Deck 22: The Ankle and Foot

Question 1

Each of the following is true about surgical repair/reconstruction of the lateral ligament complex of the ankle and postoperative management except:

A) The most common procedure is a direct repair and imbrication of the torn ligaments through an open surgical approach.
B) After reconstruction of the lateral ligaments that includes a tendon autograft and tendon transposition (often the peroneus brevis tendon)to reinforce the lateral aspect of the ankle,there may be some permanent loss of full ankle inversion postoperatively.
C) The ankle is immobilized in plantarflexion and slight eversion for 4 to 6 weeks postoperatively;therefore the patient must remain non-weight-bearing on the operated lower extremity during the period of immobilization to prevent rupture of the repair site.
D) It is usually permissible to remove the ankle immobilizer by about 4 to 6 weeks postoperatively to begin active range of motion exercises of the ankle.

Answer 1

C

Question 2

Your patient has rheumatoid arthritis and is complaining of pain in her ankles and feet when walking.You observe her gait and notice short steps and poor push-off.This is consistent with what deformity in rheumatoid arthritis?

A) Everted calcaneus and pronated forefoot
B) Inverted calcaneus and pronated forefoot
C) Everted calcaneus and supinated forefoot
D) Inverted calcaneus and supinated forefoot

Answer 2

A

Question 3

John is a 25-year-old active athlete and outdoorsman who suffered a severe lateral ankle injury 5 years ago,resulting in progressive subtalar arthritis,pain,and instability of the ankle and hindfoot.His quality of life and ability to work are now restricted due to the pain and instability despite repeated sessions in therapy.The surgical procedure of choice for John is most likely:

A) Arthrodesis (fusion).
B) Arthroplasty (TAA).
C) Brostrom procedure.
D) Watson-Jones procedure.

Answer 3

A

Question 4

Following a severe (grade 3)inversion sprain,your patient complains of pain just distal and lateral to the knee joint.The pain is likely the result of:

A) Subluxation of the proximal tibiofibular joint.
B) Tear of the lateral collateral ligament.
C) Tear of the lateral head of the gastrocnemius.
D) Referred pain from gait deviations due to sore ankle joints and ligaments.

Question 5

During initial evaluation of a patient with a complaint of low back pain,you perform a standing posture alignment screening and discover that his left leg appears shorter than the right as you compare iliac crests,greater trochanter,head of the fibula,and medial malleolus.What related possible foot deformity should you look for while still in standing?

A) Excessive right foot pronation compared to the left
B) Excessive left foot pronation compared to the right
C) Excessive left foot supination compared to the right
D) Hallux valgus on the right

Question 6

Your patient has regained normal strength and range of motion during rehabilitation following a traumatic injury that severely stressed several ligaments and joints of the ankle.He continues to have problems while walking,including stumbling and poor control while walking on gravel or other uneven surfaces.To remedy this problem,your exercise program should focus on:

A) Strengthening exercises for the invertor and evertor muscles of the ankle using elastic resistance.
B) Stretching the invertor and evertor muscles of the ankle.
C) Performing balance training with closed-chain disturbed balance activities on a rocker/balance board.
D) Practicing walking on uneven surfaces while wearing a custom-made ankle/foot orthosis that controls inversion and eversion.

Question 7

Which of the following special tests may be used to confirm or rule out a rupture of the Achilles tendon during a physical examination of a patient?

A) Thompson test
B) Anterior drawer of the ankle
C) Talar tilt test
D) Test for Homan's sign

Question 8

Each of the following is a true statement about total ankle arthroplasty (TAA)and postoperative rehabilitation except:

A) At the close of surgery,the foot and ankle typically are immobilized in a neutral position in a well-padded compression dressing and short-leg posterior splint.
B) A patient with peripheral arterial disease of the lower extremities in addition to advanced arthritis of the ankle is not an appropriate candidate for TAA.
C) After a TAA that involved biological fixation,weight bearing on the operated lower extremity during ambulation with a walker initially is permissible only while wearing an ankle immobilizer and may need to be partially restricted for several weeks to allow time for some degree of bio-ingrowth to occur.
D) TAA is an appropriate procedure for a patient with advanced arthritis combined with marked instability of the ankle.

Question 9

Your patient sustained a fracture of the right calcaneus as the result of a motor vehicle accident 3 months ago.After 10 weeks in a cast followed by a rocker bottom immobilization boot that prevented ankle and foot motion,the fracture shows radiological evidence of bony union.The patient has been ambulating (weight bearing as tolerated)while wearing the boot and is now supposed to discontinue wearing it slowly.Your examination reveals marked limitation of dorsi- and plantarflexion and a high,rigid arch.There is no visible swelling,and pain (2/10)occurs at the end of the day and during passive range of motion (PROM)with overpressure.Which of the following is the most appropriate intervention during the first week of therapy?

A) PROM of the ankle (dorsiflexion/plantarflexion and calcaneal inversion/eversion)
B) Gentle passive stretching of ankle musculature
C) Grade II joint mobilization at the subtalar joint
D) Grade III joint mobilization at the midtarsal joint

Question 10

Your patient has a diagnosis of rheumatoid arthritis and is developing a capsular pattern in the foot and ankle.Which joint-mobilization technique could perpetuate or worsen the impairment/deformity typically associated with RA of the foot and ankle?

A) Stabilize the mortise and glide the talus in an anterior direction
B) Stabilize the calcaneus and glide the cuboid in a plantar direction
C) Stabilize the talus and glide the navicular in a dorsal direction
D) Stabilize the talus and glide the calcaneus in a lateral direction

Question 11

Your uncle called you last night after playing three games in a softball tournament yesterday.He indicated that late in the third game while trying to stretch a double into a triple,he felt a sudden,sharp pain in his calf,which significantly interfered with his ability to continue running.He is able to move his foot "up and down," but both motions are painful.He is also able to walk if he "takes it slow." From the information your uncle gave you and the fact that he is a 42-year-old weekend warrior,your preliminary hypothesis is that your uncle may have sustained a(n):

A) Fracture of the tibia.
B) Achilles tendon rupture.
C) Plantaris rupture.
D) Syndesmosis injury.

Question 12

A patient underwent a triple arthrodesis of the hindfoot 12 weeks ago and is now allowed to ambulate without the rigid boot.The patient has been referred to you for exercises to improve range of motion and strength of the operated lower extremity and to reestablish a normal gait pattern.Which of the following interventions is inappropriate to include in your treatment plan to restore this patient's function?

A) Passive stretching of the plantar flexors
B) Grade III medial and lateral sustained glides to increase inversion and eversion
C) Grade III sustained posterior glides of the talus on the tibia to increase dorsiflexion
D) Closed-chain training to improve lower extremity control

Question 13

Which one of the following ligaments of the ankle is most frequently stressed with an inversion sprain?

A) Posterior talofibular
B) Anterior talofibular
C) Calcaneofibular
D) Deltoid

Question 14

A 40-year-old teacher who has been referred to you has experienced pain along the plantar aspect of the heel for more than 6 months.It is most noticeable when getting out of bed in the morning,upon standing after sitting for longer than 1 hour,and after playing racquetball.During walking,pain is most noticeable at the terminal stance/preswing phase of gait.The mostly likely disorder causing these symptoms is:

A) Plantar fasciitis.
B) Calcaneal bursitis.
C) Achilles tendinitis.
D) Posterior tibialis tendinitis.

Question 15

Each of the following is an expected improvement after total ankle arthroplasty for advanced arthritis except:

A) Increased mediolateral stability of the ankle.
B) Alleviation of pain.
C) Sufficient range of motion of the ankle for functional activities.
D) Decreased joint deformity.

Question 16

Which of the following most accurately describes the deformities that progressively develop in rheumatoid arthritis of the foot/ankle?

A) Fixed supination of the foot,hallux valgus,hallux rigidus,dorsal subluxation of the proximal phalanges on the metatarsal heads
B) Fixed pronation of the foot,hallux valgus,hallux rigidus,plantar subluxation of the proximal phalanges on the metatarsal heads
C) Fixed pronation of the foot,hallux valgus,hallux rigidus,dorsal subluxation of the proximal phalanges on the metatarsal heads
D) Fixed supination of the foot,hallux valgus,hallux rigidus,plantar subluxation of the proximal phalanges on the metatarsal heads