Pes Cavus

Dr. D. N. Bid
Pes Cavus
• In pes cavus the arch is higher than normal, and often
there is also clawing of the toes.

• The close resemblance to deformities seen in neurological

disorders where the intrinsic muscles are weak or
paralyzed suggests that all forms of pes cavus are due to
some type of muscle imbalance.

• There are rare congenital causes, such as arthrogryposis,

but in the majority of cases pes cavus results from an
acquired neuromuscular disorder : [see Box in next slide].
• A specific abnormality can often be identified;
hereditary motor and sensory neuropathies and
spinal cord abnormalities (tethered cord
syndrome, diastematomyelia) are the commonest
in Western countries but poliomyelitis is the most
common cause worldwide.

• Occasionally the deformity follows trauma – burns

or a compartment syndrome resulting in
Volkmann’s contracture of the sole.
Meaning
• [Tethered spinal cord syndrome is a neurologic disorder caused
by tissue attachments that limit the movement of the spinal
cord within the spinal column. These attachments cause an
abnormal stretching of the spinal cord.]

• [Diastematomyelia, also known as a split cord malformation,

refers to a type of spinal dysraphism (spina bifida occulta) when
there is a longitudinal split in the spinal cord.]
Pathology
• The toes are drawn up into a ‘clawed’ position,
the metatarsal heads are forced down into the
sole and the arch at the midfoot is accentuated.

• Often the heel is inverted and the soft tissues in

the sole are tight.

• Under the prominent metatarsal heads

callosities may form.
Clinical features
• Patients usually present at the age of 8–10 years.

• Deformity may be noticed by the parents or the

school doctor before there are any symptoms.

• There may be a past history of a spinal disorder,

or a family history of neuromuscular defects.

• As a rule both feet are affected.

• Pain may be felt under the metatarsal heads or
over the toes where shoe pressure is most marked.

• Callosities appear at the same sites and walking

tolerance is reduced.

• Enquire about symptoms of neurological

disorders, such as muscle weakness and joint
instability.
• The overall cavus deformity is usually obvious;
in addition the toes are often clawed and the heel
may be varus.

• Closer inspection will show the components of

the high arch; this is important because it leads
to an understanding of the responsible
deforming forces.
• Rang (1993) presented a tripod analogy that
simplifies the problem.

• The foot is likened to a tripod of which the calcaneus,

fifth metatarsal and first metatarsal form the legs.

• Combinations of deformities affecting one or more of

these ‘legs’ produce the common types of high arch,
namely plantaris, cavovarus, calcaneus and
calcaneo-cavus (Fig. 21.17).
• The toes are held cocked up, with hyperextension at the MTP
joints and flexion at the IP joints.

• There may be callosities under the metatarsal heads and corns

on the toes.

• Early on the toe deformities are ‘mobile’ and can be corrected

passively by pressure under the metatarsal heads; as the
forefoot lifts, the toes flatten out automatically.

• Later the deformities become fixed, with the MTP joints

permanently dislocated.
• Mobility in the ankle and foot joints is important.

• In the cavo-varus foot, the heel is inverted.

• The block test is useful to check if the deformity is

reversible (Fig. 21.18); if it is, this signifies that the
subtalar joint is mobile.

• If the cavus deformity has been present for a long time,

then movements of the ankle, subtalar and midtarsal
joints are usually limited.
• A neurological examination is important to try to
identify a reason for the deformity.

• Disorders such as hereditary sensory and motor

neuropathy and Friedreich’s ataxia must always
be excluded, and the spine should be examined
for signs of dysraphism
Imaging
• Weightbearing x-rays of the foot contribute
further to the assessment of the deformity and
the state of the individual joints.

• On the lateral view, measurement of the

calcaneal pitch and Meary’s angle help to
determine the components of the high arch (Fig.
21.19).
• In a normal foot the calcaneal pitch is between
10 and 30 degrees, whereas Meary’s angle,
formed by the axes of the talus and first
metatarsal, is zero, i.e. these axes are parallel.

• In a calcaneus deformity, the calcaneal pitch is

increased; in a plantaris deformity, Meary’s
lines meet at an angle.
• MRI scans of the spine will exclude a structural
disorder, especially if this is more common than
polio as a cause of high-arched feet in the region.
Treatment
• Often no treatment is required; apart from the
difficulty of fitting shoes, the patient has no
complaints.

• Foot deformity : In general, patients need

treatment only if they have symptoms.
▫ However, the problem with high-arched feet is that it is
often a progressive disorder that becomes more difficult
to treat when the deformities are fixed;
▫ therefore treatment should start before the feet become
stiff.
• Non-operative treatment in the form of custom-
made shoes with moulded inserts may provide
some relief but does not alter the deformity or
influence its progression.

• Surgery is often needed and the type of procedure

will depend on the child’s age, underlying cause,
site and flexibility of the individual deformities
and type of muscle imbalance.
• The aim of surgery is to provide a pain-free,
plantigrade, supple but stable foot.

• The methods available are soft tissue releases,

osteotomies and tendon transfers.

• However, the deformity first needs to be corrected

before a tendon transfer is considered;
additionally, the transfer only works if the
joints are mobile.
• An equinus contracture is dealt with by
lengthening of the tendo Achillis and posterior
capsulotomies of the ankle and subtalar joints.

• The varus hindfoot, if shown to be reversible by

Coleman’s block test, may benefit from a
release of the plantar fascia (the tight fascia acts as a
contracted windlass on weightbearing, accentuating the
deformity).
• However, if the subtalar joint is stiff, then
calcaneal osteotomy will be needed; two types
are commonly used:

▫ (1) the lateral closing wedge (an opening wedge on

the medial side is a comparable operation but is
fraught with wound problems);

▫ (2) a lateral translation osteotomy.

• Treatment of a calcaneo-cavus deformity (which is
the least common type of high arch) differs according
to the age of the child.

• In young children (who usually have a neurological

problem) tendon transfers, e.g. transferring the
tibialis anterior through the interosseous
membrane to the calcaneum, may be combined
with tenodesis of the ankle using the tendo
Achillis.
• Older children may need:

▫ crescentic calcaneal osteotomies, which will

correct both varus and calcaneus deformities or

▫ variations of a triple arthrodesis.

• Midfoot deformities are usually:
▫ cavus (plantarflexed first metatarsal) or
▫ plantaris (plantarflexed first and fifth
metatarsals).

• The Jones tendon transfer helps elevate the

depressed first metatarsal by using the extensor
hallucis longus tendon as a sling through the
neck of the first metatarsal.
• Often the peroneus longus is overactive and is
partly responsible for pulling the first metatarsal
down;
▫ some balance is restored by dividing this tendon
on the lateral side of the foot and attaching the
proximal end to the peroneus brevis,
▫ thereby removing the deforming force and
improving the power of eversion simultaneously.
• Occasionally the deformity affecting the first metatarsal
is fixed, in which case a dorsal closing wedge osteotomy
at the base of the metatarsal is needed.

• A plantaris deformity is treated along similar lines for

the first ray, and combined with a plantar fascia release
if the deformity is mobile, but basal metatarsal
osteotomies or even a wedge resection and arthrodesis
across the midfoot are needed for rigid deformities.
• In severe examples and in those who have either
relapsed or who have responded poorly with soft
tissue releases and osteotomies,
▫ salvage surgery in the form of a triple arthrodesis
is recommended;
▫ it produces a stiff but plantigrade and pain-free
foot.
• Clawed toes: Correction of a clawed first toe is
by the Jones tendon transfer, which involves
either a tenodesis or fusion of the IP joint.

• Clawing of the lesser toes is treated with a flexor

tendon transfer to the extensor hood of each toe,
and MTP joint capsulotomies if the toes are still
passively correctable; however, if the deformities
are fixed, proximal IP fusion is needed.
Next Year……PT Mx
Physiotherapy
• Suggested 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.
• 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. 
Physiotherapy Management
• Pre-operatively
▫ When practical the patient will be seen pre-operatively,
and with consent, the following assessed:
 Current functional levels
 General health
 Social / work / hobbies
 Functional Range of Movement
 Gait / mobility, including walking aids and orthoses
 Post-operative expectations
 Patient information leaflet issued
 Post-operative management explained
• Post-operatively:
▫ Always check the operation notes, and the post-
operative instructions.
▫ Discuss any deviation from routine guidelines with the
team concerned.
▫ This is very important as the patient may have had a
combination of techniques which may affect weight-
bearing status and progressions.
 Initial rehabilitation Phase:
0-6 weeks

• Goals:
▫ To be safely and independently mobile with
appropriate walking aid, adhering to weight
bearing status
▫ To be independent with home exercise
programme as appropriate
▫ To understand self management / monitoring,
e.g. skin sensation, colour, swelling,
temperature, circulation
• Restrictions
▫ Ensure that weight bearing restrictions are adhered to:
▫  Standard RNOH pes cavus surgery:
▫ Full Plaster of Paris (POP) with ankle plantargrade for 2 weeks
Non Weight Bearing (NWB)
▫ POP changed at 2 weeks. Progress to Full Weight Bearing
(FWB) in POP
▫ POP removed at 6 weeks. May require aircast boot or other
orthosis. FWB
▫ If any other surgical techniques used ensure you
check any restrictions with team as these may differ
▫ Elevation
▫ If sedentary employment, may be able to return to work from 4
weeks post-operatively, as long as provisions to elevate leg, and
no complications
• Treatment:
▫ Likely to be in POP
▫ Pain-relief: Ensure adequate analgesia
▫ Elevation: ensure elevating leg with foot higher
than waist
▫ Exercises: teach circulatory exercises
▫ Education: teach how to monitor sensation, colour,
circulation, temperature, swelling, and advise what
to do if concerned
▫ Mobility: ensure patient independent with
transfers and mobility, including stairs if necessary
• On discharge from ward:
▫ Independent and safe mobilising, including stairs if
appropriate
▫ Independent with transfers
▫ Independent and safe with home exercise programme /
monitoring
•  Milestones to progress to next phase:
▫ Out of POP. Team to refer to physiotherapy at 6 weeks
from clinic.
▫ Progression from NWB to FWB phase. Team to refer to
physiotherapy if required to review safety of mobility /
use of walking aids
▫ Adequate analgesia
 Recovery rehabilitation phase:
6 weeks – 12 weeks
• Goals:
▫ To be independently mobile out of aircast boot
▫ To achieve full range of movement
▫ To optimise normal movement
• Restrictions:
Ensure adherence to weight bearing status
No strengthening against resistance until at least
3 months post-operatively of tenodesis / any
tendon transfers if performed
Do not stretch any tendon transfers / ligament
reconstructions if performed. They will naturally
lengthen over a 6 month period
• Treatment:
▫ Pain relief
▫ Advice / Education
▫ Posture advice / education
▫ Mobility: ensure safely and independently mobile
adhering to appropriate weight bearing
restrictions. Progress off walking aids as able once
reaches FWB stage
▫ Gait Re-education
▫ Wean out of aircast boot once advised to do so,
and provision of plaster shoe as appropriate, if
patient unable to get into normal footwear
• Exercises:
 Passive range of movement (PROM)
 Active assisted range of movement (AAROM)
 Active range of movement (AROM)
 Strengthening exercises as appropriate
 Core stability work
 Balance / proprioception work once appropriate
 Stretches of tight structures as appropriate (e.g. Achilles
Tendon), not of tendon transfers / ligament
reconstructions if performed
 Review lower limb biomechanics. Address issues as
appropriate
▫ If tendon transfer performed, encourage isolation of transfer
activation without overuse of other muscles. Biofeedback likely to
be useful
▫ Swelling Management
• Manual therapy:
▫ Soft tissue techniques as appropriate
▫ Joint mobilisations as appropriate ensuring
awareness of osteotomy sites and those joints
which may be fused, and therefore not appropriate
to mobilise
• Monitor sensation, swelling, colour,
temperature, circulation
• Orthotics if required via surgical team
• Hydrotherapy if appropriate
• Pacing advice as appropriate
• Milestones to progress to next
phase:
▫ Full range of movement
▫ Independently mobilising out of aircast boot
▫ Neutral foot position when weight bearing /
mobilising
▫ Tendon transfers activating if performed
• Failure to meet milestones:
▫ Refer back to team / Discuss with team
▫ Continue with outpatient physiotherapy if
still progressing
 Intermediate Rehabilitation Phase
12 weeks – 6 months
• Goals:
▫ Independently mobile unaided
▫ Wearing normal footwear
▫ Optimise normal movement
▫ Grade 4 or 5 muscle strength around ankle
(NB. This may vary if neurological cause for
pes cavus)
• Treatment
Further progression of the above treatment:
Pain relief
Advice / Education
Posture advice / education
Mobility: Progression of mobility and
function
Gait Re-education
• Exercises:
▫ Range of movement
▫ Strengthening exercises as appropriate
▫ Core stability work
▫ Balance / proprioception work
▫ Stretches of tight structures as appropriate (e.g.
Achilles tendon), not of transfers / ligament
reconstructions if performed.
▫ Review lower limb biomechanics. Address issues as
appropriate
▫ If tendon transfer performed progress isolation of
transfer activation without overuse of other muscles.
Biofeedback likely to be useful
• Swelling Management
• Manual therapy:
▫ Soft tissue techniques as appropriate
▫ Joint mobilisations as appropriate ensuring
awareness of those which may be fused and
therefore not appropriate to mobilise

• Monitor sensation, swelling, colour,

temperature, circulation
• Orthotics if required via surgical team
• Hydrotherapy if appropriate
• Pacing advice as appropriate
• Milestones to progress to next
phase:
▫ Independently mobile unaided
▫ Wearing normal footwear
▫ Adequate analgesia
▫ Tendon transfers to be activating if
performed
• Failure to meet milestones:
▫ Refer back to team / Discuss with team
▫ Continue with outpatient physiotherapy if
still progressing
 Final rehabilitation phase
• Goals: 6 months – 1 year
▫ Return to gentle low-impact sports
▫ Establish long term maintenance programme
▫ Grade 5 muscle strength around ankle and grade 4 or
5 of tendon transfers if performed (NB. This may vary
if neurological cause for pes cavus)
•  Treatment:
▫ Mobility / function: Progression of mobility and
function, increasing dynamic control with specific
training to functional goals
▫ Gait Re-education
• Exercises:
▫ Progression of exercises including range of movement,
strengthening, transfer activation, balance and
proprioception, core stability
• Swelling Management

• Manual therapy
▫ Soft tissue techniques as appropriate
▫ Joint mobilisations as appropriate ensuring awareness of
those which may be fused and therefore not appropriate to
mobilise
• Pacing advice
• Milestones for discharge
Independently mobile unaided
Appropriate patient-specific functional
goals achieved
Independent with long term maintenance
programme
Failure to progress

• If a patient is failing to progress, then consider

the following:
 POSSIBLE ACTION
PROBLEM
Swelling Ensure elevating leg regularly
Use ice as appropriate if normal skin
sensation and no contraindications
Decrease amount of time on feet
Pacing
Use walking aids
Circulatory exercises
If decreases overnight, monitor closely
If does not decrease overnight, refer back
to surgical team or to GP
 POSSIBLE ACTION
PROBLEM

Pain Decrease activity

Ensure adequate analgesia
Elevate regularly
Decrease weight bearing and use
walking aids as appropriate
Pacing
Modify exercise programme as
appropriate
If persists, refer back to surgical
team or to GP
 POSSIBLE ACTION
PROBLEM

Breakdown of wound Refer to surgical team or to

e.g. inflammation, GP
bleeding, infection
 POSSIBLE ACTION
PROBLEM
Transfer not activating Start working in NWB gravity eliminated
position with AAROM and then build up as
able
Biofeedback
Ensure adequate analgesia as appropriate
Ensure swelling under control as
appropriate
Ensure foot neutral when mobilising to
avoid excessive shear. Consider orthotics
referral via surgical team if unable to keep
neutral
Refer back to surgical team if no
improvement
 POSSIBLE ACTION
PROBLEM
Numbness/altered Review immediate post-operative
sensation status if possible

Ensure swelling under control

If new onset or increasing refer
back to surgical team or GP
If static, monitor closely, but inform
surgical team and refer back if
deteriorates or if concerned
Thanx 4 yr attention……………