Deformities observed with Pes cavus includes : *clawing of the toes *posterior hind foot deformity (described as an increased calcaneal angle) *contracture of the plantar fascia *cock-up deformity of the great toe Following References were used to prepare this powerpoint presentation which makes the slides accurate and relaible for studying purpose; Therapeutic Exrercise – Carolyn Kisner Orthopaedic Physical Assessment – Magee Orthopaedic Medicine – L. Ombregt Campbell’s Operative Orthopaedics Slides includes following headings; DEFINITION TYPES ORTHOPAEDIC ASSESSMENT MEDICAL MANAGGEMENT PHYSIOTHERAPY MANAGEMENT SURGICAL MANAGEMENT

1. PES CAVUS
SALONI PATIL ( 3RD YEAR BPT )

2. SYNONYMS
 Talipes Cavus
 Cavoid Foot
 High-arched Foot
 Ṣupinated Foot Type

3. INDEX
DEFINITION
TYPES
ORTHOPAEDIC ASSESSMENT
MEDICAL MANAGGEMENT
PHYSIOTHERAPY MANAGEMENT
SURGICAL MANAGEMENT
REFRENCES

4. DEFINITION
 Pes cavus is a foot with an abnormally high plantar longitudinal arch.
 Associated deformities observed with Pes cavus includes :
*clawing of the toes
*posterior hind foot deformity (described as an increased calcaneal angle)
*contracture of the plantar fascia
*cock-up deformity of the great toe
 This can cause increased weight bearing for the metatarsal heads and associated Metatarsalgia and calluses

5. TYPES OF PES CAVUS
 Pes Cavovarus :
*seen primarily in neuromuscular disorders such as Charcot-Marie-Tooth disease.
*Pes cavovarus presents with the calcaneus in varus, the first metatarsal plantarflexed, and a claw-toe deformity.
*Radiological analysis of pes cavus in Charcot-Marie-Tooth disease shows the forefoot is typically plantar flexed in relation to the rear foot.
 Pes Calcaneocavus :
*which is seen primarily following paralysis of the Triceps Surae due to poliomyelitis, the calcaneus is dorsi-flexed and the forefoot is plantar-flexed.
*Radiological analysis of pes calcaneocavus reveals a large talo-calcaneal angle.
 Pes Cavus :
*the calcaneus is neither dorsi-flexed nor in varus and is highly arched due to a plantar-flexed position of the forefoot on the rear-foot.
*A combination of any or all of these elements can also be seen in a ‘combined’ type of pes cavus that may be further categorized as flexible or rigid.

6. ETIOLOGY
CAVOVARUS
 Charcot-Marie Tooth
 Myelomeningocoele (S1)
 Friedreich’s ataxia
 Muscular dystrophy
 Polyneuritis
 Compartment syndrome
 Trauma
 Residual clubfoot
CALCANEOCAVUS
 Myelomeningocoele (L5 with weak S1)
 Poliomyelitis
 CP
CAVUS (PLANTARIS)
 Weakness of calf musculature

7. ORTHOPAEDIC ASSESSMENT
A] DEMOGRAPHIC DATA
B] CHIEF COMPLAINT
 Patients complains of pain , instability , difficulty walking and problems with footwear.
 The symptoms vary with the degree of deformity.
 Also presents with lateral foot pain from increased weight bearing on the lateral foot

8. C] HISTORY
• The presentation for patients with pes cavus is highly variable, depending largely on the extent of the deformity.
• Patients can present with lateral foot pain from increased weightbearing on the lateral foot.
• Metatarsalgia is a frequent symptom. Ankle instability can be a presenting symptom, especially in patients with hindfoot
varus and weak peroneus brevis.
• Weakness and fatigue can be observed in patients with neuromuscular disease.
• 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.
• Patients should be questioned about weakness/clumsiness, indicating intrinsic muscle involvement.

9. D] BODY CHART
Area – Foot and Ankle
Onset – Gradual / Insidious
Type – Dull Aching
Depth – Deep
Constancy – Intermittent

10. E] AGGRAVATING FACTOR – prolonged standing and during activities of daily living.
F] RELIEVING FACTOR – Rest
G] SEVERITY – Vas Scale
H] IRRITABILITY – Moderate
I] 24 HOURS PATTERN
J] PAST HISTORY – Ask for any h/o trauma
K] MEDICAL HISTORY – Charcot-Marie-Tooth disease
L] FAMILY HISTORY – Clinically significant

11. M] SOCIAL HISTORY – Work / Sports / Hobbies affected
N] ECONOMIC HISTORY – Modified KuppuSwamy Scale.
OBJECTIVE ASSESMENT
OBSERVATION
POSTURE –
• Observe foot posture in standing and arch posture
• Subtle evidence of foot drop may be evident, if there is calf wasting (stork leg deformity)
MOTOR EXAMINATION
• Rigidity maybe present [ Modified Ashworth Scale ]

12. GAIT
The feet should be examined –
with the patient walking and standing –
both from the front and behind.
• Recruitment of secondary ankle
dorsiflexors (cock-up toes in swing
phase).
During the gait cycle,
• The foot remains locked in hindfoot
inversion and forefoot varus throughout
the stance phase, causing less stress
dissipation.
• This can result in metatarsalgia, stress
fracture of the fifth metatarsal, plantar
fasciitis, medial longitudinal arch pain,
ilio-tibial band syndrome and instability

13. ROM TESTING
*AROM and PROM - ankle, subtalar joint, midfoot, forefoot and toes.
*Lower limb muscle length Test
FUNCTIONAL ASSESMENT
(Oswetry disability index - ODI)
(Patient specific functional scale – PSFS)
ROM
• The mobility of the subtalar joint/hindfoot is assessed by the block test described by Coleman.
• The patient’s heel and lateral border are placed on a block approximately 2.5 cm thick. The first to
third/fourth metatarsals are allowed to fall into pronation, eliminating their effect on the tripod.
• During weight bearing, the hindfoot that returns to valgus is flexible and those that do not are considered
rigid.

14.  Anteroposterior (AP) and lateral radiographs are routine, and it is essential that they are taken standing.
**The cavus is quantified by Meary’s angle, the angle between the long axis of the first metatarsal and the long axis
of the talus.
This should normally be 0°
**The Calcaneal Pitch is assessed by the angle formed between a line drawn along the inferior border of the
calcaneus and the weight bearing surface.
An angle of greater than 30° is abnormal, and consistent with c a v o v a r u s / c a l c a n e o c a v u s
 If Charcot-Marie-Tooth is suspected EMGs and nerve conduction studies should be performed as an initial
investigation.

15. PROBLEM LIST
BONY STRUCTURE AND FUNCTION ACTIVITY LIMITATION
Pain Walking limitation
Hind foot Stiffness Gait Deviation
Lateral foot pain Unable to weight bear
Restricted ROM Difficulty in daily activities

16. SHORT TERM GOALS LONG TERM GOALS
To reduce pain To correct deformity
To increase the ROM Pain free ambulation
To reduce stiffness To strengthen weak muscles
To reduce any muscle tightness Gait training and Argonomics

17. MEDICAL MANAGEMENT
 The goal of treatment is to allow the patient to ambulate without symptoms.
 The underlying cause must be identified in order to determine if the disorder is
progressive

18. Physiotherapy management
 Conservative management is appropriate in the minimally symptomatic mild case or in cases where surgical treatment is
contraindicated.
 Well-fitting, pliable shoes, pliable metatarsal bar orthoses, and ankle-foot orthoses may all be appropriate.
 Conservative management of patients with painful pes cavus typically involves strategies to reduce and redistribute
plantar pressure loading, with use of foot orthoses and specialized cushioned footwear.
The orthoses for pes cavus needs to accomplish to several specific goals:
Increasing plantar surface contact area.
The overload on the metatarsal heads is a result of limited plantar surface contact due to high arch and limited ankle-joint
dorsiflexion.
Increasing the plantar surface contact ensures the foot to bear more weight in the arch while the metatarsal heads bear less
weight during activity.

19.  Resisting against excessive supination
Lateral ankle stability and laterally deviated subtalar joint axis (STJ) are frequently associated with high-arched feet.
This position results in an excessive supinator torque around the subtalar joint axis.
 Resisting against recessive pronation and supination forces
Rearfoot instability is caused by an extension of the laterally deviated subtalar axis.
In flexible pes cavus, midtarsal flexibility complicates the later portion of the stance pgase of gait.
The forefoot pathology produces midtarsal joint supination, that leads to excessive pronation of the rearfoot.
Some pes cavus suffer from both lateral ankle instability at midstance and rearfoot pronation at late midstance. stretching and
strengthening of tight and weak muscles, debridement of plantar callosities, osseous mobilization, massage, manipulation of the foot
and ankle, and strategies to improve balance
 Orthotics with extra-depth shoes to offload bony prominences and prevent rubbing of the toes may improve symptoms.
 For varus deformities, a lateral wedge sole modification can improve function.
 Bracing for supple deformities or foot drop may allow patients to ambulate
 In patients with sensation deficits, Plastazote linings in the brace are required and frequent inspection of the skin for ulceration is
warranted.

20. INDICATIONS FOR SURGICAL RX
 progressive deformity
 painful callosities or ulceration
 symptomatic clawing
 ankle instability.
 Feet with supple deformities require only soft tissue release with or without tendon transfer.
 In the younger patient in whom deformities may change, several procedures may be necessary to
accommodate growth or compensate for altering neurology.
 Where a specific fixed bony deformity exists in an otherwise supple foot, which prevents
planti-grade loading, then an osteotomy is done to correct this deformity along with the appropriate soft
tissue corrections is indicated.

21. SURGICAL MANAGEMENT
 Correcting a cavovarus foot
 Most of the corrections involve tendon transfers and capsular and facial
releases
 Correction of plantar flexion of the first ray by performing a dorsiflexion
 ST tarso-metatarsal arthrodesis.
 Reduction of hind foot varus by performing a lateralizing calcaneal
osteotomy.
 Arthrodesis 1st TMT joint, lateral calcaneal osteotomy for hind foot

22. DEGREES OF PES CAVUS
FIRST DEGREE PES CAVUS
 Child is clumsy with repeated falls.
 Foot appears normal.
 Deformity appears when foot is
relaxed.
 Child catches his toes against low
objects such as edges of carpet.
 Mild extensor weakness.
RX
 Daily manipulation – supinating fore foot and everting
heel.
 Anterior arch bar in shoes.
 If not corrected then girdle stone tendon transfer
operation.
 Through an incision on each toe extending distally from
metatarsophalyngeal joint.
 Long and short toe flexors are brought to lateral aspect
of proximal phalynx and sutured to the extensor
expansion.

23. SECOND DEGREE PES CAVUS
 Flexion of the fore foot.
 Plantar fascia is felt to be tense
and contracted.
 Clawing of great toe.
 Great toe clawing can be
corrected by upward pressure
on the ball of great toe.
RX
 A shoe fitted with a metatarsal bar
may give temporary relief.
 Stiendlers Procedure : Plantar fascia
release.
 Jones Procedure : The extensor
halluces longus tendon is divided at
its insertion and passed through the
neck of first metatarsal +
interphalyngeal joint fusion.

24. THIRD DEGREE PES CAVUS
 The arches of foot is markedly
raised.
 All toes are clawed.
 Tendocalcaneus may begin to
appear contracted.
 Painful callosities are seen.
 Deformities are rigid and cannot
be corrected by finger pressure
under 1st metatarsal head.
RX
 Stiendlers procedure + Muscle
sliding operation.
 Japas ‘V’osteotomy of tarsus :
Apex of V is proximal and
highest point of cavus.
 Dwayers Calcaneal Otetomy.

25. FOURTH DEGREE PES CAVUS
 In addition to cavus and claw
toes.
 Adduction at tarsometatarsal
joints resulting in varus
deformity.
 Rigid and painful foot.
 Walking becomes painful and
difficult.
FIFTH DEGREE PES CAVUS
 Seen on paralytic conditions
(poliomyelitis)
 Whole foot is contracted into
rigid equino varus with high
arch.
 Tender callosities.
 The patient is very disabled.

26. RX OF FOURTH & FIFTH DEGREE PES CAVUS
 Dunns triple arthrodesis.
 Lambrinudis arthrodesis (triple arthrodesis : subtalar + calcaneo cuboid
+ talo navicular joint fusion)
 Cols Anterior tarsal wedge osteotomy.

27. Summary
Assess individual components of the foot:
 hindfoot, forefoot, MTPJ
Assess overall deformity type:
 cavus/plantaris
 cavovarus
 Calcaneocavus
Seek a cause:
 family history, intrinsics, drop foot – Charcot-MarieTooth
 back abnormalities, progressive deformity – spinal defects

28. REFERENCES
 Therapeutic Exrercise – Carolyn Kisner
 Orthopaedic Physical Assessment – Magee
 Orthopaedic Medicine – L. Ombregt
 Campbell’s Operative Orthopaedics