MODULE 2: Foot Pathologies

Session 2: Pes Cavus

INDEX
OBJECTIVE ........................................................................ 3
PES CAVUS ....................................................................... 4
BIBLIOGRAPHY ................................................................. 22

Module 2 Session 2 ___ 3/22

OBJECTIVE
The main goals to be attained by the student during this work session are summarized
in the following points:

Know the different disorders or diseases which lead to a high-arched foot.

Identify the different typologies of Pes Cavus.

Obtain a good knowledge of the biomechanical assessment of the Pes Cavus

diseases.

Know the most relevant quantitative methods for the assessment of Pes Cavus.

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

4/22 ___ Module 2 Session 2

PES CAVUS
Pes cavus is the general term used to describe a high-arched foot. The deformity
consists of several different components, including varying degrees of rearfoot varus,
forefoot equinus, metatarsus adductus and digital deformities.
Pes Cavus is often caused by a neurologic disorder or other medical condition like
cerebral palsy, Charcot Marie Tooth disease, spinal bifida, polio, muscular dystrophy or
stroke. In other cases of Pes Cavus, the high arch may represent an inherited
structural abnormality. (Figure 1)

Figure 1. Pes Cavus 1

In one third of cases Pes Cavus is congenital. Acquired Pes Cavus often occurs due to
neurological abnormalities (Figure 2. Pes Cavus ).
In less serious forms of Pes Cavus there are usually no symptoms and treatment is
put on hold.
In growing children (in the case of rectifiable Pes Cavus) a foot bed is sometimes
prescribed, which should cause the longitudinal arches to collapse, by means of
pressure on the underside of the heel bone and behind (proximal) the heads of the
metatarsals, in combination with pressure on the instep by the shoe (a three-point
pressure).
If a varus tilt of the heel bone occurs in the Pes Cavus, this should be corrected where
possible (Figure 2).
In extreme cases the Pes Cavus is operated on.

Figure 2. Pes Cavus 2

ONLINE TRAINING

Module 2 Session 2 ___ 5/22

BIOMECHANICAL ASSESSMENT
CLINICAL EXPLORATION

This deformity represents an osseous malformation characterized by:

o

Tibia formed in a bowed position.

Subtalar joint formed in such a way that the calcaneus is excessively inverted
when the foot is maintained at its neutral position.

As a result of this deformity, the lower leg is typically unable to assume a

perpendicular position during heel-strike.

The rearfoot varus deformity represents the combined degrees of the tibiofibular
varus and the subtalar varus. A deformity greater than the ideal value of 4 (2 of
the subtalar varum and 2 of the tibiofibular varum) is extremely common on
cavus feet.

Pes Cavus is also represented by a valgus deformity on the forefoot. This deformity
is caused by an osseous abnormality in the talonavicular and calcaneocuboid
joints.

Seriousness of pathology can be decreased when it is a flexible foot (if the intern
longitudinal arch deforms by pushing the 1st metatarsal head upwards,
maintaining the ankle in right angle and the knee in flexion).

Depending on the degree of muscle extensor contracture can be associated claw

toes to cavus foot.

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

6/22 ___ Module 2 Session 2

POSTERIOR FRONTAL VIEW:

Varus position of the heel on loaded foot without neutralized subtalar joint:

Bisector of calcaneus
Obtained from:

Posterior frontal view.

Tools:

Goniometer. Copy pencil.

Definition:

Bisector of calcaneus.

Methodology:

1. Palpate the medial and lateral edge of the two

proximal thirds of the calcaneus.
2. Mark the following three points:

Proximal point.

Distal point.

Central point between the proximal and distal

one.

3. Extend a line linking the three points to include the

distal third of calcaneus (bisector of calcaneus).
4. Measure the angle formed between the bisector of
calcaneus and the vertical axis with help of a
goniometer.
Criteria:

Image:

ONLINE TRAINING

Bisector of calcaneus > 6 of valgus : Calcaneus

valgus

0 < Bisector of calcaneus < 6 of valgus: Range

of normality

Bisector of calcaneus
Calcaneus varus

>

of

varus:

Module 2 Session 2 ___ 7/22

Gait analysis

Initial contact produced on the metatarsal zone instead of on the heel zone.

1st phase

During the second and third gait phases, support is produced on the metatarsal
heads and heel zones.

2nd & 3rd phase

Normal takes off on the metatarsal and toe zones.

4th & 5th phase

If the cavus foot is associated to a claw toes (neurologic cavus foot) the take
off is done without the help of toes because they are dorsally subluxated, and
thus metatarsal heads are overloaded. During the take off there is a strong
contraction of the extensor muscles (not counteracted by the action of the
interbone muscles, as it occurs on a normal foot). Toes lift like claw toes
rubbing the upper part of the toes with the shoe. This causes helomas and
hyperqueratosis that can be very painful.

4th & 5th phase

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

8/22 ___ Module 2 Session 2

FOOTWEAR WEAR-OUT ANALYSIS

Outsole worn out on the zone of the metatarsal heads.

Outsole worn out on the posterioexternal zone of heel.

Shoe counter twisted outwards.

If the patient has claw toes the footwear can be worn out on the upper shoe.

PLANTAR MORPHOLOGY (FOOTPRINTS)

QUALITATIVE EVALUATION:

o
o
o

o
o
o
o

o
o

o
o
o

Pre cavus foot:

Normal shape of the curvature of the internal part of the midfoot.
Intense support on the four internal toes.
Prominence on the external part of the midfoot.
Functional cavus foot:
Almost normal shape of the curvature of the internal part of the midfoot.
Narrower support on the internal part between forefoot and midfoot.
Absence of toes on footprint.
Functional cavus foot are tolerated, but on situations of overuse can cause
metatarsagias and helomas on the 1st and 5th metatarsal heads, as well as
fasciitis and tendonitis.
First grade cavus foot:
Midfoot support < 1/3 of the total foot width.
Appearance of toes support on footprint.
Second grade cavus foot:
Interrupted lateral midfoot support, although prolongations of anterior and
posterior support persist partially.
Third grade cavus foot:
Total absence of the lateral support of the midfoot, including prolongations of
anterior and posterior supports.
Absence of toes on footprints.
Characterized by great retraction of tendons, that causes support place on very
small areas of the rear- and forefoot, and thus, the appearance of painful
helomas and hyperqueratosis.

ONLINE TRAINING

Module 2 Session 2 ___ 9/22

QUANTITATIVE EVALUATION:

Chippaux Index
Obtained from:

Footprint.

Tools:

Conventional or digital podoscope, ink footprint and

photopodogram.

Definition:

Indicates the area of the midfoot on a smooth

surface.

Methodology:

It is measured by dividing the value of the narrower

zone of the midfoot (E) by the value of the parallel
line on the wider zone of the forefoot (D), and
multiplying by 100.
Chippaux Index = 100*E/D

Criteria:

Chippaux criteria:
o

Chippaux Index < 25% Tendency to

cavus foot.

25% < Chippaux Index < 45%: Normality

range

Chippaux Index > 45%: Tendency to

flatness and/or pronation.

Smirak and Viladot criteria:

o

Chippaux Index < 33% Tendency to

cavus foot.

33% < Chippaux Index < 50%: Normality

range.

Chippaux Index > 50%: Tendency to

flatness and/or pronation.

Image:

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

10/22 __ Module 2 Session 2

Staheli Index
Obtained from:

Footprint.

Tools:

Conventional or digital podoscope, ink footprint and

photopodogram.

Definition:

Relation between midfoot and rearfoot.

Methodology:

It is measured by dividing the value of the narrower

zone of the midfoot (E) by the value of the parallel
line on the wider zone of the rearfoot (F).
Staheli Index = E/F

Criteria:

Image:

ONLINE TRAINING

Staheli Index < 0.6: Tendency to cavus foot.

0.6 < Staheli Index < 0.7: Normality range.

Staheli Index > 0.7: Tendency to flatness and/or

pronation.

Module 2 Session 2 __ 11/22

Clarke Index
Obtained from:

Footprint.

Tools:

Conventional or digital podoscope, ink footprint and

photopodogram.

Definition:

Objective method for measuring internal longitudinal

arch.

Methodology:

Angle between lines A, that joins the more internal

point of the forefoot and the more internal point of
the rearfoot, with line B, that joins the more internal
point of the forefoot with the deeper part of the
footprint.

Criteria:

Clarke Angle < 31: Tendency to flatness and/or

pronation.

31 < Clarke Angle < 45: Normality range.

Clarke Angle > 45: Tendency to cavus foot.

Image:

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

12/22 __ Module 2 Session 2

Hernndez Corvo Index

Obtained from:

Footprint.

Tools:

Conventional or digital podoscope, ink footprint and

photopodogram.

Definition:

Indicates a classification of the foot depending on the

shape of the footprint.

Methodology:

1. Draw a line tangent to the more internal point of

the forefoot (point 1) and the more internal point of
the rearfoot (point 1). This line is named as initial
trace.
2. Detect the upper point of the forefoot (point 2) and
the lower point of the rearfoot (point 2).
3. Draw a perpendicular line to the initial trace
passing by point 2 and another one passing by point
2.
4. The distance on the initial trace between point 1
and point 2 is named as fundamental mean. This
distance must be noted down and copied along the
initial trace as many times as fit on the footprint.
5. Draw lines 3, 4 and 5, perpendicular to the initial
trace.
6. On the external part of the footprint, draw following
lines:

Line 6: perpendicular to line 3, and below line 3.

Line 7: perpendicular to line, 4 and below line 4.

Line 8: perpendicular to line 5, and below line 5.

7. Measure value of X or forefoot width, that is the

distance between the initial trace and line 6, parallel
to line 3.
8. Draw line 9, perpendicular to line 4 and line 5, that
pass by the more internal point of the footprint
between line 4 and line 5.
9. Measure value of Y or midfoot width, that is the
distance between line 7 and line 9, parallel to line 4.
10. Measure distance AY, from line 9 to the initial
trace (it is the complementary distance to Y).
11. Measure value of TA or rearfoot width, that is
the distance between the initial trace and line 8,

ONLINE TRAINING

Module 2 Session 2 __ 13/22

Hernndez Corvo Index

parallel to line 5.
12.- Apply following formula:
Hernndez Corvo Index = 100*(X-Y)/X
Criteria:

0% < Hernndez Corvo Index < 34%: Flat foot.

35% < Hernndez Corvo Index < 39%: Flat foot

Normal foot.

40% < Hernndez Corvo Index < 54%: Normal

foot.

55% < Hernndez Corvo Index < 59%: Normal

foot Cavus foot.

60% < Hernndez Corvo Index < 74%:

Cavus foot.

75% < Hernndez Corvo Index < 84%:

Strong Cavus foot.

85% < Hernndez Corvo Index < 100%:

Extreme Cavus foot.

Image:

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

14/22 __ Module 2 Session 2

X-RAY
LATERAL VIEW ON LOADED FOOT:

Djian Annonier or medial frame angle

Obtained from:

Lateral view. Loaded foot.

Tools:

X-ray.

Definition:

Angle formed by the following axis:

Criteria:

Image:

ONLINE TRAINING

First longitudinal Metatarsal axis.

Calcaneal axis.

Djian Annonier angle < 115: Cavus foot.

115 < Djian Annonier angle < 135: Normality

range.

Djian Annonier angle > 135: Flat foot.

Module 2 Session 2 __ 15/22

Meary-Tomeno line or Shade line

Obtained from:

Lateral view. Loaded foot.

Tools:

X-ray.

Definition:

Line that passes through the middle points of the

neck and the head of the Talus.

Criteria:

ormal foot: when the projection of the MearyTomeno line or Shade line passes through the axis
of the Navicular, 1st Cuneiform and 1st Metatarsal.

Anterior cavus foot:

Meary-Tomeo line > 10
Inclination angle of the calcaneus < 30
Meary-Tomeo lines intersect on the 1st
metatarsal base or on the Lisfranc joint

Posterior cavus foot:

Meary-Tomeo line < 10
Inclination angle of the calcaneus > 30
Meary-Tomeo lines intersect proximally to
Chopart joint.

Image:

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

16/22 __ Module 2 Session 2

External Moreau-Costa-Bertani angle

Obtained from:

Lateral view. Loaded foot.

Tools:

X-ray.

Definition:

Angle formed by the following lines:

Criteria:

Image:

ONLINE TRAINING

Line formed from the lower point of the 5th

Metatarsal to the lower point of the Calcaneocuboid
joint.

Line formed from the lower point of the

Calcaneocuboid joint to the lower point of the
posterior calcaneal tuberosity.

145: Normal value.

< 145: Pes Cavus.

Module 2 Session 2 __ 17/22

Talus- 1st Metatarsal angle

Obtained from:

Lateral view. Loaded foot.

Tools:

X-ray.

Definition:

Angle formed by the Talus axis and the axis of the 1st
Metatarsal.

Criteria:

-4 < Talus-1st Metatarsal angle < +4: Normality

range.

Talus-1st Metatarsal angle > 4: Pes Cavus.

Image:

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

18/22 __ Module 2 Session 2

Hibbs angle
Obtained from:

Lateral view. Loaded foot.

Tools:

X-ray.

Definition:

Angle formed by the following lines:

Criteria:

Image:

ONLINE TRAINING

Diafisis axis of the 1st Metatarsal.

Calcaneal axis.

Hibbs angle < 130: Pes Cavus.

130 < Hibbs angle < 160: Normality range.

Hibbs angle > 160: Pes Planus.

Module 2 Session 2 __ 19/22

Obliqueness of the metartarsals related to the

ground
Obtained from:

Lateral view. Loaded foot.

Tools:

X-ray.

Definition:

Angle formed by one of the longitudinal Metatarsal

axis and the ground. There is one Obliqueness angle
per Metatarsal bone.

Criteria:

20: Normality value of the Obliqueness angle of

the 1st Metatarsal.

15: Normality value of the Obliqueness angle of

the 2nd Metatarsal.

10: Normality value of the Obliqueness angle of

the 3rd Metatarsal.

8: Normality value of the Obliqueness angle of

the 4th Metatarsal.

5: Normality value of the Obliqueness angle of

the 5th Metatarsal.

Image:

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

20/22 __ Module 2 Session 2

DORSOPLANTAR VIEW ON LOADED FOOT:

Kite Angle
Obtained from:

Dorsoplantar view. Loaded foot.

Tools:

X-ray.

Definition:

Angle formed by the longitudinal axis of the Calcaneus

and the Talus.

Criteria:

Kite Angle < 15: Tendency to supine

rearfoot.

15 < Kite Angle < 25: Normality range.

Kite Angle > 25: Tendency to prone rearfoot.

Image:

ONLINE TRAINING

Module 2 Session 2 __ 21/22

VALIDATION
The use of the proper orthotic solution should relax structures (like plantar fascia and
muscles), reduce overpressures in metatarsal heads and heel area, provide comfort,
and in consequence, reduce foot pain and normalize gait.

BAROPODOMETRY (PRESSURE INSOLES)

A proper orthotic solution tends to relax structures, increasing the support surface and
favouring a homogeneous distribution of loads and pressures.
Changes the ground-foot reaction force, originates a series of force vectors which
actuate obliquely to the ground in front of the calcaneus, and helps the correction of
the deformity. The retrocapital bar relieves the hyperpressure areas at metatarsal
heads level and rise them since it applies forces oblique to the ground, which causes
the flattening of the foot.

Biomechanical assessment of foot pathologies, and design and manufacture of orthotic solutions

22/22 __ Module 2 Session 2

BIBLIOGRAPHY
1. J.L. Moreno de la Fuente; Podologa general y biomecnica, Masson (2003)
Barcelona, Spain.
2. Thomas C. Michaud D.C. Newton, Massachusetts. Foot Orthoses, and other
formas of conservative foot care. Williams & Wilkins (1993). Baltimore, USA.
3. A.Chevrot; Diagnstico por imagen de las afecciones del pie, Masson, 2000
Barcelona, Spain.
4. M. Nez-Samper, L.F. Llanos; Biomecnica, medicina y ciruga del pie. Masson
(2007), 2ed Barcelona, Spain
5. R. Viladot, O.Cohi, S. Clavell; Ortesis y prtesis del aparato locomotor. 2.1.
Extremidad inferior; Masson (1987) Barcelona, Spain.
6. American Academy of Orthopaedic Surgeons. Atlas of orthotics. Biomechanical
principles and application. The C.V. Mosby Company (1985). ST. Louis,
Toronto, Princeton.
7. Enrique Viosca, MFrancisca Peydro, Antonio Puchol, Carlos Soler, Jaime Prat,
Aleixandre Corts, Javier Snchez, Juan M. Belda, Rubn Lafuente, Raquel
Poveda. Gua de uso y prescripcin de productos ortoprotsicos a medida
Instituto de Biomecnica de Valncia (1993). Valencia, Spain.
8. Ronald L. Valmassy, DPM, MS. Clinical biomechanics of the lower extremities.
Mosby- Year Book, Inc. (1996)
9. Andr-R. Baehler. Tcnica ortopdica: indicaciones. Tomo I: Biomecnica
Extremidad inferior. Masson (1999). Barcelona, Spain.
10. Donald Lorimer, Gwen French, Maureen ODonnell, J. Gordon Burrow. Neales
Disorders of the foot. Diagnosis and Management sixth edition. Churchill
Livingstone (2002).
11. Gerald F. Harris, Peter A. Smith, Richard M. Marks. Foot and ankle motion
analysis. Clinical treatment and technology. Taylor &Francis Group (2008).
12. A. I. Kapandji. Fisiologa articular. Tomo 2: Miebro inferior. 5th edition. Editorial
medica Panamericana (1998).
13. NVOS-Orthobanda. ORTHOPEDISCHE SCHOENTECHNIEK. Boek 2 Orthopedie.
Uitgeverij De Dienst (2002)

ONLINE TRAINING