A concept that is commonly overlooked during the physical examination is an assessment of hindfoot alignment. Hindfoot varus has been noted as a risk factor for ankle instability because of increased stress on the lateral ligaments, which may serve as both a predisposing factor to injury and hinder healing after an injury. Biomechanically, a varus hindfoot results in a stiffer foot position at an impact that reduces the foot's shock absorption power during the gait cycle and in a higher rate of failure of initial surgical management of lateral instability. The degree of varus that leads to these risks has not been established, but higher degrees of the varus may warrant discussion of lateral displacement or closing wedge calcaneal osteotomy as an adjuvant to lateral ligament stabilization. The clinician should also consider a Coleman Block test to evaluate for the forefoot-driven hindfoot varus. If present, a dorsiflexion first metatarsal osteotomy may be indicated to correct the hindfoot varus rather than a calcaneal osteotomy; sometimes both are required.
J Am Acad Orthop Surg. 2021;29(1):e5-e13. © 2021 American Academy of Orthopaedic Surgeons