Achilles Tendon Disorders — MCQs
Which artery is palpated behind the medial malleolus and in front of the Achilles tendon?
A ballet dancer presents with chronic anterolateral ankle pain. Most likely diagnosis?
A 40 year old male who is being treated for UTI with Oflazacin presents to you with sudden onset of pain in the back of the ankle while running. It is still possible for him to walk but finds it difficult to stand on tiptoe. What is your diagnosis?
Best initial treatment for acute calcific tendinitis of shoulder?
A 20-year-old patient presents with chronic low backache and early morning stiffness for the last 2 years. For the past 6 months, they have also experienced bilateral heel pain. What is the most likely diagnosis?
Ruptured tendons are most commonly seen in
Sudden dorsiflexion of the foot may lead to which of the following injuries?
Most common cause of insertional tendonitis of Achilles tendon is -
A 24-year-old woman experiences pain in the heel when walking uphill, which decreases when walking downhill. X-ray shows a bone spur. What is the diagnosis?
Open reduction (OR) is not required in which fracture?
Achilles Tendon Disorders Indian Medical PG Practice Questions and MCQs
Question 1: Which artery is palpated behind the medial malleolus and in front of the Achilles tendon?
- A. Peroneal artery
- B. Anterior tibial artery
- C. Dorsalis pedis artery
- D. Posterior tibial artery (Correct Answer)
- E. Popliteal artery
Explanation: ***Posterior tibial artery*** - This artery is directly accessible for palpation in the **retromalleolar groove**, situated between the medial malleolus and the Achilles tendon. - It is a common site for assessing **peripheral circulation** in the foot. *Peroneal artery* - The peroneal artery is located **deep within the posterior compartment** of the leg, making it difficult to palpate at the ankle. - It primarily supplies the lateral compartment and is not typically palpable at the described location. *Anterior tibial artery* - The anterior tibial artery runs along the **anterior compartment** of the lower leg and, at the ankle, becomes the dorsalis pedis artery. - It is best palpated on the **dorsum of the foot** as the dorsalis pedis artery, not behind the medial malleolus. *Dorsalis pedis artery* - This artery is a continuation of the anterior tibial artery and is found on the **dorsum of the foot**, typically lateral to the extensor hallucis longus tendon. - While an important pulse point, it is not located behind the medial malleolus. *Popliteal artery* - The popliteal artery is located in the **popliteal fossa** behind the knee, where it can be palpated with deep pressure. - It is proximal to the ankle and divides into the anterior and posterior tibial arteries, making it anatomically distant from the medial malleolus.
Question 2: A ballet dancer presents with chronic anterolateral ankle pain. Most likely diagnosis?
- A. Lateral Ankle Sprain (Correct Answer)
- B. Calcaneal Stress Fracture
- C. Tibialis Posterior Tendinitis
- D. Anterior Ankle Impingement Syndrome
Explanation: **Lateral Ankle Sprain** - **Chronic anterolateral ankle pain** in a ballet dancer is highly suggestive of a **lateral ankle sprain**, often due to repetitive strain and instability. - Sprains commonly involve the **anterior talofibular ligament (ATFL)** and **calcaneofibular ligament (CFL)**, leading to persistent discomfort and potential functional deficits. *Calcaneal Stress Fracture* - A **calcaneal stress fracture** typically presents with **heel pain** that is worse with weight-bearing activities, rather than primarily anterolateral pain. - While common in athletes, the pain location is less consistent with the description in the question. *Tibialis Posterior Tendinitis* - **Tibialis posterior tendinitis** causes pain and tenderness along the **medial arch** and posterior aspect of the ankle, often associated with a **flatfoot deformity**. - The pain location described (anterolateral) does not align with the typical presentation of this condition. *Anterior Ankle Impingement Syndrome* - **Anterior ankle impingement syndrome** results from compression of soft tissues or bony spurs at the **anterior ankle joint**, typically causing pain with **dorsiflexion**. - While possible in a dancer, the presentation as chronic anterolateral pain without specific mention of dorsiflexion-related pain makes a lateral ankle sprain a more probable initial diagnosis.
Question 3: A 40 year old male who is being treated for UTI with Oflazacin presents to you with sudden onset of pain in the back of the ankle while running. It is still possible for him to walk but finds it difficult to stand on tiptoe. What is your diagnosis?
- A. Deep vein thrombosis
- B. Achilles tendon rupture (Correct Answer)
- C. Fracture calcaneus
- D. Plantar fasciitis
Explanation: ***Achilles tendon rupture*** - Sudden onset of **posterior ankle pain**, difficulty standing on **tiptoe**, and a history of **fluoroquinolone** (Oflazacin) use are classic signs of Achilles tendon rupture. - Fluoroquinolones are known to increase the risk of **tendinopathy** and tendon rupture, especially in older adults and those with pre-existing tendon issues. *Deep vein thrombosis* - While DVT can cause **calf pain** and swelling, it typically does not present with a sudden "pop" or immediate inability to stand on tiptoe, and is not directly associated with fluoroquinolone use in this manner. - There would usually be signs of **swelling** and **tenderness** to palpation along the calf veins, not specifically localized to the Achilles tendon. *Fracture calcaneus* - A calcaneal fracture would typically result from a **high-impact injury** (e.g., fall from height) and would cause severe pain, inability to bear weight, and significant swelling, which is not fully described here. - While an X-ray would be definitive, the mechanism and symptoms better fit a soft tissue injury like a tendon rupture. *Plantar fasciitis* - Plantar fasciitis causes **heel pain**, especially with the first steps in the morning or after rest, and typically does not present as an acute injury from running with sudden pain in the back of the ankle. - The pain is usually in the **sole of the foot**, not the posterior ankle, and does not commonly lead to difficulty standing on tiptoe due to an acute event.
Question 4: Best initial treatment for acute calcific tendinitis of shoulder?
- A. Surgical Removal
- B. Steroid Injection
- C. Ultrasound Therapy
- D. NSAIDs and Physical Therapy (Correct Answer)
Explanation: ***NSAIDs and Physical Therapy*** - **NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)** are the first-line treatment for acute pain and inflammation associated with calcific tendinitis. - **Physical therapy** helps maintain joint mobility, reduce stiffness, and strengthen surrounding muscles, preventing chronic issues. *Surgical Removal* - **Surgical removal** of calcium deposits is typically reserved for cases that are refractory to conservative treatments after several months or for severe, disabling symptoms. - It is an **invasive procedure** and not the initial approach for acute presentation. *Steroid Injection* - **Corticosteroid injections** can provide temporary pain relief by reducing inflammation, but they do not address the underlying calcium deposits. - Repeated injections can have adverse effects on tendon health and are generally considered after **NSAIDs** have failed. *Ultrasound Therapy* - **Ultrasound therapy** may be used as an adjunct treatment to help break down calcium deposits or to reduce inflammation, but it is not typically the sole initial treatment. - Its effectiveness is **variable**, and it is often combined with other modalities like NSAIDs and physical therapy.
Question 5: A 20-year-old patient presents with chronic low backache and early morning stiffness for the last 2 years. For the past 6 months, they have also experienced bilateral heel pain. What is the most likely diagnosis?
- A. Mechanical pain
- B. Ankylosing spondylitis (Correct Answer)
- C. Disc prolapse
- D. TB spine
Explanation: ***Ankylosing spondylitis*** - The combination of **chronic low backache** and **early morning stiffness** is highly characteristic of inflammatory back pain seen in ankylosing spondylitis. [1] - **Bilateral heel pain** (enthesitis) is a common extra-articular manifestation of ankylosing spondylitis, further supporting the diagnosis. [1] *Mechanical pain* - **Mechanical back pain** typically worsens with activity and improves with rest, in contrast to inflammatory back pain which improves with activity. [2] - It does not usually present with systemic features or enthesitis like heel pain. [2] *Disc prolapse* - **Disc prolapse** usually presents with radicular pain (nerve pain) that radiates down the leg, often unilateral, and is exacerbated by specific movements or coughing. - Early morning stiffness and bilateral heel pain are not typical features of a disc prolapse. *TB spine* - **TB spine** (Pott's disease) often presents with constitutional symptoms like fever, weight loss, and night sweats along with back pain, which are not mentioned here. - While it causes chronic back pain and stiffness, it's typically more localized with vertebral collapse and neurological deficits, and generally doesn't cause bilateral heel pain.
Question 6: Ruptured tendons are most commonly seen in
- A. Overuse (Correct Answer)
- B. Direct trauma from injury
- C. Structural abnormalities from birth
- D. Tumor-related structural changes
Explanation: ***Overuse*** - Chronic **overuse** leads to **microtrauma and degeneration** within the tendon, weakening it over time and making it susceptible to rupture even with minimal acute stress. - This is particularly common in tendons that experience **repetitive strain**, such as the Achilles tendon, rotator cuff, and patellar tendon. *Direct trauma from injury* - While acute, high-impact **direct trauma** can cause tendon ruptures, it is not the most common mechanism overall. - Many traumatic ruptures occur in tendons already weakened by **chronic degeneration**, rather than purely healthy tendons. *Structural abnormalities from birth* - **Congenital structural abnormalities** are relatively rare causes of primary tendon rupture. - These conditions usually present earlier in life with functional limitations rather than sudden rupture in adulthood. *Tumor-related structural changes* - **Tumors** can, in rare cases, weaken tendons and lead to rupture, but this is a far less common cause compared to overuse. - Tendon compromise due to a tumor usually involves direct invasion or pressure, which is not the predominant etiology for the majority of tendon ruptures.
Question 7: Sudden dorsiflexion of the foot may lead to which of the following injuries?
- A. Anterior talofibular ligament injury
- B. Tendo Achilles avulsion injury (Correct Answer)
- C. Rupture of deltoid ligament
- D. Tarsal tunnel syndrome
Explanation: ***Tendo Achilles avulsion injury*** - **Sudden dorsiflexion** of the foot, especially if forced or excessive, can cause extreme stretch on the **Achilles tendon**, potentially leading to its avulsion or rupture. - This mechanism often occurs during activities requiring a forceful push-off or landing with the foot in dorsiflexion, placing significant tensile stress on the tendon. *Anterior talofibular ligament injury* - This injury typically results from an **inversion sprain** of the ankle, where the foot is forcefully turned inward, causing damage to the lateral ankle ligaments. - **Dorsiflexion** alone is not the primary mechanism for injury to the **anterior talofibular ligament**. *Rupture of deltoid ligament* - The **deltoid ligament** is located on the medial side of the ankle and is most commonly injured with an **eversion sprain**, where the foot rolls outward. - While extreme dorsiflexion can put some strain on anterior fibers, it is not the primary mechanism, and a concomitant eversion force would likely be required for rupture. *Tarsal tunnel syndrome* - This condition involves **compression of the tibial nerve** as it passes through the tarsal tunnel, typically causing pain, numbness, and tingling in the sole of the foot. - It is often caused by chronic factors such as swelling, repetitive stress, or structural abnormalities, rather than an acute traumatic event like sudden dorsiflexion.
Question 8: Most common cause of insertional tendonitis of Achilles tendon is -
- A. Improper shoe wear
- B. Overuse (Correct Answer)
- C. Infections from the ankle joint
- D. Steroid injections
Explanation: ***Overuse*** - **Repetitive strain** on the Achilles tendon, often from activities like running or jumping, is the most common etiology for **insertional Achilles tendonitis**. - **Microtrauma** from excessive loading leads to inflammation and degeneration at the tendon's insertion point on the calcaneus. *Improper shoe wear* - While **inappropriate footwear** can contribute to Achilles tendonitis by altering foot mechanics or providing inadequate support, it is less frequently the primary cause compared to overwhelming **overuse**. - It often exacerbates existing issues or contributes to the development of tendonitis in conjunction with high-impact activities. *Infections from the ankle joint* - **Infections** of the ankle joint (septic arthritis) are a rare cause of localized Achilles tendonitis and would present with systemic signs of infection and severe joint involvement. - Tendonitis from infection is specifically known as **infectious tenosynovitis**, and usually involves adjacent structures, not typically causing isolated insertional tendonitis of the Achilles tendon directly. *Steroid injections* - **Steroid injections** near the Achilles tendon are generally *avoided* due to the risk of **tendon rupture**, not because they are a common cause of insertional tendonitis. - While they can have adverse effects, they are not typically a primary initiating factor for the condition itself.
Question 9: A 24-year-old woman experiences pain in the heel when walking uphill, which decreases when walking downhill. X-ray shows a bone spur. What is the diagnosis?
- A. Achilles tendinitis
- B. Plantar fasciitis
- C. Calcaneal exostosis (Correct Answer)
- D. Osteomyelitis of calcaneum
Explanation: ***Calcaneal exostosis*** - This condition involves a **bone spur** on the calcaneus, specifically at the insertion of the **Achilles tendon**. - The pain when walking uphill and improvement when walking downhill are classic signs because uphill walking increases **dorsiflexion** and tension on the Achilles tendon, irritating the spur. *Achilles tendinitis* - While Achilles tendinitis also causes **heel pain**, the primary issue is inflammation of the tendon itself, not necessarily an improvement with downhill walking. - The presence of a distinct bone spur on X-ray, as described, more directly points to mechanical irritation from an **exostosis**. *Plantar fasciitis* - This typically presents as **heel pain** that is worst with the first steps in the morning or after prolonged rest, and not specifically exacerbated by walking uphill or down. - The pain is usually located on the **underside of the heel**, not primarily described as an issue with Achilles tendon mechanics. *Osteomyelitis of calcaneum* - This is an **infection of the bone**, which would present with signs of systemic infection like fever, malaise, and severe, persistent pain that is not typically relieved by changing walking angles. - A bone spur on its own is not indicative of an **infection** without other signs and symptoms.
Question 10: Open reduction (OR) is not required in which fracture?
- A. Fracture of the patella
- B. Fracture of the outer one-third of the radius (Correct Answer)
- C. Displaced fracture of the olecranon
- D. Fracture of the condyle of the humerus
Explanation: ***Fracture of the outer one-third of the radius*** - Fractures of the **outer one-third of the radius** (distal radius fractures) often can be managed with **closed reduction and casting** if stable and adequately reduced. - While some unstable distal radius fractures require OR, many stable patterns, especially those with minimal displacement or good alignment after closed manipulation, do not. *Fracture of the patella* - Many patellar fractures lead to significant **extensor mechanism disruption**, necessitating OR with **tension band wiring** or screw fixation to restore quadriceps function. - Displaced patellar fractures, especially transverse ones, require surgical fixation to prevent extensor lag and **nonunion**. *Displaced fracture of the olecranon* - Displaced olecranon fractures disrupt the **triceps mechanism** and compromise elbow stability, almost always requiring **open reduction and internal fixation (ORIF)**, typically with tension band wiring. - Without surgical repair, a displaced olecranon fracture can lead to significant loss of extension strength and **nonunion**. *Fracture of the condyle of the humerus* - Fractures of the humeral condyle, particularly in children, often require OR due to the risk of **avascular necrosis** (especially lateral condyle) and the need for **precise anatomical reduction** to prevent joint incongruity and cubitus varus/valgus deformities. - Intra-articular and displaced condylar fractures almost invariably require surgical intervention to ensure harmonious joint function and prevent long-term complications like **stiffness and deformity**.
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