FOOT AND ANKLE
2025
1*Figures 1 and 2 are the T2-weighted MR image and AP radiograph of a 55-year-old laborer who
sustains an ankle sprain after a fall from scaffolding. Initial films are read by radiology as normal. Despite
an exhaustive 6-month course of immobilization; shoe modifications; and therapy, the patient continues
to have activity-related lateral hindfoot pain, which has prevented him from returning to work. On
examination, the patient has full eversion strength that is painless. Ankle range of motion is full and
painless. No anterior drawer is observed. There is tenderness and mild swelling distal to the sinus tarsi.
,Sensation and motor are intact and the skin is otherwise unremarkable in appearance. An MRI is
obtained. What is the next best step?
1- Referral for complex regional pain syndrome (CRPS) workup
2- Lace-up ankle brace
3- Excision of the superior anterior process of the calcaneus
,4-Arthroscopic Brostrom
Correct answer : 3
The patient has a nonunion of anterior process of the calcaneus. His symptoms are consistent with the
examination and imaging findings, and he has failed nonsurgical treatment. Therefore, surgical excision
of the nonunion fragment is indicated. No findings consistent with CRPS are seen in this patient. He has
activity-related pain at a focal area and is without skin changes. A lace-up ankle brace is unlikely to
provide substantial immobilization and pain control at the hindfoot. In addition, the patient has tried
nonsurgical therapies without lasting improvement. The patient has complaints, examination, and
imaging findings consistent with a single diagnosis. A lateral ankle stabilization procedure such as a
Brostrom is not indicated because the patient has no instability on examination.
2*Figure 1 is the T1-weighted lateral MR image and Figure 2 is the T2-weighted lateral MR image of a
25-year-old woman with ankle pain for the last year that is associated with walking down stairs and
playing sports. No known injury has been identified. The ankle pain has been managed with rest,
therapy for range of motion, and a period of immobilization. Intra-articular steroid injection provided
limited relief of symptoms. What is the best next step?
, Intra-articular platelet-rich plasma injection
Anterior ankle arthroscopy with marrow stimulation
Posterior ankle arthroscopy with debridement
Open peroneal tendon repair
Correct answer : 3
The patient has ankle pain that is consistent with an os trigonum. The MR images show inflammation
about the posterior ankle and a bright line between the talus and the os trigonum. Initial management
typically is rest and therapy. Steroid injection under ultrasonography about the os trigonum has been
described. Surgical treatment can be either open or arthroscopic. Arthroscopic treatment has shown
earlier return to sport, but longer-term studies have not shown a significant difference between the two
techniques.
Figure of question 3+4+5+6
2025
1*Figures 1 and 2 are the T2-weighted MR image and AP radiograph of a 55-year-old laborer who
sustains an ankle sprain after a fall from scaffolding. Initial films are read by radiology as normal. Despite
an exhaustive 6-month course of immobilization; shoe modifications; and therapy, the patient continues
to have activity-related lateral hindfoot pain, which has prevented him from returning to work. On
examination, the patient has full eversion strength that is painless. Ankle range of motion is full and
painless. No anterior drawer is observed. There is tenderness and mild swelling distal to the sinus tarsi.
,Sensation and motor are intact and the skin is otherwise unremarkable in appearance. An MRI is
obtained. What is the next best step?
1- Referral for complex regional pain syndrome (CRPS) workup
2- Lace-up ankle brace
3- Excision of the superior anterior process of the calcaneus
,4-Arthroscopic Brostrom
Correct answer : 3
The patient has a nonunion of anterior process of the calcaneus. His symptoms are consistent with the
examination and imaging findings, and he has failed nonsurgical treatment. Therefore, surgical excision
of the nonunion fragment is indicated. No findings consistent with CRPS are seen in this patient. He has
activity-related pain at a focal area and is without skin changes. A lace-up ankle brace is unlikely to
provide substantial immobilization and pain control at the hindfoot. In addition, the patient has tried
nonsurgical therapies without lasting improvement. The patient has complaints, examination, and
imaging findings consistent with a single diagnosis. A lateral ankle stabilization procedure such as a
Brostrom is not indicated because the patient has no instability on examination.
2*Figure 1 is the T1-weighted lateral MR image and Figure 2 is the T2-weighted lateral MR image of a
25-year-old woman with ankle pain for the last year that is associated with walking down stairs and
playing sports. No known injury has been identified. The ankle pain has been managed with rest,
therapy for range of motion, and a period of immobilization. Intra-articular steroid injection provided
limited relief of symptoms. What is the best next step?
, Intra-articular platelet-rich plasma injection
Anterior ankle arthroscopy with marrow stimulation
Posterior ankle arthroscopy with debridement
Open peroneal tendon repair
Correct answer : 3
The patient has ankle pain that is consistent with an os trigonum. The MR images show inflammation
about the posterior ankle and a bright line between the talus and the os trigonum. Initial management
typically is rest and therapy. Steroid injection under ultrasonography about the os trigonum has been
described. Surgical treatment can be either open or arthroscopic. Arthroscopic treatment has shown
earlier return to sport, but longer-term studies have not shown a significant difference between the two
techniques.
Figure of question 3+4+5+6
