The ABFAS qualification pathway includes separate Foot Surgery and Reconstructive Rearfoot/Ankle (RRA) Surgery didactic examinations, plus a NEW computer-based patient simulation (CBPS) examination for each area. The adaptive didactic examinations ask you to interpret findings and select sound clinical or surgical decisions. In CBPS, you gather case-relevant evidence, establish a diagnosis, choose treatment and respond to developments in the case. Foot and RRA differ most clearly in the procedures they assess: Foot didactic intraoperative questions exclude RRA procedures, while RRA covers reconstructive rearfoot and ankle surgery. Work through the concepts below by connecting examination findings, imaging, anatomy, operative mechanics and complications. The cases illustrate clinical reasoning; they are not a single combined ABFAS examination.
Foot Surgery Didactic
1. Read a hallux valgus deformity in three dimensions
A hallux valgus assessment begins with the standing foot because loading can expose deformity that is less apparent when the patient sits. Examine first-ray mobility, hallux rotation, first metatarsophalangeal motion, lesser-toe crowding and where pain occurs. On weight-bearing radiographs, trace the first metatarsal relative to the second, then assess whether the hallux remains centered on its metatarsal head. Sesamoid position helps reveal how the metatarsal head and plantar support have shifted relative to each other. A medial prominence may contribute to shoe pressure, but it is only one visible part of the deformity. The correction should match the first-ray position, joint congruity and any instability demonstrated on examination. The ABFAS Foot Surgery Didactic content outline includes first-ray deformity and procedure selection as relevant subjects.
Worked example: A patient reports medial shoe pressure and pain when pushing off. Standing views show a medially deviated first metatarsal, a laterally deviated hallux and sesamoids displaced relative to the metatarsal head. The joint remains mobile. These findings indicate both first-ray malalignment and joint displacement. Removing only the prominence may ease rubbing but leaves the forces driving the toe sideways.
Watch the distinction: A large medial bump does not, by itself, establish the required correction. Assess the loaded metatarsal position, joint alignment and sesamoids before selecting a procedure.
Reference: [4]
2. Match hallux rigidus treatment to joint damage
In hallux rigidus, identify when motion hurts and how much joint surface remains functional. A dorsal osteophyte can strike the proximal phalanx near the end of dorsiflexion, producing a sharp terminal impingement despite relatively comfortable motion through the middle of the arc. A joint-preserving procedure may relieve that block when cartilage and joint space are otherwise reasonably preserved. Diffuse cartilage loss changes the mechanism: opposing surfaces hurt throughout motion, so removing a dorsal spur leaves the main pain generator. Examine active and passive motion, axial loading, crepitus and whether pain is dorsal or deep within the joint. Read standing radiographs for dorsal spurring, joint-space narrowing and metatarsal-head shape. Treatment selection also depends on the patient's functional demands, acceptable motion and the extent of degeneration.
Worked example: One patient has a dorsal first metatarsophalangeal osteophyte, preserved joint space and pain only at terminal dorsiflexion. Dorsal decompression could address the impinging bone while preserving motion. Another has pain through the middle of the arc, crepitus and diffuse narrowing. Isolated spur removal would leave painful cartilage contact; a more definitive joint procedure deserves consideration.
Watch the distinction: A visible osteophyte is not proof that impingement is the sole problem. Midrange pain and diffuse narrowing point to joint-surface disease that spur removal cannot resolve.
Reference: [4]
3. Trace transfer loading across the forefoot
During gait, the first ray normally accepts substantial load as the body moves over the forefoot. If it is elevated, shortened or otherwise unable to bear its share, pressure shifts toward the lesser metatarsal heads. The patient may describe a new painful spot beneath the second ray, but the mechanical cause can lie at the previously operated first ray. Compare plantar callus distribution, first-ray position and toe purchase while standing. Weight-bearing radiographs help show elevation or shortening; examination can reveal stiffness or an unstable first metatarsophalangeal joint. Also assess a long second metatarsal, plantar plate instability and local stress injury before attributing all pain to transfer loading. A durable plan addresses the load path and the symptomatic tissue, with footwear or offloading considered alongside correction of a structural driver when indicated.
Worked example: After first-ray surgery, a patient develops a dense callus and pain beneath the second metatarsal head. Standing films show the first metatarsal elevated, and the second toe remains stable. The elevated ray is taking less plantar load, so the second head absorbs more. Callus care may reduce immediate discomfort, but it cannot restore first-ray contact.
Watch the distinction: Pain under the second metatarsal does not automatically mean that metatarsal is too long. Check whether an elevated or insufficient first ray shifted load there.
Reference: [4]
4. Separate plantar plate injury from interdigital neuritis
The plantar plate resists dorsal displacement of a lesser toe at its metatarsophalangeal joint. Injury weakens that restraint, so the toe may drift, lose purchase or subluxate. Palpate beneath the affected joint and compare its drawer stability with adjacent joints; pain and excessive translation at that location support plate insufficiency. Interdigital neuritis usually centers in the web space and may send burning or tingling into neighboring toes. Compression of the interspace can reproduce nerve symptoms, whereas joint stress more directly reproduces plate pain. Both disorders can coexist, and a patient's description of “ball-of-foot pain” does not localize either one. Weight-bearing views show alignment and subluxation; additional imaging can clarify an uncertain soft-tissue lesion. Choose treatment according to the demonstrated instability and pain source rather than the nearest tender structure.
Worked example: A second toe drifts toward the hallux and no longer presses firmly against the floor. Drawer testing produces excess dorsal movement and pain directly beneath its metatarsophalangeal joint. The interspace is nontender, without radiating tingling. Plantar plate failure with joint instability best explains the pattern; treating a presumed neuroma would leave the unstable toe unchanged.
Watch the distinction: Forefoot burning is not required for every plantar plate injury, and toe drift is not typical proof of a neuroma. Reproduce pain at the joint and test stability.
Reference: [4]
5. Choose correction for a flexible or fixed toe
A lesser-toe deformity must be described joint by joint. Determine whether the metatarsophalangeal, proximal interphalangeal and distal interphalangeal positions can each be corrected passively. Then check whether reducing one joint permits another to straighten. A flexible deformity suggests that muscle and tendon forces, capsular tightness or metatarsophalangeal malalignment are maintaining an otherwise mobile toe. Soft-tissue balancing may restore a better force relationship when the joint surfaces remain reducible. A rigid interphalangeal contracture contains a fixed structural component; tendon balancing alone cannot straighten a joint that no longer moves. Examine skin pressure points, toe purchase, neurovascular status and the neighboring rays before choosing a correction. The Foot Surgery Didactic guide provides related forefoot topics; the key decision here is where flexibility ends and fixed deformity begins.
Worked example: A clawed third toe straightens when its metatarsophalangeal joint is reduced and the extensor tension relaxes. Its interphalangeal joints remain passively mobile, supporting a flexible imbalance. In a second patient, the proximal interphalangeal joint stays bent despite careful reduction elsewhere. Correcting only the extensor pull would leave that fixed joint bent and its dorsal pressure point intact.
Watch the distinction: The visible bend is not necessarily the only joint that needs attention. Test passive correction at every joint and see whether reducing the metatarsophalangeal joint changes the toe.
Reference: [4]
6. Localize a fifth metatarsal fracture
Proximal fifth metatarsal fractures are distinguished by the exact course of the fracture line, not simply by saying “base fracture.” A tuberosity avulsion lies at the most proximal prominence and commonly follows an inversion force that pulls on attached soft tissues. A fracture farther distal at the metaphyseal-diaphyseal junction occupies a region with more limited healing capacity and warrants particular attention to union. Read anteroposterior, oblique and lateral views to locate the line in relation to the tuberosity and the articulation with the fourth metatarsal. Assess displacement, skin, point tenderness and the possibility of another midfoot injury. Pain over the lateral border can occur with either pattern, so symptoms alone cannot reliably classify it. Management follows fracture location and stability together with the patient's activity needs and healing risks.
Worked example: After an inversion injury, a patient has focal tenderness at the fifth metatarsal base. The oblique view shows a line through the proximal tuberosity and a small fragment displaced laterally. This is a tuberosity avulsion. If the line instead crossed the metaphyseal-diaphyseal junction farther distal, concern about delayed union would be greater and the treatment discussion would change.
Watch the distinction: Do not label every proximal fifth metatarsal fracture a junctional fracture. Locate the line precisely because a tuberosity avulsion and a more distal fracture have different healing concerns.
Reference: [4]
7. Detect unstable Lisfranc injury
The Lisfranc complex stabilizes the tarsometatarsal junction, particularly the relationship between the medial cuneiform and second metatarsal base. A twisting force can injure that restraint without producing an obvious fracture on an unloaded film. Plantar midfoot bruising, focal tarsometatarsal tenderness, swelling and pain with forefoot stress raise suspicion. Compare alignment across the joints on appropriate radiographic views; weight-bearing images, when safely obtainable, may reveal separation that disappears without load. Advanced imaging can clarify subtle fracture or ligament injury when examination and plain films disagree. Determine whether the joints remain aligned under physiologic load, since instability changes management. Protect a suspicious injury while completing that assessment. Ability to take steps does not prove the ligament complex is intact or that the injury is a simple sprain.
Worked example: A player twists the foot, then walks with a limp. There is plantar bruising and focal pain at the first and second tarsometatarsal joints. Unloaded films appear aligned, but safe weight-bearing comparison views show separation between the first and second rays. Loading has exposed lost restraint, so this is an unstable Lisfranc injury requiring protection and definitive assessment.
Watch the distinction: A nearly normal unloaded radiograph cannot exclude Lisfranc instability. If plantar bruising and focal midfoot pain persist, assess alignment under load when safe or use further imaging.
Reference: [4]
8. Define the depth of a diabetic foot infection
A diabetic foot infection must be mapped by depth and compartment. Surface erythema may indicate cellulitis, but fluctuance suggests a drainable collection, pain or motion findings may implicate a joint, and an ulcer reaching bone raises concern for osteomyelitis. Examine the wound's location, undermining, drainage, tissue viability, surrounding compartments and neurovascular supply. Review systemic findings because fever or instability changes urgency. Radiographs can show gas, foreign material or destructive bone change, although early bone infection may not yet be visible. Additional imaging helps define an abscess or bone extent when it will change source control. Obtain meaningful specimens from the involved tissue or fluid when feasible; a superficial swab may reflect colonizing organisms. Treatment combines appropriate antimicrobial care with drainage, removal of nonviable tissue and correction of an ongoing pressure source when indicated.
Worked example: A plantar ulcer has surrounding warmth and a fluctuant area. A sterile probe reaches bone, and radiographs describe cortical erosion directly beneath the wound. The findings support an abscess with probable contiguous bone infection, not cellulitis alone. Assess perfusion and systemic illness, obtain appropriate deep specimens, and arrange drainage and source control alongside antimicrobial treatment.
Watch the distinction: Redness around an ulcer does not define the full infection. Fluctuance, a deep tract and underlying bone change call for assessment beyond the visible skin margin.
Reference: [4]
9. Separate ischemic from neuropathic tissue loss
Neuropathy and ischemia can act together, but they injure tissue through different mechanisms. Loss of protective sensation allows repeated pressure at a metatarsal head without enough pain to prompt unloading. Arterial insufficiency reduces oxygen delivery and limits repair, making even a small wound harder to heal. Examine monofilament or other protective sensation, skin temperature, capillary appearance, pedal pulses, deformity and callus. Note whether the wound sits at a pressure point, a toe tip or a poorly perfused border. Palpable pulses help but do not fully quantify tissue perfusion; absent pulses or a cool foot justify objective vascular assessment suited to the case. Management must relieve mechanical pressure, control infection if present and address inadequate blood supply before expecting a closure or reconstruction to heal reliably.
Worked example: A patient has a painless plantar ulcer beneath the second metatarsal head, absent protective sensation, cool toes and no palpable pedal pulses. Neuropathy explains why pressure repeatedly injured that site without warning pain. The cool pulseless foot adds concern about inadequate healing blood flow. Offload the ulcer and obtain objective perfusion assessment before relying on local wound closure.
Watch the distinction: An insensate ulcer is not necessarily well perfused. Neuropathy explains the injury pattern, while cool skin and absent pulses signal a separate threat to healing.
Reference: [4]
10. Do not mistake crystals for exclusion of infection
Crystal arthritis and septic arthritis can both produce a hot, red, exquisitely painful first metatarsophalangeal joint. Finding urate crystals establishes that gout is present in the sampled fluid, but it does not show that bacteria are absent. The possibility of both conditions matters when fever, systemic illness, purulent fluid, a nearby wound or unusually severe pain accompanies the flare. Assess the whole patient and inspect for a source of infection. Aspirated fluid can be examined for crystals and sent for microbiologic studies; interpret cell counts in clinical context rather than as an absolute separator. If infection remains credible, prompt joint assessment and source control take priority because cartilage can be damaged quickly. A prior history of gout informs the differential, yet each new episode still requires reasoning from its current findings.
Worked example: A patient with previous gout develops fever and a swollen first metatarsophalangeal joint. Aspirated fluid looks purulent and contains urate crystals. The crystals explain one inflammatory process, but fever and purulence leave septic arthritis possible. Send appropriate fluid studies, evaluate systemic illness and arrange urgent management of suspected joint infection while interpreting the microbiology.
Watch the distinction: Crystals do not sterilize a joint. Treating a febrile, purulent presentation as gout alone can delay drainage and directed care for a concurrent infection.
Reference: [4]
11. Plan the work-up of an atypical forefoot mass
A forefoot mass should be characterized before its tissue is removed. Record growth, pain, skin changes, depth, fixation to surrounding structures and neurovascular findings. A small, superficial, stable lesion with typical benign features differs from one that grows, lies deep to fascia or erodes bone. Radiographs identify mineralization or skeletal effects; cross-sectional imaging can define the lesion's extent and its relationship to tendons, nerves, vessels and compartments. When aggressive features are present, coordinate the biopsy route with the team that may provide definitive treatment. The tract and any contaminated tissue may need to be incorporated into that treatment, so an unplanned incision can reduce later options. Histology is needed to establish the diagnosis; location on the sole or a familiar surface appearance does not make an enlarging deep mass benign.
Worked example: A plantar forefoot mass has enlarged steadily, feels fixed beneath the fascia and is associated with cortical erosion on radiographs. These findings are atypical for a routine superficial nodule. Define its extent with suitable imaging and arrange a planned biopsy. Marginally removing it immediately could leave disease behind and complicate definitive surgery.
Watch the distinction: A mass is not safe to excise casually because it is palpable or resembles a common lesion. Growth, depth and bone destruction require planned imaging and tissue diagnosis.
Reference: [4]
12. Analyze delayed bone healing by cause
Bone healing depends on a suitable biological environment and enough mechanical stability for bridging tissue to mature. When a metatarsal osteotomy remains painful, ask whether bone ends have contact, the fixation has held, alignment maintains useful loading and infection is present. Serial radiographs may show a persistent gap, absent bridging, hardware loosening or progressive deformity; additional imaging can clarify uncertain union. Review wound history, smoking exposure, vascular supply and other patient factors that affect repair. Mechanical instability can prevent healing even if graft supplies new biological material. Conversely, stronger fixation alone may fail when infected or nonviable tissue remains. Revision planning therefore begins with the cause: restore viable contact and alignment, control infection when present, provide stable fixation and add graft or other biological support when the defect warrants it.
Worked example: Months after a metatarsal osteotomy, the patient has focal pain with loading. Films show a persistent gap, no bridging bone and screws that have loosened. Motion at the site is a likely barrier to union. Confirm the healing state and evaluate infection, then plan viable bone contact and stable revision fixation; graft alone would not stop the motion.
Watch the distinction: A persistent gap does not automatically call for graft alone. Loose fixation points to instability, which must be corrected for new bone to bridge the osteotomy.
Reference: [4]
13. Protect structures during first-ray exposure
A first-ray approach should expose the intended correction while preserving nearby nerves, vessels, tendons and skin blood supply. Before incision, identify the planned bone or joint work and anticipate which structures cross the approach. During a medial first metatarsophalangeal exposure, a dorsomedial cutaneous nerve branch may lie close to the incision or capsule. Protecting it requires deliberate layer-by-layer dissection and recognition of variable anatomy, rather than assuming a fixed safe line. Preserve enough soft tissue around the joint to support healing while obtaining adequate visualization for the correction. Check that retractors and fixation paths do not trap a nerve or damage a tendon. A technically accurate bone cut can still leave a poor outcome if a sensory branch is injured or the soft-tissue envelope is compromised. Surgical anatomy remains relevant from exposure through closure.
Worked example: During a medial approach for hallux valgus correction, a small sensory branch crosses the planned capsular exposure. The surgeon identifies and gently protects it before opening the capsule, then keeps fixation away from its course. Cutting blindly through the layer could cause lasting painful numbness despite a well-aligned first metatarsal.
Watch the distinction: A familiar incision does not guarantee that the nerve is elsewhere. Identify the actual structures encountered, since their course varies and injury can matter independently of alignment.
Reference: [4]
14. Recognize a postoperative systemic emergency
Postoperative assessment starts by separating expected local recovery from a systemic event. Incisional soreness and swelling can follow foot surgery, but sudden breathlessness, pleuritic chest pain, syncope or a new rapid pulse demands immediate evaluation. Venous thromboembolism is one possible cause, especially after reduced mobility, though cardiac and pulmonary emergencies also belong in the differential. Check vital signs and oxygenation if available, recognize instability, and arrange emergency medical assessment rather than prolonging an office wound review. A normal-looking incision does not lower the urgency of cardiopulmonary symptoms. Likewise, a painful swollen calf may warrant focused evaluation for deep venous thrombosis even before chest symptoms appear. The key sequence is to identify the new systemic threat, stabilize or escalate care promptly, then return to procedure-specific issues once the patient is safe.
Worked example: Several days after forefoot surgery, a patient reports sudden shortness of breath and sharp chest pain with breathing. The pulse is rapid, while the incision is clean and only mildly swollen. Pulmonary embolism is among the urgent possibilities. Check immediate clinical stability and arrange emergency assessment; local wound care cannot explain or resolve the cardiopulmonary findings.
Watch the distinction: A clean incision does not make sudden postoperative breathlessness routine. Systemic symptoms require their own urgent assessment even when the operated foot appears to be healing.
Reference: [4]
15. Find the cause of recurrent hallux valgus
Recurrent hallux valgus is a finding to explain before it is a deformity to reoperate. Establish what the first procedure corrected, when the toe drift returned and which symptoms now matter to the patient. Examine first-ray mobility, hallux range of motion, lesser-ray crowding and pain over hardware or the joint. On standing films, compare metatarsal alignment, joint congruity, sesamoid position and evidence of healing at the prior correction. A residual proximal first-ray deformity or instability can keep driving the hallux laterally despite an apparently successful distal maneuver. Other possibilities include incomplete correction, joint degeneration or overcorrection elsewhere. Revision selection should address the demonstrated mechanical source and account for scar, bone stock and soft tissues. Repeating prominence removal may temporarily reduce shoe pressure while allowing the same deforming forces to act.
Worked example: A patient has renewed bunion pain after a distal first-metatarsal correction. Standing films show persistent first-metatarsal divergence, and examination shows excessive first-ray mobility. The earlier procedure did not control the proximal driver. Revision planning should address that malalignment and instability while assessing the joint and previous fixation; another bump removal would not correct the cause.
Watch the distinction: Recurrence does not prove that the previous eminence removal was too small. Trace the residual first-ray and joint mechanics before choosing a revision procedure.
Reference: [4]
RRA Surgery Didactic
16. Stage adult acquired flatfoot by flexibility
Adult acquired flatfoot assessment turns on whether the deformity can be corrected and which joints remain healthy. Examine standing heel valgus, arch collapse, forefoot abduction, posterior tibial tendon function and the ability to perform a single-leg heel rise. Then test passive hindfoot correction, ankle motion and any forefoot supination that appears when the heel is reduced. Weight-bearing imaging shows alignment and whether subtalar or other hindfoot joints have lost space. A flexible valgus foot with preserved joint surfaces may be suitable for a combination of realignment and soft-tissue procedures when symptoms warrant surgery. Fixed valgus with painful degeneration calls for a structural approach that addresses the arthritic joint. The RRA Surgery Didactic guide covers related rearfoot and ankle decisions; flexibility remains the first branching point in this one.
Worked example: A patient has medial ankle pain and cannot complete a single-leg heel rise. The heel rests in valgus but moves toward neutral by hand, and standing films show preserved subtalar joint space. This is a flexible deformity, so realignment with appropriate soft-tissue work is plausible. A heel fixed in valgus with marked subtalar narrowing would call for a different solution.
Watch the distinction: A failed heel rise does not by itself establish a rigid stage. Test passive correction and read the joint surfaces before choosing reconstruction or fusion.
Reference: [4]
17. Read ankle arthritis with limb alignment
Ankle arthritis is a loading problem as well as a cartilage problem. Standing views show where joint space has narrowed and whether the talus tilts beneath the tibia. Trace the tibial axis, talar position and hindfoot alignment to understand why one side of the joint bears more force. Varus hindfoot alignment can maintain medial edge loading, while a deformity above or below the ankle may alter the apparent joint position. Examine whether the deformity is flexible, which joints are painful and how the foot meets the ground. Treatment choice depends on the amount and distribution of cartilage loss, the correctability of alignment, adjacent-joint condition and patient goals. Even when a joint-directed procedure is appropriate, leaving a substantial alignment driver unaddressed may continue abnormal stress or compromise the intended correction.
Worked example: Standing radiographs show medial ankle narrowing, varus tilt of the talus and a varus heel. The pattern links cartilage loss with concentrated medial loading. Examine whether the heel and talus can be corrected and identify the level of deformity. A plan focused only on the painful ankle surface could leave the varus load path in place.
Watch the distinction: Joint-space narrowing is not the whole diagnosis. Read the tibia, talus and hindfoot together, since their alignment determines how force passes through the damaged surface.
Reference: [4]
18. Locate the driver of cavovarus
Cavovarus can originate partly in the forefoot or persist as a fixed hindfoot deformity. A plantarflexed first ray may tip the foot so the heel compensates into varus during standing. The Coleman block test places support under the lateral forefoot and heel while leaving the first ray free to drop. If heel varus corrects in that position, the hindfoot retains flexibility and the forefoot is a major driver. If varus persists, look for a fixed hindfoot component, joint degeneration or other structural causes. Examine muscle balance, ankle instability, callus distribution and neurologic findings because these can sustain or result from the deformity. The test guides where correction must act; it does not substitute for full standing imaging or a complete evaluation of all involved joints.
Worked example: A patient has a high arch, pressure beneath the first metatarsal and a varus heel. With the lateral foot and heel on a block and the first ray hanging free, the heel moves toward neutral. The hindfoot is flexible; the plantarflexed first ray is driving much of the standing varus. Treating the heel as fixed would misplace the primary correction.
Watch the distinction: A varus heel seen in standing does not prove a fixed heel deformity. Unload the first ray and observe whether the hindfoot corrects.
Reference: [4]
19. Identify the source of equinus
Dorsiflexion testing with the knee extended and flexed helps locate a common source of equinus. The gastrocnemius crosses both knee and ankle; flexing the knee reduces its tension. If ankle dorsiflexion improves substantially with the knee flexed while the hindfoot is held in a consistent position, gastrocnemius tightness is likely contributing. Persistent restriction in both positions suggests involvement of the soleus-Achilles complex, an ankle joint block or another fixed restraint. Control subtalar motion during testing so apparent dorsiflexion is not produced by midfoot collapse. Compare passive motion with gait and symptoms, since equinus can increase forefoot loading or complicate a flatfoot correction. Before selecting any lengthening or release, identify the limiting structure and consider the functional risk of weakening it. The test informs, rather than dictates, the procedure.
Worked example: With the heel held steady, a patient's ankle barely dorsiflexes when the knee is extended but gains clear motion when the knee flexes. Relaxing the gastrocnemius explains the change, supporting isolated gastrocnemius contribution. In another patient, flexion produces no gain; assess the broader Achilles complex and joint for the remaining block.
Watch the distinction: An apparent gain from midfoot collapse is not true ankle dorsiflexion. Stabilize the hindfoot and compare the two knee positions before assigning the restriction to gastrocnemius.
Reference: [4]
20. Recognize a symptomatic tarsal coalition
A painful rigid flatfoot in an adolescent calls for examination of subtalar motion, not an assumption that every flat arch is flexible. A tarsal coalition creates an abnormal connection between tarsal bones and restricts normal joint movement. The foot may remain in valgus, fail to form an arch during heel rise and develop recurrent sprains as motion is redirected to neighboring structures. Compare passive subtalar inversion and eversion with the other foot and identify the painful region. Radiographs can show signs of a bony bridge or altered joint shape; cross-sectional imaging can define the coalition and surrounding joint condition when needed for planning. Management depends on symptoms, coalition anatomy, alignment and whether adjacent joints have become arthritic. The structural restriction explains why exercises intended for an ordinary flexible flatfoot may not address the cause.
Worked example: An adolescent has recurrent ankle sprains and aching around a flat, valgus hindfoot. The arch does not re-form on heel rise, passive subtalar motion is restricted and imaging describes a calcaneonavicular bridge. These findings support symptomatic coalition. Define alignment and joint condition before choosing treatment; a routine flexible-flatfoot plan would miss the motion-blocking structure.
Watch the distinction: A flat arch in a young patient is not automatically flexible or harmless. Pain, recurrent sprains and restricted subtalar motion should prompt evaluation for coalition.
Reference: [4]
21. Describe residual clubfoot by components
A treated clubfoot can retain one component while others are corrected. Describe the foot from front to back: cavus raises the medial arch, forefoot adduction turns the forefoot inward, hindfoot varus turns the heel inward, and equinus limits ankle dorsiflexion. Examine each component actively and passively, then use standing alignment and joint imaging when the child can bear weight. Flexibility matters because a reducible position and a fixed bony deformity call for different corrections. Also check gait, skin pressure, calf function and whether limited dorsiflexion comes from the ankle or a more proximal muscle-tendon restriction. The RRA Surgery Didactic guide provides further preparation for this anatomical scope. In any case, name the remaining components before choosing a treatment target.
Worked example: A previously treated child walks on the lateral heel. The forefoot points forward and is passively straight, but the heel remains in varus and ankle dorsiflexion is restricted. The residual findings are hindfoot varus and equinus, not persistent forefoot adduction. Assess whether each remaining component is flexible and whether the ankle joint is involved before planning correction.
Watch the distinction: Calling every abnormality “recurrent clubfoot” can lead to repeating a forefoot procedure. A straight forefoot does not correct heel varus or restore ankle dorsiflexion.
Reference: [4]
22. Interpret a displaced calcaneal fracture
A displaced calcaneal fracture can disturb both the posterior subtalar joint and the three-dimensional shape of the heel. Examine the skin for tenting, blisters and swelling, and document sensation and perfusion before focusing on the CT scan. Standing or nonstanding radiographs can show loss of heel height or widening; CT clarifies posterior facet fragments, displacement and comminution. Those findings guide whether joint congruity and heel shape can be restored, while the soft-tissue envelope affects when and how an operation can be performed. A threatened skin area may demand urgent action even when definitive reconstruction must wait for safer exposure. The ABFAS examination content outline identifies rearfoot trauma and procedure-related decisions within the RRA scope; the clinical decision still depends on the particular fracture and patient.
Worked example: After a fall, a patient's heel is wide, the lateral skin is markedly swollen, and CT shows a depressed posterior facet. The joint surface is incongruent and the heel's shape has changed, so an articular assessment alone is incomplete. Protect and reassess the swollen skin, then plan treatment that addresses joint alignment and heel morphology when the soft tissues permit.
Watch the distinction: A detailed CT does not make swollen lateral skin irrelevant. Operating through a compromised envelope can create a wound problem even if the fracture reduction is accurate.
Reference: [4]
23. Assess talar neck injury and blood supply
The talus has substantial cartilage coverage and a blood supply that can be disrupted by a displaced neck fracture, especially when adjacent joints dislocate. First assess skin, pulses, sensation and the position of the foot. Prompt reduction addresses deformity and pressure on soft tissues; imaging then defines fracture alignment and associated joint injury. Stabilizing the fracture restores anatomy, but it does not prove that circulation within the talar body survived. Follow-up therefore asks two separate questions: is the fracture uniting, and is the talar body retaining a congruent, supported joint surface? Serial radiographs and case-specific advanced imaging can help when pain or structural changes raise concern. Osteonecrosis may precede subchondral collapse, and collapse changes the mechanical problem from impaired bone viability to loss of joint support.
Worked example: A displaced talar neck fracture comes with a subtalar dislocation and tense skin. After documenting neurovascular findings, the deformity is reduced promptly, alignment is confirmed, and definitive fracture care is planned. At follow-up, a healed incision and normal skin do not settle talar viability. Persistent pain or evolving bone changes require assessment for osteonecrosis and surface collapse.
Watch the distinction: Successful reduction solves the immediate malalignment, not the blood-supply question. Assuming the talus is safe because the skin recovered can miss delayed osteonecrosis.
Reference: [4]
24. Distinguish ligament instability from tendon subluxation
Lateral ankle giving way and a snap behind the fibula may come from different structures. Anterior talofibular ligament laxity is assessed with an anterior drawer maneuver, while calcaneofibular ligament laxity may contribute to abnormal talar tilt. Peroneal tendons normally run in a groove behind the fibula under a retaining structure; disruption of that restraint can let them move over the fibular edge during active motion. Ask where the patient feels the event and try to reproduce it with resisted dorsiflexion and eversion while observing the tendons. Palpate the retromalleolar course and assess ligament stability separately. Dynamic imaging can demonstrate tendon movement when the examination is uncertain, while other imaging can assess tendon tears or associated bone shape. Treatment should address the symptomatic structure demonstrated by the findings.
Worked example: A patient reports a visible snap behind the lateral malleolus during exercise. Resisted eversion reproduces tendon movement over the fibular edge, while the ankle drawer examination is stable. Peroneal tendon instability best explains this presentation. Assess tendon integrity and its restraint before planning care; an isolated lateral ligament reconstruction would leave the observed snapping mechanism in place.
Watch the distinction: A complaint of ankle “instability” does not identify a torn ligament. A retromalleolar snap reproduced by tendon activation points to a different mechanical failure.
Reference: [4]
25. Separate Charcot change from focal bone infection
Neuropathy can allow repetitive loading of an injured foot without protective pain, producing joint fragmentation, warmth, swelling and progressive deformity. Infection can produce similar warmth and bone changes, and the two conditions can coexist. Start with skin integrity: a deep ulcer or tract adjacent to a focal abnormal bone supports contiguous osteomyelitis, whereas widespread changes across several joints with intact skin may favor active Charcot neuroarthropathy. Examine perfusion and systemic illness, compare imaging distribution with the examination, and use laboratory studies or targeted sampling when they can resolve remaining uncertainty. No single warm foot finding reliably settles the distinction. Management also diverges: suspected active Charcot change needs prompt protection from further mechanical collapse, while an abscess or infected bone requires infection-directed evaluation and source control.
Worked example: An insensate patient has a hot swollen midfoot. Imaging shows fragmentation across multiple joints, and careful examination finds no wound or focal tract. Active Charcot change is a strong working diagnosis, so protect the foot and assess alignment. If a later ulcer probes toward one newly destructive bone, investigate superimposed osteomyelitis rather than attributing every change to neuropathy.
Watch the distinction: Warmth and fragmentation do not automatically mean infection, and a Charcot diagnosis does not exclude it. The ulcer pathway and pattern of bone change matter.
Reference: [4]
26. Treat the septic ankle as a joint emergency
Bacteria within an ankle joint can rapidly damage cartilage and extend into adjacent tissue. Suspect septic arthritis when passive motion is severely painful, especially with effusion, fever or systemic illness, but absence of fever alone cannot settle the diagnosis. Assess vital signs, skin and nearby wounds; obtain case-relevant imaging and aspirate joint fluid for cell assessment, microscopy and microbiology when feasible without delaying urgent care. Crystal disease may resemble infection and may coexist with it, so crystals do not cancel a concerning clinical picture. A purulent aspirate or strong combined evidence calls for prompt joint drainage and antimicrobial treatment guided by cultures and the patient's condition. The sequence is recognition, focused sampling, source control and follow-up of clinical response, with urgent resuscitation when systemic instability is present.
Worked example: A patient is febrile, and a swollen ankle hurts intensely with minimal passive motion. Aspiration produces cloudy fluid. The working diagnosis is septic ankle arthritis; send appropriate fluid studies, assess for systemic infection, and arrange urgent drainage and antimicrobial care. A splint may ease motion-related pain, but it cannot remove the infected joint contents.
Watch the distinction: Treating a hot ankle as a sprain because radiographs show no fracture misses a joint emergency. Plain films do not rule out septic arthritis.
Reference: [4]
27. Connect talar osteonecrosis to collapse
Osteonecrosis means part of the talus has impaired blood supply and compromised bone repair. Early disease may be visible on MRI while the weight-bearing joint surface remains shaped and supported on radiographs. That distinction matters because a preserved surface can leave room to consider protective or joint-preserving approaches, guided by symptoms, lesion extent and cause. Once weakened subchondral bone collapses, the talar dome becomes incongruent; altered contact pressure then accelerates pain and secondary ankle or subtalar arthritis. Compare serial standing images for new depression, joint-space changes and alignment, rather than interpreting the word “osteonecrosis” as one fixed stage. Treatment decisions must account for the structure that remains: reducing load may protect an intact surface, but cannot rebuild a collapsed one. The patient's function and adjacent joints also affect the plan.
Worked example: MRI identifies a talar dome region of osteonecrosis, while standing radiographs show a smooth, supported surface. Document the preserved architecture and assess joint-preserving options. Months later, a new subchondral depression appears with joint incongruity and worsening weight-bearing pain. The problem has advanced to mechanical collapse; simple offloading cannot restore the former articular contour.
Watch the distinction: An MRI diagnosis alone does not tell you whether the joint surface has failed. Collapse, alignment and secondary arthritis determine the mechanical stage.
Reference: [4]
28. Plan biopsy around definitive tumor care
A rapidly growing, deep or destructive ankle mass needs characterization before tissue is removed. History and examination establish growth rate, pain, skin change, neurologic findings and vascular findings. Radiographs can show bone destruction; cross-sectional imaging defines the lesion, its relation to compartments and neurovascular structures, and the most informative site for sampling. Biopsy is a planned part of definitive tumor care because its tract may need to be removed with the lesion. A poorly placed incision or broad dissection can contaminate tissue planes and make later treatment harder. Coordinate the imaging, biopsy route and subsequent care with the appropriate tumor team. This reasoning applies even when a superficial location initially suggests a familiar benign lump: depth, growth and destructive imaging findings outweigh that first impression.
Worked example: An ankle mass has enlarged over several months, and imaging shows cortical destruction with a soft-tissue component. Document nerve and vessel function, obtain imaging that maps its full extent, and arrange a deliberately placed biopsy through a route compatible with definitive treatment. Immediate local excision would risk leaving disease behind and complicating later surgery.
Watch the distinction: Taking a large sample through the easiest incision is not automatically safer. Biopsy placement can determine which tissues must be addressed during definitive tumor care.
Reference: [4]
29. Build a stable subtalar fusion
Subtalar fusion succeeds when viable opposing bone surfaces meet in a useful hindfoot position and remain stable long enough to unite. Residual cartilage blocks direct bone contact, so joint preparation must expose appropriate bone while preserving its capacity to heal. Correcting varus or valgus matters because fusion fixes that position; a united but malaligned joint can shift load to the ankle, midfoot or lateral border. Compression and fixation limit motion across the prepared surfaces, while graft or other biological support may be considered when contact or bone stock is deficient. Before selecting a construct, evaluate deformity, adjacent-joint disease, bone quality, prior infection and the soft-tissue envelope. Hardware supplies stability; it cannot substitute for sound preparation, adequate contact or acceptable alignment. Postoperative protection then supports the biological process of union.
Worked example: A painful arthritic subtalar joint is prepared for fusion, but the heel remains in varus and cartilage remains on opposing surfaces. Even rigid screws would lock in poor alignment and leave limited bone contact. Correct the heel position, prepare viable opposing surfaces, obtain contact and compression, and choose fixation that maintains the correction while union develops.
Watch the distinction: A strong screw construct does not guarantee fusion. Persistent cartilage, a gap or malalignment can defeat a technically secure-looking fixation.
Reference: [4]
30. Diagnose failure after hindfoot fusion
Persistent pain after hindfoot fusion has several possible sources: incomplete union, malalignment, adjacent-joint overload, infection or a painful implant. Localize pain and examine the incision, warmth, deformity and neurovascular status. Compare serial weight-bearing radiographs for alignment, bridging and hardware changes; CT can clarify an uncertain fusion site. Broken hardware often indicates ongoing motion, but does not explain why union failed. Review the original joint preparation and contact, smoking or other healing factors, and any history suggesting infection. Obtain targeted infection studies or specimens when the findings warrant them before choosing revision. A useful revision plan corrects the cause as well as the visible failure: restore alignment and viable contact, control infection if present, and provide sufficient stability and biological support for the revised fusion.
Worked example: A patient remains painful after hindfoot fusion. Radiographs show a persistent joint gap and a broken screw, while the heel is mildly malaligned. The screw failure supports continued motion and probable nonunion. Confirm fusion status, assess the deformity and investigate any infection clues before revision; replacing the screw alone would leave the gap and alignment problem unresolved.
Watch the distinction: Broken hardware is evidence of mechanical stress, not a complete diagnosis. Infection, inadequate contact or malalignment may be the reason the construct was overloaded.
Reference: [4]
Foot Surgery NEW CBPS
31. Work through a symptomatic bunion case
A Foot Surgery NEW CBPS bunion case calls for a focused sequence of information gathering and treatment reasoning. First separate shoe pressure over the prominence from pain inside the first metatarsophalangeal joint or beneath lesser metatarsal heads. Examine joint motion and congruity, first-ray position and stability, lesser-toe symptoms, skin and neurovascular status. Weight-bearing views show how the metatarsal, hallux and sesamoids align under load; joint degeneration changes the available correction choices. Then connect the demonstrated deformity to a procedure that corrects its mechanical driver, considering nonoperative care and patient goals. The ABFAS CBPS preparation page describes gathering relevant examination and diagnostic findings before diagnosis and treatment. In a practical response, make those findings explicit instead of jumping from the visible prominence straight to an operation.
Worked example: A patient reports shoe pressure over a bunion and aching at the first joint. Examination finds a mobile joint, an unstable first ray and intact perfusion. Standing films show first-metatarsal malalignment and displaced sesamoids without diffuse joint loss. The response is symptomatic hallux valgus driven partly by first-ray instability; discuss suitable conservative care and a correction that addresses that instability.
Watch the distinction: Removing only the medial prominence may relieve shoe contact briefly while leaving first-ray malalignment. A practical case answer should show why the chosen correction matches the examined deformity.
32. Manage a drifting second toe
A drifting second toe can result from plantar plate failure at the metatarsophalangeal joint, but a fixed digital contracture, interdigital nerve pain and other causes can coexist. Ask where pain began and whether the toe changed position over time. Examine plantar joint tenderness, drawer instability, toe purchase, reducibility and any proximal interphalangeal contracture. Check the adjacent interspace for radiating nerve symptoms. Weight-bearing radiographs show joint subluxation and metatarsal relationships; further imaging may help define soft tissue when the diagnosis remains uncertain. The plantar plate resists dorsal displacement of the proximal phalanx, so loss of its support explains instability and progressive crossover. Management should address that unstable joint and relevant loading factors. Correcting only a visible hammertoe deformity leaves the primary metatarsophalangeal instability in place.
Worked example: A second toe has drifted toward the hallux over several months. Plantar metatarsophalangeal tenderness and a positive drawer test reproduce pain; standing views show dorsal subluxation. This pattern supports plantar plate insufficiency with joint instability. Assess reducibility and metatarsal loading before selecting treatment. A proximal interphalangeal procedure alone would straighten one joint without stabilizing the symptomatic one.
Watch the distinction: A crooked second toe is not necessarily an isolated hammertoe. Drawer instability and plantar joint pain locate the failure at the metatarsophalangeal joint.
33. Respond to an infected forefoot ulcer
A diabetic forefoot ulcer with fever, fluctuance or soft-tissue gas must be assessed as a potentially deep, limb-threatening infection. Establish systemic stability first, then examine the wound's depth, drainage, surrounding tissue, sensation and arterial perfusion. Imaging helps locate gas, abscess, foreign material and possible bone involvement; deep operative or aspirated specimens are more informative for directed therapy than a superficial swab when source control is required. Fluctuance indicates a collection that antimicrobials alone may not adequately clear. Gas raises concern for aggressive infection but needs interpretation with the whole case. Plan urgent drainage and removal of nonviable tissue, with antimicrobial treatment and reassessment of perfusion and residual infection. The practical response should state what must happen now and what information will guide subsequent limb care.
Worked example: A patient with diabetes has fever, a plantar ulcer, a fluctuant forefoot and gas visible in the soft tissues. Assess vital signs and perfusion, map the infection with case-relevant imaging, and arrange urgent surgical source control with appropriate specimens and antimicrobial care. Dressings alone cannot drain the collection or remove nonviable infected tissue.
Watch the distinction: A small skin opening can hide a large deep infection. Judging severity by surface redness alone overlooks fluctuance, gas, systemic illness and possible bone involvement.
34. Evaluate a nonhealing ischemic toe wound
Wound closure requires oxygen and nutrients delivered through adequate arterial flow. A toe ulcer that persists despite pressure relief may therefore reflect ischemia, infection, repeated trauma or several causes together. Examine temperature, color, capillary response, pulses, tissue loss and signs of infection; document sensation and footwear pressure as well. Objective vascular testing helps establish whether perfusion is sufficient for healing, while vascular imaging may define an intervention target when ischemia is suspected. Interpret test results alongside the wound rather than relying on palpation alone, since edema or calcified vessels can complicate bedside assessment. Debridement, reconstruction or amputation planning should account for the level of viable, perfused tissue and any need to improve inflow. The Foot Surgery NEW CBPS guide can help you practice this examination-to-treatment sequence.
Worked example: A small toe ulcer has not healed after pressure relief. The foot is cool, pedal pulses are absent and there is no spreading redness. Document the wound and neurovascular findings, obtain objective perfusion assessment, and arrange vascular evaluation before elective closure. The immediate problem is inadequate healing capacity from suspected ischemia, even though the wound is small.
Watch the distinction: A technically neat closure cannot overcome poor arterial delivery. Treating the skin defect without assessing perfusion risks another open wound.
35. Reduce a first metatarsophalangeal dislocation
A dorsal first metatarsophalangeal dislocation can stretch skin and threaten digital nerves or vessels. Document perfusion, sensation, skin pressure and any open wound, then use radiographs to define joint position and associated fracture. Appropriate prompt closed reduction may restore alignment, but it should be controlled and followed by repeat examination and imaging. If the joint remains incongruent or reduction meets a firm block, plantar plate, sesamoid complex or other soft tissue may be interposed. Repeated forceful attempts can injure cartilage or soft tissue without solving that mechanical obstacle. Direct visualization and reduction may then be needed, followed by assessment of joint stability and associated injury. In a practical case response, distinguish the urgent pressure problem from the later decision about how to maintain a stable, congruent joint.
Worked example: After trauma, the hallux is dorsally displaced and its skin is tense. Sensation and perfusion are recorded, and radiographs confirm dislocation without a large fracture. A controlled closed attempt fails; repeat views show persistent incongruity. Suspect interposed plantar structures and arrange direct reduction rather than repeating forceful manipulation, then reassess joint stability and neurovascular status.
Watch the distinction: Failure of one appropriate reduction attempt does not justify unlimited force. A persistent block suggests interposed tissue that needs a different approach.
36. Resolve a subtle midfoot trauma case
The Lisfranc complex stabilizes the tarsometatarsal joints under load. A twisting injury may injure this restraint while initial non-weight-bearing films look almost normal. Plantar bruising, focal midfoot tenderness, pain with forefoot stress and difficulty bearing weight increase suspicion, but walking does not exclude injury. Compare the alignment of metatarsal bases and cuneiforms on weight-bearing views when the patient can safely tolerate them; comparison views or advanced imaging may clarify subtle injury. Separation or malalignment under load indicates lost restraint and raises concern for an unstable injury. Protect the foot while defining stability and planning treatment, because continued loading can worsen displacement and lead to painful deformity. The decision is based on the combined examination and loaded alignment, not on the reassuring appearance of an unloaded image alone.
Worked example: A player walks off the field after a midfoot twist but has plantar bruising and tenderness at the tarsometatarsal joints. Initial unloaded films seem aligned. Weight-bearing comparison views reveal separation between the first and second rays. That loaded displacement supports an unstable Lisfranc injury; protect the foot and arrange definitive assessment rather than treating it as a routine sprain.
Watch the distinction: Walking ability does not prove Lisfranc ligament integrity. A foot may tolerate some steps while its joints separate under load.
37. Map a child's extra digit before surgery
Congenital polydactyly involves more than an extra skin-covered toe. Radiographs may show duplicated phalanges, a shared metatarsal head or a broader metatarsal duplication. Examination should compare each digit's alignment, nail, motion, sensibility, circulation and contribution to shoe fit and gait. The surgeon must identify which joint surfaces, collateral ligaments, tendons and blood supply will remain after removal of one digit. When two toes share a joint, excision can leave the retained toe unstable or deviated unless its support is reconstructed. Growth also affects how a child's foot will develop after correction. Explain the proposed retained digit and structural repair to the family, including the possibility of residual deformity. In a simulation, the key step is mapping shared anatomy before naming the toe to remove.
Worked example: A child has two lateral toes sharing one metatarsal head. One toe looks more prominent, but both have part of the joint surface and soft-tissue support. Compare function and perfusion, review the skeletal map, and choose the retained toe based on the best reconstructable alignment. Plan joint and ligament support for it; simple removal of the more visible toe could leave instability.
Watch the distinction: The most obvious extra toe is not automatically the one to excise. Shared joint and vascular anatomy can make that shortcut harmful.
38. Assess symptomatic brachymetatarsia
A congenitally short metatarsal can change forefoot loading as well as appearance. A shortened fourth ray may carry less ground force, shifting pressure to adjacent metatarsal heads and leaving its toe elevated or unstable. Ask whether the main concern is pain, shoe fit, toe position or appearance, then examine calluses, joint stability, skin and neurovascular function. Standing radiographs show the relative ray lengths and joint alignment under load. Nonoperative measures may address pressure symptoms. If lengthening is considered, the bone cannot be treated independently of its soft-tissue envelope: nerves, vessels, tendons and joint capsule must accommodate the new position, and the metatarsophalangeal joint must remain congruent. The amount and method of correction depend on that balance and the patient's goals, not appearance on an isolated radiograph.
Worked example: A patient has a short fourth metatarsal, a floating fourth toe and pain beneath the third and fifth metatarsal heads. Standing films confirm the shortened ray; examination shows adjacent calluses and a reducible fourth toe. The short ray plausibly causes transfer loading. Discuss pressure relief first, and assess joint and soft-tissue capacity before any lengthening plan.
Watch the distinction: Matching metatarsal lengths on an image is not the whole objective. Lengthening that strains the toe's nerves or leaves its joint incongruent can create new problems.
39. Test an interspace pain diagnosis
Interdigital nerve irritation commonly produces burning or tingling into adjacent toes, sometimes worsened by narrow shoes or forefoot compression. A plantar plate injury instead tends to center pain beneath a metatarsophalangeal joint and may cause drawer instability or toe drift. Bone stress injury is more likely when tenderness localizes to a metatarsal shaft and worsens with repeated loading. Map the exact pain and sensory distribution, palpate each structure separately, and test joint stability before selecting imaging or treatment. A positive interspace compression finding supports nerve involvement, but should agree with the history and absence of stronger competing findings. Radiographs can assess bone or joint alignment; additional imaging is useful when a stress injury remains plausible despite unrevealing initial films. ABFAS overview practice questions can reinforce this evidence-based differential.
Worked example: A patient has burning pain radiating into two adjacent toes, reproduced by compression of one interspace. Nearby metatarsophalangeal joints are stable and nontender, and there is no focal shaft tenderness. Interdigital nerve pain is the leading diagnosis. If repeated running later produces point tenderness along a metatarsal shaft, reassess for bone stress injury instead of assuming the nerve diagnosis explains everything.
Watch the distinction: Any forefoot pain between toes is not a neuroma. Joint instability and focal bone tenderness direct the examination toward different structures.
40. Investigate a hot first toe joint
Gout and septic arthritis can both cause a red, exquisitely painful first metatarsophalangeal joint. A past gout diagnosis raises the likelihood of another flare, but it does not exclude infection, including infection occurring alongside crystals. Assess vital signs, skin breaks, nearby wounds, immune or systemic illness, and pain with passive joint motion. When infection is a meaningful possibility, obtain joint fluid for crystal examination, cell assessment and microbiologic studies, and use other tests to evaluate the patient's systemic condition. Purulence or a strongly concerning presentation requires urgent infection-directed care, including joint source control when indicated. Interpret a positive crystal result as evidence for gout, not as a negative culture. In a practical response, explain the competing diagnoses and take the action needed to protect the joint while results develop.
Worked example: A patient with prior gout has fever, a hot first toe joint and severe pain with passive motion. Aspiration yields cloudy fluid containing urate crystals. The crystals support gout but do not settle the infection question. Send fluid for microbiology, assess systemic illness, and urgently manage suspected septic arthritis if the combined findings remain concerning.
Watch the distinction: Finding crystals is not proof that bacteria are absent. Stopping the infection work-up at that point could leave a septic joint untreated.
41. Manage an enlarging plantar mass
In a Foot Surgery NEW CBPS case, begin with growth rate, prior treatment, pain, sensory change and functional effect. Examine size, depth, mobility relative to skin and fascia, and plantar nerve and vessel function. A rapidly enlarging or deep lesion deserves imaging that defines its relationship to fascia, muscle, bone and neurovascular structures before tissue is taken. MRI can show extent, but its appearance alone may not establish histology. If the findings raise concern for an aggressive lesion, coordinate a biopsy whose route can be included in later definitive treatment. Sampling through an inconvenient plantar incision can contaminate additional tissue planes or impair a future closure. The decision sequence is examination, characterization, planned tissue diagnosis and then treatment matched to pathology. The Foot Surgery NEW CBPS guide provides further case practice.
Worked example: A plantar arch mass has doubled in size over four months. It lies deep to the fascia, and MRI shows extension along that layer without a clear tissue diagnosis. Record plantar sensation, pulses and motor function, review the full imaging extent, and arrange a coordinated biopsy. Do not excise the visible lump immediately: its margins and any required definitive resection remain unknown.
Watch the distinction: A smooth surface or modest pain does not prove that a growing deep mass is benign. Unplanned excision can obscure its true extent and complicate definitive surgery.
42. Revise a painful metatarsal nonunion
Persistent pain at an osteotomy warrants more than labeling the radiographic gap a nonunion. Determine whether the site moves, whether fixation has loosened, whether alignment creates repeated load, and whether infection or poor bone biology is present. Compare serial weight-bearing radiographs; use CT when bridging remains uncertain. Look for drainage, wound history and focal inflammatory findings, then obtain targeted infection studies when indicated. Revision should correct the failure mechanism: remove obstructing fibrous tissue, create viable opposing bone surfaces, restore contact and alignment, and provide fixation suited to the forces across the metatarsal. Bone graft or another biological adjunct can help a deficient site, but it cannot stabilize a moving interface. Also examine neighboring rays because transfer loading may explain part of the pain even after union.
Worked example: Eight months after a metatarsal osteotomy, a patient has focal pain, a persistent gap on serial films and two loose screws. The visible gap and hardware movement support mechanical nonunion. Assess alignment and infection before revision. Restore viable bone contact and stable fixation; add graft if a residual defect or poor healing biology warrants it. Simply exchanging screws leaves the gap and motion.
Watch the distinction: A painful osteotomy is not automatically a graft deficiency. If fixation is loose or the ends do not meet, graft alone leaves the mechanical cause in place.
43. Triage a postoperative wound opening
A postoperative incision opening can be limited to skin, or it can communicate with tendon, bone or fixation. Establish the timing, drainage character, pain trajectory and systemic symptoms. Examine the entire wound, surrounding erythema, tissue viability, perfusion and whether hardware is exposed. Probe only when clinically appropriate and without forcing a tract; exposed metal already signals a deep communication. Radiographs can assess implant position and bone change, while deeper imaging may be needed if the extent remains uncertain. Obtain appropriate deep specimens during indicated exploration rather than relying on a surface swab to identify the cause. Management depends on infection depth, fixation stability, bone healing and whether viable coverage is achievable. Source control and a plan for stable reconstruction take priority over cosmetic closure. In a simulation, show these findings before choosing treatment.
Worked example: Three weeks after forefoot fixation, an incision drains cloudy fluid and a screw is visible. Check vital signs, perfusion, surrounding tissue and implant stability; obtain radiographs and plan appropriate deep sampling during urgent surgical assessment. This is a possible hardware-associated deep infection. Closing skin over the screw would trap a potentially infected space and leave the source untreated.
Watch the distinction: A small opening does not mean a superficial problem. Visible fixation connects the wound to deeper tissue, so dressing size alone cannot determine infection depth or treatment.
44. Differentiate heel pain from bone stress
Heel pain needs a location and loading history. Plantar fascia pain commonly concentrates near its calcaneal origin and is prominent with the first steps after rest; symptoms may ease with initial movement. A calcaneal stress injury more often intensifies as loading continues, and squeezing the heel from both sides can reproduce deep bony pain. Examine gait, focal tenderness, swelling, neurologic symptoms and training changes rather than treating every plantar heel complaint alike. Plain radiographs can initially be unrevealing in a stress injury. If suspicion remains high, suitable advanced imaging can identify bone stress and guide activity restriction. Consider alternative causes such as nerve entrapment or fat-pad pain when the examination points elsewhere. The key decision is whether continued impact risks progression of a bone lesion.
Worked example: A runner increases hill training and develops heel pain that worsens through each run. Direct heel compression produces deep pain, while palpation at the plantar fascia origin is only mildly tender. Initial radiographs show no fracture line. Protect the heel from impact and obtain appropriate advanced imaging for suspected calcaneal stress injury. The negative radiograph does not resolve the clinical concern.
Watch the distinction: First-step pain is useful when present, but heel location alone cannot establish plantar fasciitis. Progressive impact pain and focal bony tenderness require a bone-stress assessment.
45. Escalate acute illness after forefoot surgery
A postoperative patient with confusion, fever and low blood pressure is physiologically unstable even when the incision appears healthy. First assess airway, breathing, circulation, mental status and repeated vital signs, and arrange immediate emergency evaluation. Examine the operative site, but also consider other sources of infection, medication effects, bleeding, thromboembolic disease and metabolic disturbance. Hypotension with altered mentation may reflect inadequate organ perfusion; waiting for a wound culture before escalation would delay resuscitation and diagnosis. In a CBPS response, state the urgent disposition, focused examination and case-relevant investigations in that order. The absence of drainage narrows neither the systemic differential nor the need for prompt treatment. The ABFAS CBPS preparation guidance emphasizes selecting clinically relevant actions throughout a simulated case.
Worked example: Four days after forefoot surgery, a patient is newly confused, febrile and hypotensive. The incision is dry, but that finding cannot explain away the unstable vital signs. Call for emergency assessment, reassess circulation and breathing, and communicate the surgery, medications and symptom timeline. Evaluate for systemic infection and other acute causes while resuscitative care proceeds; routine clinic follow-up is unsafe.
Watch the distinction: A clean incision does not exclude serious postoperative illness. Anchoring on the foot can miss a systemic process already impairing blood pressure and mental status.
RRA Surgery NEW CBPS
46. Build a plan for flexible adult flatfoot
Flexible adult flatfoot is a three-dimensional alignment problem, often involving posterior tibial tendon dysfunction, medial support failure, hindfoot valgus and forefoot abduction or supination. Ask where pain occurs and whether bracing or other nonoperative care has helped. Test single-leg heel rise, tendon function, passive hindfoot correction, forefoot position after the heel is corrected, and ankle dorsiflexion with the knee flexed and extended. Weight-bearing foot and ankle views reveal alignment under load; joint-space preservation helps distinguish a reconstructable flexible deformity from arthritic rigidity. Treatment can begin with load modification and support. If surgery is appropriate, pair soft-tissue repair or substitution with bony realignment where the deformity demands it, while addressing relevant equinus or forefoot imbalance. A tendon procedure alone cannot reliably carry an uncorrected valgus lever arm.
Worked example: A patient has medial ankle pain, cannot complete a single-leg heel rise, and has heel valgus that passively corrects. Standing images show valgus alignment but preserved subtalar space. Assess forefoot position and equinus, then discuss support and rehabilitation or reconstruction according to symptoms and prior care. If surgery is chosen, correct the demonstrated alignment as well as deficient soft tissue.
Watch the distinction: A failed heel rise does not by itself dictate one operation. Flexibility, joint condition, forefoot compensation and symptoms determine whether a tendon procedure needs structural correction.
47. Manage rigid arthritic hindfoot valgus
When hindfoot valgus cannot be passively corrected and the subtalar joint has lost cartilage, the problem includes both malalignment and a painful joint surface. Localize pain to the subtalar joint, lateral impingement or adjacent structures, and inspect skin, sensation and vascular status. Standing radiographs show how the heel and talus bear weight; CT can clarify joint destruction or a complex deformity when it changes planning. Supportive care may reduce symptoms, but tendon transfer cannot restore a fixed joint's motion or cartilage. For persistent severe disease, a fusion-based correction may address the painful joint while placing the heel in functional alignment. Decide which joints are actually diseased before extending a fusion. Poor positioning can shift overload to adjacent joints even if the original joint unites.
Worked example: A patient has lateral hindfoot pain, fixed heel valgus and advanced subtalar space loss on standing views. Passive inversion does not restore neutral alignment. Diagnose rigid arthritic hindfoot valgus, assess neighboring joints and discuss support or corrective fusion according to disability and treatment history. An isolated posterior tibial tendon transfer would leave the immobile arthritic subtalar joint and valgus position.
Watch the distinction: A flatfoot label does not mean the deformity remains flexible. When passive correction fails and cartilage is lost, soft-tissue balancing alone cannot solve the joint problem.
48. Resolve a pediatric rigid flatfoot case
A painful pediatric flatfoot that remains flat on heel rise or tiptoe requires a different work-up from a mobile, usually benign flexible flatfoot. Assess subtalar inversion and eversion, hindfoot alignment, peroneal spasm, focal tenderness and recurrent sprains. A tarsal coalition links two bones and restricts their normal movement; the hindfoot may compensate by staying in valgus. Weight-bearing radiographs can suggest the bridge and show alignment, while CT defines bony anatomy and MRI can identify a nonosseous coalition or associated inflammation when needed. The treatment choice depends on pain, joint degeneration, coalition characteristics and whether valgus remains correctable. Support, activity modification and immobilization can help some patients. Persistent symptoms may call for coalition-directed surgery with alignment correction when indicated.
Worked example: An adolescent has repeated ankle sprains, a painful valgus heel, an arch that does not return on heel rise and little subtalar motion. Imaging identifies a talocalcaneal coalition without established subtalar arthritis. The bridge explains the rigidity. Assess heel alignment and symptoms before considering support or coalition-directed treatment; prescribing a routine flexible-flatfoot program would miss the structural restraint.
Watch the distinction: Children with flat arches do not all have the same disorder. Pain, recurrent sprains and restricted subtalar motion are clues to coalition, even without an obvious bony prominence.
49. Analyze residual adult clubfoot
Residual clubfoot in adulthood is best described by its remaining components: cavus, forefoot adduction, hindfoot varus and equinus. Prior correction may also leave stiffness, tendon imbalance and uneven joint loading. Ask about shoe wear, callus, pain location and prior procedures. Examine each segment's passive flexibility, ankle and subtalar motion, tendon strength, skin and sensation. Standing foot, ankle and hindfoot alignment views show whether lateral overload comes from a plantarflexed first ray, fixed heel varus or both, and whether ankle arthritis contributes pain. Treatment should follow the driver. A flexible component may respond to support or targeted balancing, while fixed malalignment or established arthritis may require structural correction. Account for scars and altered anatomy from childhood treatment when planning exposure and soft-tissue coverage.
Worked example: An adult treated for clubfoot in childhood has lateral border callus, fixed heel varus and painful ankle joint-space loss. Standing views confirm varus loading. Diagnose residual hindfoot deformity with ankle arthritis, then assess neighboring joints and skin before choosing support or a structural procedure. Releasing a tight tendon alone cannot make a fixed heel neutral or restore the arthritic ankle surface.
Watch the distinction: Calling every symptom recurrent clubfoot hides the actual pain generator. Separate segment position, flexibility and joint damage before selecting a revision maneuver.
50. Act on an ankle fracture dislocation
An ankle fracture dislocation threatens skin and neurovascular structures through displacement itself, before definitive fixation is considered. Inspect for open injury, tenting, blisters and pressure over a displaced bone. Record pulses, capillary refill, motor function and sensation before reduction when feasible without delaying urgent action. Provide appropriate analgesia and reduce the talus beneath the tibia promptly, then immobilize and repeat the skin and neurovascular examination. Obtain post-reduction imaging to confirm congruity and identify remaining displacement. If perfusion is impaired or reduction fails, escalate immediately; soft-tissue interposition or a trapped fragment may block alignment. Definitive fixation planning follows fracture pattern, stability and soft-tissue condition. The RRA Surgery NEW CBPS guide extends this case-management sequence.
Worked example: After a fall, the talus is laterally displaced and the medial ankle skin is blanched and tented. Document sensation and pulses, promptly reduce the dislocation with suitable support, then reassess skin and circulation. Post-reduction films must show whether the talus is centered. Protect the reduced ankle while planning fracture fixation around swelling and skin condition.
Watch the distinction: Waiting for swelling to improve before reducing a dislocation prolongs skin pressure. Reduction is an immediate soft-tissue and alignment step, separate from definitive fixation timing.
51. Plan around calcaneal fracture soft tissues
A displaced calcaneal fracture can disrupt the posterior subtalar facet, widen the heel and alter hindfoot height or alignment. CT defines the articular fragments and shape more clearly than a single plain view, but the skin often determines when and how an operation can be performed. Examine the entire heel for swelling, blisters, threatened posterior skin and open injury; document sensation, perfusion and compartment findings. Protect the limb and reassess soft tissues while deciding whether the articular displacement and deformity warrant reconstruction. Severe lateral blisters can make an extensile exposure hazardous. Nonoperative care or a different surgical approach may be preferable when skin risk outweighs the expected benefit of a particular incision. Plan for both subtalar congruity and heel morphology, since either can drive later pain.
Worked example: CT shows a depressed posterior facet and a widened heel after a fall. Large lateral blisters cover the likely incision area, but perfusion is intact. Protect and elevate the heel, document nerve function and monitor the skin. Discuss definitive options using the CT findings and soft-tissue state; immediate wide lateral exposure through blistered skin would add wound risk.
Watch the distinction: CT displacement does not determine operative timing by itself. Ignoring blistered skin can turn an articular reconstruction into a wound complication.
52. Recognize evolving compartment syndrome
After a crush injury, swelling inside a closed fascial compartment can raise pressure enough to impair capillary flow. Large arteries may remain patent, so palpable pedal pulses do not exclude compartment syndrome. Repeated assessment matters: escalating pain, pain with passive toe motion, tense compartments, sensory change and increasing analgesic need form a concerning pattern. Check for constrictive dressings and assess every involved region; do not wait for paralysis, which is a late sign. When examination is unreliable, pressure measurement may assist, but it should not delay urgent surgical evaluation of a strongly suspicious case. Decompression, when indicated, must address the affected compartments and is time-sensitive because muscle and nerve injury progress with inadequate perfusion. A reassuring radiograph does not measure compartment physiology.
Worked example: Two hours after a foot crush injury, pain rises rapidly despite treatment. Passive toe extension causes severe pain, the foot feels tense and sensation is changing, yet pedal pulses remain palpable. Remove external constriction and obtain immediate surgical assessment for compartment syndrome. The pulse confirms large-vessel flow, not adequate capillary flow within swollen compartments.
Watch the distinction: A present pulse is not a rule-out test for compartment syndrome. Waiting for pulse loss or paralysis may allow irreversible tissue injury.
53. Work up recurrent peroneal snapping
A patient may describe both lateral ankle giving way and snapping, but these symptoms can arise from different structures. The peroneal tendons pass behind the fibula in a groove held by the superior peroneal retinaculum. Retinacular injury, groove shape or tendon pathology can permit the tendons to move over the fibular edge during active dorsiflexion and eversion. Reproduce the complaint while observing and palpating tendon movement. Separately test lateral ligament laxity and assess for tendon tear, tenderness or weakness. Dynamic ultrasound can show subluxation during motion; MRI can define associated tendon and retinacular lesions when needed. Management follows the demonstrated lesion and its persistence, including activity modification or stabilization of the tendons when appropriate. A ligament reconstruction alone will not restrain a tendon that visibly dislocates.
Worked example: A patient reports a snap behind the lateral malleolus when turning quickly. Resisted dorsiflexion and eversion visibly move the peroneal tendons over the fibula, while ligament testing shows little laxity. Diagnose peroneal tendon instability, assess tendon integrity and retinaculum, and use dynamic imaging if it clarifies treatment. Isolated ligament repair would miss the reproduced mechanism.
Watch the distinction: A lateral ankle symptom is not automatically ligament instability. Reproduced tendon movement behind the fibula points to a separate restraint failure.
54. Respond to suspected septic ankle arthritis
An infected ankle joint can rapidly damage cartilage because inflammatory cells and organisms act within a confined synovial space. Fever, warmth, effusion and marked pain with even small passive movements raise concern, although presentations vary. Assess systemic stability and possible skin breaks, prior injections or nearby infection. Obtain joint fluid for cell analysis, crystal examination, Gram stain and culture as appropriate; crystals, if present, would not exclude concurrent infection. Blood studies and cultures can support the assessment but should not substitute for joint sampling when it is feasible and clinically indicated. A purulent aspirate calls for urgent joint drainage and directed antimicrobial management. Coordinate timing of sampling and treatment with the patient's condition, especially if systemic illness makes delay unsafe. Follow clinical response and microbiology to refine care.
Worked example: A febrile patient has a swollen ankle and severe pain with minimal passive motion. Aspirated fluid is cloudy and purulent. Treat septic arthritis as the leading diagnosis: send appropriate fluid studies, assess systemic illness, arrange urgent joint drainage and begin antimicrobial care directed by the clinical state and later culture results. A sprain cannot explain the purulent joint fluid.
Watch the distinction: A swollen ankle after minor trauma is not necessarily a sprain. Fever, painful passive motion and purulent fluid demand an infection response.
55. Sort neuropathic collapse from infection
Neuropathy can permit repeated loading without protective pain, producing fracture and fragmentation across joints in Charcot neuroarthropathy. A warm, swollen foot or hindfoot may therefore resemble infection. Examine for an ulcer, sinus or recent wound and determine whether one tract approaches a particular bone. Compare the distribution of warmth, deformity and imaging changes: periarticular injury across several joints favors Charcot change, while focal bone destruction contiguous with a deep ulcer strengthens concern for osteomyelitis. These processes can coexist. Weight-bearing safety, limb protection and stabilization matter while the diagnosis is clarified, because continued loading can worsen collapse. Use MRI or other case-relevant studies when plain imaging and examination leave uncertainty, interpreting marrow changes in their clinical setting. Reconstruction planning should wait until infection status and the mechanical deformity are understood.
Worked example: An insensate patient has a warm, swollen hindfoot, intact skin and fragmentation spanning several joints. Charcot change is plausible; protect the limb and evaluate stability. At follow-up, a deep heel ulcer tracks toward one abnormal bone. That new focal route raises concern for superimposed osteomyelitis and warrants targeted infection assessment before reconstructive planning.
Watch the distinction: Warmth and abnormal bone signal do not alone prove infection in a neuropathic foot. Conversely, a compatible Charcot pattern cannot dismiss an ulcer that reaches diseased bone.
56. Follow talar injury for osteonecrosis
The talus has a vulnerable blood supply, particularly after a displaced neck injury. Later osteonecrosis means some bone has lost viable circulation, but its mechanical consequence depends on whether the subchondral surface remains supported. Review fracture union, alignment and pain location, then compare serial standing radiographs for new depression, joint incongruity and arthritis. MRI can detect osteonecrosis before radiographs show collapse, yet an MRI signal change does not by itself prove the dome has failed structurally. With preserved architecture, protective loading decisions and observation of the surface may remain relevant; options change if progressive collapse creates an incongruent ankle or subtalar joint. Explain the distinction between biological injury and mechanical failure in a CBPS response, and follow the patient over time rather than making a single-image decision.
Worked example: Five months after talar neck fixation, a patient has persistent pain. MRI shows osteonecrosis, while standing radiographs show a healed neck and an intact talar dome. Record the preserved surface, review loading and monitor serially. If later films show subchondral depression, reassess because collapse introduces joint incongruity that protection alone cannot reverse.
Watch the distinction: Osteonecrosis on MRI is not synonymous with talar collapse. Treatment reasoning changes when the weight-bearing surface actually loses shape.
57. Evaluate a destructive ankle lesion
A rapidly enlarging ankle mass with permeative bone change is potentially aggressive until tissue diagnosis establishes otherwise. Begin with duration, pain pattern, prior malignancy and constitutional symptoms, followed by skin, tendon, nerve and vascular examination. Plain films show the destructive pattern; MRI defines marrow and soft-tissue extent, including proximity to the ankle joint and neurovascular bundle. Further staging may be appropriate once the lesion's nature is considered, coordinated with the treating tumor team. Biopsy should occur after imaging so its tract crosses a planned surgical field and does not contaminate avoidable compartments. A small convenient incision can still compromise definitive treatment if placed poorly. The practical sequence is characterize the lesion, coordinate tissue diagnosis, interpret pathology with imaging and then choose definitive care. A presumed cyst diagnosis is unsafe when imaging shows bone destruction.
Worked example: A deep ankle mass has enlarged over three months, and radiographs show permeative distal tibial change. Document pulses, sensation and motor function; obtain imaging that defines bone and soft-tissue extent. Arrange a planned biopsy with a tumor team. Do not remove the palpable portion as a presumed cyst, because the full lesion and required margins are unknown.
Watch the distinction: A familiar ankle location does not make a mass benign. Destructive bone findings require an imaging and biopsy plan before local excision.
58. Investigate painful ankle fusion failure
Pain after ankle fusion may arise from motion at a nonunion, a united joint in poor alignment, overloaded adjacent joints, prominent fixation or infection. Map the pain to its source before revising the fusion. Examine skin, sinus formation, tenderness, hindfoot position and subtalar or midfoot motion. Standing views show the loaded axis; CT can clarify bridging and the location of a gap. Review serial films and inflammatory findings, then investigate infection with appropriate targeted studies or specimens when suspicion remains. A revision plan must address each confirmed driver: viable joint preparation and stable fixation for nonunion, correction of malalignment, and infection source control when present. Adding more hardware without changing a valgus position or treating infection repeats the conditions that produced failure. Adjacent-joint pain may need a different treatment altogether.
Worked example: A patient reports persistent ankle-region pain after fusion. CT shows an unbridged gap, standing images show residual valgus, and wound history raises concern for infection. Confirm the painful site and investigate infection before revision. If nonunion and malalignment are verified, revision must restore viable contact, correct the axis and provide stability; fixation alone cannot resolve every driver.
Watch the distinction: A visible fusion gap does not explain all postoperative pain. Malalignment, neighboring joints and infection can coexist and alter the revision strategy.
59. Evaluate calf symptoms after hindfoot surgery
New unilateral calf swelling after immobilized hindfoot surgery raises concern for deep venous thrombosis, even though edema can also follow surgery. Ask when swelling began, whether it is progressing, and whether chest pain, breathlessness, fainting or rapid heartbeat is present. Examine both legs for asymmetry, tenderness, skin change and perfusion while avoiding a reassuring diagnosis based on the incision alone. Arrange prompt objective venous assessment when DVT is suspected; physical findings alone cannot confirm or exclude it. Cardiopulmonary symptoms require emergency evaluation for possible pulmonary embolism or another acute cause. Treatment decisions depend on confirmed findings, bleeding risk, recent surgery and the responsible medical team. In a simulation, prioritize the urgent disposition and relevant diagnostic path before discussing routine swelling measures.
Worked example: Ten days after hindfoot surgery with immobilization, a patient develops new swelling and tenderness in one calf. Assess vital signs and ask about breathing and chest symptoms, then arrange prompt DVT evaluation. If the patient also reports pleuritic chest pain and shortness of breath, escalate immediately for emergency assessment of possible pulmonary embolism rather than waiting for routine clinic imaging.
Watch the distinction: Postoperative swelling is common, but a new asymmetric tender calf cannot be dismissed on that basis. Chest symptoms change the urgency further.
60. Integrate inflammatory disease with ankle deformity
Inflammatory arthritis can damage ankle cartilage while deformity shifts load through the hindfoot and neighboring joints. Systemic disease and its treatment may also affect bone quality, healing and skin integrity. Start with pain location, disease activity, medications, prior wounds and mobility goals. Examine the whole limb, including ankle and subtalar flexibility, hindfoot alignment, adjacent joints, skin, sensation and perfusion. Standing imaging should show the axis from leg through heel, not just the joint-space loss on an isolated ankle view. A procedure may relieve ankle pain yet leave an uncorrected valgus heel that continues edge loading or makes fixation less reliable. Choose conservative support or surgery after integrating joint condition, deformity, tissue quality and function. Plan incisions and postoperative protection around vulnerable skin and any healing concerns.
Worked example: A patient with inflammatory arthritis has valgus ankle collapse, a malaligned hindfoot and thin fragile skin. Standing views show both ankle wear and heel valgus. Examine adjacent joints and neurovascular status, review disease treatment and assess bone and skin before choosing a procedure. Correcting only the ankle image could leave the heel poorly aligned and expose fragile tissue to avoidable wound risk.
Watch the distinction: An ankle radiograph cannot by itself define the operative plan in inflammatory disease. Whole-limb alignment, neighboring joints and tissue condition can change both procedure choice and exposure.
Official references and further reading
- New Certification Process, Effective September 2020 | ABFAS
- How to Navigate the Didactic Exam | ABFAS
- CBPS Exam Preparation | ABFAS
- Part I Board Qualification Exam Content | ABFAS