Heel inversion on heel rise: A reliable sign of pediatric flatfoot decompensation

The heel rise test (HRT) is widely used to evaluate triceps surae strength and to detect posterior tibial tendon dysfunction, a key factor in flatfoot pathology. In children with flexible flatfoot, the presence or absence of heel inversion during push-off is an important clinical sign that distinguishes muscularly compensated from decompensated feet. Identifying decompensated flatfoot is clinically relevant, as it is associated with impaired gait mechanics, reduced plantarflexor performance, and potential balance deficits. This study examined whether heel inversion observed during a standardized bilateral HRT can serve as a reliable indicator of decompensated flatfoot during walking. We analyzed 358 feet from children and adolescents (aged 7–17) with idiopathic flexible flatfeet. Heel positions during HRT were rated on a five-point scale (-2 to +2), and results were correlated with 3D gait analysis. Reliability analysis showed high reliability and consistency. A positive HRT (neutral/everted heel) indicated decompensation in 77% of cases, with 100% of everted heels decompensated. However, 28% of feet with negative HRT results (heel inversion) were also decompensated. The HRT score is a reliable tool for assessing foot function during gait. It correlates with hindfoot-to-tibia inversion and foot kinematics, where lower scores indicate greater eversion, forefoot supination, and abduction. The HRT score provides a simple, quick measure of flatfoot severity. • Heel inversion in the Heel Rise Test (HRT) reliably indicates decompensated flatfeet. • HRT scores strongly correlate with hindfoot inversion during walking (R = 0.64, p < 0.001). • Intra- and interobserver reliability analysis confirms HRT as a consistent clinical tool. • A positive HRT suggests decompensation, providing a straightforward assessment in most cases.