct Answer & Explanation

. Pes calcaneocavus.

Explanation

Pes calcaneocavus is a specific morphological subtype of cavus foot characterized by a dorsiflexed calcaneus relative to the talus, often resulting in a horizontal talus and a reduced or even negative calcaneal pitch angle. This leads to an increased load on the heel and forefoot. It is distinct from the more common cavovarus, where the calcaneus is plantarflexed (increased calcaneal pitch) and in varus.

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