10/14/2020 Pes cavus - Physiopedia

Contents Editors Categories Share Cite

Pes cavus
Original Editor - Sem Bras (/User:Sem_Bras)

Top Contributors - Esraa Mohamed Abdullzaher (/User:Esraa_Mohamed_Abdullzaher), Yasmina Hossam

(/User:Yasmina_Hossam), Mathias Plas (/User:Mathias_Plas), Saeed Dokhnan (/User:Saeed_Dokhnan) and
Uchechukwu Chukwuemeka (/User:Uchechukwu_Chukwuemeka)

Contents
1 Definition
2 Etiology
3 Types of Pes cavus
4 Epidemiology
5 Pathogenesis
6 Clinically relevant Anatomy
7 Characteristics
8 Symptoms and clinical presentation
9 Medical management
10 Clinical Tests
11 Physiotherapy management
12 Surgical Management
13 References

Related online courses on +Physioplus

Online Course: Foot and Ankle
Online Course: Foot and ankle A comprehensive overview of physiotherapy of the foot and ankle Powered by
Physiopedia Start course Presented by: Physioplus Team A team of committed individuals with a very wide

Definition
Pes cavus is a foot (/Foot_Anatomy) with an abnormally high plantar longitudinal arch. People who have this
condition will place too much weight and stress on the ball and heel of the foot while standing and/or walking.

The spectrum of
associated deformities
observed with pes cavus
includes clawing of the
toes, posterior hind foot
deformity (described as an

https://www.physio-pedia.com/Pes_cavus 1/10
10/14/2020 Pes cavus - Physiopedia

(/File:230313092152high_arches.jpg)
increased calcaneal angle), contracture of the plantar fascia (/Plantar_Fasciitis), and cock-up deformity of the
great toe. This can cause increased weight bearing for the metatarsal heads and associated Metatarsalgia
(/Metatarsalgia) and calluses. </ref>[2]

Etiology
The etiology can be attributed to the brain, spinal cord, peripheral nerves, or structural problems of the foot.
When motor imbalance begins before maturation of the skeleton, there can be a substantial change in healthy
bone morphology. When cavus is acquired after skeletal maturity, there may be little or no change in the
morphology. Two-thirds of adults with symptomatic cavus foot have an underlying neurologic condition, most
commonly: Charcot-Marie-Tooth (/Charcot-Marie-Tooth_Disease:_A_Case_Study) (CMT) disease, spinal
dysraphism, polyneuritis, Intraspinal tumors, poliomyelitis (/Poliomyelitis), syringomyelia (/Syringomyelia),
Friedreich ataxia (/Friedreich%27s_Ataxia), cerebral palsy (/Cerebral_Palsy_-_The_Causes), and spinal cord
tumors, can cause muscle imbalances that lead to elevated arches[3]. A patient with a new-onset unilateral
deformity but without a history of trauma must be evaluated for spinal tumors.

The cause and deforming mechanism underlying pes cavus are complex and not well understood. Factors
considered influential in the development of pes cavus include muscle weakness and imbalance in
neuromuscular disease, residual effects of congenital clubfoot
(/Clubfoot,_Management_and_Barriers_to_treatment_in_underdeveloped_countries.), post-traumatic bone
malformation, contracture of the plantar fascia, and shortening of the Achilles tendon (/Achilles_Tendon) [4]

Pes Cavus (Claw Foot) Health Byte

[5]

Also known as Hereditary Motor and Sensory Neuropathy (HMSN), it is genetically heterogeneous and usually
presents in the first decade of life with delayed motor milestones, distal muscle weakness, clumsiness, and
frequent falls. By adulthood, Charcot-Marie-Tooth disease can cause painful foot deformities such as pes
cavus. Although it is a relatively common disorder affecting the foot and ankle, little is known about the
distribution of muscle weakness, severity of orthopaedic deformities, or types of foot pain experienced. There
are no cures or effective courses of treatment to halt the progression of any form of Charcot-Marie-Tooth
disease[6]

The development of the cavus foot structure seen in Charcot-Marie-Tooth disease has been previously linked
to an imbalance of muscle strength around the foot and ankle. A hypothetical model proposed by various
authors describes a relationship whereby weak evertor muscles are overpowered by stronger invertor
muscles, causing an adducted forefoot and inverted rearfoot. Similarly, weak dorsiflexors are overpowered by
stronger plantarflexors, causing a plantarflexed first metatarsal and anterior pes cavus[7]

https://www.physio-pedia.com/Pes_cavus 2/10
10/14/2020 Pes cavus - Physiopedia

A man is a preventive factor for hollow feet( pes cavus), but a risk factor for flat feet. There is a statistically
significant difference due to sex in the prevalence of hollow feet[8].

Types of Pes cavus

Three main types of pes cavus are regularly described in the literature: pes cavovarus, pes calcaneocavus,
and ‘pure’ pes cavus. The three types of pes cavus can be distinguished by their aetiology, clinical signs and
radiological appearance[9]

Pes cavovarus, the most common type of pes cavus, is seen primarily in neuromuscular disorders such
as Charcot-Marie-Tooth disease and, in cases of unknown aetiology, is conventionally termed
‘idiopathic’.[10] Pes cavovarus presents with the calcaneus in varus, the first metatarsal plantarflexed, and
a claw-toe deformity.[5] Radiological analysis of pes cavus in Charcot-Marie-Tooth disease shows the
forefoot is typically plantarflexed in relation to the rearfoot.[11]
pes calcaneocavus foot, which is seen primarily following paralysis of the triceps surae due
to poliomyelitis, the calcaneus is dorsiflexed and the forefoot is plantarflexed. Radiological analysis of pes
calcaneocavus reveals a large talo-calcaneal angle.
pes cavus, the calcaneus is neither dorsiflexed nor in varus and is highly arched due to a plantarflexed
position of the forefoot on the rearfoot.[12] A combination of any or all of these elements can also be seen
in a ‘combined’ type of pes cavus that may be further categorized as flexible or rigid.[13]
Also, types of Pes Cavus is based on the location of APEX of the deformity

Anterior Cavus (Forefoot Cavus) –Local –Global

Metatarsus cavus
Posterior Cavus
Combined

Epidemiology
There are few good estimates of prevalence for pes cavus in the general community. While pes cavus has
been reported in between 2 and 29% of the adult population, there are several limitations of the prevalence
data reported in these studies.[14] Population-based studies suggest the prevalence of the cavus foot is
approximately 10% [15]

Pathogenesis
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 et al. (1992)[16] described the pathogenesis of pes cavus in patients with CMT disease. An agonist and
antagonist model for the muscles determines the deformity. In CMT, the anterior tibialis muscle and the
peroneus muscle develop weaknesses. Antagonist muscles, posterior tibialis
(/Posterior_Tibial_Tendon_Dysfunction) and peroneus longus, pull harder than the other muscles, causing
deformity. Specifically, the peroneus longus (/Peroneus_longus_and_brevis_tests) pulls harder than the weak
anterior tibialis causing plantar flexion of the first ray and forefoot valgus. 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.[2]
https://www.physio-pedia.com/Pes_cavus 3/10
10/14/2020 Pes cavus - Physiopedia

Clinically relevant Anatomy

Clinically it is an abnormal elevation of the medial arch in weight bearing. Biomechanically, cavus is defined as
a varus hindfoot, high calcaneal pitch, high-pitched midfoot and plantarflexed and adducted forefoot.
When the angle between the talus and calcaneus is narrowed, the os naviculare moves to a superior position
to the cuboid, instead of medial to it. This makes it difficult for the Chopart-joint to function.
The talus is the connector of the foot and the ankle. In a neutral foot, the foot rotates around the talus and the
cuboid follows the calcaneus.

Characteristics
During the gait cycle, the foot remains locked in hindfoot inversion and forefoot varus throughout the stance
phase, causing less stress dissipation. This can result in metatarsalgia, stress fracture of the fifth metatarsal,
plantar fasciitis, medial longitudinal arch pain, ilio-tibial band syndrome and instability. This locking and
unlocking of the Chopart-joint is a critical element in the cavus-foot.

In an cavus foot, the calcaneus is rotated internally beneath the talus, resulting in an narrow anterior-posterior
talo-calcaneal angle. Since the cuboid follows the calcaneus, the cuboid is plantar to the navicular, instead of
beside it. This locks the midfoot and overloads the lateral side of the foot . Another way to look at he chopart
function is to view the foot from the front with the forefoot removed . If an axis, drawn through the two joints, is
parallel to the ground, there will be relatively free flexion. The more the axis approaches a vertical orientation,
the less flexion will be possible.In extremely high-arched feet, the weight bearing is distributed unevenly along
the metatarsal heads and the lateral border of the feet. This type of disorder causes the foot to prone to
metatarsal head and calcaneal contusions, caused by the excessive pressure of weight bearing. Also the foot
is prone to osteophyte formation at the junction of the metatarsal bases and the cuneiforms.

Symptoms and clinical presentation

Patients complain pain , instability , difficulty walking and problems with footwear .The symptoms vary with the
degree of deformity .[17] also can present with lateral foot pain from increased weight bearing on the lateral
foot.

The range of complaints reported in the literature include metatarsalgia, pain under the first metatarsal,
plantar fasciitis (/Plantar_Fasciitis), painful callosities, ankle arthritis (/Ankle_and_Foot_Arthropathies), and
Achilles tendonitis (/Achilles_Tendinopathy) [18]
keratosis
lateral Ankle instability[19]
hindfoot varus
The forefoot plantar flexion
hindfoot varus[2]
lower limb stress fractures[20]
knee pain[21]
iliotibial band friction syndrome[22]
back pain[23]
tripping[24]

Medical management
https://www.physio-pedia.com/Pes_cavus 4/10
10/14/2020 Pes cavus - Physiopedia

Medical management is to allow the patient to ambulate without any problems. It is important for the patient to
understand that surgical reconstruction does not provide a normal foot. The main goal of surgical
reconstruction is to produce a plantigrade foot and pain relief. Repeated surgical procedures can be
necessary, especially if the deformity is progressive. Surgical procedures can be broadly categorized into soft-
tissue and bony procedures. Tendon transfers and osteotomies can provide correction of the deformity without
requiring an arthrodesis.

Clinical Tests
The Coleman block test determines if the subtalar joint is flexible. The testis performed by having a
patient stand with a 1-inch wood block under the heel and lateral foot. This allows the first ray to be
plantar-flexed 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.
Increased calcaneal angle[2]

Physiotherapy management
Suggested conservative management of patients with painful pes cavus typically involves strategies to reduce
and redistribute plantar pressure loading, with the use of foot orthoses and specialized cushioned footwear.
The orthoses for pes cavus needs to accomplish several specific goals:

Increasing plantar surface contact area The overload on the metatarsal heads is a result of limited plantar
surface contact due to high arch and limited ankle joint (/Ankle_Joint) dorsiflexion. Increasing the plantar
surface contact ensures the foot to bear more weight in the arch while the metatarsal heads bear less
weight during activity.[24] (Evidence level 4)
Resisting against excessive supination Lateral ankle stability and laterally deviated subtalar joint axis
(STJ) are frequently associated with high-arched feet. This position results in an excessive supinator
torque around the subtalar joint axis.
Resisting against recessive pronation and supination forces Rearfoot instability is caused by an extension
of the laterally deviated subtalar axis. In flexible pes cavus, midtarsal flexibility complicates the later
portion of the stance phase of gait. The forefoot pathology produces midtarsal joint supination, that leads
to excessive pronation of the rearfoot. Some pes cavus patients suffer from both lateral ankle instability at
midstance and rearfoot pronation at late midstance. stretching and strengthening of tight and weak
muscles, debridement of plantar callosities, osseous mobilization, massage, chiropractic manipulation of
the foot and ankle, and strategies to improve balance[25]
(Evidence 5)
Orthotics with extra-depth shoes to offload bony prominences and prevent rubbing of the toes may
improve symptoms. For varus deformities, a lateral wedge sole modification can improve function. Bracing
for supple deformities or foot drop may allow patients to ambulate; however, in patients with sensation
deficits, Plastazote linings in the brace are required and frequent inspection of the skin for ulceration is
warranted.[26] (Evidence 1b)

Surgical Management
Correcting a cavovarus foot
Most of the corrections involve tendon transfers and capsular and facial releases
Correction of plantar flexion of the first ray by performing a dorsiflexion
ST tarso-metatarsal arthrodesis.
Reduction of hindfoot varus by performing a lateralizing calcaneal osteotomy.
https://www.physio-pedia.com/Pes_cavus 5/10
10/14/2020 Pes cavus - Physiopedia

Arthrodesis 1st TMT joint, lateral calcaneal osteotomy for hind foot[2]

Related articles

Pes valgus - Physiopedia

Definition/Description This text describes pes valgus in children. It is a problem commonly encountered in paediatric
orthopaedics and is generally considered as caused by the collapse of the medial longitudinal arch in the foot. It was found

Charcot-Marie-Tooth disease - Physiopedia

Introduction Charcot-Marie-Tooth disease (CMT) is known as a hereditary motor and sensory neuropathy (HMSN) and is the
most common inherited neuromuscular disease with a prevalence of approximately 1 in every 2,500 [1]. CMT involves the

Metatarsalgia - Physiopedia
Definition Metatarsalgia is a general term for pain in the area of the metatarsophalangeal joints. This is often seen in clinical
practice, the deformity and pain can deteriorate gait function and decrease quality of life[2]. Most common causes include:

Pes Planus - Physiopedia

Definition/Description Pes planus also known as flat foot is the loss of the medial longitudinal arch of the foot, heel valgus
deformity, and medial talar prominence.[1] In lay terms, it is a fallen arch of the foot that caused the whole foot to make

Ponseti method - Physiopedia

Introduction Ignacio Ponseti Vives, MD The Ponseti Method is a conservative and manipulative method that is utilised
worldwide to correct clubfoot or Congenital Talpes Equino Varus (CTEV)[1]. It was developed by Dr. Ignacio.V.Ponseti (1914-

References
23. Gianmarco T., Nicola N., and Guglielmo L.C. "Pes planus and pes cavus in Southern Italy: a 5 years study"
2017 http://www.iss.it/binary/publ/cont/ANN_17_02_10.pdf
(http://www.iss.it/binary/publ/cont/ANN_17_02_10.pdf)

24 Thomas G McPoil, Bill Vicenzino,Mark W Cornwall,Natalie Collins,"Can foot anthropometric measurements

predict dynamic plantar surface contact area?" 2009
https://jfootankleres.biomedcentral.com/track/pdf/10.1186/1757-1146-2-28?
site=jfootankleres.biomedcentral.com (https://jfootankleres.biomedcentral.com/track/pdf/10.1186/1757-1146-2-
28?site=jfootankleres.biomedcentral.com)

1. Foot health facts, Foot & Ankle Conditions » Cavus Foot (High-Arched
Foot)https://www.foothealthfacts.org/conditions/cavus-foot-(high-arched-foot)
(https://www.foothealthfacts.org/conditions/cavus-foot-(high-arched-foot)) (accessed 2017).
2. Physiotherapy-Treatment,orthopedic physical therapy - pes cavus. Available from:
http://www.physiotherapy-treatment.com/pes-cavus.html (http://www.physiotherapy-treatment.com/pes-
cavus.html) . (Accessed 23 April 2020)
3. Turner SN. Pes Cavus. 2018. Available from:https://emedicine.medscape.com/article/1236538-overview
(https://emedicine.medscape.com/article/1236538-overview) (Accessed 23 April 2020)
4. Burns J. Redmond A. Ouvrier R. Crosbie J. Quantification of muscle strength and imbalance in neurogenic
pes cavus, compared to health controls, using hand-held dynamometry. Foot & Ankle International.
26(7):540-4, 2005
5. LIVESTRONG.COM. Pes Cavus (Claw Foot) Health Byte. Available from
https://www.youtube.com/watch?v=coClJ8v6DR8 (https://www.youtube.com/watch?v=coClJ8v6DR8)[last

https://www.physio-pedia.com/Pes_cavus 6/10
10/14/2020 Pes cavus - Physiopedia

accessed 23/4/2020]
6. Shy ME, Blake J, Krajewski K, Fuerst DR, Laura M, Hahn AF, et al. Reliability and validity of the CMT
neuropathy score as a measure of disability. Neurology. 2005; 64: 1209–1214
7. Burns J. Redmond A. Ouvrier R. Crosbie J. Quantification of muscle strength and imbalance in neurogenic
pes cavus, compared to health controls, using hand-held dynamometry. Foot & Ankle International.
26(7):540-4, 2005
8. Troiano G, Nante N, Citarelli GL. Pes planus and pes cavus in Southern Italy: a 5 years study
(http://old.iss.it/binary/publ/cont/ANN_17_02_10.pdf). Ann Ist Super Sanità. 2017;53(2): 142-145.
(evidence 4b)
9. Meehan PL. The cavus foot. In: Morrisy RT editor. Lovell and Winter's Pediatric Orthopaedics, J.B.
Philadelphia:Lippincott, 1990
10. Giannini S, Ceccarelli F, Benedetti MG, Faldini C, Grandi G. Surgical treatment of adult idiopathic cavus
foot with plantar fasciotomy, naviculocuneiform arthrodesis, and cuboid osteotomy. A review of thirty-nine
cases. J Bone Joint Surg Am. 2002; 84-A: 62-9
11. Aktas S, Sussman MD. The radiological analysis of pes cavus deformity in Charcot Marie Tooth disease. J
Pediatr Orthop. 2000; 9: 137-40
12. Jahss MH. Evaluation of the cavus foot for orthopedic treatment. Clin Orthop Relat Res. 1983; 181: 52-63
13. Coleman SS, Chesnut WJ. A simple test for hindfoot flexibility in the cavovarus foot. Clin Orthop Relat Res
1977; 123: 60-2
14. Burns J. Landorf KB. Ryan MM. Crosbie J. Ouvrier RA. Interventions for the prevention and treatment of
pes cavus. Cochrane Database of Systematic Reviews 2007; (4):
CD006154. doi:10.1002/14651858.CD006154.pub2
(https://doi.org/10.1002%2F14651858.CD006154.pub2)
15. Sachithanandam V, Joseph B. The influence of footwear on the prevalence of flat foot. A survey of 1846
skeletally mature persons. J Bone Joint Surg Br. 1995; 77: 254-7
16. Mann DC, Hsu JD. Triple arthrodesis in the treatment of fixed cavovarus deformity in adolescent patients
with Charcot-Marie-Tooth disease. Foot Ankle. 1992;13(1):1–6.
17. Patient, Professional Reference, Pes Cavus. Available from: http://patient.info/doctor/pes-cavus
(http://patient.info/doctor/pes-cavus) (accessed 03 February 2014 ).
18. Burns J. Landorf KB. Ryan MM. Crosbie J. Ouvrier RA. Interventions for the prevention and treatment of
pes cavus. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.:
CD006154. doi:10.1002/14651858.CD006154.pub2
(https://doi.org/10.1002%2F14651858.CD006154.pub2)
19. Barrie JL, McLoughlin C, Robem N, Nuttal R, Lishman J, Wardle F, et al. Ankle instability in pes cavus. J
Bone Joint Surg Br. 2001; 83-B: 339
20. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Risk factors for recurrent stress fractures in
athletes. Am J Sports Med 2001; 29: 304-310
21. Dahle LK, Mueller M, Delitto A, Diamond JE. Visual assessment of foot type and relationship of foot type
to lower extremity injury. J Orthop Sports Phy Ther 1991; 14: 70-74
22. Williams DS, McClay IS, Hamill J. Arch structure and injury patterns in runners. Clin Biomech. 2001a; 16:
341-7
23. Builder MA, Marr SJ. Case history of a patient with low back pain and cavus feet. J Am Podiatr Med Assoc
1980; 70: 299-301
24. Aktas S, Sussman MD. The radiological analysis of pes cavus deformity in Charcot Marie Tooth disease. J
Pediatr Orthop. 2000; 9: 137-40
25. Manoli A, Graham B. The subtle cavus foot, "the underpronator," a review. Foot Ankle Int. 2005; 26: 256-
63
26. Burns J, Crosbie J, Ouvrier R, Hunt A. Effective orthotic therapy for the painful cavus foot: a randomized
controlled trial. Journal of the American Podiatric Medical Association. 2006;96(3):205-11
https://www.physio-pedia.com/Pes_cavus 7/10
10/14/2020 Pes cavus - Physiopedia

: Foot (/Category:Foot) Foot - Conditions (/Category:Foot_-_Conditions)

Conditions (/Category:Conditions)

Sign up to receive the latest Physiopedia news

Enter your email address

Subscribe

Our Partners

https://www.physio-pedia.com/Pes_cavus 8/10
10/14/2020 Pes cavus - Physiopedia

The content on or accessible through Physiopedia is for informational purposes only. Physiopedia is not a
substitute for professional advice or expert medical services from a qualified healthcare provider. Read more
(https://www.physio-pedia.com/Disclaimer)

pPhysiopedia (/home)

oPhysiospot (http://www.physiospot.com/)

+Physioplus (https://members.physio-pedia.com/?
utm_source=physiopedia&utm_medium=footer_logo&utm_campaign=ongoing_internal)

(https://play.google.com/store/apps/developer?id=Physiopedia+Plus+Ltd)

(https://apps.apple.com/us/developer/physiopedia-plus-ltd/id918050316)
Physiopedia

About (/Physiopedia:About)
News (http://www.physiospot.com/)
Courses (https://members.physio-pedia.com/learn/?
utm_source=physiopedia&utm_medium=footer_courses&utm_campaign=ongoing_internal)

https://www.physio-pedia.com/Pes_cavus 9/10
10/14/2020 Pes cavus - Physiopedia

Contribute (/Contribute)
Contact (https://members.physio-pedia.com/pp-contact-us/)
Content

Articles (/Articles)
Categories (/Special:Categories)
Presentations (/Lectures_and_Presentations)
Research (https://www.physiospot.com/research/)
Projects (/Projects)
Legal

Disclaimer (/Disclaimer)
Terms (/Physiopedia:Terms_of_Service)
Privacy (/Physiopedia:Privacy_Policy)
Cookies (/Physiopedia:Cookie_Policy)

(https://twitter.com/physiopedia) (https://www.facebook.com/pages/Physiopedia/304685383112)
(https://www.linkedin.com/company/physiopedia/)
(https://www.youtube.com/channel/UC7rmZeGBZR_oaY9mHvF-41A)
(https://www.instagram.com/thereal_physiopedia/)
© Physiopedia 2020 | Physiopedia is a registered charity in the UK, no. 1173185

Back to top

https://www.physio-pedia.com/Pes_cavus 10/10