Pes Cavus

Modern Study Review (AI-Generated)

High-Yield Summary

Pes cavus is a complex foot deformity characterized by a persistently high medial longitudinal arch that does not flatten with weightbearing. It often involves a combination of hindfoot varus and forefoot equinus or valgus deformities, resulting from neuromuscular imbalances. Clinically significant due to its association with pain, instability, and progressive deformity, pes cavus requires a tailored approach based on etiology and deformity pattern. Modern management prioritizes restoring a plantigrade, stable foot to optimize pain relief and function.

Key Diagnostic Findings

Current Gold Standard Treatment

Non-Operative Indications:

• Mild deformity without significant pain or instability
• Goals: achieve a plantigrade foot, redistribute plantar pressures
• Methods: stretching, custom-molded semi-rigid orthoses, bracing, physical therapy

Operative Indications:

• Progressive deformity causing pain, instability, or ulceration
• Failure of conservative management
• Neuromuscular imbalance causing fixed deformities

Surgical Options:

• Soft tissue releases (e.g., plantar fascia release)
• Osteotomies: first metatarsal dorsiflexion osteotomy, Dwyer calcaneal osteotomy (lateral column shortening)
• Tendon transfers to rebalance muscle forces (e.g., tibialis anterior or peroneal tendon transfers)
• Arthrodesis (e.g., triple fusion) reserved for rigid, arthritic deformities

Modern Complications & Outcomes

Complications:

• Recurrence of deformity due to persistent neuromuscular imbalance
• Overcorrection leading to flatfoot deformity
• Nonunion or malunion after osteotomies or fusion
• Persistent pain or instability if deformity not fully corrected

Outcomes:

• Successful correction improves pain, gait, and reduces risk of lateral ankle sprains
• Early intervention in neuromuscular cases (e.g., CMT) improves long-term function
• Multidisciplinary approach (orthopaedics, neurology, physical therapy) optimizes results

Classic Clinical Notes

Pes Cavus

Reference: Mann, R., in Surgery of the Foot and Ankle, 6th ed. Chapter 785

Main Message
There is much confusion in the literature about pes cavus. The anatomy is very variable and depends partially on the etiology.

Points of Interest

• Pes cavus – a foot with a high arch that fails to flatten with weightbearing.
• The deformity is either hindfoot, forefoot, or a combination of both.

Bony Deformity – well described in the chapter.

• Hindfoot: increased calcaneal pitch >30°, and varus.
• Forefoot: plantarflexion of the metatarsals, adduction of the forefoot, and forefoot valgus (due to the plantarflexion of the medial rays more than the lateral).
• MTP: clawing of the toes, with dorsal subluxation of the proximal phalanx.

Soft Tissue Deformity

• Plantar aponeurosis contracture. This is probably a result of the bony deformity, but undoubtedly contributes to it once a significant deformity is established.
• With the hindfoot in a vertical, varus position and the forefoot in equinus, adducted, and valgus position, the overall weightbearing surface for the foot is decreased; the main complaint at first may be metatarsalgia!

Pathomechanics

• It is produced by a muscle imbalance involving both the intrinsic and extrinsic muscles of the foot; the actual nature of that imbalance is different among disorders.
• Example: Polio – weak posterior calf musculature, normal anterior musculature – unopposed tibialis anterior pulls up on the medial border of the foot, producing a varus hindfoot. Sometimes also have no extrinsics, and the pull of the intrinsics creates a forefoot equinus, and usually hindfoot varus.
• Example: Charcot-Marie-Tooth disease: opposite from polio. The posterior compartment is normal, the anterior compartment is weak. The forefoot is the result of the pull of peroneus longus – forefoot valgus. Also, tibialis posterior pulls the calcaneus into a varus position.
• Diminished subtalar and forefoot motion results in a decrease in the patient’s ability to absorb the impact of initial ground contact. The cavus foot and decreased plantar surface areas place increased stress on the heel and metatarsal head regions. The hindfoot varus and/or significant forefoot valgus makes the ankle subject to multiple lateral sprains.

Conservative Treatment:

• Goal is to produce a plantigrade foot, with an even distribution of pressure.
• Stretching, well-molded, semiflexible orthosis, short leg bracing.

Surgical Treatment:

• Goal is to produce a plantigrade, stable foot.
• Plantar fascial release
• First Toe Jones procedure
• First metatarsal osteotomy
• Calcaneal osteotomy – Dwyer (lateral column shortening)
• Triple fusion

Last Updated on January 24, 2026 by Christian Veillette