Pes cavus

Pes cavus (in medical terminology, also high instep, high arch, talipes cavus, cavoid
foot, and supinated foot type) is a human foot type in which the sole of the foot is
distinctly hollow when bearing weight. That is, there is a fixed plantar flexion of the foot. A
high arch is the opposite of a flat foot, and somewhat less common.

Types
The term pes cavus encompasses a broad spectrum of foot deformities. 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.
Pes cavovarus, the most common type of pes cavus, is seen primarily in neuromuscular
disorders such as "harcot#$arie#Tooth disease, and in cases of un%nown aetiology,
conventionally termed as idiopathic!. Pes cavovarus presents with the calcaneus in
varus, the first metatarsal plantarflexed and a claw#toe deformity. &adiological analysis of
pes cavus in "harcot#$arie#Tooth disease shows the forefoot is typically plantarflexed in
relation to the rearfoot.
'n the 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.
&adiological analysis of pes calcaneocavus reveals a large talo#calcaneal angle.
'n pure! 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.
A combination of any or all of these elements can also be seen in a combined! type of
pes cavus that may be further categori(ed as flexible or rigid.
)espite various presentations and descriptions of pes cavus, all are characterised by an
abnormally high medial longitudinal arch, gait disturbances and resultant foot pathology.
Epidemiology
There are few good estimates of prevalence for pes cavus in the general community.
*hile pes cavus has been reported in between + and +,- of the adult population, there
are several limitations of the prevalence data reported in these studies. Population#based
studies suggest the prevalence of the cavus foot is approximately 10%.
Cause
Pes cavus may be hereditary or ac.uired, and the underlying cause may
be neurological, orthopedic or neuromuscular. Pes cavus is sometimes/but not always
/connected through 0ereditary $otor and 1ensory 2europathy Type 3 ("harcot#$arie#
Tooth disease) and 4riedreich5s Ataxia6 many other cases of pes cavus are natural.
The cause and deforming mechanism underlying pes cavus is complex and not well
understood. 4actors considered influential in the development of pes cavus include
muscle wea%ness and imbalance in neuromuscular disease, residual effects of congenital
clubfoot, post#traumatic bone malformation, contracture of the plantar fascia and
shortening of the Achilles tendon.
Among the cases of neuromuscular pes cavus, 78- have been attributed to "harcot#
$arie#Tooth disease, which is the most common type of inherited neuropathy with an
incidence of 3 per +,788 persons affected. Also %nown as 0ereditary $otor and 1ensory
2europathy (0$12), it is genetically heterogeneous and usually presents in the first
decade of life with delayed motor milestones, distal muscle wea%ness, clumsiness and
fre.uent falls. 9y adulthood, "harcot#$arie#Tooth disease can cause painful foot
deformities such as pes cavus. Although it is a relatively common disorder affecting the
foot and an%le, little is %nown about the distribution of muscle wea%ness, severity of
orthopaedic deformities, or types of foot pain experienced. There are no cures or effective
treatment to halt the progression of any form of "harcot#$arie#Tooth disease.
The development of the cavus foot structure seen in "harcot#$arie#Tooth disease has
been previously lin%ed to an imbalance of muscle strength around the foot and an%le. A
hypothetical model proposed by various authors describes a relationship whereby wea%
evertor muscles are overpowered by stronger invertor muscles, causing an adducted
forefoot and inverted rearfoot. 1imilarly, wea% dorsiflexors are overpowered by stronger
plantarflexors, causing a plantarflexed first metatarsal and anterior pes cavus.
Pes cavus is also evident in people without neuropathy or other neurological deficit. 'n the
absence of neurological, congenital or traumatic causes of pes cavus, the remaining
cases are classified as being idiopathic!, because their aetiology is un%nown.
Pain and disability
As with certain cases of flat feet, high arches may be painful due
to metatarsal compression6 however, high arches/ particularly if they are flexible or
properly cared#for/may be anasymptomatic condition.
People with pes cavus sometimes/though not always/have difficulty finding shoes that
fit and may re.uire support in their shoes. "hildren with high arches who have difficulty
wal%ing may wear specially designed insoles, which are available in various si(es and
can be made to order.
'ndividuals with pes cavus fre.uently report foot pain, which can lead to a significant
limitation in function. The range of complaints reported in the literature include
metatarsalgia, pain under the first metatarsal, plantar fasciitis, painful callosities, an%le
arthritis and Achilles tendonitis.
There are many other symptoms believed to be related to the cavus foot. These include
shoe#fitting problems, lateral an%le instability,
:
lower limb stress fractures, %nee
pain,
:
iliotibial band friction syndrome, bac% pain
:
and tripping.
4oot pain in people with pes cavus may result from abnormal plantar pressure loading
because, structurally, the cavoid foot is regarded as being rigid and non#shoc% absorbent
and having reduced ground contact area. There have previously been reports of an
association between excessive plantar pressure and foot pathology in people with pes
cavus.
Treatment
1urgical treatment is only initiated if there is severe pain, as the available operations can
be difficult. ;therwise, high arches may be handled with care and proper treatment.
1uggested 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 specialised cushioned footwear. ;ther non#surgical rehabilitation
approaches include stretching and strengthening of tight and wea% muscles, debridement
of plantar callosities, osseous mobili(ation, massage, chiropractic manipulation of the foot
and an%le and strategies to improve balance. There are also numerous surgical
approaches described in the literature aimed at correcting the deformity and rebalancing
the foot. 1urgical procedures fall into three main groups:
3. soft#tissue procedures (e.g. plantar fascia release, Achilles tendon lengthening,
tendon transfer)6
+. osteotomy (e.g. metatarsal, midfoot or calcaneal)6
<. bone#stabilising procedures (e.g. triple arthrodesis).