19/04/12

Pes Cavus

Medscape Reference Reference

News Reference Education MEDLINE

Pes Cavus
Author: Norman S Turner, MD; Chief Editor: Jason H Calhoun, MD, FACS more... Updated: Feb 11, 2010

Background
Pes cavus, as shown in the images below, 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, midfoot, hindfoot, or a combination of these sites.[1]

Pes cavus with severe hindfoot involvement.

Pes cavus with plantarflexion of the first ray.

Recent studies
Sugathan et al treated lesser-toe clawing in 11 feet (8 patients) with flexible pes cavus using a modified Jones procedure. At the final clinical review, all 11 feet were improved, with minor complications in 6 of the feet. The mean Bristol Foot Score was 27 (range, 16-55), and the mean modified American Orthopaedic Foot and Ankle Society Midfoot Score was 76 (range, 47-90), which indicated excellent results. Half of the patients had mild persistent foot
emedicine.medscape.com/article/1236538-overview#showall 1/5

19/04/12

Pes Cavus

pain, but all were satisfied with the outcome. The authors therefore concluded that the modified Jones procedure yields satisfactory correction of lesser toe clawing in patients with flexible pes cavus.[2] Naudi et al reported radiologic and clinical results with anterior tarsectomy in 39 cases (33 patients) of pes cavus. Pain decreased considerably in 75% of cases, and 68% of patients recovered normal activity. The foot was aligned correctly in 67% of cases, but at last follow-up, pes cavus remained undercorrected in 80%. In 74% of feet, adjacent joints showed progressive osteoarthritic degeneration. Subjectively, 70% of patients were very satisfied or satisfied with minor reservations, and objective outcome was excellent or good in 66% of feet. According to the authors, the overall results of the study showed that outcome in terms of function, motion, complications and satisfaction was good, but pain relief results were poor. They added that anterior tarsectomy is able to correct initial pes cavus deformity and compensate anomalies of the hindfoot, but its correction capacity is limited and its efficacy in case of clawfoot is poor.[3]

Problem
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.

Etiology
The etiology of pes cavus can be identified approximately 80% of the time. The causes include malunion of calcaneal or talar fractures, burns, sequelae resulting from compartment syndrome, residual clubfoot, and 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,[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 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 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 gastrocsoleus complex. This leads to a marked increase in the calcaneal pitch angle with normal forefoot alignment.

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

Presentation
The presentation for patients with pes cavus is quite variable, based largely on the extent of deformity. Patients can present with lateral foot pain from increased weight bearing on the lateral foot.[10] Metatarsalgia is a frequent
emedicine.medscape.com/article/1236538-overview#showall 2/5

19/04/12

Pes Cavus

symptom, as is symptomatic intractable plantar keratosis. Ankle instability can be a presenting symptom, especially in patients with hindfoot varus and weak peroneus brevis muscles. Weakness and fatigue can be observed in patients with neuromuscular disease. The severity of the presenting symptoms 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, foot positioning is analyzed, 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. 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-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. A neurologic examination is required, specifically including detailed muscle strength testing. Sensory examination reveals deficits that can be observed in CMT disease.

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.

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

Contraindications
An absolute contraindication to surgery is poor vascularity. Revascularization should be performed prior to 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.

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, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, MidAmerica Orthopaedic Association, and Minnesota Medical Association Disclosure: Nothing to disclose. Specialty Editor Board 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
emedicine.medscape.com/article/1236538-overview#showall 3/5

19/04/12

Pes Cavus

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, and Florida Medical Association Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Senior Pharmacy Editor, eMedicine Disclosure: eMedicine Salary Employment Shepard R Hurwitz, MD Executive Director, American Board of Orthopaedic Surgery Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association Disclosure: Nothing to disclose. Dinesh Patel, MD, FACS Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons Disclosure: Nothing to disclose. Chief Editor Jason H Calhoun, MD, FACS Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center 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, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association Disclosure: Nothing to disclose.

References
1. Wapner KL, Myerson MS. Pes cavus. In: Myerson MS, ed. Foot and Ankle Disorders. Philadelphia, Pa: WB Saunders; 2000:919-941. 2. 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. Nov-Dec 2009;48(6):637-41. [Medline]. 3. 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. Jun 2009;95(4):293-300. [Medline]. 4. Gallardo E, Garca 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. Feb 2006;129(Pt 2):426-37. [Medline]. 5. Holmes JR, Hansen ST Jr. Foot and ankle manifestations of Charcot-Marie-Tooth disease. Foot Ankle. Oct 1993;14(8):476-86. [Medline]. 6. Sabir M, Lyttle D. Pathogenesis of Charcot-Marie-Tooth disease. Gait analysis and electrophysiologic, genetic, histopathologic, and enzyme studies in a kinship. Clin Orthop. Apr 1984;(184):223-35. [Medline].
emedicine.medscape.com/article/1236538-overview#showall 4/5

19/04/12

Pes Cavus

7. Sabir M, Lyttle D. Pathogenesis of pes cavus in Charcot-Marie-Tooth disease. Clin Orthop. May 1983; (175):173-8. [Medline]. 8. Mann DC, Hsu JD. Triple arthrodesis in the treatment of fixed cavovarus deformity in adolescent patients with Charcot-Marie-Tooth disease. Foot Ankle. Jan 1992;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. Jul 2009;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). Nov 2005;20(9):877-82. [Medline]. 11. 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]. 12. Crosbie J, Burns J. Predicting outcomes in the orthotic management of painful, idiopathic pes cavus. Clin J Sport Med. Sep 2007;17(5):337-42. [Medline]. 13. Alexander IJ, Johnson KA. Assessment and management of pes cavus in Charcot-Marie-tooth disease. Clin Orthop. Sep 1989;(246):273-81. [Medline]. 14. Jahss MH. Evaluation of the cavus foot for orthopedic treatment. Clin Orthop. Dec 1983;(181):52-63. [Medline]. 15. Paulos L, Coleman SS, Samuelson KM. Pes cavovarus. Review of a surgical approach using selective softtissue procedures. J Bone Joint Surg Am. Sep 1980;62(6):942-53. [Medline]. 16. Mubarak SJ, Van Valin SE. Osteotomies of the foot for cavus deformities in children. J Pediatr Orthop. AprMay 2009;29(3):294-9. [Medline]. 17. Mann RA. Pes cavus. Pes cavus. In: Mann RA, Coughlin MJ, eds. Surgery of the Foot and Ankle. 6th ed. St. Louis, Mo: Mosby-Year Book; 1993:785-801. 18. Mulier T, Dereymaeker G, Fabry G. Jones transfer to the lesser rays in metatarsalgia: technique and longterm follow-up. Foot Ankle Int. Oct 1994;15(10):523-30. [Medline]. 19. Watanabe RS. Metatarsal osteotomy for the cavus foot. Clin Orthop. Mar 1990;(252):217-30. [Medline]. 20. Groner TW, DiDomenico LA. Midfoot osteotomies for the cavus foot. Clin Podiatr Med Surg. Apr 2005;22(2):247-64, vi. [Medline]. 21. Chatterjee P, Sahu MK. A prospective study of Japas' osteotomy in paralytic pes cavus deformity in adolescent feet. Indian J Orthop. Jul 2009;43(3):281-5. [Medline]. 22. Siffert RS, del Torto U. "Beak" triple arthrodesis for severe cavus deformity. Clin Orthop. Dec 1983; (181):64-7. [Medline]. 23. Wetmore RS, Drennan JC. Long-term results of triple arthrodesis in Charcot-Marie-Tooth disease. J Bone Joint Surg Am. Mar 1989;71(3):417-22. [Medline]. 24. Roper BA, Tibrewal SB. Soft tissue surgery in Charcot-Marie-Tooth disease. J Bone Joint Surg Br. Jan 1989;71(1):17-20. [Medline]. 25. Gould N. Surgery in advanced Charcot-Marie-Tooth disease. Foot Ankle. Mar-Apr 1984;4(5):267-73. [Medline]. Medscape Reference 2011 WebMD, LLC

emedicine.medscape.com/article/1236538-overview#showall

5/5