History

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 weightbearing on the lateral foot.^[22] 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 on the basis of the family history. A new-onset unilateral deformity is highly suggestive of a spinal cord tumor and necessitates an appropriate workup.

Physical Examination

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. Cockup 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 (see the images below). Documenting the strength of the individual muscles is essential for determining surgical options. Agonist and antagonist muscle weakness must be carefully examined, especially in Charcot-Marie-Tooth (CMT) disease.

Patient with cavovarus deformity in both feet. Heel varus can be appreciated as it can be viewed from front, making "peek-a-boo sign" positive.

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Same patient viewed from back, showing varus deformity of heels, which is worse on right side.

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The Coleman block test determines if the subtalar joint is flexible or forefoot-driven. The test is performed by having a patient stand with a 1-in. (2.5-cm) wood block under the heel and lateral foot (see the image below). This allows the first ray to be plantarflexed off the block. If the hindfoot corrects to a neutral position, the deformity is flexible or forefoot-driven. If the hindfoot does not correct, the deformity is rigid or not forefoot-driven.

Same patient with Coleman block test showing correction of heel varus to neutral on left side but not on right side.

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

Workup

Seaman TJ, Ball TA. Pes Cavus. Treasure Island, FL: StatPearls; 2022. [Full Text].
Balsdon ME, Bushey KM, Dombroski CE, LeBel ME, Jenkyn TR. Medial Longitudinal Arch Angle Presents Significant Differences Between Foot Types: A Biplane Fluoroscopy Study. J Biomech Eng. 2016 Oct 1. 138 (10):[QxMD MEDLINE Link].
Wapner KL, Myerson MS. Pes cavus. Myerson MS, ed. Foot and Ankle Disorders. Philadelphia: WB Saunders; 2000. 919-941.
Japas LM. Surgical treatment of pes cavus by tarsal V-osteotomy. Preliminary report. J Bone Joint Surg Am. 1968 Jul. 50 (5):927-44. [QxMD MEDLINE Link].
BREWERTON DA, SANDIFER PH, SWEETNAM DR. "IDIOPATHIC" PES CAVUS: AN INVESTIGATION INTO ITS AETIOLOGY. Br Med J. 1963 Sep 14. 2 (5358):659-61. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Krähenbühl N, Weinberg MW. Anatomy and Biomechanics of Cavovarus Deformity. Foot Ankle Clin. 2019 Jun. 24 (2):173-181. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Holmes JR, Hansen ST Jr. Foot and ankle manifestations of Charcot-Marie-Tooth disease. Foot Ankle. 1993 Oct. 14 (8):476-86. [QxMD MEDLINE Link].
Sabir M, Lyttle D. Pathogenesis of Charcot-Marie-Tooth disease. Gait analysis and electrophysiologic, genetic, histopathologic, and enzyme studies in a kinship. Clin Orthop Relat Res. 1984 Apr. (184):223-35. [QxMD MEDLINE Link].
Sabir M, Lyttle D. Pathogenesis of pes cavus in Charcot-Marie-Tooth disease. Clin Orthop Relat Res. 1983 May. (175):173-8. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
Martyn CN, Hughes RA. Epidemiology of peripheral neuropathy. J Neurol Neurosurg Psychiatry. 1997 Apr. 62 (4):310-8. [QxMD MEDLINE Link]. [Full Text].
Duat-Rodríguez A, Prochazkova M, Sebastian IP, Extremera VC, Legido MJ, Palero SR, et al. ATP1A3-related disorders in the differential diagnosis of acute brainstem and cerebellar dysfunction. Eur J Paediatr Neurol. 2021 Sep. 34:105-109. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Roper BA, Tibrewal SB. Soft tissue surgery in Charcot-Marie-Tooth disease. J Bone Joint Surg Br. 1989 Jan. 71 (1):17-20. [QxMD MEDLINE Link].
Gould N. Surgery in advanced Charcot-Marie-Tooth disease. Foot Ankle. 1984 Mar-Apr. 4 (5):267-73. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Akoh CC, Phisitkul P. Clinical Examination and Radiographic Assessment of the Cavus Foot. Foot Ankle Clin. 2019 Jun. 24 (2):183-193. [QxMD MEDLINE Link].
Peden SC, Tanner JC, Manoli A. Posterior Fibula of Pes Cavus: Real or Artifact? Answer Based on Cross-Sectional Imaging. J Surg Orthop Adv. Winter 2018. 27 (4):255-260. [QxMD MEDLINE Link].
Sanpera I, Villafranca-Solano S, Muñoz-Lopez C, Sanpera-Iglesias J. How to manage pes cavus in children and adolescents?. EFORT Open Rev. 2021 Jun. 6 (6):510-517. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link]. [Full Text].
Burns J, Landorf KB, Ryan MM, Crosbie J, Ouvrier RA. Interventions for the prevention and treatment of pes cavus. Cochrane Database Syst Rev. 2007 Oct 17. (4):CD006154. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Fernández-Seguín LM, Heredia-Rizo AM, Díaz-Mancha JA, González-García P, Ramos-Ortega J, Munuera-Martínez PV. Immediate and short-term radiological changes after combining static stretching and transcutaneous electrical stimulation in adults with cavus foot: A randomized controlled trial. Medicine (Baltimore). 2019 Nov. 98 (46):e18018. [QxMD MEDLINE Link]. [Full Text].
Alexander IJ, Johnson KA. Assessment and management of pes cavus in Charcot-Marie-tooth disease. Clin Orthop Relat Res. 1989 Sep. (246):273-81. [QxMD MEDLINE Link].
Jahss MH. Evaluation of the cavus foot for orthopedic treatment. Clin Orthop Relat Res. 1983 Dec. (181):52-63. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Myerson MS, Myerson CL. Managing the Complex Cavus Foot Deformity. Foot Ankle Clin. 2020 Jun. 25 (2):305-317. [QxMD MEDLINE Link].
Kaplan JRM, Aiyer A, Cerrato RA, Jeng CL, Campbell JT. Operative Treatment of the Cavovarus Foot. Foot Ankle Int. 2018 Nov. 39 (11):1370-1382. [QxMD MEDLINE Link].
Mubarak SJ, Van Valin SE. Osteotomies of the foot for cavus deformities in children. J Pediatr Orthop. 2009 Apr-May. 29 (3):294-9. [QxMD MEDLINE Link].
Astolfi RS, de Vasconcelos Coelho JV, Ribeiro HCT, Santos ALGD, Leite JAD. Cavus Foot Correction Using a Full Percutaneous Procedure: A Case Series. Int J Environ Res Public Health. 2021 Sep 25. 18 (19):[QxMD MEDLINE Link]. [Full Text].
Mann RA. Pes cavus. Mann RA, Coughlin MJ, eds. Surgery of the Foot and Ankle. 6th ed. St Louis: Mosby-Year Book; 1993. 785-801.
Brugh AM, Fallat LM, Savoy-Moore RT. Lateral column symptomatology following plantar fascial release: a prospective study. J Foot Ankle Surg. 2002 Nov-Dec. 41 (6):365-71. [QxMD MEDLINE Link].
Cheung JT, An KN, Zhang M. Consequences of partial and total plantar fascia release: a finite element study. Foot Ankle Int. 2006 Feb. 27 (2):125-32. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Breusch SJ, Wenz W, Döderlein L. Function after correction of a clawed great toe by a modified Robert Jones transfer. J Bone Joint Surg Br. 2000 Mar. 82 (2):250-4. [QxMD MEDLINE Link].
Watanabe RS. Metatarsal osteotomy for the cavus foot. Clin Orthop Relat Res. 1990 Mar. (252):217-30. [QxMD MEDLINE Link].
Groner TW, DiDomenico LA. Midfoot osteotomies for the cavus foot. Clin Podiatr Med Surg. 2005 Apr. 22 (2):247-64, vi. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link]. [Full Text].
Siffert RS, del Torto U. "Beak" triple arthrodesis for severe cavus deformity. Clin Orthop Relat Res. 1983 Dec. (181):64-7. [QxMD MEDLINE Link].
Li S, Myerson MS. Failure of Surgical Treatment in Patients with Cavovarus Deformity: Why Does This Happen and How Do We Approach Treatment?. Foot Ankle Clin. 2019 Jun. 24 (2):361-370. [QxMD MEDLINE Link].

Media Gallery

Pes cavus with severe hindfoot involvement.
Pes cavus with plantarflexion of first ray.
Patient with cavovarus deformity in both feet. Heel varus can be appreciated as it can be viewed from front, making "peek-a-boo sign" positive.
Same patient viewed from back, showing varus deformity of heels, which is worse on right side.
Same patient with Coleman block test showing correction of heel varus to neutral on left side but not on right side.

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Pes Cavus Clinical Presentation

History

Physical Examination

References

Tables

Contributor Information and Disclosures

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