Pes cavus is a descriptive term for a foot morphology characterized by high arch of the foot that does not flatten with weightbearing. No specific radiographic definition of pes cavus exists.  The deformity can be located in the forefoot, the midfoot, the hindfoot, or a combination of these sites.  Whereas pes cavus is a common finding, occurring in approximately 10% of the general population,  it can also be a sign of an underlying neurologic disorder. 
The spectrum of associated deformities observed with pes cavus includes clawing of the toes, posterior hindfoot deformity (described as an increased calcaneal angle), contracture of the plantar fascia, and cockup deformity of the great toe. This can cause increased weightbearing for the metatarsal heads and associated metatarsalgia and calluses.
The etiology of pes cavus can be determined approximately 80% of the time. Possible causes include the following:
The remaining 20% of cases are idiopathic and nonprogressive. Identifying the etiology is essential to determine if the deformity is progressive, which assists in operative planning.
Neuromuscular diseases, such as muscular dystrophy, Charcot-Marie-Tooth (CMT) disease, [5, 6, 7, 8, 9, 10] spinal dysraphism, polyneuritis, intraspinal tumors, poliomyelitis, syringomyelia, Friedreich ataxia, cerebral palsy, and spinal cord tumors, can cause muscle imbalances that lead to elevated arches.  A patient with a new-onset unilateral deformity but without a history of trauma must be evaluated for spinal tumors.
Multiple theories have been proposed for the pathogenesis of pes cavus. Duchenne described intrinsic muscle imbalances causing an elevated arch. Other theories include the extrinsic muscle and a combination of the intrinsic and extrinsic muscles being causes of the imbalance.
Mann described the pathogenesis of pes cavus in patients with CMT disease.  An understanding of the muscles involved and the sequence of the involvement helps in understanding the deformity. An agonist-antagonist model for the muscles determines the deformity. In CMT disease, the anterior tibialis and the peroneus brevis develop weaknesses. Antagonist muscles, the posterior tibialis and the peroneus longus, pull harder than the other muscles, causing deformity.
Specifically, the peroneus longus pulls harder than the weak anterior tibialis, causing plantarflexion of the first ray and forefoot valgus.  The posterior tibialis pulls harder than the weak peroneus brevis, causing forefoot adduction. Intrinsic muscle develops contractures while the long extensor to the toes, recruited to assist in ankle dorsiflexion, causes cockup or claw toe deformity. With the forefoot valgus and the hindfoot varus, increased stress is placed on the lateral ankle ligaments and instability can occur.
In patients with polio, the deformity is in the hindfoot and is caused by weakness of the gastrocnemius-soleus complex. This leads to a marked increase in the calcaneal pitch angle with normal forefoot alignment.
The results of surgical intervention are difficult to compare because of the multiple possible combinations of procedures necessary for successful treatment. Moreover, patients have varying degrees of deformity, disease progression, and underlying etiology, making comparison virtually impossible.
Nevertheless, some positive findings have been reported, such as Wetmore and Drennan’s report that 24% of patients with CMT disease who underwent a triple arthrodesis had satisfactory results at an average of 21 years of follow-up.  They recommended the triple arthrodesis as a salvage procedure.
Mann and Hsu reported on 12 feet in patients with CMT disease that underwent triple arthrodesis, with a follow-up that averaged 7.5 years.  Five feet were plantigrade, asymptomatic, and united. Three feet were plantigrade and asymptomatic but had nonunions. Four feet were nonplantigrade and symptomatic. The authors stated that positioning is the key to satisfactory results.
Roper and Tibrewal reported the results of soft-tissue procedures combined with osteotomies.  Ten cases of CMT disease were reviewed 14 years after surgery. Two patients required repeat surgery secondary to recurrent deformity. At last follow-up, all patients had plantigrade feet, without requiring a triple arthrodesis.
Gould discussed 18 feet in 10 patients with a 3- to 6-year follow-up.  All had satisfactory results with soft-tissue procedures combined with osteotomies, and all patients had plantigrade feet at last follow-up.
Sugathan et al treated lesser-toe clawing in 11 feet (eight patients) with flexible pes cavus using a modified Jones procedure.  At final clinical review, all 11 feet were improved, with minor complications in six. The mean Bristol Foot Score was 27, and the mean modified American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score was 76, which indicated excellent results. Half of the patients had mild persistent foot pain, but all were satisfied with the outcome.
Naudi et al reported radiologic and clinical results with anterior tarsectomy in 39 cases (33 patients) of pes cavus.  Pain decreased considerably in 75% of cases, and 68% of patients recovered normal activity. The foot was aligned correctly in 67% of cases, but at last follow-up, pes cavus remained undercorrected in 80%. In 74% of feet, adjacent joints showed progressive osteoarthritic degeneration. Subjectively, 70% of patients were very satisfied or satisfied with minor reservations, and objective outcome was excellent or good in 66% of feet.
According to Naudi et al, the overall results of this study showed that outcome in terms of function, motion, complications and satisfaction was good, but pain relief results were poor.  They added that anterior tarsectomy is able to correct initial pes cavus deformity and compensate anomalies of the hindfoot, but its correction capacity is limited, and its efficacy in case of clawfoot is poor.
Limitations to the literature exist. Most of the reported results include reviews of adolescents rather than adults. Multiple variables are included with a small population of patients; however, the current trends are toward soft-tissue procedures combined with osteotomies. Arthrodesis is reserved for salvage procedures.
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Norman S Turner, MD Assistant Professor, Department of Orthopedic Surgery, Mayo Clinic School of Medicine
Norman S Turner, MD is a member of the following medical societies: Alpha Omega Alpha, Mid-America Orthopaedic Association, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Minnesota Medical Association
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Thomas C Dowd, MD Associate Director of Orthopedic Surgery Residency Program, Department of Orthopedic Surgery, San Antonio Military Medical Center; Assistant Professor of Surgery, The Norman M Rich Department of Surgery, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine
Thomas C Dowd, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Society of Military Orthopaedic Surgeons
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: AOFAS; JBJS; AOA; AAOS.
Heidi M Stephens, MD, MBA Associate Professor, Department of Surgery, Division of Orthopedic Surgery, University of South Florida College of Medicine; Courtesy Joint Associate Professor, Department of Environmental and Occupational Health, University of South Florida College of Public Health
Heidi M Stephens, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Florida Medical Association
Disclosure: Nothing to disclose.
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