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8. Foot and Ankle MCQs

Practice Set 45 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 881

Topic: 8. Foot and Ankle

During an open Achilles tendon repair for an acute rupture, the surgeon makes a lateral para-Achilles incision. After incising the skin and subcutaneous tissue, meticulous dissection is performed to identify and protect a critical neural structure. Which nerve is the surgeon most concerned about protecting during this approach, and what is its typical course?

. Tibial nerve; it courses medially to the Achilles tendon.
. Common peroneal nerve; it courses anterior to the Achilles tendon.
. Sural nerve; it courses subcutaneously along the posterior calf, often running close to the lateral border of the Achilles tendon.
. Saphenous nerve; it courses superficially along the medial aspect of the calf.
. Posterior tibial nerve; it courses deep to the soleus muscle.

Correct Answer & Explanation

. Sural nerve; it courses subcutaneously along the posterior calf, often running close to the lateral border of the Achilles tendon.

Explanation

Correct Answer: CThe case explicitly states under 'Innervation and Vascularity': 'Of particular surgical relevance is the sural nerve, a sensory nerve... which courses subcutaneously along the posterior calf, often running close to the lateral border of the Achilles tendon. It is highly susceptible to iatrogenic injury during posterior surgical approaches.' It further notes that a 'lateral para-Achilles incision is often preferred as it places the incision further away from the path of the sural nerve, which typically courses inferolaterally.'Incorrect Options:A:The tibial nerve innervates the triceps surae complex but is deep and medial, not typically at risk with a lateral para-Achilles incision.B:The common peroneal nerve is located more proximally around the fibular head and does not course anterior to the Achilles tendon.D:The saphenous nerve is on the medial side of the leg and is not typically at risk with a lateral para-Achilles approach.E:The posterior tibial nerve is deep in the posterior compartment, not superficial and lateral to the Achilles tendon.

Question 882

Topic: 8. Foot and Ankle

A 60-year-old male, 8 weeks post-open Achilles tendon repair, is progressing through his rehabilitation. He is now in a phase focused on regaining full active and passive range of motion and initiating progressive strengthening. Which of the following activities is most appropriate for him at this stage, according to the provided rehabilitation guidelines?

. Initiating plyometric exercises like box jumps and hopping.
. Transitioning out of the CAM boot and beginning progressive resistance exercises for plantarflexors.
. Starting sport-specific drills, including cutting and agility exercises.
. Strictly non-weight-bearing with the ankle locked in 20 degrees of plantarflexion.
. Undergoing manipulation under anesthesia for persistent stiffness.

Correct Answer & Explanation

. Transitioning out of the CAM boot and beginning progressive resistance exercises for plantarflexors.

Explanation

Correct Answer: BAccording to the 'Phases of Rehabilitation' section, Phase 3 (Weeks 6/8 - 12/16) is described as 'Progressive Strengthening & Full Weight-Bearing.' The goals include 'Regain full active and passive ROM, normalize gait, restore strength and endurance.' Specific exercises listed for this phase include 'Transition out of CAM boot and into supportive athletic shoes' and 'Progressive resistance exercises for plantarflexors (seated and standing calf raises, initially bilateral, then unilateral).' This directly matches option B.Incorrect Options:A:Plyometric exercises are part of Phase 4 (Months 4-6+), 'Return to Activity & Advanced Strengthening,' which is too early at 8 weeks.C:Sport-specific drills are also part of Phase 4, too early at 8 weeks.D:Strictly non-weight-bearing with the ankle locked in plantarflexion is characteristic of Phase 1 (Weeks 0-2/3), the early immobilization and protection phase, which he has already progressed beyond.E:Manipulation under anesthesia is a salvage strategy for refractory stiffness, not a standard part of progressive rehabilitation at 8 weeks, unless severe complications have arisen.

Question 883

Topic: 8. Foot and Ankle

A surgeon is performing an open Achilles tendon repair. After identifying the ruptured tendon ends, they proceed to place sutures. The case describes common suture techniques for robust repair. Which of the following suture techniques is explicitly mentioned as a common choice for Achilles tendon repair, and what is a key principle for suture placement?

. Figure-of-eight stitch; ensuring sutures are placed only in the paratenon for gliding.
. Horizontal mattress stitch; with minimal tendon purchase to avoid tissue strangulation.
. Modified Kessler suture or Krakow locking loop stitch; ensuring adequate tendon purchase, typically 2-3 cm from the ruptured edge.
. Running simple stitch; primarily for cosmetic closure of the skin.
. Vertical mattress stitch; with knots tied superficially to facilitate later removal.

Correct Answer & Explanation

. Modified Kessler suture or Krakow locking loop stitch; ensuring adequate tendon purchase, typically 2-3 cm from the ruptured edge.

Explanation

Correct Answer: CUnder 'Tendon Reduction and Suture Placement,' the case states: 'The modified Kessler suture or Krakow locking loop stitch are common techniques. Multiple strands (e.g., 4 or 6 strands) are often preferred for maximal strength.' It further emphasizes: 'Ensure adequate tendon purchase, typically 2-3 cm from the ruptured edge, especially in the watershed zone where tissue quality might be compromised. The sutures should engage healthy tendon tissue to prevent pull-out.'Incorrect Options:A:Figure-of-eight is a general suture pattern, but not specifically highlighted as a primary core stitch for Achilles repair in the text. Sutures are placed in the tendon substance, not just the paratenon, which is repaired separately.B:Horizontal mattress is a general suture pattern, but the text emphasizes 'adequate tendon purchase, typically 2-3 cm from the ruptured edge,' not minimal purchase.D:A running simple stitch is not described as a core repair technique for the tendon itself; it's more for skin or superficial layers.E:Vertical mattress is a general suture pattern, but the text states, 'The knots should be buried where possible to minimize irritation,' contradicting superficial knot tying.

Question 884

Topic: 8. Foot and Ankle

The Achilles tendon is formed by the conjoined aponeuroses of the gastrocnemius and soleus muscles. Regarding the specific contributions and characteristics of these muscles, which statement is most accurate?

. The gastrocnemius is a pure ankle plantarflexor, originating from the posterior tibia and fibula.
. The soleus muscle is primarily a knee flexor and ankle plantarflexor, originating from the femoral condyles.
. Both the gastrocnemius and soleus muscles are innervated by the common peroneal nerve.
. The plantaris tendon, when present, lies superficial to the gastrocnemius and contributes significantly to plantarflexion.
. The gastrocnemius originates from the medial and lateral femoral condyles and is primarily a knee flexor and ankle plantarflexor, while the soleus is a pure ankle plantarflexor.

Correct Answer & Explanation

. The gastrocnemius originates from the medial and lateral femoral condyles and is primarily a knee flexor and ankle plantarflexor, while the soleus is a pure ankle plantarflexor.

Explanation

Correct Answer: EUnder 'Musculotendinous Complex,' the case states: 'The gastrocnemius muscle originates from the medial and lateral femoral condyles and is primarily a knee flexor and ankle plantarflexor. The soleus muscle originates from the posterior tibia and fibula and is a pure ankle plantarflexor.' This statement perfectly matches option E.Incorrect Options:A:The gastrocnemius is a knee flexor and ankle plantarflexor, not a pure ankle plantarflexor. The soleus is the pure ankle plantarflexor.B:This describes the gastrocnemius, not the soleus. The soleus is a pure ankle plantarflexor originating from the tibia and fibula.C:The triceps surae complex (gastrocnemius and soleus) is innervated by the tibial nerve (S1, S2), not the common peroneal nerve.D:The plantaris tendon lies 'deep to the medial head of the gastrocnemius and superficial to the soleus,' not superficial to the gastrocnemius. Its contribution to plantarflexion is also described as 'minimal.'

Question 885

Topic: 8. Foot and Ankle

A 40-year-old male, 6 months post-operative from an Achilles tendon repair, is being assessed for return to sport. He has achieved full pain-free range of motion and good calf girth. According to the provided rehabilitation guidelines, which objective criterion is crucial for determining his readiness to return to high-impact activities like running and jumping?

. Ability to perform 5 single-leg heel raises on the affected side.
. Absence of any palpable scar tissue over the repair site.
. Completion of 3 months of physical therapy, regardless of functional status.
. Single-leg heel raise endurance of >20 repetitions on the affected side, or >80-90% of the unaffected side.
. Subjective feeling of readiness, even if objective strength is not fully restored.

Correct Answer & Explanation

. Single-leg heel raise endurance of >20 repetitions on the affected side, or >80-90% of the unaffected side.

Explanation

Correct Answer: DUnder 'Phase 4: Return to Activity & Advanced Strengthening,' the case explicitly lists criteria for 'Return to Sport': 'Typically not before 6 months, and only after meeting objective criteria: ... Single-leg heel raise endurance (e.g., >20 repetitions on affected side, >80-90% of unaffected side).' This directly matches option D.Incorrect Options:A:5 single-leg heel raises is insufficient; the guideline specifies >20 repetitions or >80-90% of the unaffected side.B:While scar tissue quality is important, the absence ofanypalpable scar tissue is not a listed objective criterion for return to sport.C:The guidelines emphasize 'meeting objective criteria' rather than a strict timeline for physical therapy completion, as progression should be individualized and pain-guided.E:The guidelines explicitly state 'meeting objective criteria,' indicating that subjective feeling alone is not sufficient for return to high-impact activities.

Question 886

Topic: 8. Foot and Ankle

During a minimally invasive percutaneous repair of an acute Achilles tendon rupture, the sural nerve is at highest risk of iatrogenic injury. At approximately what distance proximal to the calcaneal insertion does the sural nerve typically cross the lateral border of the Achilles tendon?

. 2 cm
. 5 cm
. 10 cm
. 15 cm
. 20 cm

Correct Answer & Explanation

. 10 cm

Explanation

Anatomical studies show that the sural nerve crosses the lateral border of the Achilles tendon at an average of 9.8 cm (approximately 10 cm) proximal to the calcaneal insertion. Percutaneous or minimally invasive techniques must carefully account for this to avoid nerve entrapment.

Question 887

Topic: 8. Foot and Ankle

A 55-year-old male on a recent course of ciprofloxacin for a urinary tract infection suffers an acute Achilles tendon rupture while playing tennis. Which of the following best describes the pathophysiologic mechanism by which fluoroquinolones predispose to this injury?

. Upregulation of matrix metalloproteinases leading to degradation of type I collagen
. Direct toxic necrosis of the Achilles paratenon
. Inhibition of fibroblast proliferation via fibroblast growth factor (FGF) blockade
. Microvascular thrombosis in the tendon's watershed area
. Pathologic calcification of the tendon insertion site

Correct Answer & Explanation

. Upregulation of matrix metalloproteinases leading to degradation of type I collagen

Explanation

Fluoroquinolones increase the risk of tendon rupture by upregulating matrix metalloproteinases (such as MMP-1 and MMP-3) and inhibiting type I collagen synthesis. This leads to accelerated extracellular matrix degradation and structural weakening.

Question 888

Topic: 8. Foot and Ankle

A 45-year-old patient undergoes reconstruction of a chronic Achilles tendon rupture with a 6 cm defect utilizing a flexor hallucis longus (FHL) tendon transfer. The surgeon elects to harvest the FHL tendon deep in the plantar midfoot at the master knot of Henry. Which neurovascular structure is intimately associated with the FHL at this location and is at highest risk of injury?

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

Correct Answer & Explanation

. Medial plantar nerve

Explanation

At the master knot of Henry, the FHL crosses deep to the flexor digitorum longus (FDL). The medial plantar nerve runs immediately medial to this crossing point and is at high risk of injury during deep midfoot harvest of the FHL.

Question 889

Topic: 8. Foot and Ankle

A 2-year-old child presents with bilateral symmetric bowing of the lower extremities. Radiographs reveal a metaphyseal-diaphyseal angle (MDA) of 18 degrees on both sides with medial metaphyseal beaking. What is the most appropriate initial management?

. Observation and reassurance for physiologic bowing
. Knee-Ankle-Foot Orthoses (KAFO) worn continuously day and night
. Knee-Ankle-Foot Orthoses (KAFO) worn during weight-bearing activities
. Proximal tibial osteotomy with acute correction
. Lateral hemiepiphysiodesis of the proximal tibia

Correct Answer & Explanation

. Knee-Ankle-Foot Orthoses (KAFO) worn during weight-bearing activities

Explanation

An MDA greater than 16 degrees strongly indicates a high risk of progression to infantile Blount disease rather than physiologic bowing. The standard initial treatment for symptomatic children under 3 years with early-stage infantile Blount disease is bracing with KAFOs during weight-bearing activities.

Question 890

Topic: 8. Foot and Ankle

The watershed area of the Achilles tendon is notoriously susceptible to rupture and tendinosis due to relative hypovascularity. Which of the following provides the primary vascular supply to this specific region?

. Branches of the peroneal artery penetrating the musculotendinous junction
. Direct branches of the posterior tibial artery
. The intra-osseous circulation from the calcaneal insertion
. The surrounding paratenon
. The true synovial sheath enveloping the tendon

Correct Answer & Explanation

. The surrounding paratenon

Explanation

The Achilles tendon lacks a true synovial sheath and is enveloped by a paratenon. In the watershed area (approximately 2-6 cm proximal to the calcaneal insertion), the intrinsic blood supply from bone and muscle is poorest, making the tendon highly reliant on the surrounding paratenon for vascularity.

Question 891

Topic: 8. Foot and Ankle

Recent high-level evidence (including randomized controlled trials) comparing operative and non-operative management of acute Achilles tendon ruptures utilizing an early functional rehabilitation protocol demonstrates which of the following outcomes?

. A significantly lower rerupture rate in the operatively treated group
. A significantly higher rerupture rate in the operatively treated group
. No significant difference in rerupture rates between the two groups
. Lower rates of wound complications in the operatively treated group
. Superior long-term restoration of plantarflexion strength in the non-operative group

Correct Answer & Explanation

. No significant difference in rerupture rates between the two groups

Explanation

Current evidence shows that when an early functional rehabilitation protocol is employed, there is no significant difference in rerupture rates between operative and non-operative management. However, operative management consistently carries a higher risk of soft-tissue and wound complications.

Question 892

Topic: 8. Foot and Ankle

During percutaneous or minimally invasive repair of an acute Achilles tendon rupture, a nerve is iatrogenically injured while passing sutures blindly in the proximal-lateral aspect of the tendon. What sensory deficit is most likely to be observed postoperatively?

. Numbness in the first web space
. Numbness along the medial aspect of the foot
. Numbness along the lateral aspect of the foot
. Numbness over the plantar aspect of the heel
. Numbness over the central dorsum of the foot

Correct Answer & Explanation

. Numbness along the lateral aspect of the foot

Explanation

The sural nerve courses distally and crosses the lateral border of the Achilles tendon approximately 9.8 cm proximal to its insertion. It is at significant risk during percutaneous repair techniques, and injury results in sensory deficits along the lateral aspect of the foot.

Question 893

Topic: 8. Foot and Ankle

A 45-year-old male presents with a neglected chronic Achilles tendon rupture and a 6 cm defect. A flexor hallucis longus (FHL) transfer is planned for reconstruction. What is a primary biomechanical advantage of utilizing the FHL for this reconstruction compared to other local tendons?

. It fires out-of-phase with the triceps surae, stabilizing the ankle joint
. It completely eliminates the risk of decreased push-off strength in the toes
. It is the strongest deep flexor and fires in-phase with the gastrocnemius-soleus complex
. Its harvest completely avoids the neurovascular bundle at the knot of Henry
. It has a dual innervation allowing for quicker electromyographic integration

Correct Answer & Explanation

. It is the strongest deep flexor and fires in-phase with the gastrocnemius-soleus complex

Explanation

The FHL is the strongest of the deep posterior compartment muscles and naturally fires in-phase with the gastrocnemius-soleus complex during the gait cycle. Its proximity and axis of pull make it biomechanically ideal for augmenting or reconstructing large Achilles defects.

Question 894

Topic: 8. Foot and Ankle

Which of the following classes of antibiotics is classically associated with an increased risk of Achilles tendon rupture due to its direct toxic effect on tenocytes, leading to decreased type I collagen synthesis and upregulation of matrix metalloproteinases (MMPs)?

. Aminoglycosides
. Cephalosporins
. Fluoroquinolones
. Macrolides
. Tetracyclines

Correct Answer & Explanation

. Fluoroquinolones

Explanation

Fluoroquinolones (such as ciprofloxacin and levofloxacin) carry a black-box warning for tendinopathy and tendon rupture. They induce toxicity in tenocytes, resulting in a degradation of the extracellular matrix through increased MMP expression and impaired collagen synthesis.

Question 895

Topic: 8. Foot and Ankle

During an open repair of an acute midsubstance Achilles tendon rupture, the surgeon identifies a small, intact tendon located immediately medial to the ruptured Achilles. What is the distal insertion of the muscle associated with this intact tendon?

. Medial cuneiform
. Base of the first metatarsal
. Tuberosity of the navicular
. Medial aspect of the calcaneal tuberosity
. Sustentaculum tali

Correct Answer & Explanation

. Medial aspect of the calcaneal tuberosity

Explanation

The plantaris tendon lies immediately medial to the Achilles tendon and inserts on the medial aspect of the calcaneal tuberosity. It often remains intact during an Achilles rupture and can be used to augment the repair, though it must not be mistaken for the intact Achilles tendon.

Question 896

Topic: 8. Foot and Ankle

A 45-year-old male recreational athlete sustains an acute Achilles tendon rupture while playing basketball. The rupture is located in the classic 'watershed' zone. Which of the following best describes the anatomic location of this relative hypovascular area?

. 0 to 2 cm proximal to the calcaneal insertion
. 2 to 6 cm proximal to the calcaneal insertion
. 6 to 10 cm proximal to the calcaneal insertion
. Directly at the myotendinous junction
. Distal to the superior tuberosity of the calcaneus

Correct Answer & Explanation

. 2 to 6 cm proximal to the calcaneal insertion

Explanation

The Achilles tendon has a 'watershed' area of decreased intrinsic vascularity located roughly 2 to 6 cm proximal to its insertion on the calcaneus. This relative hypovascularity limits healing potential and strongly predisposes the tendon to degeneration and acute rupture.

Question 897

Topic: 8. Foot and Ankle
A 50-year-old female with a history of recent pneumonia treated with a 10-day course of antibiotics presents with an acute mid-substance Achilles tendon rupture. Which of the following describes the mechanism by which her antibiotic therapy contributed to this tendinopathy?
. Inhibition of matrix metalloproteinases
. Direct toxicity to tenocytes and downregulation of Type I collagen synthesis
. Induction of a delayed hypersensitivity reaction targeting Type III collagen
. Ischemic necrosis via profound microvascular thrombosis
. Hypertrophy of the paratenon leading to mechanical impingement

Correct Answer & Explanation

. Direct toxicity to tenocytes and downregulation of Type I collagen synthesis

Explanation

Fluoroquinolones (e.g., ciprofloxacin) are well-known risk factors for tendon rupture. They cause direct toxic effects on tenocytes, leading to decreased cell proliferation, downregulation of Type I collagen synthesis, and upregulation of matrix metalloproteinases.

Question 898

Topic: 8. Foot and Ankle

A surgeon is performing a percutaneous repair of an acute Achilles tendon rupture. To minimize iatrogenic nerve injury during suture passage, the surgeon must be mindful of the sural nerve. What is the typical anatomic relationship of the sural nerve to the lateral border of the Achilles tendon?

. It crosses the medial border of the tendon 5 cm proximal to the insertion
. It crosses the lateral border of the tendon approximately 10 cm proximal to the insertion
. It runs deep to the plantaris tendon throughout its course
. It crosses the midline of the tendon 2 cm proximal to the insertion
. It runs anterior to the fibula before piercing the superficial fascia

Correct Answer & Explanation

. It crosses the lateral border of the tendon approximately 10 cm proximal to the insertion

Explanation

The sural nerve courses distally in the posterior calf and crosses the lateral border of the Achilles tendon at an average distance of 9.8 cm to 10 cm proximal to its calcaneal insertion. This close proximity makes the nerve highly vulnerable during percutaneous Achilles repair.

Question 899

Topic: 8. Foot and Ankle

When performing an open repair of an acute Achilles tendon rupture using a posteromedial approach, which of the following structures is most at risk of iatrogenic injury if the dissection strays too far laterally?

. Tibial nerve
. Sural nerve
. Saphenous nerve
. Flexor hallucis longus
. Posterior tibial artery

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve crosses the lateral border of the Achilles tendon approximately 10 cm proximal to the calcaneal insertion. Dissection too far laterally during a posteromedial approach places this nerve at significant risk.

Question 900

Topic: 8. Foot and Ankle

Which of the following functional rehabilitation protocols for acute Achilles tendon rupture managed nonoperatively has been shown in prospective randomized trials to most closely match the re-rupture rates of operative management?

. Strict cast immobilization in equinus for 8 weeks
. Early weight-bearing in a functional orthosis with progressive range of motion
. Non-weight-bearing cast for 4 weeks followed by night splinting
. Immediate full weight-bearing in a neutral walking boot
. Casting in maximal plantar flexion for 12 weeks

Correct Answer & Explanation

. Early weight-bearing in a functional orthosis with progressive range of motion

Explanation

Recent studies demonstrate that functional rehabilitation protocols with early weight-bearing and early mobilization for nonoperatively managed Achilles ruptures yield re-rupture rates similar to operative repair. This protocol avoids the higher risks of surgical site infections and nerve injuries associated with operative intervention.

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