Tendon Disorders of Foot and Ankle — MCQs
A ballet dancer presents with chronic anterolateral ankle pain. Most likely diagnosis?
Rupture of extensor pollicis longus tendon occurs in all of the following except -
Foot eversion is caused by
Bilateral loss of ankle jerk and extensor plantar response is seen in:
A diabetic patient presents with sensory involvement, tingling, numbness, ankle swelling, and absence of pain. What is the most likely diagnosis?
High stepping gait is due to
Best method to determine gestational age in decomposed fetus?
The commonest site for venous ulcer is?
Injury at which of the following marked sites on the leg causes failure of dorsiflexion?
Unilateral high stepping gait is seen in
Tendon Disorders of Foot and Ankle Indian Medical PG Practice Questions and MCQs
Question 1: 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 2: Rupture of extensor pollicis longus tendon occurs in all of the following except -
- A. De Quervain's disease (Correct Answer)
- B. Rheumatoid arthritis
- C. Drummers
- D. Colles' fracture
Explanation: ***De Quervain's disease*** - This condition involves **tenosynovitis** of the **extensor pollicis brevis** and **abductor pollicis longus** tendons, not a rupture of the extensor pollicis longus. - The pathology is an inflammation and thickening of the tendon sheaths, distinct from a tendon tear. *Rheumatoid arthritis* - **Chronic inflammation** in rheumatoid arthritis can lead to weakening and eventual rupture of tendons, including the **extensor pollicis longus**, often due to synovitis eroding the tendon. - The condition creates an environment where tendons are vulnerable to **attrition** and damage, making rupture a recognized complication. *Drummers* - Repetitive, high-force movements involved in drumming can cause significant **stress** and microscopic damage to tendons, including the **extensor pollicis longus**. - Over time, this cumulative trauma can lead to inflammation, degeneration, and eventual **rupture** due to overuse. *Colles' fracture* - A **Colles' fracture** of the distal radius can cause a delayed rupture of the **extensor pollicis longus (EPL)** tendon. - This occurs due to attrition of the tendon as it rubs over the **roughened fracture site** or due to *avascular necrosis* of the tendon as it passes through a narrow osteofibrous tunnel.
Question 3: Foot eversion is caused by
- A. Tibialis anterior
- B. Tibialis posterior
- C. Peroneus longus (Correct Answer)
- D. Extensor digitorum
Explanation: ***Peroneus longus*** - The **peroneus longus** muscle (fibularis longus) is a primary evertor of the foot. - It originates from the head and upper lateral surface of the fibula, inserts into the medial cuneiform and first metatarsal, and its contraction pulls the foot outwards and downwards. *Tibialis anterior* - The **tibialis anterior** is the primary dorsiflexor and invertor of the foot. - It pulls the foot upwards and inwards, which is the opposite action of eversion. *Tibialis posterior* - The **tibialis posterior** is a strong invertor and plantar flexor of the foot. - It contributes to maintaining the arch of the foot and does not cause eversion. *Extensor digitorum* - The **extensor digitorum longus** primarily extends the toes and assists in dorsiflexion of the ankle. - While it may have a slight eversion component, it is not the primary muscle responsible for foot eversion.
Question 4: Bilateral loss of ankle jerk and extensor plantar response is seen in:
- A. Amyotrophic lateral sclerosis
- B. Lead poisoning
- C. Freidrich's ataxia (Correct Answer)
- D. Tabes dorsalis
Explanation: ***Freidrich's ataxia*** - **Friedreich's ataxia** is characterized by both **upper** (extensor plantar response) and **lower** (loss of ankle jerk) motor neuron signs due to degeneration of ascending and descending spinal tracts. - The combination of **ataxia**, **loss of ankle jerk reflexes**, and **extensor plantar responses** is highly suggestive of this condition. *Amyotrophic lateral sclerosis* - **ALS** typically presents with a combination of **upper** (extensor plantar response, spasticity) and **lower** (muscle atrophy, fasciculations, weakness) motor neuron signs [1]. - However, the loss of **ankle jerk reflexes** (a lower motor neuron sign) in addition to an **extensor plantar response** (an upper motor neuron sign) pointing specifically towards **Friedreich's ataxia** in this context. *Lead poisoning* - **Lead poisoning** primarily causes a **motor neuropathy**, leading to **weakness** and potentially **reduced or absent reflexes** [2]. - It does not typically cause **extensor plantar responses**, which are indicative of **upper motor neuron dysfunction**. *Tabes dorsalis* - **Tabes dorsalis**, a complication of **syphilis**, affects the **dorsal columns** and **dorsal roots**, leading to **sensory ataxia** and **loss of deep tendon reflexes**, including ankle jerks. - However, it does not typically cause an **extensor plantar response** as it involves **sensory** rather than **motor system degeneration**.
Question 5: A diabetic patient presents with sensory involvement, tingling, numbness, ankle swelling, and absence of pain. What is the most likely diagnosis?
- A. Charcot's joint (Correct Answer)
- B. Gout
- C. Rheumatoid arthritis
- D. Ankylosing spondylitis
Explanation: ***Charcot's joint*** - This condition is characterized by **neuropathic arthropathy**, resulting from nerve damage (often due to **diabetes**), leading to sensory involvement, **numbness**, and **absence of pain** [1]. - The loss of protective sensation and repeated microtrauma contribute to joint destruction, often manifesting as **swelling** and deformity, particularly in the feet and ankles [1]. *Gout* - Gout typically presents with sudden, severe episodes of **pain**, redness, and swelling in a single joint, most commonly the **big toe**. - It is caused by **uric acid crystal deposition** and is not primarily associated with sensory deficits or chronic painless swelling. *Rheumatoid arthritis* - This is a **chronic autoimmune** inflammatory disease primarily affecting the **small joints** of the hands and feet symmetrically, causing pain, stiffness, and swelling. - It does not typically present with sensory neuropathy or painless joint destruction in the way described. *Ankylosing spondylitis* - This is a **chronic inflammatory disease** primarily affecting the **spine and sacroiliac joints**, causing progressive stiffness and pain that improves with activity. - It is not associated with peripheral joint neuropathy, numbness, or painless ankle swelling [1].
Question 6: High stepping gait is due to
- A. Gluteus maximum paralysis
- B. CDH
- C. Quadriceps paralysis
- D. Foot drop (Correct Answer)
Explanation: ***Foot drop*** - **Foot drop** causes the patient to lift the leg higher during walking to prevent the toes from dragging on the ground, resulting in a **high stepping gait**. - This condition is often due to weakness or paralysis of the **dorsiflexor muscles** of the foot, typically from **peroneal nerve injury** or **L4/L5 radiculopathy**. *Gluteus maximum paralysis* - **Gluteus maximus paralysis** causes difficulty with hip extension and is often compensated by a **backward lurch** of the trunk during gait. - It results in a **Trendelenburg gait** (if the gluteus medius is also affected) or instability during standing, but not typically a high stepping gait. *CDH* - **Congenital hip dysplasia (CDH)** involves abnormal development of the hip joint. - It usually leads to a **waddling gait** due to instability and pain, or limb length discrepancy, not a high stepping gait. *Quadriceps paralysis* - **Quadriceps paralysis** results in weakness or inability to extend the knee. - Patients typically compensate by hyperextending the knee or leaning forward over the affected leg during gait, which is not a high stepping gait.
Question 7: Best method to determine gestational age in decomposed fetus?
- A. Head circumference
- B. Crown-rump length
- C. Femur length
- D. Foot length (Correct Answer)
Explanation: ***Foot length*** - **Foot length** is a reliable indicator of gestational age in a decomposed fetus because the foot is relatively **resistant to decomposition** and its growth is consistent throughout gestation. - This measurement correlates well with gestational age even when other body parts are too degraded for accurate assessment. *Head circumference* - **Head circumference** is significantly affected by decomposition, as the skull and soft tissues can undergo distortion, making accurate measurement difficult. - While generally useful in viable fetuses, its reliability decreases sharply with advanced decomposition. *Crown-rump length* - **Crown-rump length** is highly susceptible to inaccuracies in decomposed fetuses due to the fragility of the spine and neck, leading to potential stretching or compression. - This measurement requires an intact body to be reliable, which is often not the case in decomposition. *Femur length* - **Femur length** can be a useful indicator, but in advanced decomposition, the ends of the bone (epiphyses) may be damaged or detached, affecting the accuracy of the overall measurement. - While more resilient than soft tissues, it is generally less reliable than foot length when decomposition is extensive.
Question 8: The commonest site for venous ulcer is?
- A. Instep of foot
- B. Lower 1/3 leg and ankle (Correct Answer)
- C. Lower 2/3 of leg
- D. Middle 1/3 of leg
Explanation: **Lower 1/3 leg and ankle** - Venous ulcers most commonly occur in the "gaiter area," which refers to the **lower third of the leg** and around the **medial malleolus (ankle)**. This region is subject to the highest venous pressure. - The elevated venous pressure in the lower leg, due to venous insufficiency, leads to extravasation of fluid and cells, causing tissue damage and ulcer formation. *Instep of foot* - Ulcers on the instep of the foot are less common for typical venous ulcers, though they can occur with various etiologies. - This area is more commonly associated with neuropathic ulcers in diabetic patients or pressure ulcers. *Lower 2/3 of leg* - While the lower leg is generally affected, specifying the lower **two-thirds** is less precise than the "lower 1/3 and ankle" for the most frequent location of venous ulcers. - The pathophysiology of venous insufficiency disproportionately affects the most dependent part of the lower limb. *Middle 1/3 of leg* - The middle third of the leg is less frequently the primary site for venous ulcers compared to the ankle region. - Ulcers in this area might suggest a different etiology or advanced, widespread venous disease.
Question 9: Injury at which of the following marked sites on the leg causes failure of dorsiflexion?
- A. Anterior aspect of the thigh (site 1)
- B. Medial aspect of the leg (site 4)
- C. Lateral aspect of the leg (site 3) (Correct Answer)
- D. Posterior aspect of the thigh (site 2)
Explanation: ***Lateral aspect of the leg (site 3)*** - Site 3 points to the **fibula head** and the adjacent region on the lateral aspect of the leg. This is the anatomical location where the **common fibular nerve (peroneal nerve)** wraps around. - The common fibular nerve innervates the muscles responsible for **dorsiflexion** and eversion of the foot. Damage to this nerve, often due to trauma at the fibular neck, leads to **foot drop** and an inability to dorsiflex the foot. *Anterior aspect of the thigh (site 1)* - Site 1 points to the distal femur, which is part of the thigh. Nerves in the anterior thigh (e.g., **femoral nerve**) primarily control hip flexion and knee extension. - Damage here would affect movements of the hip and knee, not directly causing failure of dorsiflexion of the foot. *Medial aspect of the leg (site 4)* - Site 4 points to the medial tibia. This area is associated with the **tibial nerve** and saphenous nerve, which primarily innervate muscles for plantarflexion and inversion of the foot, or provide sensory innervation. - Injury to the tibial nerve would result in an inability to plantarflex and invert the foot, not dorsiflexion. *Posterior aspect of the thigh (site 2)* - Site 2 points to the posterior aspect of the thigh, which is the region for the hamstrings. The **sciatic nerve** and its branches (tibial and common fibular) pass through this region. - While the common fibular nerve originates from the sciatic nerve in the posterior thigh, an injury at this level would likely cause more widespread motor and sensory deficits than isolated dorsiflexion failure, and site 3 is a more common and specific site for common fibular nerve injury isolated to foot drop.
Question 10: Unilateral high stepping gait is seen in
- A. Distal radiculopathy
- B. Cauda equina syndrome
- C. L5 radiculopathy (Correct Answer)
- D. None of the options
Explanation: ***L5 radiculopathy*** - Damage to the **L5 nerve root** can cause weakness in the **tibialis anterior muscle**, leading to **foot drop**. [1] - To compensate for the foot drop and prevent tripping, the patient develops a **high stepping gait** (steppage gait) on the affected side. [1] *Distal radiculopathy* - This term is too general; **radiculopathy** refers to nerve root compression but does not specify which root or its precise distal effects. - While a radiculopathy can cause weakness, "distal" does not specifically localize to L5 or unilateral foot drop. *Cauda equina syndrome* - This is a serious condition involving **compression of multiple nerve roots** below the conus medullaris. - It typically causes bilateral symptoms, including **saddle anesthesia**, bowel/bladder dysfunction, and often bilateral leg weakness, not isolated unilateral foot drop. *None of the options* - This option is incorrect because **L5 radiculopathy** directly explains unilateral high stepping gait due to foot drop.
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