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8. Foot and Ankle MCQs

Practice Set 331 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 6601

Topic: 8. Foot and Ankle

The Lisfranc ligament, critical for maintaining midfoot stability, primarily connects which two osseous structures?

. Medial cuneiform to the base of the first metatarsal
. Medial cuneiform to the base of the second metatarsal
. Middle cuneiform to the base of the second metatarsal
. Cuboid to the base of the fourth metatarsal
. Navicular to the medial cuneiform

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is an interosseous ligament that runs obliquely from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the strongest and most crucial ligament for the stability of the tarsometatarsal articulation.

Question 6602

Topic: 8. Foot and Ankle

Acute Achilles tendon ruptures most frequently occur in a relatively hypovascular 'watershed' area. Where is this zone located relative to the calcaneal insertion?

. At the direct osseous insertion
. 2 to 6 cm proximal to the insertion
. 8 to 10 cm proximal to the insertion
. At the musculotendinous junction
. In the deep fascial compartment of the soleus

Correct Answer & Explanation

. 2 to 6 cm proximal to the insertion

Explanation

The Achilles tendon has a relative watershed zone of decreased vascularity approximately 2 to 6 cm proximal to its insertion on the calcaneus. This anatomic vulnerability makes it the most common site for spontaneous rupture.

Question 6603

Topic: 8. Foot and Ankle

During normal human locomotion, peak ankle dorsiflexion typically occurs during which specific phase of the gait cycle?

. Initial contact
. Loading response
. Mid-stance
. Terminal stance
. Pre-swing

Correct Answer & Explanation

. Terminal stance

Explanation

Peak ankle dorsiflexion (approximately 10 degrees) occurs during terminal stance, just before heel-off. This range of motion allows the body's center of mass to advance smoothly over the planted foot.

Question 6604

Topic: 8. Foot and Ankle
During the normal healing process of a completely lacerated and surgically repaired Achilles tendon, which of the following best describes the transition of collagen types during the remodeling phase?
. Type I replaces Type II
. Type II replaces Type I
. Type III replaces Type I
. Type I replaces Type III
. Type III replaces Type IV

Correct Answer & Explanation

. Type I replaces Type III

Explanation

During the initial inflammatory and proliferative phases of tendon healing, fibroblasts primarily produce Type III collagen, which is weaker and highly disorganized. In the remodeling phase, this is gradually replaced by stronger, more aligned Type I collagen to increase the tensile strength of the tendon.

Question 6605

Topic: 8. Foot and Ankle

The Lisfranc ligament is crucial for the stability of the midfoot. Which of the following anatomically describes the attachments of this interosseous ligament?

. Medial cuneiform to the base of the first metatarsal
. Lateral cuneiform to the base of the second metatarsal
. Medial cuneiform to the base of the second metatarsal
. Middle cuneiform to the base of the second metatarsal
. Cuboid to the base of the fourth and fifth metatarsals

Correct Answer & Explanation

. Medial cuneiform to the base of the first metatarsal

Explanation

The primary Lisfranc ligament is an interosseous ligament that runs from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. There is no direct ligamentous connection between the base of the first and second metatarsals, making this area vulnerable to injury.

Question 6606

Topic: Midfoot & Hindfoot

A 55-year-old overweight female presents with progressive flattening of her left medial longitudinal arch and pain behind the medial malleolus. She is unable to perform a single-leg heel rise on the left. Her hindfoot is in valgus but is flexible and corrects when she stands on her toes on both feet. What is the most appropriate surgical management for this stage of posterior tibial tendon dysfunction (PTTD)?

. Gastrocnemius recession and orthotics
. Flexor digitorum longus (FDL) transfer to the navicular and medializing calcaneal osteotomy
. Subtalar arthrodesis
. Triple arthrodesis
. Tibiotalocalcaneal (TTC) arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer to the navicular and medializing calcaneal osteotomy

Explanation

The patient has Stage II PTTD (flatfoot deformity that is flexible, indicated by hindfoot correction on toe rise, but inability to perform a single heel rise due to incompetent PTT). The gold standard surgical treatment for Stage II includes a joint-sparing procedure: FDL transfer (to replace the PTT) combined with a medializing calcaneal osteotomy (to correct the valgus and restore biomechanical axes).

Question 6607

Topic: 8. Foot and Ankle

A 35-year-old sustains an acute Achilles tendon rupture. If non-operative management with an early functional weight-bearing protocol is chosen, how do outcomes compare to surgical repair according to recent high-level evidence?

. Significantly higher re-rupture rates in the non-operative group
. Significantly higher rates of deep vein thrombosis in the non-operative group
. Similar re-rupture rates but lower soft-tissue complication rates in the non-operative group
. Increased risk of sural nerve injury in the non-operative group
. Substantially lower return to sport rates in the non-operative group

Correct Answer & Explanation

. Similar re-rupture rates but lower soft-tissue complication rates in the non-operative group

Explanation

Recent RCTs utilizing early functional rehabilitation protocols show that non-operative management has equivalent re-rupture rates to surgery, while completely avoiding surgical site and soft-tissue complications.

Question 6608

Topic: Midfoot & Hindfoot

In adult-acquired flatfoot deformity secondary to posterior tibial tendon dysfunction (PTTD), progressive collapse of the medial longitudinal arch occurs. What primary structural failure leads directly to talonavicular uncoverage and significant forefoot abduction?

. Rupture of the anterior talofibular ligament
. Attenuation of the spring (calcaneonavicular) ligament
. Contracture of the Achilles tendon
. Tear of the peroneal brevis tendon
. Degeneration of the plantar fascia

Correct Answer & Explanation

. Attenuation of the spring (calcaneonavicular) ligament

Explanation

The posterior tibial tendon acts as the primary dynamic stabilizer of the arch. When it fails, excessive stress is transferred to the static stabilizers, particularly the spring (calcaneonavicular) ligament, leading to its attenuation and subsequent plantarflexion/medial rotation of the talar head.

Question 6609

Topic: 8. Foot and Ankle

A 24-year-old rugby player injures his midfoot. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the 1st and 2nd metatarsals. An avulsion fracture (fleck sign) is noted. The injured ligament in this condition normally connects which two structures?

. Medial cuneiform to the base of the 1st metatarsal
. Medial cuneiform to the base of the 2nd metatarsal
. Middle cuneiform to the base of the 2nd metatarsal
. Navicular to the medial cuneiform
. Lateral cuneiform to the cuboid

Correct Answer & Explanation

. Medial cuneiform to the base of the 2nd metatarsal

Explanation

The Lisfranc ligament is a strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. Disruption of this ligament causes midfoot instability and requires operative stabilization.

Question 6610

Topic: 8. Foot and Ankle

During a normal physiological gait cycle, at which specific phase does maximum ankle dorsiflexion occur?

. Heel strike
. Loading response
. Midstance
. Terminal stance
. Pre-swing

Correct Answer & Explanation

. Terminal stance

Explanation

Maximum ankle dorsiflexion (approximately 10 to 15 degrees) occurs during terminal stance, just before heel-off. This motion allows the body's center of mass to advance anteriorly over the supporting foot before plantarflexion initiates push-off.

Question 6611

Topic: 8. Foot and Ankle
A 45-year-old patient suffers a complete rupture of the Achilles tendon. During the early remodeling and proliferative phase of tendon healing, which type of collagen is predominantly synthesized to rapidly bridge the functional gap before maturation?
. Type I
. Type II
. Type III
. Type IV
. Type X

Correct Answer & Explanation

. Type III

Explanation

During the early phases of tissue repair (granulation and early remodeling), fibroblasts predominantly synthesize Type III collagen, which forms cross-links rapidly but is mechanically weaker. Over months of maturation, this is slowly replaced by the stronger Type I collagen, the primary constituent of normal tendons.

Question 6612

Topic: 8. Foot and Ankle

A 14-year-old girl presents with progressive bilateral cavovarus foot deformities and frequent ankle sprains. Examination shows intrinsic muscle wasting in the hands and decreased sensation in a stocking-glove distribution. Genetic testing confirms the most common form of this condition. What is the underlying genetic mutation?

. SMN1 gene deletion
. PMP22 gene duplication
. Frataxin gene trinucleotide repeat
. Dystrophin gene deletion
. Fibrillin-1 gene mutation

Correct Answer & Explanation

. PMP22 gene duplication

Explanation

Charcot-Marie-Tooth (CMT) disease type 1A is the most common subtype and is caused by a duplication of the PMP22 (Peripheral Myelin Protein 22) gene on chromosome 17. It presents with distal muscle weakness, sensory loss, and cavovarus feet.

Question 6613

Topic: 8. Foot and Ankle

A 9-year-old child with spastic diplegic cerebral palsy exhibits a crouch gait pattern. This specific gait abnormality is most commonly caused by iatrogenic over-lengthening or weakness of which of the following muscle-tendon units?

. Iliopsoas
. Hamstrings
. Achilles tendon
. Rectus femoris
. Tibialis anterior

Correct Answer & Explanation

. Achilles tendon

Explanation

Over-lengthening of the Achilles tendon (triceps surae) leads to weakness of plantar flexion and loss of the plantar flexion-knee extension couple during gait. This results in excessive ankle dorsiflexion and unopposed knee flexion during the stance phase, producing a crouch gait.

Question 6614

Topic: 8. Foot and Ankle

A 40-year-old male sustains an acute Achilles tendon rupture. Non-operative management with an early functional rehabilitation protocol is chosen. Compared to traditional surgical repair, what does current Level I evidence indicate regarding re-rupture rates and deep infection rates when using functional rehabilitation?

. Significantly higher re-rupture rate, lower infection rate
. Similar re-rupture rate, higher infection rate
. Similar re-rupture rate, lower infection rate
. Significantly lower re-rupture rate, similar infection rate
. Significantly higher re-rupture rate, similar infection rate

Correct Answer & Explanation

. Similar re-rupture rate, lower infection rate

Explanation

Recent high-quality level I evidence (such as the Willits et al. trial) demonstrates that non-operative management utilizing an early functional rehabilitation protocol results in re-rupture rates that are statistically similar to operative repair, while completely eliminating surgical complications such as deep infection.

Question 6615

Topic: 8. Foot and Ankle

A 22-year-old football player sustains an axial load to a plantarflexed foot. Weight-bearing radiographs reveal widening between the 1st and 2nd metatarsal bases. The critical stabilizing ligament injured in this scenario connects which two structures?

. Medial cuneiform to 1st metatarsal base
. Medial cuneiform to 2nd metatarsal base
. Middle cuneiform to 2nd metatarsal base
. Lateral cuneiform to 3rd metatarsal base
. Cuboid to 4th metatarsal base

Correct Answer & Explanation

. Medial cuneiform to 2nd metatarsal base

Explanation

The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the primary stabilizer of the tarsometatarsal joint complex.

Question 6616

Topic: 8. Foot and Ankle

A 40-year-old recreational athlete presents with an acute Achilles tendon rupture. Based on current high-level randomized controlled trials, how do the outcomes of functional nonoperative rehabilitation compare to surgical repair?

. Surgical repair has a significantly lower rerupture rate but higher deep vein thrombosis rate
. Functional nonoperative rehab has equal rerupture rates but higher infection risk
. Functional nonoperative rehab has comparable rerupture rates and lower overall complication rates
. Surgical repair results in significantly improved long-term plantar flexion strength
. Nonoperative treatment requires rigid casting for 12 weeks to achieve equivalence

Correct Answer & Explanation

. Functional nonoperative rehab has comparable rerupture rates and lower overall complication rates

Explanation

Recent meta-analyses and randomized trials show that functional rehabilitation protocols (early weight-bearing in a boot) for Achilles ruptures yield rerupture rates comparable to surgical repair. Furthermore, nonoperative management avoids surgical complications such as infection and sural nerve injury.

Question 6617

Topic: 8. Foot and Ankle

Comparing operative versus nonoperative management for acute Achilles tendon ruptures using early functional rehabilitation protocols, operative management is specifically associated with a higher risk of which complication?

. Tendon re-rupture
. Deep vein thrombosis
. Plantar flexion weakness
. Sural nerve injury
. Decreased range of motion

Correct Answer & Explanation

. Sural nerve injury

Explanation

When early functional weight-bearing rehabilitation is employed, the re-rupture rates between operative and nonoperative management are similar. However, operative management carries a definitively higher risk of iatrogenic soft tissue complications, including wound breakdown, infection, and sural nerve injury.

Question 6618

Topic: 8. Foot and Ankle

A 45-year-old construction worker experiences acute low back pain radiating down the lateral aspect of his left leg to the dorsum of his foot. Examination reveals a positive straight leg raise test on the left. He demonstrates 3/5 strength in ankle dorsiflexion and great toe extension. The Achilles and patellar reflexes are symmetric and 2+. Which of the following nerve roots is most likely compressed?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L5

Explanation

Correct Answer: C. L5A posterolateral disc herniation at the L4-L5 level typically impinges the traversing L5 nerve root. The L5 nerve root provides motor innervation to the extensor hallucis longus (EHL, great toe extension), tibialis anterior (ankle dorsiflexion), and gluteus medius (hip abduction). It provides sensory innervation to the lateral calf and the dorsum of the foot. The L4 root (affected by L3-L4 herniation) mediates the patellar reflex, and the S1 root (affected by L5-S1 herniation) mediates the Achilles reflex and ankle plantarflexion.

Question 6619

Topic: 8. Foot and Ankle

A 42-year-old weekend warrior sustains an acute Achilles tendon rupture while playing tennis. He elects for non-operative management. The Achilles tendon is most vulnerable to rupture in a specific watershed zone. Where is this zone located relative to the calcaneal insertion?

. At the exact osteotendinous junction
. 2 to 6 cm proximal to the calcaneal insertion
. 8 to 12 cm proximal to the calcaneal insertion
. At the musculotendinous junction of the medial gastrocnemius
. At the musculotendinous junction of the soleus

Correct Answer & Explanation

. 2 to 6 cm proximal to the calcaneal insertion

Explanation

Correct Answer: 2 to 6 cm proximal to the calcaneal insertionThe Achilles tendon has a watershed area of relative hypovascularity located approximately 2 to 6 cm proximal to its insertion on the calcaneus. This decreased blood supply, combined with repetitive mechanical stress, makes this specific region the most common site for degenerative tendinopathy and acute ruptures.

Question 6620

Topic: 8. Foot and Ankle

A 48-year-old male presents with a right-sided foot drop and radiating leg pain. Examination reveals 3/5 strength in ankle dorsiflexion and great toe extension. To clinically differentiate a compressive L5 radiculopathy from a common peroneal nerve palsy, the examiner should test the strength of which of the following movements?

. Ankle plantarflexion
. Ankle eversion
. Ankle inversion
. Knee extension
. Knee flexion

Correct Answer & Explanation

. Ankle inversion

Explanation

Correct Answer: Ankle inversionDifferentiating an L5 radiculopathy from a common peroneal nerve palsy is a classic clinical challenge, as both conditions cause foot drop (weakness in ankle dorsiflexion and great toe extension). The key to differentiating them lies in testing muscles innervated by the L5 nerve root that travel via a different peripheral nerve. Ankle inversion is primarily controlled by the tibialis posterior muscle, which is innervated by the tibial nerve (L4, L5). In an L5 radiculopathy, ankle inversion will be weak. In a common peroneal nerve palsy, the tibial nerve is unaffected, so ankle inversion strength will be preserved. Ankle eversion (peroneus longus/brevis) is innervated by the superficial peroneal nerve and would be weak in both conditions.

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