Pes cavus.pdf

Dr. Anjaly Anna Biju (PT)
PES CAVUS
PREPARED BY,
ANJALY ANNA BIJU

CONTENTS
• Definition
• Relevant anatomy
• Epidemiology
• Etiology
• Types
• Pathoanatomy
• Clinical features
• Assessment
• Special test
• Radiological features
• Management
• References

DEFINITION
Pes cavus of foot with an
exaggeration of the longitudinal
arch of the foot

Synonyms
Talipes cavus
1
Cavoid foot
2
High arched foot
3 Claw foot
6
Talipes plantaris
4
Contracted foot
5

Associated deformities
01 Forefoot adduction & PF
02 Mid foot high pitched
03 Hind foot varus
04 Contracture of plantar fascia
05 Plantar flexion of 1st ray
07 Cock up deformity-Thumb
06 Clawing of toes
08 High calcaneal pitch

Clinically, Pes cavus is an
abnormal elevation of the
medial arch in weight
bearing
Biomechanically, Pes cavus
is a varus hind foot, high
calcaneal pitch, high pitched
mid foot, PF & adducted
forefoot
RE DEFINE

RELEVANT ANATOMY
HIND FOOT
MID FOOT
FORE FOOT
Phalanges
Metatarsals
Navicular
3 Cuneiforms
Cuboid
Calcaneum
Talus
Tibia & fibula

PF DF Invertors Evertors
• Gastronemius
• Soleus
• Tibialis
posterior
• Peroneus
longus
• Peroneus
brevis
• FDL
• FHL
• Tibialis
anterior
• Peroneus
tertius
• EDL
• EHL
• Tibialis
posterior
• Tibialis
anterior
• Gastronemius
• Soleus
• Peroneus
longus
• Peroneus
tertius
• Peroneus
brevis

Arches of foot
Longitudinal Transverse
Medial
Lateral
Anterior
Posterior

Arch Composition Key stone Muscle support Others
Medial
longitudinal arch
(MLA)
• Calcaneus
• Navicular
• Talus
• 3
Cunieforms
• 3 medial
Meta tarsals
Talar head • Tibialis anterior
• Peroneus
longus
• FHL
• Plantar fascia
• Spring ligament
• Plantarligament
s
Higher than
lateral arch
Lateral
longitudinal arch
(LLA)
• Calcaneus
• Cuboid
• 2 Lateral
meta tarsals
Cuboid • Peroneus
longus & brevis
• Short plantar
muscles
• Plantar
ligaments
• Plantar fascia

Functions of arches of foot
Acts as a shock absorber
Concavity of the arch protects the soft tissues of the sole
Acts as a lever to propel the body forward in walking, running…
Serve as an adaptable, supportive base for the entire body

Tripod
1st metatarsal head
5th metatarsal head
Calcaneus

EPIDEMIOLOGY
Between 2-29% of adult population has been reported pes
cavus
Approximately 10 % is the prevalence
There is no known gender difference for pes cavus

ETILOGY
1
Neurological
• Charcot Marie tooth
(CMT) disease
• Spinal dysraphism
• Poliomyelitis
• Parkinson's disease
• Syringomyelia
• ALS
• CP
• Spinal cord tumors
2
Traumatic
• Compartment
syndrome
• Talar neck malunion
• Burns
• Peroneal nerve injury
• Hind foot instability
• Distal tibial fracture
• Calcaneal malunion
3
Idiopathic
• RA
• Ankle OA
• Diabetic foot syndrome

ETILOGY (Cont)
Untreated club
foot 01
Contracture of plantar
fascia
02
Shortening of
TA tendon
03
Muscle weakness-
Intrinsic foot muscle &
PF
04

PATHOANATOMY

Forefoot driven pes cavus
Caused by neurological diseases
and is the result of muscular
imbalances
Weak tibialis anterior, intrinsic foot
muscles, and peroneus brevis are
overpowered by a stronger peroneus
longus and posterior tibialis
The attachment of the peroneus longus
at the metatarsals and medial
cuneiform results in plantar flexion of
the first ray and forefoot adduction
When a foot with fixed forefoot pronation
bears weight, the hindfoot is forced to
counter-correct into varus, in order to
restore the tripod

Forefoot driven pes cavus
As the deformity develops, the
Achilles tendon may eventually
act as an invertor of the foot and
will shorten over time
The unopposed contracture of the
tibialis posterior and peroneus
longus will lead to subtalar joint
inversion
During gait- compensatory heel varus,
a locked midfoot & forefoot PF &
decreased shock absorption

Hindfoot driven pes cavus
Due to the result of trauma
includes malunited fractures of
distal tibia, talar neck, calcaneum
The varus deformity will result
over time as an attempt to obtain
a plantigrade foot by
compensation through the
subtalar joint

Clawing of the toes
Weak intrinsic muscles
Uncontrolled action of the
long toe flexors
Clawing of toes
Cock up deformity
Occur at MTP joint
Due to the over pull of the
FDL & shortening of plantar
fascia

TYPES
Pes cavovarus
1
Most common type
Seen primarily in neuromuscular disorders
Present with calcaneum in varus, 1st metatarsal in PF & claw toe deformity

TYPES
Pes calcaneocavus
2
Seen primarily following paralysis of the triceps surae due to poliomyelitis
The calcaneus is dorsiflexed & forefoot is plantar flexed
X ray reveals large talo-calcaneal angle

TYPES
Pes cavus
3
The calcaneum is neither dorsi flexed nor in varus
Highly arched foot due to a plantar flexed position of the forefoot on
the rear foot
May be further categorized as flexible or rigid

CLINICAL FEATURES
Pain
1
Instability
2
Difficulty walking
3
Plantar fascitis
4
Metatarsalgia
5
Painful callosities
6
LL Stress fracture
7
Painful bony prominence
8

CLINICAL FEATURES
Knee pain
01
Back pain
02
Clawed toes
03
Cock up
deformity of
thumb
04

ASSESSMENT
C/C
Frequent ankle sprain
Pain in the foot arch due to increased stress on one part of the foot
Occasionally knee pain
Shoes that do not fit any more or wear out quickly
Pain over the bony prominence
Painful calluses
Common sites of pain are; cuboid region, heel, 1st MT head, lateral foot

HISTORY
History of trauma, burn injury
Family history of similar deformities
Medical history for OA,RA, diabetes & other neurological conditions
Type- Dull aching
P/F- Prolonged standing, daily activities

O/O
• Shape & symmetry of
the foot
• Skin & soft tissue for
callosities
• Foot posture & arches
• Deformities- claw toes,
cockup deformity of
thumb
• Hairy patches or dimples
– spinal dysraphism
• Scoliosis- CMT
• Peak-a- boo heel
• Muscle atrophy
O/P
• Bony alignment of the
foot
• For stress fractures of 5th
metatarsals
• Tenderness
O/E
• ROM
• Muscle tightness
• Gait
• Detailed neurological
examination- reflexes,
sensation, proprioception

‘Peak a boo’ heel
• Ability to see the heel pad easily from the
front when the patient stands on both the
feet
• In a normal foot it is not visible due to the
natural valgus alignment of the hind foot

SPECIAL TEST
Coleman block test
Aim:
To determine whether the hindfoot varus deformity is fixed or flexible
Procedure:
• Placing a roughly 1-inch block under the lateral side of the forefoot and heel
• The first metatarsal head should hang off the edge of the block
• The examiner must then evaluate the hindfoot to determine if removing the first metatarsal’s
deforming effects has allowed the hindfoot to correct from varus to valgus
Interpretation:
• If the hindfoot varus does not correct, the deformity is rigid & requires surgical correction
• If the block test restores hindfoot valgus, then the deformity is flexible and driven by the
forefoot

RADIOLOGICAL EXAMINATION
X- Ray
Weight bearing views of the foot & ankle
1
Evaluate the position of inferior aspect of the medial cuneiform & 5th metatarsal base on
lateral view
Calcaneal axial view- For hind foot evaluation
When the 5th metatarsal base is closer to the floor, the foot is in cavus

2 Meary’s angle
A line measured along the long axis of the talus and first metatarsal, is normally zero
But in the cavus foot, the first metatarsal is plantarflexed,- increasing the angle
A mild cavus foot may have a Meary’s angle of 5-10°, with severe cavus feet having
angles >20°

3 Hibb angle
This is a measurement between the longitudinal axis of the calcaneus and first
metatarsal
Values in normal feet are generally less than 45 degrees
In patients in pes cavus deformities, the angle is often greater than 90 degrees

4 Talocalcaneal angle on the AP view
The angle between lines drawn down the axis of the talus and calcaneus measured on
a weight-bearing foot radiograph
In a normal foot the angle is twenty to 40°
When the angle is decreased, this indicates that the talus and calcaneus are more
parallel, and the foot is in cavus

5
The angle of the medial arch
This angle is measured from where the calcaneus rests against the ground, to the
talonavicular joint at the apex and to the medial sesamoid where it contacts the ground
again
In cavus foot the angle is less than 120°
Djian-Annonier angle

6
The angle made between the line from the plantar surface of the calcaneus to the
inferior surface of the 5th metatarsal head
Normal range of calcaneal pitch 18–32°
In cavus foot the angle increases
Calcaneal angle

CT
For evaluation of the joints for arthrosis for surgical planning and a
complete evaluation of the hindfoot position
MRI
Evaluation of the lateral ligamentous complex, peroneal tendon
pathology, osteochondral lesions, and evaluation of fifth metatarsal
base fractures

Conservative PT management

1 Pain controlled by a suitable modality- Faradic foot bath & hot packs
3 A small sand bag is placed over the dorsum of the foot
OR
Self stretching by placing the heel of the normal foot over the dorsum the
deformed one
4 Weight of the sand bag or normal foot offers a passive stretch to the
contracted plantar fascia
2
Anti inflammatory medications, Medications for spasticity (Baclofen,
Dantrolene)

5 Dorsiflexion combined with toe extension- Offers a stretching effect to the
longitudinal arch
6 Resisted toe extension – For preventing clawing of the toes
7 Activity modification
8 Strengthening of DF
7 Stretching - Gastronemius

9 Corrective shoes with soft padding – To encourage weight bearing over the
arch
• Custom orthoses – For milder symptoms
• Restrictive orthoses- For rigid & severe deformities
• Eg: Arizona brace

Surgical management

Steindler’s operation
All the muscles on the under surface of the calcanuem &
plantar fascia are divided
The divided muscles slide forward & get attached to the
bone distally
Thus, cavus position is corrected
A below knee POP cast applied in corrected position for 3-4
weeks

Steindler’s release
Lambrinudi’s operation

Lambrinudi’s operation
Arthrodesis of IP joints to correct clawing
Plantar fascia is divided along with the tendons of EDL
The foot is then stretched, Deformity is corrected & immobilized in
plaster cast for 3-4 weeks
Fasciotomy
Balancing of the muscular forces is recommended to avoid fusion
failure

Posterior tibial tendon may be transferred to the dorsum of
the foot to augment the weak tibialis anterior
Peroneus longus may also be transferred to the peroneus
brevis to reduce the pull on the first ray and to reduce PF
Tendon transfers

Gastrocnemius recession for the correction of hind foot
deformities
First metatarsal dorsiflexion osteotomy for fore-foot driven
cavus
Soft tissue releases
Osseous alignment procedures

Post surgical PT management

1 Exercises to joints free from immobilization
3 Stretching to flatten longitudinal arch
2 On removal of POP- Active exercises to MTP , IP Joints, ankle & foot
4 Friction massage for surgical scars
5 Re educating the muscles (Strengthening)

REFERENCES
Essentials of orthopedics & applied physiotherapy, Jayant
joshi
Pes Cavus
Travis J. Seaman; Thomas A. Ball, 2022.

Pes cavus.pdf

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