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8. Foot and Ankle MCQs

Practice Set 313 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 6241

Topic: 8. Foot and Ankle

In an adolescent with a progressive cavus foot, what is the most important long-term complication to prevent with appropriate management?

. Development of bunions and hammertoes.
. Chronic lateral ankle instability and progressive arthritis of the hindfoot.
. Cosmetic dissatisfaction and difficulty with shoe wear.
. Plantar fasciitis and Achilles tendinopathy.
. Stress fractures of the metatarsals.

Correct Answer & Explanation

. Chronic lateral ankle instability and progressive arthritis of the hindfoot.

Explanation

While bunions, hammertoes, cosmetic issues, plantar fasciitis, and stress fractures are common problems in cavus feet, the most significant long-term complications that impact function and require more aggressive surgical intervention are chronic lateral ankle instability and progressive degenerative arthritis of the hindfoot (subtalar and midtarsal joints). The varus hindfoot puts chronic stress on the lateral ankle ligaments and leads to uneven loading of the subtalar joint, ultimately causing pain and debilitating arthritis. Preventing these severe joint issues is a primary goal of comprehensive management.

Question 6242

Topic: 8. Foot and Ankle

A 30-year-old runner sustains an acute inversion injury to his right ankle. He presents to the emergency department unable to bear weight. Radiographs are ordered. According to the Ottawa Ankle Rules, which of the following findings would necessitate ankle radiographs?

. Pain in the malleolar zone and an inability to bear weight immediately after the injury and in the emergency department
. Ecchymosis and swelling over the lateral malleolus
. Tenderness over the medial malleolus only
. Limited range of motion in dorsiflexion
. Pain in the malleolar zone and tenderness over the base of the fifth metatarsal

Correct Answer & Explanation

. Pain in the malleolar zone and an inability to bear weight immediately after the injury and in the emergency department

Explanation

The Ottawa Ankle Rules state that ankle radiographs are required if there is pain in the malleolar zone AND any of the following: inability to bear weight both immediately and in the emergency department (four steps), or bone tenderness at the posterior edge or tip of the lateral malleolus, or bone tenderness at the posterior edge or tip of the medial malleolus. Therefore, pain in the malleolar zone and an inability to bear weight immediately after the injury and in the emergency department is a clear indication for radiographs. Tenderness over the base of the fifth metatarsal would necessitate foot radiographs, not necessarily ankle radiographs, unless there is also malleolar zone pain. Ecchymosis, swelling, and limited range of motion are common symptoms but not standalone indications for radiographs according to Ottawa Ankle Rules.

Question 6243

Topic: 8. Foot and Ankle

Which of the following describes the anatomical relationship of the calcaneofibular ligament (CFL)?

. It originates from the distal anterior fibula and inserts onto the lateral talus.
. It runs anteriorly from the distal fibula to the calcaneus, deep to the peroneal tendons.
. It is an extracapsular ligament that runs posteriorly and inferiorly from the fibula to the calcaneus, superficial to the peroneal tendons.
. It is an extracapsular ligament that runs anteriorly and inferiorly from the fibula to the calcaneus, deep to the peroneal tendons.
. It originates from the posterior fibula and inserts onto the posterior talus.

Correct Answer & Explanation

. It is an extracapsular ligament that runs anteriorly and inferiorly from the fibula to the calcaneus, deep to the peroneal tendons.

Explanation

The CFL is an extracapsular ligament that runs anteriorly and inferiorly from the distal fibula to the lateral aspect of the calcaneus. Crucially, it runs deep to the peroneal tendons. The ATFL originates from the distal anterior fibula and inserts onto the lateral talus. The PTFL originates from the posterior fibula and inserts onto the posterior talus. The CFL's deep relationship to the peroneal tendons is important for surgical approaches.

Question 6244

Topic: 8. Foot and Ankle

Which of the following is considered a dynamic stabilizer of the lateral ankle?

. Anterior talofibular ligament
. Calcaneofibular ligament
. Peroneus longus and brevis muscles
. Posterior talofibular ligament
. Interosseous membrane

Correct Answer & Explanation

. Peroneus longus and brevis muscles

Explanation

Dynamic stabilizers are muscles and their tendons that cross a joint and contribute to its stability through active contraction. The peroneus longus and brevis muscles are the primary dynamic stabilizers of the lateral ankle, actively resisting inversion and providing eversion force. The ATFL, CFL, and PTFL are static stabilizers (ligaments). The interosseous membrane stabilizes the tibia and fibula proximally.

Question 6245

Topic: 8. Foot and Ankle

A 16-year-old female high school basketball player presents with persistent pain, swelling, and recurrent 'popping' sensation over the lateral ankle after an inversion injury 3 months ago. Examination reveals tenderness along the course of the peroneal tendons, and she is able to voluntarily sublux her peroneal tendons over the lateral malleolus. What is the most likely diagnosis?

. Chronic lateral ankle instability with ATFL tear
. Peroneal tendon subluxation/dislocation
. Ankle impingement syndrome
. Osteochondral lesion of the talus
. Sural nerve entrapment

Correct Answer & Explanation

. Peroneal tendon subluxation/dislocation

Explanation

Recurrent 'popping' or 'snapping' over the lateral malleolus, combined with tenderness along the peroneal tendons and the ability to voluntarily sublux them, is highly suggestive of peroneal tendon subluxation or dislocation. This often occurs after an acute dorsiflexion-eversion injury, but can be mistaken for or coexist with lateral ankle sprains. While chronic instability, impingement, OCLs, and nerve entrapment can cause lateral ankle pain, the specific symptom of 'popping' and demonstrable subluxation points directly to peroneal tendon pathology.

Question 6246

Topic: Ankle Trauma & Sports

What is the typical mechanism of injury for a lateral ankle sprain involving the ATFL?

. Dorsiflexion and eversion
. Plantarflexion and inversion
. Isolated dorsiflexion
. Isolated inversion
. Plantarflexion and eversion

Correct Answer & Explanation

. Plantarflexion and inversion

Explanation

The most common mechanism of injury for a lateral ankle sprain, specifically involving the ATFL, is plantarflexion and inversion. In this position, the ATFL is most taut and therefore most susceptible to injury. Dorsiflexion and eversion are more associated with syndesmotic or deltoid ligament injuries. Isolated dorsiflexion or inversion without a plantarflexion component is less common for ATFL injury.

Question 6247

Topic: 8. Foot and Ankle

When evaluating a patient with chronic lateral ankle instability, what is the primary purpose of obtaining stress radiographs (anterior drawer and talar tilt views)?

. To assess for associated osteochondral lesions of the talus.
. To visualize the extent of soft tissue edema and inflammation.
. To objectively quantify the degree of mechanical laxity.
. To identify potential fractures not visible on routine radiographs.
. To evaluate the integrity of the peroneal tendons.

Correct Answer & Explanation

. To objectively quantify the degree of mechanical laxity.

Explanation

Stress radiographs (anterior drawer and talar tilt views) are crucial for objectively quantifying the degree of mechanical laxity in chronic lateral ankle instability. They provide direct measurements of anterior talar translation and talar tilt, which can confirm and grade the instability. While other imaging modalities (MRI, CT) or plain radiographs serve other purposes, stress views specifically assess the functional laxity of the joint. OCLs are better seen on MRI/CT, soft tissue edema on MRI, and fractures on plain radiographs/CT. Peroneal tendons are best evaluated clinically and with MRI.

Question 6248

Topic: 8. Foot and Ankle

A 28-year-old patient presents with chronic lateral ankle pain and instability after multiple sprains. Physical exam reveals tenderness over the anterior aspect of the lateral malleolus, and a positive anterior drawer test. Which of the following is a common differential diagnosis for persistent lateral ankle pain that should be considered in addition to ligamentous instability?

. Posterior impingement syndrome
. Achilles tendonitis
. Tarsal tunnel syndrome
. Anterolateral impingement syndrome
. Medial deltoid ligament tear

Correct Answer & Explanation

. Anterolateral impingement syndrome

Explanation

Anterolateral impingement syndrome, often due to synovitis or scar tissue formation in the ankle joint's anterolateral gutter, is a common cause of persistent pain after an ankle sprain, even when instability has been addressed or is being managed. It can mimic or coexist with mechanical instability. Posterior impingement involves the posterior ankle, Achilles tendonitis affects the posterior heel/calf, tarsal tunnel syndrome involves the posterior tibial nerve on the medial side, and a medial deltoid ligament tear is a medial ankle injury.

Question 6249

Topic: 8. Foot and Ankle

What is considered a normal anterior talar translation on stress radiographs (anterior drawer view) for an adult ankle?

. Less than 3 mm
. Less than 5 mm
. Less than 8 mm
. Less than 10 mm
. Less than 12 mm

Correct Answer & Explanation

. Less than 3 mm

Explanation

Generally, an anterior talar translation of less than 3 mm is considered normal. A difference of more than 3 mm compared to the contralateral ankle, or an absolute translation greater than 8-10 mm, is often indicative of ATFL insufficiency. However, thresholds can vary slightly between studies. The question asks for 'normal', so less than 3mm is the most appropriate answer.

Question 6250

Topic: 8. Foot and Ankle

Which of the following describes 'functional ankle instability'?

. Objective laxity of the lateral ankle ligaments on stress radiographs.
. Recurrent episodes of ankle 'giving way' due to ligamentous rupture.
. Subjective feeling of instability or apprehension without demonstrable mechanical laxity.
. Instability caused by a congenital deformity of the ankle joint.
. Pathologic scarring leading to joint stiffness and decreased range of motion.

Correct Answer & Explanation

. Subjective feeling of instability or apprehension without demonstrable mechanical laxity.

Explanation

Functional ankle instability refers to a subjective feeling of the ankle 'giving way' or apprehension, without objective evidence of mechanical laxity on physical examination or stress radiographs. This is often attributed to impaired proprioception, neuromuscular control deficits, or dynamic muscular weakness. Mechanical instability, in contrast, refers to objective laxity of the ligaments. Functional instability is often managed with intensive proprioceptive and strengthening rehabilitation.

Question 6251

Topic: Ankle Trauma & Sports
In an acute Grade III lateral ankle sprain, which ligaments are typically involved?
. Only the ATFL
. ATFL and CFL
. ATFL, CFL, and PTFL
. ATFL and AITFL
. CFL and PTFL

Correct Answer & Explanation

. ATFL and CFL

Explanation

A Grade III lateral ankle sprain typically involves a complete rupture of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). The posterior talofibular ligament (PTFL) is rarely injured in isolation and usually only in severe dislocations or fracture-dislocations. The AITFL is part of the syndesmosis. Therefore, ATFL and CFL are the key ligaments in a Grade III lateral ankle sprain.

Question 6252

Topic: 8. Foot and Ankle

What is the primary goal of the initial RICE (Rest, Ice, Compression, Elevation) protocol for an acute lateral ankle sprain?

. To accelerate ligamentous healing and strength.
. To prevent chronic instability and return to sport quickly.
. To minimize swelling, pain, and facilitate early rehabilitation.
. To objectively assess the degree of ligamentous injury.
. To prepare the ankle for immediate surgical intervention.

Correct Answer & Explanation

. To minimize swelling, pain, and facilitate early rehabilitation.

Explanation

The primary goal of the RICE protocol (Rest, Ice, Compression, Elevation) for an acute lateral ankle sprain is to minimize swelling, reduce pain, and control inflammation, thereby facilitating early mobilization and rehabilitation. It does not directly accelerate ligamentous healing or prevent chronic instability in the long term, nor is it for objective assessment or immediate surgical preparation. It's a foundational acute management strategy.

Question 6253

Topic: 8. Foot and Ankle

Which nerve is most at risk of injury during a lateral ankle ligament reconstruction (e.g., modified Brostrom procedure)?

. Deep peroneal nerve
. Superficial peroneal nerve (musculocutaneous nerve)
. Sural nerve
. Tibial nerve
. Saphenous nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve is the most commonly injured nerve during lateral ankle ligament reconstruction procedures due to its superficial course along the lateral aspect of the ankle, often close to the incision site for ATFL and CFL repair. The superficial peroneal nerve is also at risk, but the sural nerve's anatomical proximity makes it particularly vulnerable. The deep peroneal nerve is anterior, the tibial nerve is posterior-medial, and the saphenous nerve is medial.

Question 6254

Topic: 8. Foot and Ankle

What is the main advantage of an arthroscopic approach for lateral ankle stabilization (e.g., arthroscopic Brostrom) compared to open techniques?

. Reduced rehabilitation time and earlier return to sport.
. Superior long-term stability outcomes.
. Better visualization of posterior subtalar joint pathology.
. Decreased soft tissue dissection and potentially fewer complications like sural nerve injury.
. Ability to repair the PTFL directly.

Correct Answer & Explanation

. Decreased soft tissue dissection and potentially fewer complications like sural nerve injury.

Explanation

The main advantages of an arthroscopic approach for lateral ankle stabilization include decreased soft tissue dissection, smaller incisions, and potentially fewer complications such as sural nerve injury, as the direct ligament repair is performed percutaneously or through smaller portals. While rehabilitation may be similar, superior long-term stability is still debated, and direct PTFL repair is uncommon. Visualization of the posterior subtalar joint is not the primary advantage; rather, it's the minimally invasive nature for the lateral ankle complex.

Question 6255

Topic: 8. Foot and Ankle

In the context of chronic ankle instability, what is the significance of a subtle cavovarus foot deformity?

. It makes the ankle more prone to eversion sprains.
. It is a protective factor against recurrent inversion sprains.
. It increases the risk of recurrent inversion sprains due to a functionally supinated foot position.
. It is always a contraindication to a modified Brostrom repair.
. It has no significant impact on ankle stability.

Correct Answer & Explanation

. It increases the risk of recurrent inversion sprains due to a functionally supinated foot position.

Explanation

A subtle cavovarus foot deformity (high arch with hindfoot varus) significantly increases the risk of recurrent inversion ankle sprains. The functionally supinated position of the foot places the ankle in a position of mechanical disadvantage, making it more susceptible to inversion injuries and exacerbating chronic instability. It must be addressed pre-operatively, as isolated ligamentous repair in the presence of a significant cavovarus foot can lead to failure. It is not a protective factor and does not exclusively contraindicate Brostrom but necessitates addressing the underlying foot alignment.

Question 6256

Topic: Ankle Trauma & Sports

Which of the following ligaments is taut during ankle dorsiflexion and therefore best assessed for inversion instability in this position?

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

Correct Answer & Explanation

. Calcaneofibular ligament (CFL)

Explanation

The calcaneofibular ligament (CFL) is taut in dorsiflexion, which makes this the optimal position to assess its integrity using the talar tilt test. The ATFL is taut in plantarflexion and resists anterior translation. The PTFL resists posterior translation. The deltoid ligament is on the medial side, and the AITFL is part of the syndesmosis.

Question 6257

Topic: 8. Foot and Ankle

Which of the following is an absolute contraindication for a modified Brostrom-Gould procedure?

. Generalized ligamentous laxity (Beighton score 7/9)
. Presence of an osteochondral lesion of the talus
. Significant cavovarus foot deformity
. Failure of previous conservative treatment
. Concomitant peroneal tendinopathy

Correct Answer & Explanation

. Significant cavovarus foot deformity

Explanation

A significant cavovarus foot deformity is often considered a relative or absolute contraindication to an isolated modified Brostrom-Gould procedure because the underlying biomechanical malalignment will place excessive stress on the repair, leading to a high risk of failure. In such cases, a concomitant osteotomy (e.g., lateralizing calcaneal osteotomy) to correct the hindfoot alignment is necessary. Generalized ligamentous laxity and concomitant OCL or peroneal tendinopathy are not absolute contraindications but rather indications for an augmented repair/reconstruction or addressing the concomitant pathology, respectively. Failure of conservative treatment is an indication for surgery.

Question 6258

Topic: 8. Foot and Ankle

What finding on a standard mortise view radiograph would suggest a possible syndesmotic injury in the setting of an ankle sprain?

. Increased talar tilt
. Anterior talar translation
. Widening of the medial clear space and/or tibiofibular clear space
. Posterior subluxation of the talus
. Os trigonum syndrome

Correct Answer & Explanation

. Widening of the medial clear space and/or tibiofibular clear space

Explanation

On a standard mortise view radiograph, widening of the medial clear space (space between the medial malleolus and the talus, normally <4mm) and/or widening of the tibiofibular clear space (distance between the fibula and the posterior tibia, normally <6mm) are suggestive of a syndesmotic injury. These findings indicate disruption of the ligaments that bind the distal tibia and fibula together. Increased talar tilt and anterior talar translation are signs of lateral ankle instability, not syndesmotic injury. Posterior subluxation and os trigonum syndrome are other pathologies.

Question 6259

Topic: 8. Foot and Ankle

During rehabilitation for chronic lateral ankle instability, what is the primary focus of balance and proprioceptive training?

. To increase the bulk of the peroneal muscles.
. To enhance the passive stability provided by the ligaments.
. To improve neuromuscular control and reflex responses to sudden perturbations.
. To reduce the overall weight-bearing load on the ankle joint.
. To stretch tight Achilles tendon complexes.

Correct Answer & Explanation

. To improve neuromuscular control and reflex responses to sudden perturbations.

Explanation

Balance and proprioceptive training primarily aim to improve neuromuscular control and reflex responses to sudden perturbations. This enhances the dynamic stability of the ankle, allowing muscles to react quickly and appropriately to prevent recurrent sprains, even in the presence of some mechanical laxity. While peroneal muscle strength is part of rehabilitation, proprioceptive training focuses on nerve-muscle coordination. Ligaments provide passive stability; proprioception augments dynamic stability. Weight-bearing and Achilles stretching are other components of rehab but not the primary focus of proprioception.

Question 6260

Topic: 8. Foot and Ankle

Which of the following conditions is most likely to mimic the symptoms of chronic lateral ankle instability but is primarily due to inflammation of the soft tissues around the lateral malleolus, rather than ligamentous laxity?

. Chronic osteochondral lesion of the talus
. Peroneal tendinopathy
. Syndesmotic instability
. Tarsal coalition
. Ankle arthritis

Correct Answer & Explanation

. Peroneal tendinopathy

Explanation

Peroneal tendinopathy (inflammation or degeneration of the peroneal tendons) can cause chronic lateral ankle pain, swelling, and a feeling of weakness or instability, closely mimicking ligamentous instability. However, the primary pathology is in the tendon, not the ligaments themselves. While OCLs, syndesmotic instability, tarsal coalition, and arthritis can also cause lateral ankle pain, peroneal tendinopathy is a particularly common mimic and often coexists with chronic ligamentous instability.

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