Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Pes Cavus

  • Author: Norman S Turner, MD; Chief Editor: Jason H Calhoun, MD, FACS  more...
 
Updated: Oct 15, 2014
 

Background

Pes cavus is a high arch of the foot that does not flatten with weight bearing. No specific radiographic definition of pes cavus exists. The deformity can be located in the forefoot, the midfoot, the hindfoot, or a combination of these sites.[1]

The spectrum of associated deformities observed with pes cavus includes clawing of the toes, posterior hindfoot deformity (described as an increased calcaneal angle), contracture of the plantar fascia, and cock-up deformity of the great toe. This can cause increased weight-bearing for the metatarsal heads and associated metatarsalgia and calluses.

Next

Etiology

The etiology of pes cavus can be determined approximately 80% of the time. Possible causes include the following:

  • Malunion of calcaneal or talar fractures
  • Burns
  • Sequelae resulting from compartment syndrome
  • Residual clubfoot
  • Neuromuscular disease

The remaining 20% of cases are idiopathic and nonprogressive. Identifying the etiology is essential to determine if the deformity is progressive, which assists in operative planning.

Neuromuscular diseases, such as muscular dystrophy, Charcot-Marie-Tooth (CMT) disease,[2, 3, 4, 5, 6, 7] spinal dysraphism, polyneuritis, intraspinal tumors, poliomyelitis, syringomyelia, Friedreich ataxia, cerebral palsy, and spinal cord tumors, can cause muscle imbalances that lead to elevated arches. A patient with a new-onset unilateral deformity but without a history of trauma must be evaluated for spinal tumors.

Multiple theories have been proposed for the pathogenesis of pes cavus. Duchenne described intrinsic muscle imbalances causing an elevated arch. Other theories include the extrinsic muscle and a combination of the intrinsic and extrinsic muscles being causes of the imbalance.

Mann described the pathogenesis of pes cavus in patients with CMT disease.[8] An understanding of the muscles involved and the sequence of the involvement helps in understanding the deformity. An agonist-antagonist model for the muscles determines the deformity. In CMT, the anterior tibialis and the peroneus brevis develop weaknesses. Antagonist muscles, the posterior tibialis and peroneus longus, pull harder than the other muscles, causing deformity.

Specifically, the peroneus longus pulls harder than the weak anterior tibialis, causing plantarflexion of the first ray and forefoot valgus.[9] The posterior tibialis pulls harder than the weak peroneus brevis, causing forefoot adduction. Intrinsic muscle develops contractures while the long extensor to the toes, recruited to assist in ankle dorsiflexion, causes cock-up or claw toe deformity. With the forefoot valgus and the hindfoot varus, increased stress is placed on the lateral ankle ligaments and instability can occur.

In patients with polio, the deformity is in the hindfoot and is caused by weakness of the gastrocnemius-soleus complex. This leads to a marked increase in the calcaneal pitch angle with normal forefoot alignment.

Previous
Next

Pathophysiology

The pathophysiology of the deformity is based on the etiology (see Etiology).

Previous
Next

Presentation

The presentation for patients with pes cavus is highly variable, depending largely on the extent of the deformity. Patients can present with lateral foot pain from increased weight-bearing on the lateral foot.[10] Metatarsalgia is a frequent symptom, as is symptomatic intractable plantar keratosis. Ankle instability can be a presenting symptom, especially in patients with hindfoot varus and weak peroneus brevis. Weakness and fatigue can be observed in patients with neuromuscular disease. Symptom severity is as variable as the symptoms themselves.

Evaluation of a patient who presents with pes cavus begins with a thorough history and complete examination to determine the etiology. Patients with a unilateral deformity frequently have a history of major trauma. Neuromuscular disorders can be identified by family history. A new-onset unilateral deformity is highly suggestive of a spinal cord tumor and necessitates an appropriate workup.

Examination begins with observation of the gait. Hindfoot positioning is evaluated through gait analysis looking for varus. During swing phase, analysis of foot positioning is carried out, looking for anterior tibialis weakness and foot drop. Cock-up toes can be observed with recruitment of the extensor hallucis longus (EHL). The shoe should also be inspected for increased lateral wear.

The range of motion of the ankle, subtalar, midfoot, and forefoot is examined. The deformity is determined to be flexible or rigid. The forefoot is observed for plantarflexion, and the hindfoot is observed for varus. Documenting the strength of the individual muscles is essential for determining surgical options. Agonist and antagonist muscle weakness must be carefully examined, especially in CMT disease.

The Coleman block test determines if the subtalar joint is flexible. The test is performed by having a patient stand with a 1-in. wood block under the heel and lateral foot. This allows the first ray to be plantarflexed off the block. If the hindfoot corrects to a neutral position, the deformity is flexible. If the hindfoot does not correct, the deformity is rigid.

A neurologic examination is required, specifically including detailed muscle strength testing. Sensory examination reveals deficits that can be observed in CMT disease.

Previous
Next

Indications

The goal of treatment is to produce a plantigrade foot that allows even distribution of weight. Failure to maintain an asymptomatic plantar grade foot is an indication for surgery.

Previous
Next

Relevant Anatomy

The relevant anatomy depends on the etiology of the deformity and the procedure performed (see Surgical therapy).

Previous
Next

Contraindications

An absolute contraindication for surgery is poor vascularity. Revascularization should be performed before reconstruction if warranted. Ideally, the soft tissues around the ankle and foot should be intact, without excessive swelling or ulceration. If an ulcer is present, the wound should be healed before reconstruction in order to minimize infection risk.

Previous
 
 
Contributor Information and Disclosures
Author

Norman S Turner, MD Assistant Professor, Department of Orthopedic Surgery, Mayo Clinic School of Medicine

Norman S Turner, MD is a member of the following medical societies: Alpha Omega Alpha, Mid-America Orthopaedic Association, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Minnesota Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jason H Calhoun, MD, FACS Department Chief, Musculoskeletal Sciences, Spectrum Health Medical Group

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Michigan State Medical Society, Missouri State Medical Association, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, Texas Orthopaedic Association, Musculoskeletal Infection Society

Disclosure: Nothing to disclose.

Additional Contributors

Heidi M Stephens, MD, MBA Associate Professor, Department of Surgery, Division of Orthopedic Surgery, University of South Florida College of Medicine; Courtesy Joint Associate Professor, Department of Environmental and Occupational Health, University of South Florida College of Public Health

Heidi M Stephens, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Florida Medical Association

Disclosure: Nothing to disclose.

References
  1. Wapner KL, Myerson MS. Pes cavus. Myerson MS, ed. Foot and Ankle Disorders. Philadelphia, Pa: WB Saunders; 2000. 919-941.

  2. Gallardo E, García A, Combarros O, Berciano J. Charcot-Marie-Tooth disease type 1A duplication: spectrum of clinical and magnetic resonance imaging features in leg and foot muscles. Brain. 2006 Feb. 129(Pt 2):426-37. [Medline].

  3. Holmes JR, Hansen ST Jr. Foot and ankle manifestations of Charcot-Marie-Tooth disease. Foot Ankle. 1993 Oct. 14(8):476-86. [Medline].

  4. Sabir M, Lyttle D. Pathogenesis of Charcot-Marie-Tooth disease. Gait analysis and electrophysiologic, genetic, histopathologic, and enzyme studies in a kinship. Clin Orthop. 1984 Apr. (184):223-35. [Medline].

  5. Sabir M, Lyttle D. Pathogenesis of pes cavus in Charcot-Marie-Tooth disease. Clin Orthop. 1983 May. (175):173-8. [Medline].

  6. Berciano J, Gallardo E, García A, Pelayo-Negro AL, Infante J, Combarros O. New insights into the pathophysiology of pes cavus in Charcot-Marie-Tooth disease type 1A duplication. J Neurol. 2011 Sep. 258(9):1594-602. [Medline].

  7. Joo SY, Choi BO, Kim DY, Jung SJ, Cho SY, Hwang SJ. Foot deformity in charcot marie tooth disease according to disease severity. Ann Rehabil Med. 2011 Aug. 35(4):499-506. [Medline]. [Full Text].

  8. Mann DC, Hsu JD. Triple arthrodesis in the treatment of fixed cavovarus deformity in adolescent patients with Charcot-Marie-Tooth disease. Foot Ankle. 1992 Jan. 13(1):1-6. [Medline].

  9. Schuberth JM, Babu-Spencer N. The impact of the first ray in the cavovarus foot. Clin Podiatr Med Surg. 2009 Jul. 26(3):385-93, Table of Contents. [Medline].

  10. Burns J, Crosbie J, Hunt A, Ouvrier R. The effect of pes cavus on foot pain and plantar pressure. Clin Biomech (Bristol, Avon). 2005 Nov. 20(9):877-82. [Medline].

  11. Najafi B, Barnica E, Wrobel JS, Burns J. Dynamic plantar loading index: understanding the benefit of custom foot orthoses for painful pes cavus. J Biomech. 2012 Jun 1. 45(9):1705-11. [Medline]. [Full Text].

  12. Burns J, Landorf KB, Ryan MM, Crosbie J, Ouvrier RA. Interventions for the prevention and treatment of pes cavus. Cochrane Database Syst Rev. 2007. (4):CD006154. [Medline].

  13. Crosbie J, Burns J. Predicting outcomes in the orthotic management of painful, idiopathic pes cavus. Clin J Sport Med. 2007 Sep. 17(5):337-42. [Medline].

  14. Alexander IJ, Johnson KA. Assessment and management of pes cavus in Charcot-Marie-tooth disease. Clin Orthop. 1989 Sep. (246):273-81. [Medline].

  15. Jahss MH. Evaluation of the cavus foot for orthopedic treatment. Clin Orthop. 1983 Dec. (181):52-63. [Medline].

  16. Paulos L, Coleman SS, Samuelson KM. Pes cavovarus. Review of a surgical approach using selective soft-tissue procedures. J Bone Joint Surg Am. 1980 Sep. 62(6):942-53. [Medline].

  17. Mubarak SJ, Van Valin SE. Osteotomies of the foot for cavus deformities in children. J Pediatr Orthop. 2009 Apr-May. 29(3):294-9. [Medline].

  18. Mann RA. Pes cavus. Pes cavus. Mann RA, Coughlin MJ, eds. Surgery of the Foot and Ankle. 6th ed. St. Louis, Mo: Mosby-Year Book; 1993. 785-801.

  19. Mulier T, Dereymaeker G, Fabry G. Jones transfer to the lesser rays in metatarsalgia: technique and long-term follow-up. Foot Ankle Int. 1994 Oct. 15(10):523-30. [Medline].

  20. Sugathan HK, Sherlock DA. A modified Jones procedure for managing clawing of lesser toes in pes cavus: long-term follow-up in 8 patients. J Foot Ankle Surg. 2009 Nov-Dec. 48(6):637-41. [Medline].

  21. Watanabe RS. Metatarsal osteotomy for the cavus foot. Clin Orthop. 1990 Mar. (252):217-30. [Medline].

  22. Groner TW, DiDomenico LA. Midfoot osteotomies for the cavus foot. Clin Podiatr Med Surg. 2005 Apr. 22(2):247-64, vi. [Medline].

  23. Naudi S, Dauplat G, Staquet V, Parent S, Mehdi N, Maynou C. Anterior tarsectomy long-term results in adult pes cavus. Orthop Traumatol Surg Res. 2009 Jun. 95(4):293-300. [Medline].

  24. Chatterjee P, Sahu MK. A prospective study of Japas' osteotomy in paralytic pes cavus deformity in adolescent feet. Indian J Orthop. 2009 Jul. 43(3):281-5. [Medline]. [Full Text].

  25. Zhou Y, Zhou B, Liu J, Tan X, Tao X, Chen W, et al. A prospective study of midfoot osteotomy combined with adjacent joint sparing internal fixation in treatment of rigid pes cavus deformity. J Orthop Surg Res. 2014 Jun 5. 9:44. [Medline]. [Full Text].

  26. Siffert RS, del Torto U. "Beak" triple arthrodesis for severe cavus deformity. Clin Orthop. 1983 Dec. (181):64-7. [Medline].

  27. Wetmore RS, Drennan JC. Long-term results of triple arthrodesis in Charcot-Marie-Tooth disease. J Bone Joint Surg Am. 1989 Mar. 71(3):417-22. [Medline].

  28. Roper BA, Tibrewal SB. Soft tissue surgery in Charcot-Marie-Tooth disease. J Bone Joint Surg Br. 1989 Jan. 71(1):17-20. [Medline].

  29. Gould N. Surgery in advanced Charcot-Marie-Tooth disease. Foot Ankle. 1984 Mar-Apr. 4(5):267-73. [Medline].

 
Previous
Next
 
Pes cavus with severe hindfoot involvement.
Pes cavus with plantarflexion of the first ray.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.