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ABPOPPM In-Training Exam

Module: Medicine

Set 1 of 3

Questions 1-3 present different clinical scenarios related to the same pathology. Choose the best response
for each clinical scenario.

A 41 year-old female complains of great toe pain in shoe gear. She underwent bunion surgery 3 years ago. Her
pain began soon after surgery and has worsened. Current radiographs are shown.

Which of the following is the most appropriate shoe gear?

A. Straight lasted
B. Custom molded
C. Semi curve lasted
D. Extra depth

Correct Answer: B

Suggested Reading:

Goldberg B, Hsu J. Shoes. Atlas of Orthoses and Assistive Devices, 3rd Edition, 1997 Mosby: St Louis Chapter
11 pp225-239

Jahss M. Footwear. Disorders of the Foot, 2nd Edition, 1991 Saunders: Philadelphia Chapter 107 pp 2879-2910
ABPOPPM In-Training Exam

Module: Medicine

Set 2 of 3

The radiographs below are from a 41 year-old female who is 2 weeks post bunion surgery.

Which of the following is the most appropriate treatment at this time?

A. Hallux taping in abduction


B. Cortisone injection to the first MPJ
C. Soft tissue mobilization of the hallux
D. Reverse last shoe with padding
E. Immediate surgical revision

Correct Answer: E

Suggested Reading:

Bevernage BD, Leemrijse T, Hallux Varus: Classification and Treatment Foot and Ankle Clinics: The Hallux
2009: WB Saunders, Philadelphia, March 14(1) pp51-65

Gerbert J, Hallux Varus. Textbook of Bunion Surgery 2001:Saunders, Philadelphia Chapter 17 pp411-433
ABPOPPM In-Training Exam

Module: Medicine

Set 3 of 3

The radiographs below are from a 71 year-old female who is 6 years following bunion surgery. She is
asymptomatic.

Which of the following is the most important determinant of treatment?

A. Flexibility of hallux adduction


B. Contracture of the IPJ
C. Absence of pain
D. Crepitation with one MPJ dorsiflexion

Correct Answer: C

Suggested Reading:

Bevernage BD, Leemrijse T, Hallux Varus: Classification and Treatment Foot and Ankle Clinics: The Hallux
2009: WB Saunders, Philadelphia, March 14(1) pp51-65

Gerbert J, Hallux Varus. Textbook of Bunion Surgery 2001:Saunders, Philadelphia Chapter 17 pp411-433
ABPOPPM In-Training Exam

Module: Medicine

A 68 year-old rheumatoid arthritic female with the deformities shown is scheduled for first MTP joint
arthrodesis with resection of metatarsal heads 2, 3, 4, 5.

Which of the following is the best post-operative gait assistive device for partial weight bearing for this patient?

A. Single pronged cane


B. Wheel walker
C. Forearm crutch
D. Platform crutch

Correct Answer: D

Suggested Reading:

Goldberg B, Hsu J. Shoes. Atlas of Orthoses and Assistive Devices, 3rd Edition, 1997 Mosby: St Louis Chapter
38 pp557-573

Youdas JW, Kotajarvi BJ, Padgett DJ, Kaufman KR: Partial weight bearing gait using conventional assistive
devices. Arch Phys Med Rehabil 2005: 86(3): 394-398
ABPOPPM In-Training Exam

Module: Medicine

Set 1 of 3

Questions 5-7 present different clinical scenarios related to the same pathology. Choose the best response
for each clinical scenario.

A 28 year-old male complains of sudden onset of pain to the right heel. He denies injury or change in activity.
Examination demonstrates an antalgic gait. You suspect a stress fracture.

Based on the radiograph which of the following is the best initial treatment for this patient?

A. Immobilization
B. Gait training
C. Low Dye taping
D. Iontophoresis

Correct Answer: A

Suggested Reading:

Smith SB, Shane HS: Simple bone cyst of the calcaneus. A case report and literature review JAPMA 1994: 84(3)
pp127-130

Letts M, Moreau G: Unicameral bone cyst of the calcaneus in children: J Pediatr Orthop 1994: Jan 14(1)
pp101-104
ABPOPPM In-Training Exam

Module: Medicine

Set 2 of 3

A. 28 year-old male complains of dull aching pain to the right heel. He denies injury or change in activity. The
discomfort is present when non-weight bearing and is exacerbated by activity.

Based on the radiographs, which of the following is the most likely diagnosis?

A. Osteoid osteoma
B. Unicameral bone cyst
C. Fibrous dysplasia
D. Osteosarcoma

Correct Answer: B

Suggested Reading:

Conrad E, Osseous Tumors of the Lower Extremity. Oncology: Diagnosis and Treatment 2008:Thieme, Chapter
31 pp173

Canale S, Benign Tumors of the Bone. Campbells Operative Orthopaedics 10th edition, 2003: Mosby
Philadelphia Chapter 20 pp796-799
ABPOPPM In-Training Exam

Module: Medicine

Set 3 of 3

A 54 year-old female with a pacemaker is seen for evaluation of right heel pain of sudden onset. She denies a
change in activity or trauma.

In addition to the radiograph shown, which of the following is most appropriate to work up her problem?

A. Ultrasound
B. Three phase bone scan
C. MRI
D. CT scan

Correct Answer: D

Suggested Reading:

Gallagher T, Lim-Dunham J, Vade A: CT findings of unicameral calcaneal bone cyst containing a fluid-fluid
level, Computerized Medical Imaging and Graphics 2007: 31(2) pp111-113

Faris O, Shein M: Government Viewpoint: US Food & Drug Administration: Pacemakers, ICD and MRI,
Pacing and Clinical Electrophysiology, 2005: April 24(4) pp 268-269
ABPOPPM In-Training Exam

Module: Medicine

Set 1 of 3

Questions 8-10 present different clinical scenarios related to the same pathology. Choose the best
response for each clinical scenario.

A 30 year-old male is seen in the ED for evaluation of a left toe injury that occurred within the last 2 hours. He
was kicked from behind while playing soccer.

Based on the accompanying radiographs, which of the following is the most appropriate immediate course of
action?

A. Order an MRI
B. Attempt closed reduction
C. Obtain medial compartment pressures
D. Immobilize and place non-weight bearing

Correct Answer: B

Suggested Reading:

Bucholz R, Heckman J, Court-Brown C. Fractures and Dislocations of the Midfoot and Forefoot. Rockwood &
Green’s Fractures in Adults, 6th edition, 2006 Lippincott, Williams&Wilkins:Philadelphia Chapter 56 p2383-
2391

Coughlin M, Mann R, Saltzman C. Dislocations of the Foot. Surgery of the Foot and Ankle, 8th edition,2007
Mosby: St Louis, Chapter 40 pp2183-2197
ABPOPPM In-Training Exam

Module: Medicine

Set 2 of 3

Which anatomical structure is most likely preventing the closed reduction?

A. Dorsal capsule
B. Plantar plate
C. Collateral ligaments
D. Intersesamoid ligament

Correct Answer: C

Suggested Reading:

Bucholz R, Heckman J, Court-Brown C. Fractures and Dislocations of the Midfoot and Forefoot. Rockwood &
Green’s Fractures in Adults, 6th edition, 2006 Lippincott, Williams&Wilkins:Philadelphia Chapter 56 p2383-
2391

Coughlin M, Mann R, Saltzman C. Dislocations of the Foot. Surgery of the Foot and Ankle, 8th edition,2007
Mosby: St Louis, Chapter 40 pp2183-2197
ABPOPPM In-Training Exam

Module: Medicine

Set 3 of 3

What is the best shoe modification for this patient to prevent re-dislocation?

A. Medial carbon shank


B. One quarter inch heel lift
C. Lateral sole wedge
D. Metatarsal bar

Correct Answer: A

Suggested Reading:

Bucholz R, Heckman J, Court-Brown C. Fractures and Dislocations of the Midfoot and Forefoot. Rockwood &
Green’s Fractures in Adults, 6th edition, 2006 Lippincott, Williams&Wilkins:Philadelphia Chapter 56 p2383-
2391

Puddu G, Giombini A, Selvanetti A. Rehabilitation of the Foot Following Sports-related Injuries and Surgical
Treatment Rehabilitation of Sports Injuries: Current Concepts 2001, Springer. Chapter 14 pp 167
ABPOPPM In-Training Exam

Module: Medicine

Set 1 of 2

Questions 11 and 12 relate to the following clinical scenario:

A 13 year-old boy is presented by his mother for evaluation of bilateral heel pain, accentuated after basketball
and when he rises from a recumbent position.

Examination reveals pain elicited with side-to-side compression to the calcaneus bilaterally. There is pain with
palpation to the inferior Achilles bilaterally. Ankle dorsiflexion with knee extended is 12°. Subtalar joint range
of motion on the right is 30° inversion and 5° eversion; on the left there is 25° inversion and 5° eversion.
Patellar and Achilles DTRs are normal and no clonus is observed. Radiographs are shown.

Which of the following is the most likely diagnosis for this patient?

A. Tarsal tunnel syndrome


B. Calcaneal apophysitis
C. Tarsal coalition
D. Os trigonum fracture

Correct Answer: B

Suggested Reading:

Hendrix C, Calcaneal apophysitis (Sever disease), Clinics in Podiatric Medicine and Surgery, 2005: Elsevier,
Jan 22(1) pp 55-62

Cassas K, Cassettari-Wayhs A, Childhood and Adolescent Sports-Related Overuse Injuries, American Family
Physician, 2006 pp1014-1022
ABPOPPM In-Training Exam

Module: Medicine

Set 2 of 2

Which of the following is the best initial treatment for this patient?

A. Night splint
B. Isometric plantar stretching
C. Silicone heel lifts and icing
D. Discontinuation of all activity

Correct Answer: C

Suggested Reading:

Hendrix C, Calcaneal apophysitis (Sever disease), Clinics in Podiatric Medicine and Surgery, 2005: Elsevier,
Jan 22(1) pp 55-62

Cassas K, Cassettari-Wayhs A, Childhood and Adolescent Sports-Related Overuse Injuries, American Family
Physician, 2006 pp1014-1022
ABPOPPM In-Training Exam

Module: Medicine

Set 1 of 2

Questions 13-14 relate to the following clinical scenario:

A 28 year-old female underwent an excisional biopsy of the right calcaneus. She has been instructed to remain
non-weight bearing on the right lower extremity.

What is the appropriate sequence for this patient for ascending stairs with axillary crutches?

A. Right foot on advanced step followed by crutches and left foot on same advance step
B. Right foot on advanced step followed by crutches and left foot on the next advanced step
C. Left foot on advanced step followed by crutches and right foot on same advanced step
D. Left foot on advanced step followed by crutches and right foot on the next advanced step

Correct Answer: C

Suggested Reading:

Dreeban O, Wheelchairs, Assistive Devices and Gait Training, Introduction to Physical Therapy for Physical
Therapist Assistants, 2006 Jones & Barlett:Sudbery Chapter 14 pp262
ABPOPPM In-Training Exam

Module: Medicine

Set 2 of 2

What is the appropriate sequence for this patient for descending stairs with axillary crutches?

A. Descend with the left foot and follow with crutches and the right foot on the same lower step
B. Descend with the right foot and crutches followed by the left foot on same lower step
C. Descend with the right foot and crutches and follow with the left foot on the next advanced lower step
D. Descend with left foot and crutches followed by the right foot on the next advanced lower step

Correct Answer: B

Suggested Reading:

Dreeban O, Wheelchairs, Assistive Devices and Gait Training, Introduction to Physical Therapy for Physical
Therapist Assistants, 2006 Jones & Barlett:Sudbery Chapter 14 pp235-265

Dutton M, Gait Analysis, Orthopaedic Examination, Evaluation, and Intervention, 2004 McGaw-Hill
Professional: Chapter 13 pp396
ABPOPPM In-Training Exam

Module: Medicine

A 78 year-old male with DM2 is seen for evaluation of an ulcer to the right hallux which occurred after wearing
new shoes. There is a 50 pack-year history of tobacco use. He has a pacemaker and underwent a left carotid
endarterectomy several years ago.

Examination reveals:
• a necrotic non-infected ulcer to the medial IPJ
• inability to feel a 5.07 Semmes-Weinstein filament to the pedal dermatomes
• non-palpable pedal pulses
• digits appear hyperemic but are cool to the touch
• capillary refill is greater then 3 seconds to all digits

Laboratory findings reveal:

Patient Normal
BUN 27 mg/dl 7-25 mg/dl
Creatinine 1.7 mg/dl 0.7-1.4 mg/dl
Glucose 176 mg/dl 60-109 mg/dl

Which of the following studies is most appropriate for the patient at this time?

A. Arterial duplex scan


B. Magnetic resonance angiogram
C. Computer tomography angiogram
D. Digital pulse volume recordings

Correct Answer: A

Suggested Reading:

AbuRahma A, Bergan J, Duplex Scanning for Lower Extremity Arterial.Disease. Non invasive Vascular
Diagnosis-A Practical Guide to Therapy, 2nd Edition, 2007: Springer, London Chapter 21 pp 253-261

Tins B, Oxtoby J, Patel S.Comparison of CT angiography with conventional arterial angiography in aortoiliac
occlusive disease. British Journal of Radiology, 2001 74(879) pp219-225
ABPOPPM In-Training Exam

Module: Medicine

A 32 year-old female complains of experiencing acute pain in the posterior right ankle during a tennis game.

Based on the accompanying MRI, which of the following is the most likely diagnosis?

A. Inflamed retrocalcaneal bursa


B. Tumor or mass within the Achilles tendon
C. Focal calcification of the Achilles tendon
D. Avulsion fracture of the calcaneus at the Achilles tendon insertion
E. Partial rupture of the Achilles tendon

Correct Answer: E

Suggested Reading:

Schweitzer M, Karasick D. Review: MR Imaging Disorders of the Achilles Tendon, American Journal of
Roentgenology; 2000; 175(3):613-25
ABPOPPM In-Training Exam

Module: Medicine

A 32 year-old male presents to the ED following a fall and unable to bear weight on the right lower extremity.
Ankle radiographs are shown

Which of the following clinical findings would be most significant in determining the timing for surgical
intervention?

A. Exquisite pain with light touch to the anterior and medial ankle
B. Non-palpable DP and PT pulses
C. Superficial disruption of skin integument
D. Inability to passively dorsiflex and plantarflex the ankle joint
E. Fracture blisters

Correct Answer: B

Suggested Reading:

Stannard J, Schmidt A, Kregor P. “Ankle Fractures and Dislocations”, Surgical Treatment of Orthopaedic
Trauma, Thieme,2007:792-811

Haig S, Flores C. “AnkLe and Distal Tibia”. Orthopedic Emergencies :A Radiographic Atlas. McGaw-Hill,
2004:23-33
ABPOPPM In-Training Exam

Module: Medicine

A 73 year-old female underwent a left total hip arthroplasty. Five days following the surgery she experienced
sudden left buttock pain and progressive weakness of left ankle. Examination on the sixth post-op day reveals
Achilles reflex 0/4 and patellar reflex 2/4. Muscle strength of the left foot extensors, flexors, invertors and
evertors is 0/5.

Which of the following nerves is most likely injured?

A. Peroneal nerve
B. Tibial nerve
C. Femoral nerve
D. Sciatic nerve

Correct Answer: D

Suggested Reading:

Solheim L, Hagen R. Femoral and sciatic neuropathies after total hip arthroplasty. Acto Orthoopaedica, 1980
51(1) pp531-534

Callaghan J, Rosenberg A, Rubash H, The Hip. The Adult Hip 2nd Edition, 2006: Lippinocott, Williams &
Wilkins,Philadelphia Chapter 3 pp52-65
ABPOPPM In-Training Exam

Module: Medicine

A 56 year-old male complains of long-term pain in his first MTP joint. Examination reveals moderately severe
pain and crepitation with dorsiflexion. He is undomiciled and uninsured.

His radiographs are shown.

Which of the following shoe recommendation/modification is most appropriate for this patient?

A. Heel lift
B. Extra depth shoes
C. Less rigid-soled shoes
D. Metatarsal rocker bar

Correct Answer: D

Suggested Reading:

Banks A, Downey M, Martin D, Miller S. “Hallux Limitus and Hallux Rigidus”. McGlamry’s Comprehensive
Textbook of Foot and Ankle Surgery, 3 ed., Lippincott, Williams & Wilkins, 2001: 679-713

Grady J, Axe T, Zager E, Sheldon L. A Retrospective Analysis of 772 Patients with Hallux Limitus, Journal
American Podiatric Medical Association, 2002:92(2):102-8
ABPOPPM In-Training Exam

Module: Medicine

A talar neck fracture is treated by ORIF, performed via a posterior lateral approach. Post-operatively the patient
develops numbness along the lateral aspect of the foot.

Which nerve was most likely injured?

A. Dorsal intermediate cutaneous


B. Lateral plantar
C. Saphenous
D. Sural

Correct Answer: D

Suggested Reading:

Rockwood C, Green D, Bucholz R, Heckman J, Court-Brown C. “Fractures of the Talus”. Rockwood & Green’s
Fractures in Adults, 6 ed., Lippincott, Williams & Wilkins, 2005: 2249-93

Stannard J, Schmidt A, Kregor P. “Foot Fractures ”, Surgical Treatment of Orthopaedic Trauma,


Thieme,2007:815-25
ABPOPPM In-Training Exam

Module: Medicine

A 56 year-old morbidly obese male is consulted for evaluation and treatment of a heel ulcer. Past medical
history includes DM2, coronary heart disease and hypertension.

Examination reveals:
• palpable pedal pulses and an ABI of 1.4
• absent protective sensation as noted with a 10g monofilament wire.
• a clean plantar, well-circumscribed, granular heel ulcer; there are no signs of infection, and the lesion
does not probe deeply.

What assistive device is most indicated for this patient?

A. Standard walker
B. Axillary crutches
C. Platform knee walker
D. Manual wheel chair

Correct Answer: C

Suggested Reading:

Hsu J, Michael J, Fisk J. Assistive Devices: Canes, Cruthces and Walkers.AAOS Atlas of Orthoses and Assistive
Devices 2008 :Elsevier:Philadelphia Chapter 42 pp533-543

Youdas JW, Kotajarvi BJ, Padgett DJ, Kaufman KR: Partial weight bearing gait using conventional assistive
devices. Arch Phys Med Rehabil 2005: 86(3): 394-398
ABPOPPM In-Training Exam

Module: Medicine

Set 1 of 2

Questions 22 and 23 relate to the following clinical scenario:

A 68 year-old male who suffered a left pelvic fracture in a motor vehicle accident 8 weeks ago presents for
evaluation of the left lower extremity for bracing, while the patient is undergoing therapy.

Examination reveals:
• +4/5 strength to the quadriceps and iliopsoas muscles
• +5/5 strength to the leg extensors and flexors
• Patellar reflex is 1/4 and Achilles reflex is 3/4

Which of the following nerves is most likely injured?

A. Peroneal
B. Sciatic
C. Tibial
D. Femoral

Correct Answer: D

Suggested Reading:

Solheim L, Hagen R. Femoral and sciatic neuropathies after total hip arthroplasty. Acto Orthoopaedica, 1980
51(1) pp531-534

Callaghan J, Rosenberg A, Rubash H, The Hip. The Adult Hip 2nd Edition, 2006: Lippinocott, Williams &
Wilkins,Philadelphia Chapter 3 pp52-65
ABPOPPM In-Training Exam

Module: Medicine

Set 2 of 2

Which of the following is the most appropriate orthosis for this patient?

A. Patellar tendon bearing


B. Dynamic assist ankle-foot
C. Locked knee-foot
D. Hip-knee-foot

Correct Answer: C

Suggested Reading:
Ritchie D Exploring the Potential of AFO Devices. Podiatry Today, 2003 Jan 16(1)

Seymour R, Orthoses for Patients with Neurologic Disorders- Clinical Decision Making, Prosthetics and
Orthotics, Lower Limb and Spinal.2002: Lippincott, Williams&Wilkins, Philadelphia Chapter 16 pp367-427
ABPOPPM In-Training Exam

Module: Medicine

A 34 year-old male underwent ORIF of a talar neck fracture 4 months previously. Current radiographs
demonstrate avascular necrosis of the lateral aspect of the talar body.

Which of the following vascular sources is NOT likely to be involved?

A. Lateral malleolar
B. Posterior tibial
C. Perforating peroneal
D. Anterior tibial

Correct Answer: B

Suggested Reading:

Rockwood C, Green D, Bucholz R, Heckman J, Court-Brown C. “Fractures of the Talus”. Rockwood & Green’s
Fractures in Adults, 6 ed., Lippincott, Williams & Wilkins, 2005: 2249-93

Banks A, Downey M, Martin D, Miller S. “Talar Fractures”. McGlamry’s Comprehensive Textbook of Foot and
Ankle Surgery, 3 ed., Lippincott, Williams & Wilkins, 2001: 1865-97

Stannard J, Schmidt A, Kregor P. “Foot Fractures ”, Surgical Treatment of Orthopaedic Trauma,


Thieme,2007:815-25
ABPOPPM In-Training Exam

Module: Medicine

A 70 year-old male with DM1 exhibits a rocker-bottom deformity, as shown on the accompanying radiograph.
He recently underwent extensive wound care to heal a plantar ulcer. Surgical correction to prevent recurrance is
not an option at this time.

Which of the following foot wear is best prescribed for this patient?

A. Plastizote healing sandal


B. Rocker sole shoes with leather orthoses
C. Leather laced shoes with metatarsal rocker bars
D. Custom molded shoes with plastizote insoles

Correct Answer: D

Suggested Reading:

Veves A, Giurini J, LoGerfo F. “Charcot Changes in the Diabetic Foot”.The Diabetic Foot, Medical and
Surgical Management,Humana Press; 2002:221-45

Pollard J, Stress R. A Guide to Bracing for Charcot, Podiatry Today, 2004:17(6)


ABPOPPM In-Training Exam

Module: Medicine

A 28 year-old male requires marked limited weight bearing to both the right and left lower extremities due to
bilateral calcaneal fractures. Axillary crutches are to be dispensed.

Which of the following is the most accurate statement for achieving a swing-through gait with the crutches
dispensed?

A. Crutches secured to axilla and when supine crutch extends anterior to the foot
B. Elbows flexed 30° and when supine crutch extends lateral to the calcaneus
C. Crutches two fingers inferior to axilla and with elbows extended
D. Elbows extended and when supine crutch extends anterior to the foot

Correct Answer: B

Suggested Reading:

Goldberg B, Hsu J. Shoes. Atlas of Orthoses and Assistive Devices, 3rd Edition, 1997 Mosby: St Louis Chapter
38 pp557-573

Dreeban O, Wheelchairs, Assistive Devices and Gait Training, Introduction to Physical Therapy for Physical
Therapist Assistants, 2006 Jones & Barlett:Sudbery Chapter 14 pp235-265
ABPOPPM In-Training Exam

Module: Medicine

Set 1 of 2

Questions 27 and 28 relate to the following clinical scenario:

A 3 week old female is presented for evaluation of her right foot. Examination demonstrates forefoot adductus,
hindfoot varus, and ankle equinus. The deformity is non-reducible.

Based on the exam and accompanying radiograph, what is the most likely diagnosis?

A. Metatarsus adductus
B. Vertical talus
C. Skewfoot
D. Talipes equinovarus

Correct Answer: D

Suggested Reading:

Wood L, Winter R, Morrissy R, Weinstein S: “The Foot” Lovell & Winters Pediatric Orthopaedics 6 ed,
Lippincott, Williams& Wilkins 2005: 1257-1329

Dimeglio A, Benshael H, Souchet Ph, Mazeau Ph, Bonnet F. Classification of Clubfoot, Journal of Pediatric
Orthopaedics B, 1995:4(2):129-36
ABPOPPM In-Training Exam

Module: Medicine

Set 2 of 2

Which of the following is the most appropriate initial treatment for this patient?

A. Application of short leg cast


B. Percutaneous abductor hallucis tenotomy
C. Manipulation and an above knee cast
D. Percutaneous Achilles tenotomy

Correct Answer: C

Suggested Reading:

Wood L, Winter R, Morrissy R, Weinstein S: “The Foot” Lovell & Winters Pediatric Orthopaedics 6 ed,
Lippincott, Williams& Wilkins 2005: 1257-1329

Steheli L. Clubfoot: Ponseti Management 3ed, Journal Bone and Joint Surgery (Am) 2008; 90(11):2313-21

Dimeglio A, Benshael H, Souchet Ph, Mazeau Ph, Bonnet F. Classification of Clubfoot, Journal of Pediatric
Orthopaedics B, 1995:4(2):129-36
ABPOPPM In-Training Exam

Module: Medicine

A 75 year-old obese male with DM2 complains of a "flat foot" on the right which was first noted less than one
year ago. There is no history of acute trauma. Examination reveals edema extending to the medial ankle,
decreased muscle strength and decreased range of motion in plantarflexion, inversion and abduction of the
forefoot.

Based on clinical exam and the radiograph shown which of the following is the most likely diagnosis?

A. L5-S1 disc herniation


B. Partial rupture of the tibialis posterior tendon
C. Neuropathic arthropathy
D. Partial rupture of peroneus longus tendon
E. L3-L4 disc herniation

Correct Answer: B

Suggested Reading:

Myerson M. Adult Acquired Flatfoot Deformity. Treatment of Dysfunction of the Posterior Tibial Tendon
(Instructional Course Lecture AAOS): Journal of Bone and Joint Surgery 1996; 78: 780-92

Pomeroy G, Pike H, Beals T, Manli A. Current Concepts Review: Acquired Flatfoot in Adults Due to
Dysfunction of the Posterior Tibial Tendon. Journal of Bone & Joint Surgery, 1999; 81A:1173-82
ABPOPPM In-Training Exam

Module: Medicine

A 20 year-old football player sustains a dorsiflexion-external rotation injury to his right ankle. He is examined
on the sideline.

Which of the following is most useful to evaluate possible syndesmotic ankle injury?

A. Positive squeeze test


B. Positive anterior draw test
C. Positive dorsiflexion external rotation test
D. Pain with palpation to the calcaneofibular ligament

Correct Answer: B

Suggested Reading:

Alonoso A, Khoury L, Adams R. Clinical Test for Ankle Syndesmosis Injury: Reliability and Prediction of
Return to Function Journal of Orthopaedic & Sport Physical Therapy: 1998, 27(4)

Nussbaum E, Hosea T et al. Prospective Evaluation of Syndesmotic Ankle Sprains without Diastasis. The
American Journal of Sports Medicine: 2001, 29(1) p 31-5
ABPOPPM In-Training Exam

Module: Medicine

A 37 year-old male is being treated for a third metatarsal fracture sustained 8 weeks ago. He had been treated
with non-weight bearing crutch walking and an elastic compression wrap. His past medical history includes
Crohn’s disease for which he has been taking prednisone, 40 mg. q.i.d., for 5 years. Current radiographs are
shown.

Which of the following should be considered at this time?

A. Increase the prednisone dosage


B. Add NSAID therapy
C. Utilize a bone stimulator
D. Perform ORIF of fracture
E. Continue crutch walking and elastic wraps

Correct Answer: C

Suggested Reading:

Rockwood C, Green D, Bucholz R, Heckman J, Court-Brown C. “Local Complications-Complications in Bone


Healing”. Rockwood & Green’s Fractures in Adults, 6 ed., Lippincott, Williams & Wilkins, 2005: 584-93

Nelson F, et al. Use of Physical Forces in Bone Healing, Journal of the American Academy of Orthopaedic
Surgeons, 2003 11(5):344-54
ABPOPPM In-Training Exam

Module: Medicine

An 18 year-old male was playing soccer and was kicked by another player. He presents to the ED within one
hour of injury complaining of pain to the right foot.

Based on the accompanying radiographs, what anatomic structure was most likely disrupted during the injury?

A. Intersesamoid ligament
B. Flexor hallucis brevis tendon
C. Medial capsule first metatarsal
D. Intermetatarsal tranverse ligament

Correct Answer: C

Suggested Reading:

Gray H: Anatomy of the Human Body, 20th ed. 2000, Lea & Febiger: Philadelphia
Glasoe WM, Yack HJ, Saltzman CL: Anatomy and Biomechanincs of the First Ray,
Physical therapy 1999:79(9)
ABPOPPM In-Training Exam

Module: Medicine

A 32 year-old female complains of pain and swelling of her right foot. She sustained an injury to her left foot
approximately three months ago, but did not seek medical intervention. Radiographs reveal a mid-diaphyseal
spiral oblique fracture of the fifth metatarsal as shown.

In addition to a bone stimulator which of the following is the most appropriate treatment?

A. Below knee non-weight bearing cast


B. Weight-bearing CAM walker
C. Surgical shoe with crutches
D. Rigid sole walking shoe

Correct Answer: A

Suggested Reading:

Couglin M, Mann R, Saltzmann C. “Fractures of the Midfoot and Forefoot”. Surgery of the Foot and Ankle, 8
ed. Mosby Elsevier, 2007:2223-25

Rosenberg G, Sferra J. Treatment for acute fractures and non-unions of the proximal fifth metatarsal Journal of
the American Academy of Orthopedic Surgeons 2000: 8(5):332-38
ABPOPPM In-Training Exam

Module: Medicine

A 43 year-old female with sickle cell disease complains of pain and swelling of her hip and ankle following an
inversion injury and fall.

Which of the following is contraindicated for this patient?

A. NSAID’s
B. Opioids
C. Ice
D. Iontophoresis

Correct Answer: C

Suggested Reading:

Saleem S, Rice L. Case Report: Limb amputation in hemoglobin SC disease after application of ice and
elevation. American Journal of Hematology 2006:82(1):53-54

National Institutes of Health: The Management of Sickle Cell Disease 4 ed, 2002
ABPOPPM In-Training Exam

Module: Medicine

A 30 year-old male sustained a tibial fracture two years ago, resulting in peroneal nerve palsy and a drop foot
with weak eversion capability. He relates subsequent success with stretching and exercise but still complains of
"catching" his big toe when he tires. Examination reveals a plantar grade and supple foot.

Which of the following devices is most appropriate for this patient?

A. Custom-molded foot orthosis with Morton’s extension


B. Flexible ankle stirrup brace
C. Hinged AFO
D. Patellar tendon bearing brace

Correct Answer: C

Suggested Reading:

Couglin M, Mann R. “Congenital and acquired neurologic disorders”. Surgery of the Foot and Ankle, 7 ed.
Mosby, 1999:552-3
ABPOPPM In-Training Exam

Module: Medicine

Set 1 of 2

Questions 36 and 37 relate to the following clinical scenario:

A 24 year-old male presents with right foot and ankle pain with ambulation18 months following a motor vehicle
accident where he was a passenger. He complained of foot pain at the time but this was not addressed as they
were secondary to other, more life threatening injuries. Examination reveals minimal ankle edema; the ankle
dorsiflexes to neutral; he has full ankle joint plantar flexion but limited, painful eversion and inversion of the
hindfoot. Radiographs are shown.

Which of the following is the most likely diagnosis for this patient?

A. AVN of the talar body and osteoarthritis of the talonavicular joint


B. AVN of the talar body and non-union of the talar neck
C. Non-union of the talar neck and osteoarthritis of the talonavicular joint
D. Chronic osteomyelitis to the talus and osteoarthritis to the talonavicular joint

Correct Answer: B

Suggested Reading:

Rockwood C, Green D, Bucholz R, Heckman J, Court-Brown C. “Fractures of the Talus”. Rockwood & Green’s
Fractures in Adults, 6 ed., Lippincott, Williams & Wilkins, 2005: 2249-93

Banks A, Downey M, Martin D, Miller S. “Talar Fractures”. McGlamry’s Comprehensive Textbook of Foot and
Ankle Surgery, 3 ed., Lippincott, Williams & Wilkins, 2001: 1865-97

Stannard J, Schmidt A, Kregor P. “Foot Fractures ”, Surgical Treatment of Orthopaedic Trauma,


Thieme,2007:815-25
ABPOPPM In-Training Exam

Module: Medicine

Set 2 of 2

Which of the following is the most appropriate intervention for this patient?

A. Application of a bone stimulator


B. Use of custom-molded foot orthosis
C. Tibial-calcaneal arthrodesis
D. Intra-articular steroid injection

Correct Answer: C

Suggested Reading:

Rockwood C, Green D, Bucholz R, Heckman J, Court-Brown C. “Fractures of the Talus”. Rockwood & Green’s
Fractures in Adults, 6 ed., Lippincott, Williams & Wilkins, 2005: 2249-93

Banks A, Downey M, Martin D, Miller S. “Talar Fractures”. McGlamry’s Comprehensive Textbook of Foot and
Ankle Surgery, 3 ed., Lippincott, Williams & Wilkins, 2001: 1865-97

Horst F, Gilbert B, Nunley J. Avascular necrosis of the Talus: Current treatment options, Foot and Ankle Clinics
of North America ,2004:9(4);757-73
ABPOPPM In-Training Exam

Module: Medicine

Which of the following findings is associated with adult acquired flatfoot deformity secondary to posterior tibial
dysfunction?

A. Plantar fascial rupture


B. Forefoot adduction
C. Hallux varus
D. Achilles contracture

Correct Answer: D

Suggested Reading:

Pomeroy G, Pike H, Beals T, Manli A. Current Concepts Review: Acquired Flatfoot in Adults Due to
Dysfunction of the Posterior Tibial Tendon. Journal of Bone & Joint Surgery, 1999; 81A:1173-82
ABPOPPM In-Training Exam

Module: Medicine

An 18 year-old male is training to run his first marathon.

Which of the following is the best recommendation for his fluid intake around race time?

A. Restrict fluid intake two hours before the race


B. Drink low osmolality fluids before, during and after the race
C. Drink fluids high in fructose during and after the race
D. Drink unrestricted fluid amounts during and after the race

Correct Answer: B

Suggested Readings:

Siegel A et al: Hyponatremia in Marathon Runners due to Inappropriate Arginine Vasopressin Secretion.
American Journal of Medicine, 2007 120(7)

Emax Health: Message to Marathoners: Watch your fluid intake May 2005
Maharam L: Fluid Recommendations for our Runner and Walkers: Too much is dangerous. Trainingteam.org
ABPOPPM In-Training Exam

Module: Medicine

Which of the following findings is associated with rupture of the posterior tibial tendon in a flexible adult
acquired flatfoot (stage 2 PTTD) secondary to posterior tibial dysfunction?

A. Tear of the spring ligament


B. Contracture of the Achilles tendon
C. Abduction of the calcaneal cuboid joint
D. Lateral ankle impingement

Correct Answer: D

Suggested Reading:

Pomeroy G, Pike H, Beals T, Manli A. Current Concepts Review: Acquired Flatfoot in Adults Due to
Dysfunction of the Posterior Tibial Tendon. Journal of Bone & Joint Surgery, 1999; 81A:1173-82

Gazdag A, Cracchiolo A. Rupture of the Posterior Tibial Tendon. Evaluation of Injury of the Spring Ligament
and Clinical Assessment of Tendon Transfer and Ligament Repair, Journal Bone & Joint
Surgery(AM)1997:79(5):675-81

Thoradson D. “Tendon Disorders” Foot and Ankle 2 ed, Lippincott, Williams & Wlkins, 2004:153-81
ABPOPPM In-Training Exam

Module: Medicine

A 27- year-old male presents to the ED with a degloving injury to the left foot.

The structure depicted by the arrow is a branch of what nerve?

A. Saphenous
B. Superficial peroneal
C. Deep peroneal
D. Posterior tibial

Correct Answer: B

Suggested Reading:

Gray H: Anatomy of the Human Body, 20th ed, 2000 Lea & Febiger: Philadelphia, p963-6

Cunningham J, Robinson A: Cunningham’s Textbook of Anatomy, 5th ed., 1918 William Wood & C0. New
York, p731
ABPOPPM In-Training Exam

Module: Medicine

A 52 year-old male runner is seen for evaluation of pain to the inferior right calcaneus of 6 months duration.
Radiographs are negative for bony pathology. He is unable to obtain relief with immobilization, ice, eccentric
strengthening and orthotic management.

Which of the following is the most appropriate treatment for this patient?

A. Corticosteriod injection
B. Shock wave treatment
C. Achilles tenolysis
D. Achilles coblation

Correct Answer: B

Suggested Reading:

Rompe J, Furia J, Maffulli N. Eccentric Loading Compared with Shock Wave Treatment for Chronic
Insertional Achilles Tendinopathy The Journal of Bone and Joint Surgery, 2008: 90(1)

Akhtar M, Montgomery H, Shenolikar A. Achilles tendon rupture following coblation for insertional Achilles
tendinosis, The Foot, 2009: 19(1)

Fridman R, Cain J, Weil L Jr, Weil L Sr. Extracorporeal Shockwave Therapy for the Treatment of Achilles
Tendinopathies, Journal of American Podiatric Medical Association, 2008: 98(6)

DeHeer P, Offutt S. Conquering Achilles Tendonitis In Athlete, Podiatry Today, 2002: 15(11)
ABPOPPM In-Training Exam

Module: Medicine

A 41 year-old male injured his left ankle while thrown from wave runner. He is uncertain of the exact
mechanism of injury. His left ankle is ecchymotic and edematous. Skin and neurovascular structures are intact.
He is unable to bear weight on his left lower extremity. Radiographs are shown

Which of the following is the most appropriate treatment for this patient?

A. Short leg non-weight bearing cast for 6 weeks


B. Air Stirrup splint and limited activity for three to 6 weeks
C. Closed reduction and short leg walking cast for 6 weeks
D. Open reduction internal fixation with non weight bearing

Correct Answer: D

Suggested Reading:

Chapman M: Chapman’s Orthopaedic Surgery, 3rd ed. 2001, Lippincott, Williams & Wilkins, Philadelphia,
Section II, Chapter 25 page 818

Bucholz R, Heckman J, Court-Brown C. Fractures and Dislocations of the Midfoot and Forefoot. Rockwood &
Green’s Fractures in Adults, 6th ed. 2006, Lippincott, Williams&Wilkins, Philadelphia, Chapter 53 p2170
ABPOPPM In-Training Exam

Module: Medicine

A 63 year-old male complains of persistent pain at the plantar right foot. There is a history of lateral ulcerations
there as well. He states the foot pain and has worsened over the last two years, when he suffered a CVA. He
has tried stretching, bracing and custom footwear without relief of pain. Examination reveals the foot to be
postured in fixed equinovarus. There is 5/5 quadriceps and hamstring strength and the knee is intrinsically
stable.

Which of the fllowing is the most appropriate treatment for this patient?

A. CROW walker
B. Ankle arthrodesis
C. Triple arthrodesis with tendo achilles lengthening
D. Tibial nerve injection with Lidocaine and phenol

Correct Answer: C

Suggested Reading:

Coughlin M, Mann R, Saltzman C. Surgery of the Foot and Ankle, 8th edition,2007, Mosby: St Louis, Chapter
31 p1794-1797

McGlamery D, Banks A, Downey M, Martin D, Miller S: Neurologic Disorders: McGlamry’s Comprehensive


Textbook of Foot and Ankle Surgery, 3rd ed. 2001, Lippincott, Williams & Wilkins, Philadelphia, Section
V,Chapter 33 p1062
ABPOPPM In-Training Exam

Module: Medicine

A 63 year-old female tripped over a parking curb yesterday and experienced sudden right foot pain. She has had
difficulty walking on the right foot since that time. Examination reveals diffuse edema and ecchymosis to the
medial heel and foot but no erythema. Skin integument and neurovascular structures are intact on the right foot.
Radiographs are shown.

Which of the following is the most likely etiology of the patient’s pain?

A. Acute gouty arthropathy


B. Fractured posterior talar process
C. Sinus tarsi syndrome
D. Navicular fracture

Correct Answer: D

Suggested Reading:

Wulker N, Stephens M, Cracchio A. An Atlas of foot and ankle surgery. Midfoot fractures and dislocations.
Mosby, St. Louis, 1998 Chapter 20, p144

Chapman M: Fractures and Dislocations of the Midfoot and Forefoot:Chapman’s Orthopaedic Surgery, 3rd ed.
2001, Lippincott, Williams & Wilkins, Philadelphia, Section VI, Chapter 111 page 2992-4
ABPOPPM In-Training Exam

Module: Medicine

A 22 year-old collegiate football player underwent primary repair of an Achilles tendon rupture on the right.

Which of the following is the appropriate position to maintain the foot immediately post-operatively?

A. Neutral to 10° of dosiflexion


B. Resting equinus
C. 10 to 20° of plantarflexion
D. 20 to 30° of plantarflexion

Correct Answer: D

Suggested Reading:

Poyton AR, O’Rouke K. Analysis of skin perfusion over the Achilles tendon in varying degrees of
plantarflexion Foot Ankle International 2001, 22(7), p 572-74

Calder J, Saxby T: Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a
prospective study. British Journal of Sports Medicine 2005, 39(11), p 857-59
ABPOPPM In-Training Exam

Module: Medicine

A 44 year-old male presents to the ED for a laceration injury to his left foot sustained when a metal stake
penetrated his rubber soled shoes along the medial arch. Examination reveals palpable pedal pulses and
sensation intact to the dermatomes of the left foot. Muscle testing demonstrates compromise in his ability to
dorsiflex and invert. He demonstrates an antalgic gait.

Based on the suspected diagnosis, long-range compromise would occur primarily in which of the following
phases of gait?

A. Swing and contact


B. Contact and midstance
C. Midstance and propulsion
D. Propulsion and swing

Correct Answer: A

Suggested Reading:

Whittle, M Gait Analysis: an introduction 3rd ed. 2002 Butterworth Heinemann, Oxford, Chapter 2 page 68

Nordin, M and FrankelVH: Basic biomechanics of the musculoskeletal system, 3rd ed. 2001, Lippincott,
Williams & Wilkins, Philadelphia, Section III, Chapter 18 page 455
ABPOPPM In-Training Exam

Module: Medicine

You are treating a 22 year-old female for chronic regional pain syndrome of the right foot following a motor
vehicle accident six months earlier. You elect to perform a sympathetic ankle block with 20cc’s of 0.5%
Marcaine, plain, but failed to aspirate prior to your injection. The patient complains of dizziness and heart
palpations prior to losing consciousness. While staff is already calling 911, the patient goes into respiratory and
cardiac arrest.

In addition to performing CPR, which of the following is the most appropriate treatment at this time?

A. Apply and inflate an ankle tourniquet to 250 mmHG


B. Administer intravenous propofol (Diprivan)
C. Place the patient in a Trendelburg position
D. Administer intravenous 20% Intralipid

Correct Answer: D

Suggested Reading:

Kapitanyan R, Su M: Toxicity, Local Anesthetics, Emedicine-Web MD, June 10,2009

Corman S, Skledar S, Use of Lipid Emulsion to Reverse Local Anesthetic-Induced Toxicity, The Annals of
Pharmcotherapy 2007, 41(11) 1873-77.
ABPOPPM In-Training Exam

Module: Medicine

A 62 year-old male with DM 2 presents with mummified gangrenous changes to the first three toes on the right.
TCPO2 findings are 15mmHG dorsal right foot, 27mmHG at the ankle and 35mmHG above the ankle. Right
ABI is less than 1.3. The consulting service also obtained an arteriogram on this patient’s right lower
extremity.

Based on the vascular findings, which of the following is the most likely amputation level for healing?

A. Chopart
B. Symes
C. Tranmetatarsal
D. Transtibial

Correct Answer: D

Suggested Reading:

Chahin C, Rose B: Lower-Extremity Atherosclerotic Arterial Disease: Imaging. Emedicine - Web MD, Feb
9,2007

Robinson AHN, Brodsky JW. Surgical aspects of the diabetic foot. Journal of Bone and Joint Surgery-British,
2009, 91B(1) p 1-7
ABPOPPM In-Training Exam

Module: Medicine

A gymnast presents with radiating right thigh and buttock pain. Sharp shooting pain is elicited on a straight leg
raise test and especially with hip flexion, adduction, and internal rotation. There sharp pain upon palpation of
the sciatic notch.

Which of the following is the most likely diagnosis?

A. Piriformis syndrome
B. Iliofemoral ligament sprain
C. Entrapment of the lateral femoral cutaneous nerve
D. Sacroiliac joint strain

Correct Answer: A

Suggested Reading:

Ropper AH, Samuels MA, "Chapter 11. Pain in the Back, Neck, and Extremities" (Chapter). Ropper AH,
Samuels MA: Adams and Victor's Principles of Neurology, 9e:
http://www.accessmedicine.com/content.aspx?aID=3631240.

www.nyu.edu/classes/keefer/pain/pain2.htm

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