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8. Foot and Ankle MCQs

Practice Set 314 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 6261

Topic: Ankle Trauma & Sports

What is the typical timeframe for initiating protected weight-bearing after a modified Brostrom-Gould procedure?

. Immediately post-op with full weight-bearing.
. Non-weight-bearing for 6 weeks, then gradual progression.
. Partial weight-bearing in a boot or brace after 2 weeks.
. Full weight-bearing after 3 months.
. Non-weight-bearing for 3 months.

Correct Answer & Explanation

. Partial weight-bearing in a boot or brace after 2 weeks.

Explanation

After a modified Brostrom-Gould procedure, protected weight-bearing typically begins after 2 weeks in a walking boot or brace, often progressing to full weight-bearing by 4-6 weeks, depending on surgeon preference and patient progress. Immediate full weight-bearing is generally avoided to protect the repair. Non-weight-bearing for 6 weeks or 3 months is too conservative for most primary repairs, and full weight-bearing at 3 months is usually when more advanced activities are initiated.

Question 6262

Topic: 8. Foot and Ankle

Which imaging modality is most useful for diagnosing an associated intra-articular loose body in a patient with chronic lateral ankle instability and persistent mechanical symptoms?

. Plain radiographs
. MRI
. CT scan
. Ultrasound
. Bone scan

Correct Answer & Explanation

. CT scan

Explanation

While MRI is excellent for soft tissue and bone edema, a CT scan is superior for identifying bony intra-articular loose bodies due to its high resolution in bone detail. Plain radiographs can show larger, radio-opaque loose bodies, but may miss smaller ones. MRI can sometimes miss small bony loose bodies, especially if they are purely cartilaginous and not ossified. Ultrasound is useful for tendons but not intra-articular loose bodies. Bone scan indicates metabolic activity but not specific morphology.

Question 6263

Topic: 8. Foot and Ankle

Which of the following criteria is NOT typically used to define chronic ankle instability?

. Recurrent episodes of ankle 'giving way' or apprehension.
. Persistent symptoms for at least 3-6 months.
. Objective mechanical laxity on physical examination or stress radiographs.
. Failure of previous surgical stabilization attempts.
. A history of at least two lateral ankle sprains.

Correct Answer & Explanation

. Recurrent episodes of ankle 'giving way' or apprehension.

Explanation

Chronic ankle instability is typically defined by recurrent episodes of 'giving way' or apprehension, persistent symptoms for at least 3-6 months despite adequate conservative treatment, and often objective mechanical laxity. A history of multiple sprains (usually at least two) is also commonly associated. Failure of previous surgical stabilization attempts is a criterion for revision surgery, not a primary diagnostic criterion for the initial diagnosis of chronic ankle instability itself.

Question 6264

Topic: 8. Foot and Ankle

A 19-year-old athlete undergoes a modified Brostrom-Gould procedure for chronic lateral ankle instability. Postoperatively, he experiences persistent burning pain and numbness along the lateral aspect of his foot, extending to his little toe. Which nerve is most likely affected?

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

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve supplies sensory innervation to the lateral aspect of the ankle, the lateral border of the foot, and the little toe. Given its superficial course in the surgical field for a lateral ankle stabilization, it is the most common nerve to be injured or irritated, leading to symptoms of burning pain, numbness, or dysesthesia in its distribution. The superficial peroneal nerve typically supplies the dorsum of the foot, deep peroneal the web space, saphenous the medial ankle, and medial plantar the sole of the foot.

Question 6265

Topic: 8. Foot and Ankle

Which of the following factors would most strongly favor surgical intervention over continued conservative management for chronic lateral ankle instability?

. Occasional 'giving way' during high-impact sports only.
. Generalized hypermobility with a Beighton score of 8/9.
. Persistent mechanical instability on stress radiographs despite 6 months of supervised rehabilitation.
. Patient preference for non-surgical options.
. Moderate swelling and tenderness over the ATFL region.

Correct Answer & Explanation

. Persistent mechanical instability on stress radiographs despite 6 months of supervised rehabilitation.

Explanation

Persistent mechanical instability demonstrated on stress radiographs, despite a prolonged and adequate course of supervised rehabilitation, is the strongest indication for surgical intervention. This indicates that conservative measures have failed to restore sufficient stability. Occasional giving way might be managed conservatively. Generalized hypermobility makes surgical repair more challenging and might lead to considering augmentation or reconstruction, but it doesn't alone mandate surgery. Patient preference is important but doesn't override objective findings. Swelling and tenderness are symptoms but not definitive indicators for surgery.

Question 6266

Topic: 8. Foot and Ankle

What is the role of the posterior talofibular ligament (PTFL) in ankle stability?

. It is the primary restraint to anterior talar translation.
. It primarily resists inversion in dorsiflexion.
. It provides stability against posterior talar displacement.
. It stabilizes the distal tibiofibular joint.
. It is part of the deltoid ligament complex.

Correct Answer & Explanation

. It provides stability against posterior talar displacement.

Explanation

The posterior talofibular ligament (PTFL) is the strongest of the lateral ankle ligaments. Its primary role is to resist posterior talar displacement and excessive ankle dorsiflexion. It is rarely injured in isolation, typically requiring severe ankle trauma, such as dislocations or fracture-dislocations. The ATFL resists anterior translation, the CFL resists inversion, and the AITFL stabilizes the syndesmosis.

Question 6267

Topic: 8. Foot and Ankle

A patient with chronic lateral ankle instability complains of anterior ankle pain, particularly during activity. On examination, a painful clunk is elicited with forced dorsiflexion and palpation of the anterolateral gutter. What is the most likely additional diagnosis?

. Posterior tibial tendon dysfunction
. Peroneal tendon subluxation
. Anterolateral impingement syndrome
. Tarsal tunnel syndrome
. Flexor hallucis longus tenosynovitis

Correct Answer & Explanation

. Anterolateral impingement syndrome

Explanation

Anterolateral impingement syndrome is a common sequela of ankle sprains and chronic instability. It presents with anterior ankle pain, especially with dorsiflexion, and a painful 'clunk' or tenderness in the anterolateral gutter. This is often due to synovitis, scar tissue, or osteophytes forming in this space. Other options are less likely given the specific symptoms: PTTD is medial, peroneal subluxation is lateral with popping, tarsal tunnel is posterior-medial nerve entrapment, and FHL tenosynovitis is posterior ankle pain with big toe movement.

Question 6268

Topic: 8. Foot and Ankle

What is the main concern with using tenodesis procedures (e.g., Chrisman-Snook or Watson-Jones) for lateral ankle reconstruction compared to anatomical repairs (e.g., modified Brostrom)?

. They are technically more demanding.
. They have a higher risk of sural nerve injury.
. They can alter normal ankle biomechanics and lead to stiffness or loss of motion.
. They are less effective in providing long-term stability.
. They are associated with higher rates of infection.

Correct Answer & Explanation

. They can alter normal ankle biomechanics and lead to stiffness or loss of motion.

Explanation

Tenodesis procedures like Chrisman-Snook or Watson-Jones use portions of the peroneal tendons to create a new ligamentous restraint. While effective in providing stability, a major concern is that they are non-anatomical reconstructions, which can alter normal ankle biomechanics, potentially leading to overtightening, stiffness, restricted range of motion, and even subtalar joint arthrosis over time. Anatomical repairs aim to restore the native ligamentous anatomy more precisely. Risk of nerve injury or infection is general to any surgery, and their effectiveness is generally good, but biomechanical alteration is a key distinction.

Question 6269

Topic: 8. Foot and Ankle

When performing a modified Brostrom procedure, what is the significance of tensioning the repaired ligaments with the foot in slight eversion and dorsiflexion?

. This position helps to isolate the ATFL for primary repair.
. This over-tensions the repair to ensure maximum stability.
. This prevents injury to the sural nerve during closure.
. This reduces tension on the repaired ligaments during the immediate postoperative period.
. This is the functional position that the ankle should be able to achieve postoperatively without excessive laxity.

Correct Answer & Explanation

. This is the functional position that the ankle should be able to achieve postoperatively without excessive laxity.

Explanation

Tensioning the repaired ligaments in slight eversion and dorsiflexion is a critical step in the modified Brostrom procedure. This position ensures that the repair is taut enough to prevent recurrent inversion, but not so tight as to restrict normal ankle motion. It aims to achieve a stable, yet mobile, ankle in its functional range. Over-tensioning can lead to stiffness, while inadequate tensioning can result in persistent laxity.

Question 6270

Topic: 8. Foot and Ankle

What diagnostic finding is most indicative of a chronic syndesmotic instability?

. Increased talar tilt on inversion stress radiographs.
. Anterior talar translation on anterior drawer stress radiographs.
. Widening of the tibiofibular clear space and/or medial clear space on weight-bearing or stress mortise views.
. Osteochondral lesion of the talus on MRI.
. Tenderness over the ATFL insertion.

Correct Answer & Explanation

. Widening of the tibiofibular clear space and/or medial clear space on weight-bearing or stress mortise views.

Explanation

Chronic syndesmotic instability is characterized by pathological motion at the distal tibiofibular joint. Radiographically, this is best demonstrated by widening of the tibiofibular clear space and/or the medial clear space on weight-bearing or stress mortise views. This indicates disruption of the syndesmotic ligaments (AITFL, PITFL, interosseous membrane). Increased talar tilt and anterior talar translation are indicative of lateral ankle ligamentous instability, while OCLs are common concomitant findings. Tenderness over the ATFL is a sign of lateral ankle sprain.

Question 6271

Topic: 8. Foot and Ankle

What is the primary reason for performing an ankle arthroscopy prior to or concurrently with an open lateral ankle ligament repair?

. To obtain tissue samples for biopsy.
. To confirm the diagnosis of ligamentous rupture.
. To address concomitant intra-articular pathologies, such as osteochondral lesions or impingement.
. To significantly reduce the overall surgical time.
. To allow for earlier weight-bearing postoperatively.

Correct Answer & Explanation

. To address concomitant intra-articular pathologies, such as osteochondral lesions or impingement.

Explanation

Ankle arthroscopy is often performed prior to or concurrently with an open lateral ankle ligament repair primarily to identify and address concomitant intra-articular pathologies that are frequently associated with chronic instability, such as osteochondral lesions of the talus, synovitis, loose bodies, or anterolateral impingement. These conditions, if left untreated, can contribute to persistent pain and unsatisfactory outcomes even after the ligaments are stabilized. While it can confirm rupture, its main utility in this context is addressing other issues.

Question 6272

Topic: 8. Foot and Ankle

A patient reports recurrent episodes of a 'giving way' sensation and pain over the lateral aspect of the ankle, specifically posterior to the lateral malleolus, with active eversion. What additional physical exam maneuver should be performed to assess this specific complaint?

. Anterior drawer test
. Talar tilt test
. Peroneal tendon subluxation test (resisted eversion with dorsiflexion)
. Thompson test
. Calcaneal squeeze test

Correct Answer & Explanation

. Peroneal tendon subluxation test (resisted eversion with dorsiflexion)

Explanation

Recurrent 'giving way' and pain posterior to the lateral malleolus, especially with active eversion, is highly suspicious for peroneal tendon subluxation or dislocation. The peroneal tendon subluxation test (also known as the peroneal snap test or resisted eversion with dorsiflexion) involves actively or passively dorsiflexing and everting the ankle against resistance, which can reproduce the subluxation/dislocation of the peroneal tendons and elicit pain or a snapping sensation. Anterior drawer and talar tilt tests assess ligamentous instability. Thompson test assesses Achilles integrity, and calcaneal squeeze tests for calcaneal fracture.

Question 6273

Topic: Ankle Trauma & Sports

Which of the following patient populations is generally NOT considered a good candidate for primary lateral ankle ligament repair (e.g., modified Brostrom procedure)?

. Young, high-demand athlete with recurrent instability.
. Patient with chronic instability, no significant generalized laxity, and good tissue quality.
. Patient with significant generalized ligamentous laxity and poor quality local tissues.
. Patient who has failed 6 months of comprehensive physiotherapy.
. Patient with isolated ATFL and CFL insufficiency.

Correct Answer & Explanation

. Patient with significant generalized ligamentous laxity and poor quality local tissues.

Explanation

Patients with significant generalized ligamentous laxity (e.g., high Beighton score) and poor quality local tissues are generally not good candidates for primary repair (like modified Brostrom). In these cases, the native tissues are often too attenuated or inherently weak to provide long-lasting stability, leading to a higher failure rate. For such patients, an anatomical reconstruction using an autograft or allograft is often a more appropriate choice. Other listed groups are generally good candidates for primary repair if indicated.

Question 6274

Topic: 8. Foot and Ankle

What is the term for the subjective feeling of instability or apprehension, often without demonstrable mechanical laxity on examination, after an ankle sprain?

. Mechanical instability
. Chronic ankle sprain
. Ligamentous insufficiency
. Functional ankle instability
. Recurrent sprain syndrome

Correct Answer & Explanation

. Functional ankle instability

Explanation

Functional ankle instability refers to the subjective feeling of the ankle 'giving way' or apprehension despite the absence of objective mechanical laxity. This is thought to be related to impaired proprioception and neuromuscular control. Mechanical instability, in contrast, involves objective evidence of ligamentous laxity. Chronic ankle sprain is a broader term for persistent symptoms, and ligamentous insufficiency denotes actual damage to ligaments.

Question 6275

Topic: 8. Foot and Ankle

During an oral examination, when asked about indications for surgery for chronic lateral ankle instability, which 'C' is NOT typically part of the 'Triple C' criteria?

. Chronic instability (symptoms > 6 months)
. Conservative treatment failure
. Concomitant pathology (e.g., OCL, impingement)
. Cosmetic deformity (of the foot and ankle)
. Clinical instability (positive stress tests)

Correct Answer & Explanation

. Cosmetic deformity (of the foot and ankle)

Explanation

The 'Triple C' criteria for surgical indications for chronic lateral ankle instability typically refer to: 1) Chronic symptoms (usually >6 months), 2) Conservative treatment failure, and 3) Clinical/mechanical instability (demonstrated by positive stress tests or stress radiographs), sometimes also including Concomitant pathology. Cosmetic deformity is not a medical indication for surgery in the context of chronic ankle instability.

Question 6276

Topic: 8. Foot and Ankle

A patient develops a painful neuroma along the lateral aspect of their ankle following an ankle sprain. Which nerve is most commonly involved in this scenario?

. Deep peroneal nerve
. Sural nerve
. Tibial nerve
. Saphenous nerve
. Common peroneal nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve is the most common nerve to be involved in neuroma formation along the lateral aspect of the ankle following trauma, including ankle sprains or surgery. Its superficial course makes it vulnerable to direct injury or entrapment within scar tissue, leading to a painful neuroma. The deep peroneal nerve is more anterior, tibial nerve posterior-medial, saphenous medial, and common peroneal nerve more proximal.

Question 6277

Topic: Ankle Trauma & Sports

Which examination technique involves stabilizing the distal tibia with one hand and inverting the hindfoot with the other, primarily to assess the integrity of the CFL?

. Anterior drawer test
. Talar tilt test (inversion stress)
. External rotation stress test
. Squeeze test
. Kleiger test

Correct Answer & Explanation

. Talar tilt test (inversion stress)

Explanation

The talar tilt test, specifically applying an inversion stress with the ankle in neutral or slight dorsiflexion, primarily assesses the integrity of the calcaneofibular ligament (CFL). Increased talar tilt compared to the contralateral side suggests CFL insufficiency. The anterior drawer test assesses the ATFL. External rotation and squeeze tests are for syndesmotic injuries, and Kleiger test is also for syndesmotic and deltoid ligament integrity.

Question 6278

Topic: Ankle Trauma & Sports

A patient presents with a chronic high ankle sprain, affecting the syndesmosis. Which ligament is the primary static stabilizer of the distal tibiofibular syndesmosis?

. 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

The anterior inferior tibiofibular ligament (AITFL) is the primary static stabilizer of the distal tibiofibular syndesmosis, along with the posterior inferior tibiofibular ligament (PITFL) and the interosseous membrane. The ATFL, CFL, and PTFL are components of the lateral ankle complex, not the syndesmosis. The deltoid ligament is on the medial side of the ankle.

Question 6279

Topic: 8. Foot and Ankle

Which type of orthosis is generally recommended for conservative management of chronic lateral ankle instability to provide both support and allow for rehabilitation?

. Soft compression sleeve
. Rigid custom ankle-foot orthosis (AFO)
. Semi-rigid ankle stirrup brace
. Post-operative cam walker boot
. Basic athletic tape

Correct Answer & Explanation

. Semi-rigid ankle stirrup brace

Explanation

A semi-rigid ankle stirrup brace (e.g., ASO, Air-Stirrup) is generally recommended for conservative management of chronic lateral ankle instability. These braces provide mechanical support to limit inversion and eversion while still allowing for some dorsiflexion and plantarflexion, thus enabling rehabilitation exercises and activity. A soft sleeve offers minimal support. A rigid AFO is too restrictive for most rehabilitation. A cam walker boot is used for acute injury or post-operatively, not typically for chronic instability management during activity. Athletic tape provides support but often loses effectiveness and can cause skin irritation.

Question 6280

Topic: 8. Foot and Ankle

Which anatomical structure is responsible for dynamically everting the foot and resisting excessive inversion, thereby complementing the lateral ankle ligaments?

. Tibialis anterior tendon
. Flexor digitorum longus tendon
. Peroneus brevis tendon
. Posterior tibialis tendon
. Achilles tendon

Correct Answer & Explanation

. Peroneus brevis tendon

Explanation

The peroneal tendons (peroneus longus and brevis) are the primary dynamic stabilizers responsible for everting the foot and resisting excessive inversion. They act as active protectors against ankle sprains, complementing the static stability provided by the lateral ankle ligaments. The tibialis anterior and posterior tibialis are invertors (or dorsiflexors/plantarflexors). The flexor digitorum longus flexes toes, and the Achilles tendon plantarflexes the ankle.

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