Injections of the Foot and Ankle
A 60-year-old man with ankle osteoarthritis undergoes an ultrasound-guided tibiotalar joint injection. What is the primary advantage of ultrasound guidance compared with a landmark-based approach?
A. Eliminates the need for informed consent
B. Allows use of lower corticosteroid doses
C. Improves injection accuracy and reduces neurovascular injury risk
D. Prevents post-procedure pain
E. Guarantees long-term symptom relief
Answer: C. Improves injection accuracy and reduces neurovascular injury risk
Ultrasound guidance has been shown to improve the accuracy of foot and ankle injections and may decrease the risk of neurovascular injury and inadvertent intratendinous injection.
A physician is uncertain whether a patient's lower-extremity erythema represents cellulitis or an abscess. Which diagnostic modality has the best evidence for distinguishing between the two conditions?
A. Plain radiography
B. MRI
C. CT scan
D. Point-of-care ultrasonography
E. Blood cultures
Answer: D. Point-of-care ultrasonography
Point-of-care ultrasonography (POCUS) reliably differentiates cellulitis from abscess. Cellulitis often demonstrates a characteristic cobblestone appearance, whereas abscesses appear as hypoechoic or heterogeneous fluid collections.
A 38-year-old woman presents for cosmetic treatment of forehead lines that are only visible when she raises her eyebrows. Which of the following best explains the mechanism by which botulinum toxin improves her condition?
A. Increased collagen synthesis in the dermis
B. Inhibition of acetylcholine release at the neuromuscular junction
C. Direct stimulation of fibroblast activity
D. Decreased sebaceous gland activity
Answer: B. Inhibition of acetylcholine release at the neuromuscular junction
Botulinum toxin blocks acetylcholine release by cleaving SNAP-25, preventing vesicle fusion at the neuromuscular junction. This results in temporary muscle paralysis, reducing contraction and smoothing dynamic wrinkles. It does not directly affect collagen or sebaceous glands.
A. Continue indefinitely without reassessment
B. Use the highest effective dose immediately
C. Individualize treatment and reassess regularly
D. Avoid behavioral interventions once medication is started
Answer: C. Individualize treatment and reassess regularly
Guidelines emphasize cautious, individualized use of atypical antipsychotics with regular reassessment of risks and benefits. Given limited evidence and potential adverse effects, treatment should not be static or automatic.
A 72-year-old veteran asks whether COVID-19 vaccination is still worthwhile given prior infection and circulating variants. What is the best evidence-based response?
A. Vaccines are no longer effective
B. Vaccines only reduce mild symptoms
C. Vaccines reduce ED visits, hospitalization, and mortality
D. Vaccines are only beneficial in unvaccinated individuals
E. Vaccines increase hospitalization risk
Answer: C. Vaccines reduce ED visits, hospitalization, and mortality
The observational study summarized in the article demonstrates that COVID-19 vaccines remain effective in the Omicron era, significantly reducing emergency visits, hospitalizations, and death. While absolute benefit is smaller than earlier in the pandemic, the clinical impact remains meaningful, similar to other respiratory vaccines.
A 48-year-old woman complains of burning pain in the forefoot and describes feeling as though she is "walking on a pebble." Examination reproduces symptoms when the forefoot is squeezed across the metatarsal heads. Which diagnosis is most likely?
A. Plantar fasciitis
B. Tarsal tunnel syndrome
C. First metatarsophalangeal arthritis
D. Interdigital (Morton) neuroma
E. Achilles tendinopathy
Answer: D. Interdigital (Morton) neuroma
Interdigital (Morton) neuroma commonly presents with burning forefoot pain and the sensation of having a pebble in the shoe. Symptoms are often reproduced with direct compression or the metatarsal squeeze test. The most common location is between the third and fourth metatarsals.
A 68-year-old woman presents with redness and warmth of both lower legs for the past 2 months. She denies fever, chills, or pain. Examination reveals bilateral erythema involving the medial lower legs that improves when the legs are elevated. What is the most likely diagnosis?
A. Bilateral cellulitis
B. Necrotizing fasciitis
C. Venous stasis dermatitis
D. Erysipelas
E. Deep abscess
Answer: C. Venous stasis dermatitis
Cellulitis is typically unilateral. Bilateral lower-extremity erythema should prompt evaluation for alternative diagnoses, particularly venous stasis dermatitis, which commonly presents with bilateral erythema that improves with limb elevation.
A 50-year-old patient has deep glabellar lines visible both at rest and during facial expression. What is the most appropriate expectation when treating with botulinum toxin alone?
A. Complete resolution after one treatment
B. Minimal improvement due to lack of muscle involvement
C. Improvement primarily in dynamic component, with limited effect on static lines
D. Permanent elimination of wrinkles
Answer: C. Improvement primarily in dynamic component, with limited effect on static lines
Botulinum toxin is most effective for dynamic wrinkles caused by muscle contraction. Static wrinkles(visible at rest) are less responsive and may require multiple treatments or adjunctive therapies such as fillers.
A clinician reviews the literature before prescribing an atypical antipsychotic for ASD. Which of the following limitations of the evidence base is most important?
A. Large number of long-term adult studies
B. Consistent reporting of rare adverse effects
C. Lack of sufficient adult data and long-term outcomes
D. Uniform study methodologies across trials
Answer: C. Lack of sufficient adult data and long-term outcomes
The evidence is limited by few adult studies and lack of long-term (>3 months) data. Additionally, adverse event reporting is inconsistent, making it difficult to fully assess long-term safety.
A 65-year-old man with type 2 diabetes has an A1C of 7.6% on metformin. He has no major comorbidities. According to the ACP guideline summarized in the article, what is the most appropriate A1C target?
A. <6.0%
B. <6.5%
C. <7.0%
D. 7–8%
E. 8.5%
Answer: D. 7–8%
The ACP guideline recommends an A1C goal of 7–8% for most patients with type 2 diabetes. More aggressive targets (<6.5%) are not routinely recommended and may increase harm (e.g., hypoglycemia) without clear benefit.
A 55-year-old runner with plantar fasciitis has persistent symptoms despite physical therapy and a prior corticosteroid injection. He asks about platelet-rich plasma (PRP). According to the article, which statement is most accurate?
A. PRP has been shown to be inferior to corticosteroid injection at 3 months
B. PRP is contraindicated after a prior steroid injection
C. PRP may outperform corticosteroids at 3 months, with benefits lasting up to 12 months
D. PRP has no evidence supporting its use in plantar fasciitis
E. PRP is associated with a higher rupture rate than corticosteroids
Answer: C. PRP may outperform corticosteroids at 3 months, with benefits lasting up to 12 months
The article cites a systematic review and meta-analysis demonstrating that PRP outperformed corticosteroid injections at 3 months, with benefits persisting for 6 to 12 months. PRP is considered a promising option, particularly for persistent plantar fasciitis symptoms.
A 42-year-old man presents with a painful, fluctuant 3-cm abscess on his thigh. Incision and drainage are performed successfully. Which of the following is the most evidence-based next step?
A. No further treatment is necessary
B. Add cephalexin for 10 days
C. Add trimethoprim-sulfamethoxazole or clindamycin
D. Pack the abscess cavity routinely
E. Obtain superficial wound cultures before treatment
Answer: C. Add trimethoprim-sulfamethoxazole or clindamycin
For uncomplicated abscesses, incision and drainage is the primary treatment. However, randomized trials have shown that adding trimethoprim-sulfamethoxazole or clindamycin decreases treatment failure and recurrence.
Which of the following patients has a clear contraindication to botulinum toxin injection?
A. 45-year-old with controlled hypertension
B. 52-year-old with history of migraines
C. 34-year-old pregnant woman
D. 60-year-old with mild hyperlipidemia
Answer: C. 34-year-old pregnant woman
Contraindications include pregnancy, neuromuscular disorders (e.g., myasthenia gravis), and hypersensitivity to components. Other listed conditions are not contraindications.
A clinician is considering starting aripiprazole for a child with ASD-related behavioral symptoms. According to current evidence, which of the following is the most accurate statement?
A. Strong evidence supports long-term use beyond 1 year
B. Benefits are clearly clinically significant in all patients
C. Evidence supports modest short-term improvement with uncertain long-term effects
D. It eliminates the need for behavioral therapy
Answer: C. Evidence supports modest short-term improvement with uncertain long-term effects
The evidence demonstrates low-certainty, short-term (≈3 months) improvements in symptoms such as irritability. However, long-term data are lacking, and improvements may not always be clinically meaningful. Ongoing reassessment is recommended.
A 70-year-old man with atrial fibrillation undergoes catheter ablation. One year later, he has no recurrence of arrhythmia and has a CHA₂DS₂-VASc score of 2. What is the best management of anticoagulation?
A. Continue anticoagulation indefinitely
B. Reduce to low-dose anticoagulation
C. Discontinue anticoagulation
D. Switch to aspirin
E. Alternate anticoagulation every 6 months
Answer: C. Discontinue anticoagulation
The article summarizes a randomized trial showing that in patients with no AF recurrence 1 year after ablation, discontinuing anticoagulation resulted in lower rates of stroke, systemic embolism, and major bleeding compared with continuing therapy. This challenges prior practice of lifelong anticoagulation based solely on CHA₂DS₂-VASc.
A 52-year-old woman presents with chronic plantar heel pain that has persisted despite stretching, orthotics, and NSAID therapy. She requests a corticosteroid injection. Which of the following complications should be specifically discussed as a known risk of plantar fascia corticosteroid injection?
A. Posterior tibial tendon rupture
B. Plantar fascia rupture and heel fat pad atrophy
C. Talar dome fracture
D. Hallux valgus progression
E. Common peroneal nerve injury
Answer: B. Plantar fascia rupture and heel fat pad atrophy
Corticosteroid injections for plantar fasciitis can provide short-term pain relief but are associated with an increased risk of plantar fascia rupture and heel fat pad atrophy, particularly with repeated injections. The risk of rupture increases with successive injections. A retrospective review reported a rupture incidence of 2.4% after up to three injections.
A 55-year-old man presents with cellulitis of the lower extremity. He has no systemic symptoms, normal vital signs, and no significant comorbidities. What is the recommended duration of antibiotic therapy?
A. 3 days
B. 5 days
C. 10 days
D. 14 days
E. 21 days
Answer: B. 5 days
Multiple studies and guideline recommendations support a 5-day course of antibiotics for uncomplicated cellulitis. Longer courses do not improve outcomes when patients are responding appropriately to treatment.
A patient develops eyelid ptosis several days after receiving botulinum toxin injections to the glabellar region. What is the most likely cause?
A. Injection into the frontalis muscle
B. Diffusion of toxin into the levator palpebrae superioris
C. Local allergic reaction
D. Injury to the facial nerve
Answer: B. Diffusion of toxin into the levator palpebrae superioris
Blepharoptosis is a known complication caused by toxin diffusion into the levator palpebrae superioris. It is technique-dependent and more likely with improper injection placement or excessive dosing.
A 16-year-old adolescent with ASD is started on risperidone for behavioral issues. Which of the following outcomes has evidence of improvement with this therapy?
A. Core social communication deficits
B. Irritability and inappropriate speech
C. IQ and cognitive function
D. Language acquisition
Answer: B. Irritability and inappropriate speech
Atypical antipsychotics may improve associated behavioral symptoms such as irritability, obsessive-compulsive behaviors, and inappropriate speech. They do not treat core ASD features like social communication deficits or cognitive function.
A patient with type 2 diabetes on metformin requires additional therapy. According to the guideline discussed in the article, which medication class should generally be avoided due to lack of demonstrated benefit?
A. SGLT-2 inhibitors
B. GLP-1 receptor agonists
C. DPP-4 inhibitors
D. Insulin
E. Sulfonylureas
Answer: C. DPP-4 inhibitors
The ACP guideline recommends against routine use of DPP-4 inhibitors because they have not shown meaningful benefit in reducing morbidity or mortality. In contrast, SGLT-2 inhibitors and GLP-1 receptor agonists are preferred due to proven outcome benefits.
A family physician is preparing to inject a patient with Achilles tendinopathy. Which of the following is the most appropriate recommendation regarding corticosteroid use?
A. Inject corticosteroid directly into the Achilles tendon under ultrasound guidance
B. Corticosteroid injection is recommended only if symptoms have lasted more than 6 months
C. Intratendinous corticosteroid injection should be avoided because of rupture risk
D. Ultrasound guidance eliminates the risk of tendon rupture
E. Triamcinolone is contraindicated in all tendon injections
Answer: C. Intratendinous corticosteroid injection should be avoided because of rupture risk
The article specifically states that corticosteroid injection directly into weight-bearing tendons, such as the Achilles tendon, is not recommended because of the increased risk of tendon rupture.
A 60-year-old man presents with rapidly progressive erythema of the thigh. Examination shows tense edema, hemorrhagic bullae, severe pain extending beyond the visible margins of infection, and decreased sensation over the affected area. Vital signs are normal. What is the most appropriate next step?
A. Outpatient oral cephalexin
B. Venous Doppler ultrasonography
C. Reassure because vital signs are normal
D. Emergent surgical consultation for suspected necrotizing fasciitis
E. Topical antibiotic therapy
Answer: D. Emergent surgical consultation for suspected necrotizing fasciitis
Features suggestive of necrotizing fasciitis include:
Importantly, clinicians should not be reassured by normal vital signs. Necrotizing fasciitis is a surgical emergency requiring urgent debridement and broad-spectrum antibiotics.
A patient asks how long the effects of botulinum toxin injections will last. What is the most accurate response?
A. 1–2 weeks
B. 1–2 months
C. 3–4 months
D. 1 year
Answer: C. 3–4 months
The clinical effect of botulinum toxin typically lasts 3–4 months, after which neuromuscular function gradually returns. With repeated treatments, duration may increase slightly, but regular reinjection is required to maintain results.
A 7-year-old boy with autism spectrum disorder (ASD) is brought in for severe irritability and frequent tantrums. His parents ask about medication options. Which of the following medications has evidence for short-term improvement in irritability in children with ASD?
A. Haloperidol
B. Risperidone
C. Sertraline
D. Lithium
Answer: B. Risperidone
Evidence from randomized controlled trials shows that atypical antipsychotics such as risperidone (and aripiprazole) can reduce irritability and some behavioral symptoms in children with ASD over short-term treatment (approximately 3 months). Other listed medications are not supported by the article for this indication.
A 58-year-old woman develops a provoked DVT after knee surgery. She completes 3 months of anticoagulation. She also has obesity and chronic inflammatory disease. What is the best next step in management based on recent evidence?
A. Stop anticoagulation
B. Continue full-dose anticoagulation indefinitely
C. Continue low-dose apixaban for 12 months
D. Switch to aspirin
E. No further therapy unless recurrence
Answer: C. Continue low-dose apixaban for 12 months
The article highlights a randomized trial showing that patients with provoked VTE plus at least one persistent risk factor (e.g., obesity, chronic inflammatory disease) benefit from extended therapy. Low-dose apixaban (2.5 mg BID) for 12 months significantly reduced recurrent VTE (NNT ≈ 11) compared with stopping at 3 months. This represents a shift from traditional teaching that all provoked VTE stops at 3 months—persistent risk factors change management.