A rearfoot or ankle case rarely turns on one image or one diagnosis. You need to identify an immediate threat, examine the structure that could explain the complaint, choose investigations that change management, and connect the findings to a defensible plan. A painful flatfoot, for example, may be flexible and tendon driven, rigid with joint disease, or complicated by infection or poor perfusion. Each leads to a different next step. This guide develops those distinctions through original cases across physical examination, diagnostic procedures, diagnosis, and treatment. Work through the sequence in each case: establish what is happening, decide what remains uncertain, then choose treatment and follow-up that fit the patient.
Physical Examination
1. Examine the threatened limb first
A displaced ankle can threaten skin, nerves, and blood flow before its fracture pattern is fully known. In an ABFAS RRA Surgery NEW CBPS case, begin with the exposed or tented skin, wound contamination, foot color and temperature, pedal pulses, capillary refill, toe movement, and sensation in distinct nerve territories. Record findings before and after urgent reduction so a change can be recognized. A palpable pulse does not settle every perfusion question, and absent pulses can reflect displacement or arterial injury. Protect an open wound and address gross deformity promptly while arranging appropriate imaging and definitive care. Detailed ligament stress testing can wait until the limb is safe. Persistent pallor, poor refill, or progressive neurologic loss after reduction demands immediate reassessment and vascular evaluation.
Worked example: A patient arrives with a displaced ankle, pale tented skin, and reduced toe sensation. Before reduction, the surgeon documents a weak pedal pulse, delayed refill, active toe movement, and the precise sensory deficit. After urgent reduction, skin tension resolves but the foot stays cool and refill remains poor. Persistent impaired perfusion triggers immediate vascular evaluation; routine fracture planning cannot safely proceed first.
Watch the distinction: A visible fracture can draw attention away from threatened tissue. Recording pulses once, after reduction, misses the comparison needed to detect persistent or newly developed compromise.
2. Read alignment during stance and gait
Standing alignment shows how body weight passes through the tibia, ankle, hindfoot, and forefoot. View the patient from behind and in front, then watch several steps, turns, and shoe contact. Heel varus can shift load laterally and add stress to the lateral ankle and subtalar region; heel valgus can accompany medial arch collapse or ankle malalignment. Compare the tibial axis with heel position, inspect forefoot position, and note where the shoe wears. Gait may reveal compensation that a static photograph misses, such as lateral border walking or early heel rise. Record what is observed before naming the deformity's driver. Seated examination and passive correction determine whether the position originates in the forefoot, hindfoot, ankle, or a combination. The broader ABFAS certification guide provides pathway context for this case-based clinical reasoning.
Worked example: A patient reports repeated lateral ankle pain. From behind, the heel stands in varus; the outer shoe edge is worn, and gait loads the lateral border. These findings support a lateral overload mechanism, but they do not identify its source. The surgeon next checks first-ray position, hindfoot correction, ankle alignment, and muscle balance before planning treatment.
Watch the distinction: Shoe wear alone cannot diagnose hindfoot deformity. Footwear, gait compensation, and forefoot position can alter wear, so compare it with standing alignment and flexibility findings.
Reference: [1]
3. Test whether hindfoot deformity corrects
Two feet can look equally valgus while needing different treatment because one deformity is mobile and the other fixed. With the patient relaxed, guide the heel toward neutral while stabilizing the leg and assessing subtalar motion. Then test whether the forefoot remains plantigrade and whether correction causes pain or reveals an ankle-level tilt. A correctable hindfoot suggests that joints may still accommodate realignment, making joint-sparing options more plausible when cartilage and other findings support them. A heel that cannot reach neutral may reflect contracture, bony malalignment, coalition, or arthritic joint change. Painful crepitus or markedly restricted subtalar motion strengthens concern for joint disease. Passive correction is one part of the decision: weightbearing imaging, symptom location, skin condition, and patient function still determine whether reconstruction is appropriate.
Worked example: Two patients each stand with heel valgus. In the first, manual pressure brings the heel to neutral and subtalar motion is comfortable. In the second, the heel remains valgus and inversion produces focal subtalar pain. The first may be considered for correction that preserves motion; the second needs imaging for structural joint disease before a procedure is selected.
Watch the distinction: Matching standing angles do not imply matching pathology. Treating a rigid, arthritic heel as though it were flexible can leave painful joint surfaces and residual malalignment.
Reference: [1]
4. Localize posterior tibial tendon dysfunction
The posterior tibial tendon helps invert the hindfoot and support the medial arch. Assess tenderness and swelling along its course behind the medial malleolus, then compare resisted inversion with the opposite side. A single-leg heel rise tests more than strength: a functioning hindfoot normally moves toward inversion as the heel lifts. Failure to rise, or rising without heel inversion, supports loss of the tendon and its supporting mechanism. Pain may limit effort, so interpret the maneuver with the rest of the examination rather than alone. Inspect forefoot abduction, medial arch collapse, and whether the hindfoot can be corrected passively. These findings distinguish a tendon problem within a flexible deformity from a later, rigid joint problem. Weightbearing views then show how much alignment changes under load.
Worked example: A patient has swelling behind the medial malleolus, weak resisted inversion, and cannot complete a single-leg heel rise. During an assisted rise, the heel stays valgus instead of inverting. The combined findings support posterior tibial tendon dysfunction with loss of effective hindfoot control. The surgeon then tests flexibility and obtains loaded alignment views before choosing treatment.
Watch the distinction: A low arch by itself does not prove tendon failure. Some flatfeet remain functional, while pain, weakness, failed heel inversion, and progressive deformity provide stronger evidence.
Reference: [1]
5. Use the Coleman block for cavovarus
The Coleman block test asks whether a plantarflexed first ray forces the hindfoot into varus during stance. Place a block beneath the lateral foot and heel while leaving the first ray unsupported. If the medial forefoot can drop below the block, its deforming effect is removed; a flexible heel should then swing toward neutral or valgus. Compare heel position on level ground and on the block, observing that the patient stands naturally rather than gripping or twisting the foot. Correction suggests a forefoot-driven component, while persistent varus suggests fixed hindfoot malalignment or another driver. The test guides which structures require correction, but it does not prove that one procedure is sufficient. Check muscle balance, lateral ligament stability, joint condition, and weightbearing imaging before settling on a reconstruction.
Worked example: A heel measures 8° varus on level ground. With the first ray hanging free beside a Coleman block, it measures 2° valgus. Moving from 8° varus through neutral to 2° valgus is a 10° correction. This supports a flexible, forefoot-driven component; the surgeon still examines the first ray and muscle balance before planning correction.
Watch the distinction: A heel that corrects on the block is not automatically normal. The test identifies a mechanical driver; lateral instability or a separate ankle problem may still need evaluation.
Reference: [1]
6. Separate ankle from subtalar motion
The tibiotalar joint chiefly produces dorsiflexion and plantarflexion, while the subtalar joint contributes inversion and eversion of the hindfoot. Stabilize the leg and move the ankle through its arc, noting where pain begins, where it peaks, and whether crepitus or a hard stop occurs. Then hold the talus and assess hindfoot inversion and eversion as separately as the patient's anatomy allows. Pain on uneven ground may suggest subtalar disease, but it is less specific than reproduced joint pain combined with restricted motion and matching imaging. Tenderness over tendons or the sinus tarsi may point elsewhere. A stiff ankle can also shift demand onto the subtalar joint. Localize the likely pain generator before discussing a joint procedure, and check loaded radiographs for the predicted pattern.
Worked example: A patient describes anterior ankle pain when walking downhill. Dorsiflexion and plantarflexion reproduce it, with an anterior hard stop; controlled hindfoot inversion and eversion remain comfortable. The tibiotalar joint is the leading pain source. Weightbearing ankle films are obtained to look for joint narrowing or impingement before any joint-directed treatment is chosen.
Watch the distinction: Pain called 'ankle pain' does not necessarily come from the ankle joint. Subtalar, tendon, and nerve disorders can occupy the same region and require different treatment.
Reference: [1]
7. Assess chronic lateral ankle instability
Chronic lateral instability has both mechanical and functional features. Ask whether the ankle gives way, on what surface, and whether episodes involve a new sprain or a sensation of poor control. Compare anterior drawer and talar tilt with the uninjured side while keeping the foot position and examiner force consistent. Increased translation or tilt supports ligament laxity, but pain, guarding, and generalized flexibility can change the result. Inspect standing heel alignment, first-ray position, gait, peroneal function, and range of motion. Varus loading can repeatedly stress reconstructed or native lateral ligaments; weakness and impaired balance can produce giving way even without marked laxity. Investigate associated cartilage injury when deep pain, swelling, or catching persists. The treatment target follows the combined mechanical picture, not one positive maneuver.
Worked example: After several sprains, a patient gives way on uneven ground. Anterior drawer is greater than on the opposite side, and standing examination shows heel varus. The drawer supports lateral ligament insufficiency; varus adds a continuing lateral load. The surgeon checks flexibility, peroneal strength, and joint symptoms before deciding whether rehabilitation, alignment correction, ligament treatment, or a combination is needed.
Watch the distinction: A positive drawer does not explain every episode of giving way. Ignoring varus, weakness, or an intra-articular lesion can leave the cause of recurrent symptoms untreated.
Reference: [1]
8. Examine the syndesmosis
The syndesmosis holds the distal tibia and fibula together around the talus. External rotation of the foot can strain this complex and, in a more extensive injury, transmit force up the interosseous membrane toward the proximal fibula. Palpate the anterior distal tibiofibular interval and follow tenderness proximally. A carefully performed external-rotation maneuver may reproduce pain over the syndesmosis, but acute fracture, swelling, and guarding limit specificity. Examine the whole fibula, medial ankle, and neurovascular status. Mortise widening or a proximal fibular injury changes concern for instability. Record the injury mechanism and focal findings, then obtain appropriate radiographs and further assessment if stability remains uncertain. Do not force provocative tests through severe pain or let a normal-looking lateral ligament region end the examination.
Worked example: After an external-rotation injury, a patient is tender above the ankle over the distal tibiofibular interval. Gentle external rotation reproduces pain there, and palpation also reveals proximal fibular tenderness. The pattern raises concern for a syndesmotic injury with a more extensive fibular component. Imaging must include the relevant leg and ankle anatomy before the injury is treated as a simple sprain.
Watch the distinction: Lateral ankle pain after trauma is not always a low ankle sprain. Missing proximal fibular tenderness can conceal a wider injury that threatens mortise stability.
Reference: [1]
9. Check Achilles continuity
A complete Achilles rupture breaks the link between calf contraction and effective plantarflexion through that tendon. Compare the resting foot position with the patient prone and knees flexed, palpate for a gap, and observe whether calf squeeze produces plantarflexion. Test active plantarflexion and heel rise only as tolerated, recognizing that other plantarflexor muscles may preserve some movement. Acute swelling can hide a gap, and partial tears can produce less clear findings. A history of a sudden snap during push-off supports the diagnosis when the examination agrees. Document skin condition and neurologic status because they influence management options. If examination is uncertain, focused imaging can clarify tendon continuity and gap characteristics. Early protection avoids further separation while definitive care is planned.
Worked example: A runner feels a posterior snap and cannot push off. Compared with the other side, the foot rests more dorsiflexed; a tendon gap is palpable, and calf squeeze produces little plantarflexion. The patient can still point the toes slightly. The concordant resting, palpation, and squeeze findings support rupture because other muscles can account for the remaining active movement.
Watch the distinction: Some active plantarflexion does not rule out Achilles rupture. The tendon must be assessed with resting posture, palpation, calf squeeze, and function together.
Reference: [1]
10. Distinguish gastrocnemius from combined tightness
The gastrocnemius crosses both the knee and ankle; the soleus crosses the ankle but not the knee. Bending the knee relaxes gastrocnemius tension, so improved ankle dorsiflexion with knee flexion points toward a gastrocnemius contribution. Measure with the hindfoot held neutral and the midfoot prevented from collapsing upward, or apparent dorsiflexion may come from the foot rather than the ankle. Repeat the maneuver with the knee straight and bent, recording angles relative to neutral and whether pain limits the movement. If dorsiflexion remains restricted in both positions, combined calf tightness, ankle joint restriction, or bony impingement becomes more plausible. This examination helps explain abnormal load and guides treatment discussion; it does not, by itself, justify a lengthening procedure. RRA NEW CBPS practice questions can be used to rehearse the complete case sequence.
Worked example: With the hindfoot controlled, dorsiflexion reaches 5° short of neutral with the knee straight and 5° past neutral with it bent. The measured gain is 10°. Since knee flexion relaxes gastrocnemius, the result supports an isolated gastrocnemius contribution, provided the extra motion occurred at the ankle rather than through midfoot collapse.
Watch the distinction: If the arch is allowed to flatten during testing, apparent ankle dorsiflexion may be false. Control the hindfoot and midfoot before interpreting the difference between knee positions.
Reference: [1]
11. Examine arterial supply to a wound
A wound needs enough blood flow to support granulation, immune defense, and closure. Examine pedal pulses, capillary refill, skin temperature, color, hair and skin changes, and the wound edge. Pale tissue with little granulation can suggest impaired perfusion, but infection, pressure, edema, and tissue trauma can also slow healing. A pulse confirms flow in a named vessel at the examination site; it does not quantify the oxygen delivered to the wound bed. Compare both feet and look for regional differences, especially when a lateral ankle or heel wound lies far from the palpated pulse. If healing capacity is uncertain, objective perfusion testing helps decide whether debridement, closure, or reconstruction is likely to succeed. Document sensory loss and pressure sources at the same visit because they often interact with ischemia.
Worked example: A lateral ankle wound has pale margins and little new tissue. Toes are cool, and the pedal pulse is weak. The surgeon records the wound size, tissue quality, pulses, refill, temperature, and sensation, then obtains objective perfusion assessment before planning closure. The appearance raises concern, but the test helps determine whether the wound has adequate healing supply.
Watch the distinction: A palpable pedal pulse does not guarantee that a wound will heal. Local perfusion, pressure, infection, and tissue quality can still prevent closure.
Reference: [1]
12. Map sensory and motor deficits
A postoperative sensory complaint becomes more useful when mapped to anatomy. Mark the exact area of altered light touch or pin sensation and compare it with the opposite foot. The sural nerve supplies much of the lateral foot; superficial peroneal branches serve much of the dorsal foot; deep peroneal sensation is concentrated in the first web space. Check ankle dorsiflexion, toe extension, eversion, and plantarflexion to see whether motor pathways are involved. The incision, retraction area, swelling, and cast pressure can suggest different mechanisms. A focal sensory patch near the operative field differs from broad weakness and sensory loss extending above the ankle. Document the initial distribution and repeat it over time; progression, severe pain, or new motor deficit changes the urgency of evaluation.
Worked example: After lateral ankle surgery, a patient reports numbness along the outer foot. Dorsiflexion, toe extension, and eversion remain strong, and the first web space has normal sensation. This pattern favors a focal sural sensory disturbance near the operative region over a broad common peroneal motor injury. The surgeon maps its borders and checks for change at follow-up.
Watch the distinction: Calling all postoperative numbness a 'peroneal nerve injury' obscures localization. Named sensory territories and motor tests help identify which nerve may actually be affected.
Reference: [1]
13. Recognize the neuropathic hot foot
Active Charcot disease can produce marked warmth, swelling, and progressive bone or joint injury despite little pain because protective sensation is impaired. Compare temperature and swelling with the other side, examine skin for an ulcer or portal of infection, and test protective sensation and perfusion. Look for a new change in arch or hindfoot position, instability, or a developing pressure point. A warm neuropathic foot is not automatically Charcot: infection, fracture, gout, and venous disease may resemble it. Conversely, modest pain must not reassure you that the skeleton is safe. Protect the limb from further loading while evaluating alignment and infection clues. Serial examination and imaging are useful because deformity may evolve. An ulcer connected to bone raises a separate infection question even when Charcot explains the overall architecture.
Worked example: A patient with lost protective sensation develops a warm, swollen hindfoot after increasing walking. Pain is mild, and there is no open wound. The surgeon compares temperature, checks pulses and skin, documents alignment, and protects the limb while obtaining appropriate imaging. Active Charcot change is plausible; the absence of severe pain does not reduce the need to prevent collapse.
Watch the distinction: Pain intensity is a poor gauge of injury in neuropathy. Waiting for severe pain can allow progressive fracture, subluxation, and pressure injury.
Reference: [1]
14. Define the extent of infection
The visible opening of an infected wound may be much smaller than the involved space beneath it. Examine the amount and character of drainage, surrounding redness, induration, fluctuance, and any track under the skin. Palpate toward tendon sheaths, implants, and neighboring joints, while avoiding forceful probing that adds trauma. Assess tendon function, pain with joint motion, fever, and other systemic findings. Fluctuance suggests a collection that may require drainage; spreading redness alone does not define an abscess. Deep infection can coexist with bone or joint involvement, so the anatomical question determines the next investigation and source-control plan. Record neurovascular status and the extent of skin compromise before intervention. Clinical deterioration, fever, or rapidly spreading tissue change calls for urgent evaluation rather than routine outpatient wound care.
Worked example: A small opening behind the heel drains pus. Fluctuance extends toward the Achilles insertion, and the patient has fever and pain with attempted push-off. The surgeon examines tendon continuity, maps the collection and surrounding skin, and investigates deep spread. The small surface opening cannot be used to judge the full infection; urgent source control is considered.
Watch the distinction: Treating drainage at the skin opening alone can leave an underlying collection. Fluctuance, tracking, tendon function, and systemic findings define the clinically important extent.
Reference: [1]
15. Assess wound depth and mechanical cause
A rearfoot wound must be described by both tissue depth and the force that keeps reopening it. Measure its location and dimensions, identify callus or undermining, and record whether tendon, fascia, or bone is exposed or contacted on careful examination. Check drainage, surrounding inflammation, sensation, and perfusion. Then observe standing heel alignment and the prominence beneath the wound. In a varus foot, the lateral plantar heel may bear disproportionate pressure; closing the surface without changing that load invites recurrence. Depth can raise concern for infection, but the absence of visible bone does not exclude deeper involvement. Imaging or tissue assessment should answer a specific infection question when the clinical findings support one. Treatment planning joins offloading, perfusion, infection control, and deformity management rather than treating the wound as an isolated skin defect.
Worked example: A plantar lateral heel ulcer lies directly under a prominence in a varus hindfoot. It extends into deep soft tissue, with no visible bone or obvious purulence. The surgeon records depth, size, perfusion, sensation, and weightbearing pressure, then offloads the area and investigates infection if further findings warrant it. Durable healing also requires addressing the lateral overload.
Watch the distinction: A clean-looking surface does not erase the mechanical cause of a wound. Without offloading the varus pressure point, local dressings or closure may fail repeatedly.
Reference: [1]
16. Examine a painful rigid flatfoot in a child
A flexible flatfoot often changes shape when the child rises onto the toes; the arch appears and the heel moves toward inversion. A painful rigid flatfoot behaves differently. Examine standing arch and heel position, passive subtalar inversion and eversion, heel-rise response, and whether peroneal muscles guard against motion. Recurrent sprains may result from restricted hindfoot adaptation rather than isolated ligament laxity. A tarsal coalition can connect bones through fibrous, cartilaginous, or osseous tissue and limit subtalar movement. Other causes of rigid flatfoot remain possible, so the physical findings should lead to anatomical imaging rather than a label alone. Compare both sides, note symptom onset, and assess whether the ankle or another joint contributes. Painful loss of motion is a stronger diagnostic cue than low arch height by itself.
Worked example: An adolescent has repeated ankle sprains and a flat arch that stays flat during heel rise. The heel does not invert, and passive subtalar inversion is restricted and painful. These findings make a coalition or other rigid hindfoot process more likely than a simple flexible flatfoot. The surgeon obtains imaging directed at the suspected hindfoot anatomy.
Watch the distinction: Calling every low arch a flexible variant misses the significance of pain and restricted subtalar motion. Heel-rise response and passive correction separate these patterns.
Reference: [1]
17. Characterize a rearfoot mass
A mass near the ankle should be mapped before anyone plans removal. Measure it in three dimensions, note whether it is superficial or deep, and assess mobility relative to skin, tendon, bone, and nearby neurovascular structures. Ask how long it has been present, how quickly it changed, and whether it causes pain, tingling, weakness, or vascular symptoms. Examine the skin for ulceration and the foot for distal deficits. Growth, deep location, fixation, and neurologic effects increase concern for an aggressive process, although examination alone cannot establish histology. Imaging should define the lesion's compartment and relationship to bone and nerves before biopsy. If malignancy is plausible, the biopsy route must be coordinated with the team that would perform definitive treatment, since a poorly placed track can complicate later surgery.
Worked example: A deep ankle mass has enlarged over several months and now causes tingling on the plantar foot. It is fixed to deeper tissue but the skin moves over it. The surgeon records size, growth, depth, mobility, and sensory change, then arranges suitable imaging and specialist-directed tissue diagnosis. Simple office excision would skip the information needed for safe planning.
Watch the distinction: A small incision does not make an unplanned excision harmless. Biopsy placement and tissue planes matter when a deep or growing lesion may require definitive surgery.
Reference: [1]
18. Reassess a painful postoperative leg
Postoperative pain should follow an improving course, so a sharp rise with new functional loss needs a fresh examination. Check dressing or cast pressure, skin color, temperature, refill, pulses, sensation, active toe movement, and pain with passive toe motion. Palpate compartments for unusual tension and inspect the wound for drainage or spreading redness. Calf swelling may suggest thrombosis; fever and purulence point toward infection; coolness and poor refill raise vascular concern. Severe pain with tense compartments and pain on passive stretch can indicate compartment syndrome even when a pulse is present. Compare findings with the immediate postoperative record and repeat them if symptoms change. An evolving threat calls for immediate surgical evaluation, including removal of constrictive external materials when appropriate, rather than waiting for a routine follow-up visit.
Worked example: The day after hindfoot surgery, pain rises despite medication. The leg feels tense, and passive toe movement sharply increases pain; the pedal pulse remains palpable. These findings require immediate assessment for compartment syndrome and prompt action by the treating surgical team. The pulse does not exclude dangerous pressure within a muscle compartment.
Watch the distinction: A normal pulse cannot rule out compartment syndrome because arterial flow may persist while tissue pressure impairs muscle and nerve perfusion. Escalating pain needs examination.
Diagnostic procedures/labs/imaging
19. Choose weightbearing alignment views
Deformity should be assessed in the position that produces symptoms: under weightbearing load when the patient can safely stand. Obtain the views needed to see foot shape, the ankle mortise, and the hindfoot axis. A nonweightbearing image may understate collapse or fail to show how the calcaneus shifts relative to the tibia. Compare talar position within the ankle with heel position beneath it. If the ankle remains centered while the heel moves laterally, the dominant coronal deformity is below the ankle; ankle tilt indicates an additional joint-level component. Add forefoot alignment and joint-space findings before deciding where correction belongs. Interpret images alongside the standing examination because rotation and positioning can distort apparent alignment. The RRA didactic study guide can complement practice with these anatomical relationships.
Worked example: A patient's heel looks valgus while standing, but a nonweightbearing ankle film looks nearly straight. Loaded ankle and hindfoot alignment views show a centered talus in the mortise and a lateral shift of the heel beneath the tibia. The main deformity is below the ankle. Treatment planning should therefore address hindfoot alignment rather than assuming ankle tilt.
Watch the distinction: A normal-looking nonweightbearing ankle image cannot settle a standing deformity. Loading may reveal hindfoot displacement or joint tilt that changes the anatomical target.
Reference: [1]
20. Interpret ankle arthritis under load
Weightbearing ankle radiographs reveal how cartilage loss and deformity behave under load. Narrowing of the medial tibiotalar space with varus talar tilt suggests asymmetric contact and concentrated medial stress. Osteophytes may explain impingement at the ends of motion, but their presence alone does not identify the chief pain source. Read the mortise, lateral view, hindfoot position, and adjacent subtalar joint together. Match those findings to tenderness, ankle motion pain, range of motion, and the patient's functional limits. Preserved subtalar motion matters because ankle fusion transfers more movement demand to neighboring joints; replacement aims to retain ankle motion but requires its own assessment of alignment, bone, soft tissue, and risk. A radiographic pattern helps frame these choices only after the symptomatic joint and deformity level are established.
Worked example: A patient has medial ankle tenderness and pain with ankle motion. Loaded films show medial tibiotalar narrowing, varus talar tilt, and a preserved subtalar joint. The symptoms and images support asymmetric ankle arthritis. The intact subtalar joint is relevant when discussing fusion and motion-preserving options, while the varus alignment must be accounted for in either plan.
Watch the distinction: Radiographic arthritis does not automatically prove that every nearby symptom comes from that joint. Correlate load-bearing images with reproduced pain, motion, and adjacent-joint findings.
Reference: [1]
21. Use CT to map complex fractures
Plain radiographs establish the injury and gross displacement, but overlapping fragments can hide the articular surface of a talar or calcaneal fracture. First document skin, perfusion, sensation, alignment, and whether urgent reduction is needed. Then use CT to trace each joint surface, locate depressed fragments, measure displacement where useful, and identify comminution that could make fixation less reliable. Review images in multiple planes rather than judging one striking slice. In a talar body injury, map both tibiotalar and subtalar surfaces because restoring one while leaving the other stepped can preserve a source of pain. CT describes bone geometry; it does not establish cartilage viability or future healing. The ABFAS RRA content outline includes trauma among its case categories.
Worked example: A patient has a displaced talar body fracture, intact pedal perfusion, and swollen but untented skin. Radiographs confirm displacement yet obscure the subtalar surface. CT shows a depressed subtalar fragment and several posterior fragments. Reduction planning must account for that depression and the limited purchase offered by comminuted bone. Follow-up should assess union, alignment, and symptoms in both involved joints.
Watch the distinction: A clear fracture line on radiographs does not mean the joint surface is fully defined. Missing an articular fragment can change the reduction target and fixation plan.
Reference: [1]
22. Image a suspected tarsal coalition
A painful rigid flatfoot with restricted subtalar motion raises suspicion for a tarsal coalition, but examination alone cannot define its location or tissue type. Begin with appropriate weightbearing foot and hindfoot radiographs to assess alignment, degenerative change, and visible signs of a bony connection. CT depicts osseous bridges and their extent particularly well. MRI helps when radiographs do not show a bridge yet a fibrous or cartilaginous coalition remains plausible; it can also show adjacent marrow edema and other painful structures. Select the next study to answer the unresolved anatomical question. Before discussing resection or fusion, determine how much joint surface is involved, whether the neighboring joint is arthritic, and whether valgus or another deformity needs correction. A negative plain film does not restore normal subtalar motion.
Worked example: An adolescent has recurrent sprains, painful restricted subtalar inversion, and a flat arch that remains flat on heel rise. Weightbearing films show valgus but no definite bony bridge. MRI identifies a cartilaginous talocalcaneal connection with adjacent marrow edema. The result explains the rigidity and supports a coalition diagnosis; alignment and joint condition still determine treatment options.
Watch the distinction: Do not dismiss coalition because a radiograph lacks an obvious bony bar. Nonosseous tissue can restrict motion and may require cross-sectional imaging to identify.
Reference: [1]
23. Use MRI for tendon and ligament questions
MRI is most useful when a focused examination identifies the structure and functional problem to explain. Posterior tibial tendon pain, swelling, weak inversion, and failure of heel inversion on heel rise create a different question from lateral giving way after repeated sprains. For tendons, assess continuity, tear length, sheath fluid, and surrounding degeneration. For ligaments, assess fiber disruption and associated cartilage or bone injury. Interpret signal changes alongside the patient's pain location, strength, alignment, and injury chronology; a mild abnormality can be incidental. Weightbearing radiographs remain useful because MRI performed unloaded may understate deformity. In an RRA case, imaging should help determine which damaged structure matters and what deforming load persists. The related Foot Surgery NEW CBPS guide addresses a different examination scope.
Worked example: A patient reports progressive medial ankle pain. Examination finds tendon swelling, weak resisted inversion, and a heel that fails to invert on attempted single-leg rise. MRI shows a longitudinal posterior tibial tendon tear, matching those deficits. Mild peroneal tendon signal appears elsewhere without lateral tenderness or weakness. The medial tear informs the working diagnosis; the unmatched signal does not redirect treatment.
Watch the distinction: An MRI report is not a ranked list of pain generators. Treating every abnormal signal can miss the structure whose dysfunction and location match the examination.
Reference: [1]
24. Investigate deep infection with MRI
For a draining postoperative ankle, define whether infection is confined to skin or reaches a collection, implant, joint, or bone. MRI can show a fluid collection, sinus tract, soft-tissue edema, and marrow changes, but its meaning depends on the wound's location and the interval since surgery. Recent operations produce sterile edema; metal can obscure or distort nearby structures. Review the operative anatomy and radiographs, ask whether a collection is drainable, and determine whether abnormal marrow directly connects to a wound or infected hardware. Contrast may help delineate a collection when appropriate, but imaging cannot name the organism. Obtain useful deep specimens during indicated drainage or debridement. If fever, spreading infection, or systemic illness is present, arrange timely source control and treatment rather than waiting for perfect imaging certainty.
Worked example: A patient develops fever and purulent drainage beside lateral ankle fixation. MRI, interpreted with metal artifact in mind, shows a defined collection extending from the wound to the plate and abnormal adjacent marrow. The findings support deep implant-associated infection with possible bone involvement. Urgent assessment for drainage and deep cultures is warranted; marrow signal alone does not prove osteomyelitis.
Watch the distinction: Postoperative marrow edema is not synonymous with bone infection. A connected wound, collection, clinical course, and appropriately collected specimens give the imaging finding its diagnostic weight.
Reference: [1]
25. Aspirate a suspected septic joint
An acutely hot, swollen ankle can reflect septic arthritis, crystal disease, or another inflammatory process. Because infection can rapidly damage cartilage, examine for systemic illness and obtain joint fluid promptly when septic arthritis is plausible. Aseptically collected fluid can be assessed for cell count with differential, crystal analysis, Gram stain, and culture. These tests answer different questions: crystals identify a possible inflammatory mechanism, while microbiology seeks an organism. No single fluid cell count or negative Gram stain reliably settles every case, especially after antimicrobial exposure. Correlate results with examination, blood tests, risk factors, and the patient's course. If clinical suspicion remains high, arrange urgent joint management even while cultures are pending. The CBPS preparation guidance emphasizes selecting pertinent investigations before committing to treatment.
Worked example: A patient with prior gout presents with a newly hot ankle, severe pain on small movements, and fever. Aspiration yields cloudy fluid containing urate crystals; Gram stain shows no organisms, while culture is pending. Gout is possible, but fever and marked joint pain leave infection unresolved. Continue urgent septic-joint evaluation and arrange source control if the overall evidence supports it.
Watch the distinction: Finding crystals does not exclude simultaneous infection. Nor does a negative Gram stain clear a joint whose clinical features remain concerning for septic arthritis.
26. Obtain useful bone and deep-tissue cultures
A surface swab from a chronic wound often captures colonizing organisms that differ from those causing deep infection. Begin by asking whether bone or deep tissue is genuinely involved, using wound examination, imaging, operative findings, and the clinical course. When feasible, collect deep tissue from the involved compartment or bone from the suspicious site with a clean technique; record the specimen's exact anatomical source. Samples obtained during necessary debridement can both identify pathogens and clarify the depth of disease. Interpret results alongside pathology when available, especially if prior antibiotics, contamination, or multiple organisms complicate the picture. A negative specimen also has limits if it missed the affected area. Culture should guide a coherent treatment plan, not substitute for drainage of a collection or relief of persistent pressure.
Worked example: A longstanding plantar heel ulcer drains above an area of calcaneal erosion. A surface swab reports several skin organisms without identifying which, if any, invades bone. During indicated debridement, separate deep tissue and calcaneal specimens are collected using clean instruments. Their anatomical labels allow culture results to be interpreted against operative findings and guide targeted treatment.
Watch the distinction: Do not call every organism on a wound swab the cause of osteomyelitis. Surface colonization can mislead treatment when the suspected disease lies deeper.
Reference: [1]
27. Interpret perfusion tests in diabetes
The ankle-brachial index compares ankle systolic pressure with brachial systolic pressure: ankle pressure divided by arm pressure. Diabetes and chronic kidney disease can leave ankle arteries stiff and difficult to compress, making the measured ankle pressure falsely high. A reassuring-looking ratio then conflicts with a cool foot, poor granulation, or a wound that does not heal. Document pulse quality and waveforms as well as the number. Toe vessels may remain more compressible, so toe pressure or toe-brachial index can better address distal perfusion; waveform analysis and vascular assessment add context. No isolated test guarantees healing. For heel reconstruction, connect the perfusion evidence to tissue viability, infection control, and the proposed incision or closure. An implausibly high ratio should trigger investigation, not confidence.
Worked example: A patient with diabetes has a cool foot and a nonhealing heel ulcer. A hypothetical arm systolic pressure is 120 mmHg, while an incompressible ankle cuff records 180 mmHg, yielding an apparent index of 180 ÷ 120 = 1.50. Because the ankle vessel did not compress normally, 1.50 cannot establish adequate perfusion. Obtain toe-based measurements and waveforms and seek vascular evaluation.
Watch the distinction: A high ankle-brachial index in a stiff artery does not prove excellent circulation. The pressure measurement may reflect vessel incompressibility rather than blood reaching the wound.
Reference: [1]
28. Investigate suspected venous thrombosis
New unilateral calf swelling after immobilization or surgery raises concern for deep vein thrombosis, even when the surgical incision is clean. Assess onset, asymmetry, tenderness, skin changes, cardiopulmonary symptoms, and competing explanations such as hematoma or infection. Venous duplex ultrasound evaluates compressibility and flow in the veins it can visualize and is the usual focused imaging choice for a symptomatic leg. Interpret a negative study in light of which segments were examined and how strong the concern remains; persistent or worsening symptoms may require reassessment. A suspected pulmonary embolism, such as new breathlessness, chest pain, or collapse, requires immediate emergency evaluation rather than a routine outpatient calf study. Confirming the diagnosis matters because anticoagulation has bleeding implications after surgery.
Worked example: Following prolonged nonweightbearing after hindfoot surgery, a patient develops new one-sided calf swelling and tenderness. The incision is dry, and there is no local wound redness, so the wound does not explain the calf findings. Arrange prompt venous duplex imaging and assess for chest symptoms. Management follows the confirmed vascular findings and postoperative bleeding context.
Watch the distinction: A normal-looking incision does not rule out thrombosis. Conversely, calf tenderness alone does not establish it; vascular imaging informs a treatment decision with real bleeding consequences.
Reference: [1]
29. Use nerve studies for localization
Electrodiagnostic testing helps distinguish a focal nerve lesion from a broader peripheral neuropathy or proximal nerve problem when examination leaves the level uncertain. First map sensory loss and specific muscle weakness, noting whether findings are unilateral, bilateral, or confined to one named nerve territory. Nerve-conduction studies assess the pattern of sensory and motor responses; needle examination can show denervation in selected muscles. A length-dependent, bilateral pattern supports a systemic neuropathy, whereas a restricted distribution can support local injury. Timing matters because some abnormalities evolve after nerve damage, and a normal study does not exclude every small-fiber or early disorder. In cavovarus reconstruction, identifying the neurologic driver informs muscle balance, recurrence risk, and whether evaluation beyond the ankle is necessary.
Worked example: A patient has bilateral cavovarus feet, distal foot weakness, and sensory loss extending beyond a single ankle nerve territory. Electrodiagnostic testing finds a bilateral length-dependent motor and sensory neuropathy. That pattern supports a broader neurologic driver over an isolated tarsal tunnel lesion. Reconstruction planning must account for persistent muscle imbalance and prompt assessment of the underlying neuropathy.
Watch the distinction: Do not label all foot numbness near an ankle deformity as local entrapment. Bilateral weakness and widespread sensory loss call for broader localization.
Reference: [1]
30. Read inflammatory markers as trends
Inflammatory markers such as C-reactive protein describe a systemic response, not the precise location or cause of disease. A value may rise with infection, surgery, trauma, or inflammatory arthritis. Interpret serial results against timing, treatment, wound findings, temperature, and function. After drainage of an abscess, a falling marker can support improvement, but persistent purulence or fever remains a stronger reason to search for residual source. Conversely, an early postoperative rise need not establish a new infection by itself. Compare values from the same analyte and units, calculate the absolute and proportional change accurately, and ask whether the clinical trajectory agrees. The RRA NEW CBPS practice questions can be used to rehearse that case-based interpretation.
Worked example: After ankle abscess drainage, C-reactive protein falls from 80 mg/L to 20 mg/L. The absolute fall is 80 − 20 = 60 mg/L; the proportional fall is 60 ÷ 80 = 0.75, or 75%. This supports a reduced inflammatory response. If fever and drainage persist, investigate an undrained focus despite the lower result.
Watch the distinction: A favorable laboratory trend does not certify source control. Treat the patient and the wound, then use the marker as supporting evidence.
Reference: [1]
31. Investigate inflammatory and crystal disease
A painful ankle belongs in a broader pattern of symptoms. Ask about duration of morning stiffness, episodic abrupt attacks, other joints, skin or systemic features, medications, and prior inflammatory diagnoses. Bilateral ankle swelling with hand involvement raises a systemic inflammatory process; a sudden, intensely inflamed single joint raises crystal disease and infection. Order tests to resolve a specific question rather than a broad panel without interpretation. Inflammatory markers support activity but do not identify the cause, and serum urate alone cannot diagnose or exclude gout during an attack. When a joint is acutely hot and septic arthritis remains plausible, aspirate for cell analysis, crystals, Gram stain, and culture. A chronic inflammatory diagnosis also affects surgical planning through tissue quality, medications, and possible involvement of neighboring joints.
Worked example: A patient has months of bilateral ankle swelling, prolonged morning stiffness, and painful hand joints. The distribution supports investigation for systemic inflammatory arthritis rather than treating one ankle as isolated mechanical wear. One ankle then becomes abruptly hot and much more painful. Aspirate that joint to assess crystals and infection while continuing the targeted systemic evaluation.
Watch the distinction: Do not let a plausible rheumatologic diagnosis explain away a new acutely hot joint. Infection or crystal disease may coexist with chronic inflammatory disease.
Reference: [1]
32. Plan imaging and biopsy for a bone lesion
An aggressive-looking bone lesion requires an anatomical map before tissue is taken. Review radiographs for its location, transition zone, matrix, cortical destruction, and fracture risk. MRI defines marrow involvement, soft-tissue extension, and nearby neurovascular structures; additional staging is directed by the specialist team and suspected diagnosis. Refer before biopsy so the tract, incision, and tissue planes fit a possible definitive operation. Sampling the wrong region can yield an unhelpful result, while an unplanned approach may contaminate tissue that later needs treatment. A biopsy supplies histology; imaging alone cannot reliably name the tumor. Meanwhile, protect a limb with concerning structural weakness and document neurologic and vascular findings. The goal is a diagnostic sequence that preserves safe treatment choices.
Worked example: An ankle radiograph reveals an enlarging lytic distal tibial lesion with cortical breach. Examination finds a deep mass but intact distal perfusion and sensation. MRI maps marrow spread and a soft-tissue component. Because fracture risk and an aggressive tumor are concerns, protect loading and refer for specialist-directed biopsy along a planned route before any definitive excision.
Watch the distinction: An office excision is not a harmless shortcut for a destructive bone lesion. Its route and extent can compromise later staging or local treatment.
Reference: [1]
33. Investigate delayed fusion
Persistent pain after subtalar fusion needs localization before calling the operation a nonunion. Ask whether pain lies at the fusion, over hardware, or in the ankle or adjacent joints; examine alignment, swelling, skin, and motion. Compare serial weightbearing radiographs for position, hardware change, and progressive bridging. Projection overlap can make union uncertain, so selective CT can show whether bone crosses the intended fusion site. CT also has limits: partial bridging may not explain symptoms, and an apparent gap should be interpreted with timing and clinical findings. If nonunion is likely, look for mechanical causes such as residual deformity or unstable fixation, biological factors affecting healing, and possible infection. Revision planning should correct the cause, not merely replace a symptomatic screw.
Worked example: Eight months after subtalar fusion, a patient has focal pain at the fusion and persistent heel varus. Serial radiographs show little interval bridging but do not clearly define the joint. CT shows a broad persistent gap across the subtalar fusion. Together, focal symptoms and imaging support nonunion evaluation, including alignment, fixation, infection, and healing factors.
Watch the distinction: Pain near a screw is not proof that hardware is the only problem. Check whether the intended joint united and whether alignment remains mechanically sound.
Reference: [1]
Diagnosis
34. Classify progressive collapsing foot deformity
Progressive collapsing foot deformity is a description of interacting components, not a synonym for a torn tendon. Assess medial arch collapse, heel valgus, forefoot abduction, and whether the ankle mortise has developed valgus tilt. Determine flexibility by manually correcting the hindfoot and observing heel response on rise; record forefoot position after the heel is corrected. Weightbearing imaging shows where the collapse occurs under load and whether joints are arthritic. A flexible foot-level pattern may permit joint-sparing correction, while rigid deformity or ankle involvement changes the options. Diagnose each component explicitly so a treatment plan can address the load path rather than one painful structure. The presence of posterior tibial tendon dysfunction is relevant, but it does not by itself classify every deformity.
Worked example: A patient has a low arch, heel valgus, and an abducted forefoot. The heel corrects manually, subtalar motion remains available, and weightbearing ankle films show a level mortise without talar tilt. This is a flexible collapse centered below the ankle. Planning should address the heel, forefoot, and supporting structures without assuming ankle arthritis or ankle valgus.
Watch the distinction: A low arch alone does not establish severity or the level of deformity. Check heel flexibility, forefoot position, and ankle alignment before naming the pattern.
Reference: [1]
35. Identify the driver of cavovarus
Cavovarus may arise from a plantarflexed first ray that drives the heel into varus, a fixed hindfoot deformity, or a combination. Inspect the forefoot, callus pattern, heel, and muscle balance while standing. With the Coleman block, support the lateral forefoot and heel while letting the first ray hang free. If the heel moves toward neutral, unloading the first ray has removed much of its varus drive; persistent heel varus points toward a structural hindfoot component. The maneuver guides anatomy but does not identify the underlying disease. Bilateral cavovarus, distal weakness, atrophy, or broad sensory loss should prompt neurologic assessment. For reconstruction, separate the correctable bony alignment problem from continuing muscle imbalance and lateral ligament insufficiency.
Worked example: A patient stands with a plantarflexed first ray and heel at 8° varus. On a Coleman block, the heel moves to 2° valgus, a 10° shift across neutral. This supports a forefoot-driven, flexible hindfoot component. Bilateral distal weakness still warrants investigation for neuropathy before choosing bony correction and muscle-balancing procedures.
Watch the distinction: A correcting heel does not mean the case is simple or purely local. Neuromuscular weakness may keep driving deformity after an anatomically sound correction.
Reference: [1]
36. Localize post-traumatic hindfoot arthritis
After a talar or calcaneal injury, ankle and subtalar joints can degenerate separately or together. Localize pain by asking what terrain provokes it and by moving the joints as independently as possible. Tibiotalar dorsiflexion and plantarflexion tend to provoke ankle pain; hindfoot inversion and eversion, especially on uneven ground, can expose subtalar disease. Examine alignment because varus or valgus can concentrate load and change the surgical plan. Weightbearing ankle, foot, and hindfoot views show joint-space loss under load; CT may clarify post-traumatic anatomy when radiographs are ambiguous. Imaging abnormalities are common after injury, so the main pain source should agree with examination. If uncertainty persists, a carefully interpreted diagnostic joint injection may help distinguish adjacent joints.
Worked example: Years after a calcaneal fracture, a patient reports pain on uneven ground. Subtalar inversion is stiff and painful, while ankle dorsiflexion is comparatively comfortable. Weightbearing imaging shows marked subtalar narrowing and a preserved tibiotalar space. The concordant history, examination, and films favor subtalar arthritis; ankle fusion would target the wrong primary joint.
Watch the distinction: Pain described as 'ankle pain' does not localize to the ankle joint. Examine subtalar motion and loaded imaging before selecting a joint-specific treatment.
Reference: [1]
37. Diagnose an unstable ankle fracture pattern
An ankle fracture's stability depends on the whole mortise, not only the visible fibular fracture. Read the fibular fracture level and displacement, medial malleolus or deltoid findings, talar position, and distal tibiofibular relationship together. Medial clear-space widening or talar shift suggests loss of medial restraint; syndesmotic tenderness and injury mechanism raise concern for distal tibiofibular disruption. Examine skin and neurovascular status first, reduce a displaced threatened ankle promptly, and reassess. Imaging should include the relevant ankle views and additional views if a proximal fibular injury is suspected. After restoring bony alignment, evaluate residual syndesmotic stability as part of definitive planning. A seemingly small fibular fragment can accompany a much larger ligamentous injury and an incongruent joint.
Worked example: A patient has an oblique fibular fracture, medial ankle tenderness, visible medial clear-space widening, and tenderness above the syndesmosis. The talus is shifted within the mortise. These findings indicate an unstable pattern involving more than the fibula. Protect the limb, reduce any threatening displacement, and plan fixation and syndesmotic assessment around restoration of mortise congruity.
Watch the distinction: Do not judge stability from fibular displacement alone. Medial restraint and syndesmotic injury can permit talar shift even when the fibular fracture looks modest.
Reference: [1]
38. Distinguish talar dome injury from occult fracture
Persistent ankle pain after an inversion injury can reflect an osteochondral lesion of the talar dome, an occult talar fracture, or another injured structure. Start with precise tenderness, swelling, mechanical symptoms, weightbearing ability, and the injury mechanism. Radiographs may miss small cartilage and subchondral injuries or an undisplaced fracture. MRI shows cartilage, marrow edema, and soft tissue; CT can define a suspected bony fragment, articular step, or fracture line. A focal osteochondral defect may explain catching, but catching alone is nonspecific. More extensive talar tenderness, displacement, or a fracture line changes protection and operative planning. Match imaging to the site of pain and reassess the entire talus rather than anchoring on a small dome abnormality.
Worked example: Several weeks after an inversion injury, a patient has persistent deep ankle pain, occasional catching, and focal talar dome tenderness. Initial radiographs show no definite fracture. MRI reveals a localized osteochondral defect with underlying marrow change; CT shows no separate displaced talar fracture. The findings support a talar dome lesion, with treatment guided by lesion stability and symptoms.
Watch the distinction: Catching is a clue, not a diagnosis. An occult talar fracture can require different protection, so examine and image for the full injury pattern.
Reference: [1]
39. Distinguish Charcot change from infection
A warm, swollen neuropathic foot or ankle with fragmentation and subluxation may have active Charcot change. Loss of protective sensation permits repeated unrecognized injury and progressive collapse. Infection becomes more likely when an ulcer or sinus connects toward abnormal bone, there is purulence or systemic illness, or a localized collection appears. Imaging patterns can overlap, particularly after surgery, and both processes can coexist. Document temperature, skin breaks, perfusion, alignment, and stability; protect and offload the limb while evaluating the source of inflammation. Radiographs show architecture, MRI can assess marrow and soft tissue, and appropriately obtained deep specimens may resolve suspected bone infection. Do not use modest pain to dismiss serious structural injury, and do not force one diagnosis when separate evidence supports both.
Worked example: A patient with neuropathy has a warm ankle, subluxation, and fragmented bone on radiographs, supporting active Charcot change. A plantar ulcer tracks toward the abnormal bone, adding concern for osteomyelitis. Offload and protect the unstable limb, assess perfusion, image the ulcer's depth, and obtain suitable deep specimens if infection remains likely. Charcot explains collapse but does not clear the ulcer.
Watch the distinction: Charcot and infection are not mutually exclusive. A neuropathic patient may have little pain despite major collapse, while an ulcer can introduce a separate bone infection.
Reference: [1]
40. Define the depth of a heel infection
Describe heel infection by the deepest involved structure because management changes with anatomy. Cellulitis involves spreading skin and subcutaneous inflammation; fluctuance or a defined collection indicates an abscess that usually requires drainage. Painful restricted motion or a tract into the ankle or subtalar joint raises concern for septic arthritis. Bone exposure, erosion, or a wound reaching bone raises concern for osteomyelitis, which requires corroborating clinical, imaging, and specimen evidence. Examine the entire heel, Achilles region, neighboring joints, perfusion, and systemic condition. MRI can help map a collection and possible deep extension, but recent surgery and marrow edema complicate interpretation. During indicated source control, collect deep specimens. Also address pressure and blood supply so the wound can heal after infection treatment.
Worked example: A patient has a draining heel ulcer, surrounding redness, fever, and deep fluctuance. MRI shows a localized collection beneath the ulcer without joint communication; the adjacent bone has no convincing destructive change. The working diagnosis includes a heel abscess with cellulitis, while septic joint involvement is unsupported by these findings. Arrange drainage, deep specimens, antimicrobial management, and offloading.
Watch the distinction: Redness around an ulcer does not describe the full infection. Deep fluctuance or a collection calls for source control, even when the surface opening is small.
Reference: [1]
41. Diagnose coalition in a rigid flatfoot
A painful flatfoot that stays flat on heel rise deserves a different workup from a flexible arch. A tarsal coalition joins two tarsal bones through bone, cartilage, or fibrous tissue, limiting subtalar motion. The restricted joint can produce hindfoot valgus, lateral pain, and recurrent sprains because the foot cannot adapt normally to uneven ground. Ask when symptoms began and whether stiffness followed an injury; examine inversion, eversion, heel-rise response, and peroneal guarding. Weightbearing radiographs show alignment and may suggest the connection. CT defines a bony bridge and its location, while MRI can clarify a nonosseous connection and associated marrow change. Name the involved bones, then assess adjacent-joint degeneration and deformity. ABFAS RRA NEW CBPS content areas include congenital disorders and deformities; they do not prescribe one treatment for every coalition.
Worked example: A teenager reports repeated ankle sprains and pain below the medial malleolus. The heel remains valgus on attempted rise, and passive subtalar inversion is restricted. CT shows a talocalcaneal osseous bridge. Diagnose a symptomatic talocalcaneal coalition rather than generic flatfoot. Review subtalar cartilage and the degree of valgus before weighing resection against a procedure that addresses a damaged joint or persistent deformity.
Watch the distinction: A flat arch alone does not establish coalition. Flexible flatfoot can have a similar standing shape; restricted subtalar motion and imaging that identifies the connection make the diagnosis specific.
Reference: [1]
42. Identify residual congenital deformity in adults
Adult pain after childhood clubfoot treatment may reflect several persistent mechanical problems rather than one new acquired deformity. Residual hindfoot varus shifts load laterally; forefoot adduction, cavus, and limited ankle dorsiflexion can add abnormal pressure or alter gait. Prior releases and operations may leave scarred skin, reduced motion, and uneven joint development. Reconstruct the history from childhood treatment through the current symptom pattern. Observe stance and gait, locate calluses, test ankle and subtalar motion separately, and check whether each component corrects manually. Weightbearing foot, ankle, and hindfoot images help locate fixed malalignment and arthritis. Compare both sides and inspect old incisions before proposing surgery. The diagnosis should identify the painful structures and residual deformity components, because an adult clubfoot may also develop a separate acquired condition.
Worked example: A 34-year-old treated for clubfoot in childhood has a small, stiff foot, heel varus, lateral callus, and limited ankle dorsiflexion. Symptoms have increased gradually without new trauma. Weightbearing films show hindfoot malalignment and ankle narrowing. The history supports residual congenital deformity with secondary joint disease. Examine subtalar motion and old scar coverage before selecting which component could safely be corrected.
Watch the distinction: Calling every adult varus foot acquired cavovarus loses the childhood mechanism and the effect of prior surgery. A single radiographic angle also cannot identify every painful joint.
Reference: [1]
43. Recognize inflammatory joint disease
Inflammatory arthritis often leaves a different clinical pattern from isolated mechanical degeneration. Look for prolonged morning stiffness, swelling in several joints, symptoms on both sides, and episodes that persist or fluctuate independent of load. Mechanical ankle arthritis more often produces activity-related pain localized to a damaged joint, though the patterns can overlap. Review systemic symptoms, skin findings, medication history, prior trauma, and hand or other joint involvement. Examine for warmth, effusion, deformity, and painful motion, then use imaging to characterize erosive or degenerative change. Targeted laboratory studies can support a suspected systemic disorder, but no single result replaces the pattern. A sudden hot ankle requires a separate infection assessment, especially with fever, a wound, or marked pain on motion. Crystal disease can also resemble infection.
Worked example: A patient has swelling in both ankles, persistent morning stiffness, and several painful hand joints. There is no ankle fracture history, and radiographs show changes in more than one joint. Systemic inflammatory arthritis is more plausible than isolated post-traumatic ankle disease, so arrange targeted evaluation. If one ankle then becomes abruptly hot and exquisitely painful, assess for septic arthritis and consider aspiration despite the existing diagnosis.
Watch the distinction: Bilateral symptoms do not make infection impossible. Systemic inflammatory disease can coexist with a septic joint, so an acutely changed ankle needs its own focused assessment.
Reference: [1]
44. Recognize a potentially aggressive lesion
A growing deep mass or destructive bone lesion needs an anatomical diagnosis before removal. Record duration, growth, pain, size, depth, mobility, and neurologic or vascular effects. Radiographs may show poorly defined destruction, cortical breach, or a soft-tissue component; none alone establishes malignancy, but the combination changes urgency. MRI maps the lesion within bone, soft tissue, and nearby neurovascular structures. Imaging should precede biopsy because the sampling route may become part of definitive surgery. Specialist coordination helps place that route where it will not compromise future reconstruction or local control. Consider benign aggressive lesions, infection, and primary or metastatic neoplasm in the differential, then narrow it using imaging and tissue findings. Protect weightbearing when structural weakening creates a credible fracture risk.
Worked example: A deep hindfoot mass has enlarged over four months and now causes plantar tingling. Radiographs show cortical breach, and MRI demonstrates a soft-tissue extension near the tibial nerve. Treat this as potentially aggressive. Document nerve function, complete local imaging, and refer for a planned biopsy. An office excision would risk incomplete diagnosis and poorly positioned tissue disruption.
Watch the distinction: A mass that is painless or slowly growing is not automatically harmless. Depth, progression, cortical destruction, and neurologic effects carry more diagnostic weight than pain alone.
Reference: [1]
45. Diagnose pain after ankle reconstruction
Pain after ankle reconstruction requires localization before revision is considered. Establish the operation performed, initial improvement, time of recurrence, wound history, and whether pain occurs with load, rest, or motion. Examine alignment, tenderness over hardware and neighboring joints, skin, and neurovascular status. Weightbearing radiographs assess position and adjacent-joint degeneration; CT can clarify uncertain fusion across the operated joint. Drainage, warmth, or systemic symptoms prompt an infection workup, with appropriate deep specimens if surgery is undertaken. A united ankle can still hurt from subtalar arthritis, malalignment, impingement, or implant irritation. Conversely, apparent hardware tenderness can overlie nonunion. Identify the principal pain generator and contributing mechanical factors before selecting an injection, bracing, hardware procedure, or revision reconstruction.
Worked example: A patient improved after ankle fusion but develops pain below the malleoli three years later. The fusion is solid on CT; weightbearing views show subtalar narrowing, and subtalar motion reproduces pain. Adjacent subtalar arthritis is the leading diagnosis. Assess hindfoot alignment and consider a targeted diagnostic injection if localization remains uncertain before discussing treatment.
Watch the distinction: Renewed pain does not prove the ankle fusion failed. Solid union and pain reproduced at a neighboring joint redirect the diagnosis, even when old implants are visible.
Reference: [1]
Treatment
46. Manage an open or threatened ankle injury
An open or skin-threatening ankle injury is a time-sensitive limb problem. First document skin condition, perfusion, sensation, and toe movement; identify gross contamination and exposed structures without repeatedly probing the wound. Protect the wound with a suitable sterile covering, immobilize the limb, and initiate appropriate open-fracture infection prevention and urgent surgical assessment. A dislocated ankle or tented skin needs prompt reduction, with analgesia or sedation appropriate to the setting. Repeat and record the same neurovascular findings immediately afterward. Persistent ischemia or neurologic deterioration requires urgent escalation rather than waiting for routine fracture imaging. Definitive irrigation, debridement, and stabilization depend on contamination, fracture anatomy, and soft-tissue viability; staged care may be needed. The CBPS case-management guidance emphasizes clinically relevant assessment before committing to treatment.
Worked example: A patient arrives with a displaced open ankle fracture, pale tented skin, and reduced toe sensation. Check pulses, refill, toe movement, and sensory territories; cover the wound and start open-fracture measures. Reduce the deformity promptly, then repeat those findings. If perfusion remains poor, obtain immediate vascular and surgical evaluation. Plan debridement and stabilization around the wound and fracture findings.
Watch the distinction: A visible pulse after reduction does not erase the need for a repeat full examination. Skin viability, sensation, motor function, and distal perfusion each require reassessment and documentation.
47. Restore an unstable ankle mortise
An unstable ankle fracture disrupts the ring that holds the talus centered beneath the tibia. Fibular shortening or rotation, medial ligament or malleolar injury, and syndesmotic disruption can each widen or tilt the mortise. Compare initial and postreduction views, inspect the entire fibula when injury pattern suggests a proximal fracture, and assess soft tissues before fixation. Restore fibular length and rotation and address medial injury according to its anatomy and the remaining mortise alignment. Only after bony reduction can syndesmotic stability be judged reliably; persistent separation or instability needs specific stabilization. Confirm a congruent mortise rather than relying on the appearance of one repaired fragment. Follow-up checks reduction, wound healing, union, and later stiffness or post-traumatic arthritis.
Worked example: Radiographs show a displaced distal fibular fracture, medial clear-space widening, and talar shift. The ankle is reduced and protected while swelling and skin are assessed. At fixation, restore fibular length and rotation, then reassess medial congruity and the syndesmosis. Residual syndesmotic instability requires treatment. Postoperative images should show the talus centered beneath the tibia.
Watch the distinction: Fixing the fibula does not automatically restore stability. An unrecognized medial or syndesmotic injury can leave the talus shifted despite a well-positioned fibular plate.
Reference: [1]
48. Protect the talus during fracture care
Displaced talar fractures threaten both joint congruity and soft tissue. A fracture-dislocation can stretch skin and neurovascular structures, so document limb findings and reduce the dislocation promptly. Plain radiographs identify the gross pattern; CT after reduction maps articular fragments, comminution, and residual displacement for definitive planning. The talus has extensive cartilage and a vulnerable blood supply, making accurate alignment and follow-up especially important. Stabilization choices depend on the fracture, skin condition, and whether a safe reduction is maintained. Protect the limb from loading while healing is assessed. Later evaluation should distinguish nonunion, avascular change, and degeneration in the ankle or subtalar joint rather than labeling all persistent pain a single complication. Initial urgency comes from dislocation and threatened tissues, not from an arbitrary calendar deadline.
Worked example: A talar neck fracture-dislocation leaves the hindfoot displaced and the medial skin taut. Record pulses, sensation, and toe movement, then perform urgent reduction and repeat the examination. CT afterward reveals a rotated articular fragment that needs definitive reduction planning. During follow-up, assess union and both ankle and subtalar symptoms because either joint can become painful.
Watch the distinction: Waiting for detailed CT before reducing a dislocated talus can prolong skin tension. Reduce the threatened alignment first, then use CT to define the remaining fracture anatomy.
Reference: [1]
49. Build a flexible flatfoot reconstruction
Flexible progressive foot collapse is a three-dimensional problem. Hindfoot valgus, forefoot abduction, medial arch collapse, and posterior tibial tendon failure can coexist, while the ankle may remain level or become involved. Determine which components correct manually and whether the subtalar and other joints retain usable cartilage. Weightbearing views locate collapse and show how the forefoot sits relative to the hindfoot. A joint-sparing reconstruction may realign the heel, reduce abduction, support an unstable medial column, and restore dynamic inversion through tendon work when indicated. Each component should solve a demonstrated problem; tendon surgery alone cannot reliably counter a persistent bony lever arm. Rigid arthritis or substantial ankle involvement changes the operation. Explain expected protection and rehabilitation, since corrected alignment must heal before full loading.
Worked example: A patient has medial tendon tenderness, weak inversion, a correctable valgus heel, forefoot abduction, and preserved subtalar joint space. The working plan is a joint-sparing correction of heel position and abduction, with tendon reconstruction and medial-column support if instability is confirmed. Isolated tendon repair would leave the load that helped produce the deformity.
Watch the distinction: A flexible flatfoot is not necessarily a tendon-only disorder. Persistent valgus or abduction can overload a repaired or transferred tendon, so the structural deformity needs its own assessment.
Reference: [1]
50. Correct cavovarus by its components
Cavovarus treatment begins by finding the driver of heel varus. A plantarflexed first ray can tip a flexible heel inward; a heel that remains varus when that ray is unloaded suggests a fixed hindfoot component. The Coleman block test examines this relationship, while weightbearing images and passive correction define the bony shape. Check muscle strength and balance, particularly peroneal function, and look for bilateral findings that suggest neuropathy. Recurrent lateral instability may result from both stretched ligaments and continuing varus loading. Treatment may combine first-ray correction, a hindfoot procedure when varus persists, tendon balancing, and ligament stabilization if instability remains. The sequence follows the mechanics: correct the load, establish muscle balance, then address residual instability. A fixed deformity cannot be corrected by tendon transfer alone.
Worked example: A patient with recurrent sprains has a plantarflexed first ray and heel varus. On a block that leaves the first ray unsupported, the heel moves from 8° varus to 2° valgus, a 10° change. This supports a forefoot-driven flexible heel. Evaluate muscle imbalance, correct the first-ray driver, and assess whether lateral ligaments still require stabilization.
Watch the distinction: Repairing lateral ligaments while leaving varus loading intact may expose the repair to the same repeated stress. First determine whether the forefoot or a fixed heel drives that load.
Reference: [1]
51. Choose a path for end-stage ankle arthritis
End-stage tibiotalar arthritis can be managed with bracing, activity adjustment, symptom control, or surgery when disability persists. Ankle arthrodesis aims for reliable pain relief by eliminating painful ankle motion, but it changes demands on neighboring joints. Total ankle replacement preserves some motion and may benefit a patient with suitable bone, soft tissue, alignment, and follow-up capacity; implant wear, loosening, and later revision are material risks. Neither option compensates for uncorrected deformity or active infection. Assess weightbearing alignment, adjacent-joint status, bone support, neurovascular and skin condition, activity demands, and prior procedures. Discuss what motion the patient actually uses and what restrictions or revisions they may face. The RRA didactic study guide can complement this case-based comparison of indications and tradeoffs.
Worked example: A patient has severe tibiotalar narrowing, pain despite bracing, preserved subtalar motion, and correctable ankle varus. Fusion could address pain but removes ankle motion; replacement may preserve motion if bone and soft tissues are suitable. Evaluate infection risk, activity, alignment correction, and expectations before choosing. Either operation must place the foot in a functional position.
Watch the distinction: Preserved subtalar motion does not make replacement automatic, and youth alone does not mandate fusion. Bone, alignment, soft tissue, activity, and willingness to accept revision risk matter.
Reference: [1]
52. Treat painful subtalar arthritis
Subtalar arthritis commonly follows calcaneal or talar injury, but hindfoot pain can also arise from the ankle, peroneal tendons, or lateral impingement. Localize tenderness and reproduce symptoms with inversion and eversion; compare ankle dorsiflexion and plantarflexion. Weightbearing radiographs show joint narrowing and heel position, while selective CT can clarify a distorted joint or uncertain union. Bracing, footwear changes, activity adjustment, and symptom treatment may help before fusion is considered. A subtalar fusion removes painful motion at that joint, so it is most defensible when the subtalar joint is the established pain source and conservative care has not met the patient’s goals. Plan correction of varus or valgus at the same time. Follow-up tracks union, alignment, wound health, and symptoms in adjacent joints.
Worked example: Years after a calcaneal fracture, a patient has pain on uneven ground, stiff painful subtalar inversion, heel valgus, and a preserved ankle joint. Bracing has not provided adequate relief. The evidence favors symptomatic subtalar arthritis. If fusion is chosen, prepare the joint and correct the heel toward functional alignment; fusing it in valgus would retain lateral impingement and uneven loading.
Watch the distinction: A radiograph showing subtalar narrowing is insufficient by itself to justify fusion. Match imaging to the examination and address heel alignment, or the painful mechanics may persist.
Reference: [1]
53. Choose care for an Achilles rupture
An acute Achilles rupture interrupts the main plantarflexion force, although other muscles may still produce some active plantarflexion. Diagnose it from the injury story, resting ankle position, palpable defect, and calf-squeeze response; use imaging when the examination is uncertain or the gap and tendon quality affect planning. Functional nonoperative care protects the tendon in a shortened position and progresses loading under a structured rehabilitation program. Repair restores tendon continuity directly but creates wound, nerve, and other surgical risks. Compare rupture features, patient activity, skin condition, comorbidities, and capacity to follow rehabilitation. Neither path succeeds if protection and progression are poorly managed. Document baseline skin and neurovascular findings, discuss rerupture and stiffness, and monitor healing and function rather than using a single early strength test as proof of recovery.
Worked example: An active runner reports a posterior snap, has a palpable gap, and shows little plantarflexion on calf squeeze. A fragile wound lies near the likely incision. Confirm complete rupture, protect the ankle, and discuss functional care versus repair. The wound raises operative soft-tissue risk, while rehabilitation reliability matters for either choice. Arrange close review of skin, tendon continuity, and progress.
Watch the distinction: Some active plantarflexion does not exclude Achilles rupture because deeper flexors can move the foot. Conversely, high activity alone does not override a serious local wound concern.
Reference: [1]
54. Offload active Charcot disease
Active Charcot neuroarthropathy arises when an insensate foot or ankle continues to bear load through inflamed, weakened bone and joints. Warmth, swelling, and progressive fragmentation can occur despite modest pain. Examine protective sensation, skin, alignment, stability, and perfusion; obtain weightbearing imaging only when safe and use further imaging if early changes are uncertain. Immediate immobilization and effective offloading reduce repetitive damage. Choose a device and follow-up plan that permit frequent skin inspection, because an ill-fitting device can create a new ulcer. Monitor temperature trend, swelling, radiographic alignment, and any wound or systemic sign that raises concern for infection. Reconstruction is considered when instability or deformity threatens a plantigrade, ulcer-free foot, with timing shaped by soft-tissue and disease activity. Neuropathy does not remove the need to investigate osteomyelitis when a wound tracks toward bone.
Worked example: A patient with loss of protective sensation has a warm, swollen hindfoot, early joint fragmentation, and no ulcer or fever. Protect and offload the foot immediately, document skin and alignment, and arrange close reassessment. If a new plantar wound appears or collapse progresses, reassess for infection and structural instability rather than simply continuing the original device unchanged.
Watch the distinction: Mild pain does not mean mild Charcot injury. Loss of sensation can mask ongoing collapse, so skin checks, offloading, and serial alignment assessment carry more weight than pain scores.
Reference: [1]
55. Control a deep ankle infection
A deep postoperative ankle infection requires source control as well as antimicrobial treatment. Fever, purulent drainage, increasing pain, and a collection beside fixation suggest disease beyond superficial skin. Examine wound tracking, perfusion, implant exposure, and joint symptoms; imaging can map a collection or bone involvement when it will change surgery. Drain or debride infected tissue promptly according to severity and obtain deep specimens from the involved area. Start empiric antimicrobial treatment when clinical urgency requires it, then refine therapy using cultures and the operative findings. Implant decisions depend on fracture union, mechanical stability, and whether infected material can be controlled while fixation remains. Follow the wound, systemic condition, and healing trajectory. In RRA NEW CBPS practice questions, the useful habit is to show why each diagnostic and treatment step follows from the case.
Worked example: Six weeks after ankle fixation, a patient has fever, purulent drainage, and MRI evidence of a collection tracking to the plate. Assess perfusion and stability, arrange urgent debridement, and collect deep tissue specimens. Treat infection promptly, then tailor antimicrobials to results. If the fracture is ununited, removing all fixation without a stability plan could create another serious problem.
Watch the distinction: A surface swab alone cannot define the organisms in a deep implant infection. Antibiotics without drainage may also leave a collection and infected tissue as an ongoing source.
56. Make a heel wound healable
A heel wound heals only when its tissue has enough perfusion and is protected from repeated pressure and uncontrolled infection. Describe depth, drainage, exposed structures, surrounding callus, and the point of maximal load. Check sensation and arterial findings; diabetes can make ankle pressure measurements misleading when arteries do not compress, so use appropriate alternative perfusion assessment when needed. A varus heel may concentrate force on its lateral plantar border, repeatedly reopening a wound even after closure. Offload immediately, investigate deep infection when findings support it, and involve vascular care if healing perfusion is uncertain. Debridement, coverage, or corrective reconstruction should follow an integrated plan for blood supply and mechanics. Monitor wound size, tissue quality, device fit, and recurrence, not just whether the skin temporarily seals.
Worked example: A diabetic patient has a plantar lateral heel ulcer beneath a varus prominence, cool toes, and limited granulation. Protect the heel from pressure, assess wound depth and infection, and obtain objective perfusion evaluation before closure. If perfusion can support healing, consider durable coverage and correction or accommodation of the lateral load. Closing skin over the same prominence would invite recurrence.
Watch the distinction: A palpable pedal pulse does not guarantee enough local perfusion for wound healing. Likewise, a clean wound surface will not stay closed while concentrated heel pressure continues.
Reference: [1]
57. Treat a symptomatic tarsal coalition
Treatment of a symptomatic tarsal coalition follows symptoms, coalition anatomy, hindfoot alignment, and joint condition. Begin with activity modification, immobilization when appropriate, footwear or support, and symptom relief, while checking whether the pain truly comes from the restricted subtalar region. CT or MRI defines the type and extent of the connection; weightbearing views show valgus and other deformity. Resection may be considered when the involved joint remains healthy and a functional motion result is plausible. Significant degeneration, extensive coalition, or rigid deformity can make fusion or broader correction more appropriate. Any operation must account for persistent valgus, since removing a bridge alone may not realign the foot. Discuss expected motion, rehabilitation, and the possibility of continued symptoms. Reassess function and alignment after treatment rather than relying on radiographic removal alone.
Worked example: An adolescent has painful rigid valgus and a talocalcaneal coalition despite activity change and a period of immobilization. Imaging shows preserved subtalar cartilage and a defined bridge. Discuss whether resection with valgus correction could restore useful function. If joint narrowing and diffuse degeneration were present instead, fusion would merit stronger consideration because bridge removal would not repair damaged cartilage.
Watch the distinction: Persistent symptoms do not automatically make every coalition a resection case. Joint degeneration and deformity determine whether preserving subtalar motion is realistic.
Reference: [1]
58. Plan correction of residual clubfoot
Adult residual clubfoot correction aims for a comfortable, stable, plantigrade foot within the limits of prior treatment. Map hindfoot varus, forefoot adduction or cavus, ankle equinus, and each joint’s remaining motion. Inspect scars and skin carefully because earlier releases can constrain incision choices and wound healing. Weightbearing imaging identifies arthritic joints and fixed bony alignment. Bracing, footwear adaptation, and pressure relief may improve function without another operation. If symptoms justify surgery, choose correction according to flexibility: tendon balancing can address a dynamic pull, osteotomy can redirect a malaligned but usable segment, and fusion may be needed for a painful rigid joint. Multiple components may require staged or combined work. Explain achievable goals, including shoe wear and ulcer prevention, rather than promising a normal range of motion.
Worked example: An adult with childhood clubfoot operations has fixed heel varus, ankle stiffness, lateral callus, and thin scarred skin. A brace improves stability but pain remains. Weightbearing views show hindfoot malalignment and ankle degeneration. Plan around which joint hurts and which deformity is fixed; a tendon transfer alone cannot straighten rigid bone, while incision planning must protect vulnerable skin.
Watch the distinction: The childhood diagnosis does not dictate one standard adult operation. Current rigidity, arthritis, load pattern, and soft-tissue condition determine what can be corrected safely.
Reference: [1]
59. Protect the diagnostic path for a tumor
An aggressive-appearing distal tibial or hindfoot lesion needs a controlled diagnostic sequence. Record pain, growth, weightbearing difficulty, neurologic findings, and systemic history. Radiographs define the bone lesion and cortical integrity; MRI maps marrow and soft-tissue extent before a biopsy disturbs the anatomy. Specialist review determines whether additional staging is needed and chooses a biopsy path compatible with later surgery. Tissue diagnosis guides definitive treatment, which may range widely depending on pathology. Avoid an unplanned excision or poorly placed biopsy that contaminates tissue planes or complicates local control. If cortical destruction suggests fracture risk, protect loading while evaluation proceeds. Document the differential, including infection and benign aggressive lesions, but let imaging and properly obtained pathology resolve it. Follow-up responsibility should remain clear while referral is arranged.
Worked example: A growing distal tibial mass accompanies pain with walking. Radiographs show an ill-defined lytic lesion and cortical destruction; MRI shows soft-tissue extension. Limit loading because the bone may be weak, document distal nerve and vascular function, and arrange specialist-directed biopsy after imaging. Definitive resection or other treatment follows pathology; removing the mass at an initial office visit would compromise planning.
Watch the distinction: A biopsy is not simply the earliest possible tissue sample. Its route can affect later surgery, so complete local imaging and coordinate the biopsy before making an incision.
Reference: [1]
60. Revise a failed hindfoot fusion
Revision of a failed subtalar or other hindfoot fusion begins with a cause analysis. Confirm nonunion with symptoms, examination, serial images, and CT when bridging remains uncertain. Assess heel alignment, fixation integrity, bone loss, infection clues, and biological risks such as nicotine exposure or impaired bone health. Pain may also arise from a neighboring joint or prominent implant, so localize it before assuming every visible gap is symptomatic. If revision is justified, remove nonviable tissue, establish viable fusion surfaces, correct malalignment, and create stable fixation with appropriate grafting when needed. Address infection through a coordinated source-control plan and modify patient factors that threaten healing. The revision goal is a stable, aligned, functional foot, not merely a new set of screws. Follow union, wound condition, and load progression.
Worked example: Eight months after subtalar fusion, a patient has focal fusion-site pain, persistent heel varus, and CT evidence of a substantial unbridged joint area. Nicotine use continues, but there is no drainage; infection still needs assessment before revision. Discuss cessation and bone health, then plan viable joint preparation, corrected heel alignment, and stable fixation. Hardware exchange alone leaves the mechanical and biological causes.
Watch the distinction: A CT gap does not explain every postoperative pain complaint, and new hardware does not cure a failed fusion mechanism. Confirm the pain source and address alignment, biology, and infection.
Reference: [1]
Official references and further reading
- Part I Board Qualification Exam Content | ABFAS
- CBPS Exam Preparation | ABFAS
- New Certification Process, Effective September 2020 | ABFAS
- NEW CBPS Overview (Board Qualified Before Fall 2020) | ABFAS