Pes Cavus Clinical Presentation

Updated: Jul 06, 2022
  • Author: Norman S Turner, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS  more...
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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. Hee 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 defor Same patient viewed from back, showing varus deformity of heels, which is worse on right side.

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

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