Pes cavus
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High-arched foot, also referred to as pes cavus, is a complex deformity in which the longitudinal arch of the foot remains excessively high during weight-bearing. The condition is often accompanied by: inward heel alignment, depression of the first metatarsal bone, forefoot adduction, and hammer or claw toes. Such a structure limits the foot's shock-absorbing ability and increases pressure under the heel, the metatarsal heads, and along the lateral edge. A high-arched foot can be an individual anatomical variant, but it may also be a symptom of a neurological disorder or the result of trauma. Management depends on the cause, the flexibility of the deformity, the patient's age, the rate of progression, and the nature of the symptoms. The foundation of therapy consists of custom-fitted insoles, appropriate footwear, physiotherapy, and overload management. A progressive or rigid deformity requires an orthopedic consultation.
Cavus foot - what it looks like
The most characteristic feature is a high medial longitudinal arch, also visible while standing. The central part of the sole has limited contact with the ground, and body weight is concentrated mainly on the heel and forefoot. However, the height of the arch itself describes only one element of a multiplanar deformity.
Typical features of pes cavus include:
- excessive longitudinal arching;
- plantar flexion of the first ray, that is, the first metatarsal bone along with the hallux;
- hindfoot varus, in which the heel deviates inward;
- forefoot adduction and supination;
- shortening of the plantar fascia;
- contracture of the gastrocnemius muscle or the Achilles musculotendinous complex;
- hammer or claw toes;
- calluses under the head of the first and fifth metatarsal bones and on the heel;
- widening of the lateral border of the sole and uneven shoe wear.
In practice, deformities driven by the forefoot, hindfoot, or both areas are distinguished. The foot may remain flexible, partially correctable, or rigid. Assessment of flexibility is facilitated by the Coleman test, during which the first metatarsal bone is unloaded. Correction of the heel alignment indicates flexible forefoot-driven varus.
Diagnostics include the assessment of posture, gait, range of motion, muscle strength, sensation, and reflexes. An examination of footwear, analysis of areas of hyperkeratosis, and weight-bearing foot radiographs are also performed. Depending on the clinical presentation, neurological examinations, electromyography, nerve conduction studies, or magnetic resonance imaging may be needed.
Cavus foot - where does it come from
The mechanism of cavus foot development is often associated with muscle imbalance. In a classic pattern, weakness of the tibialis anterior, peroneus brevis, and intrinsic foot muscles allows the stronger peroneus longus and tibialis posterior muscles to gradually alter bone alignment. The first ray undergoes plantar flexion, and the hindfoot compensatorily assumes a varus position. Over time, soft tissue shortening occurs, and the bony deformity becomes fixed.
The primary causes include:
- hereditary motor and sensory neuropathies, primarily Charcot-Marie-Tooth disease;
- spinal cord diseases, including syringomyelia, tumors, and sequelae of dysraphism;
- cerebral palsy, Friedreich's ataxia, and neuromuscular diseases;
- sequelae of poliomyelitis;
- peripheral nerve injuries, fractures, and bone union disorders;
- residual congenital clubfoot;
- contractures and chronic muscle imbalance;
- an idiopathic form, in which available diagnostics do not reveal a definitive cause.
Bilateral, progressive deformity, a family history of high-arched feet, muscle weakness, lower leg muscle atrophy, sensory disturbances, or deterioration of motor function represent indications for neurological evaluation. The sudden onset of a unilateral cavus foot requires particularly thorough evaluation, as it may be related to a lesion within the central or peripheral nervous system.
Identifying the cause has prognostic significance. In progressive diseases, the deformity may advance despite properly conducted symptomatic treatment; therefore, periodic neurological, orthopedic, and physiotherapeutic follow-up is necessary.
Cavus foot - what are the symptoms
Some people with a high-arched foot maintain good function for many years. Symptoms usually appear when the rigid foot absorbs impact energy less effectively or when overload exceeds the adaptive capacity of the tissues.
The most common complaints include:
- pain in the forefoot, heel, or lateral edge of the foot;
- burning and tenderness under the metatarsal heads;
- painful calluses, corns, and skin cracks;
- recurrent ankle sprains;
- a feeling of instability and difficulty walking on uneven ground;
- overload of the peroneal tendons and the Achilles tendon;
- plantar fasciitis or plantar fascia enthesopathy;
- foot and calf fatigue during prolonged walking;
- difficulty fitting footwear;
- knee, hip, or lumbar spine pain associated with gait pattern compensation.
A smaller ground contact area causes an increase in peak plantar pressures. Heel varus shifts the load to the lateral side of the foot, increasing the risk of fifth metatarsal overload, lateral ankle instability, and stress fractures. Claw toes can rub against the shoe upper, leading to the formation of painful skin lesions.
Muscle weakness, foot drop, balance disorders, numbness, rapidly progressing deformity, or loss of function require a medical consultation. Ulcers, signs of infection, and sudden pain combined with the inability to bear weight on the limb also require urgent evaluation.
High-arched foot - which footwear to choose
Footwear should primarily absorb shock, stabilize the hindfoot, and leave adequate space for the toes. The choice depends on the flexibility of the deformity, the location of overload areas, and the patient's activity.
Beneficial features of footwear include:
- a wide and high toe box protecting claw toes from pressure;
- a soft, shock-absorbing sole;
- a stable heel counter limiting lateral heel movement;
- lacing or an adjustable closure holding the foot;
- sufficient interior depth for a custom insole;
- flexibility of the sole in the area of physiological roll-over;
- a low, wide heel and a large ground contact area;
- an upper free of hard seams at pressure points.
Thin soles, narrow toe boxes, high heels, and unstable construction increase the concentration of pressure on the forefoot. In active individuals, athletic footwear with high cushioning and appropriate lateral stability can be useful.
An orthopedic insole is selected after a functional examination, as generic high arch support can increase local pressure. In a flexible pes cavus (hollow foot), the insole may include a depression under the first metatarsal head, support for the lateral part of the forefoot, and hindfoot correction. With a rigid deformity, soft cushioning and relieving painful points are of greater importance. An ankle-foot orthosis can improve stability in the case of significant muscle weakness or foot drop.
Cavus foot - exercises and correction
The goal of conservative treatment is to improve mobility, strength, neuromuscular control, and pressure distribution. Exercises alleviate the functional effects of the deformity, especially in its flexible form. Fixed bony alignment usually cannot be changed by exercise alone.
A physical therapy program may include:
- stretching of the gastrocnemius and soleus muscles of the calf;
- mobilization of the ankle joint toward dorsiflexion;
- gentle stretching of the plantar fascia;
- strengthening of the peroneus brevis, tibialis anterior, and intrinsic muscles of the foot;
- exercises for heel alignment control and even weight-bearing across the three support points;
- balance, proprioception, and sprain-prevention response training;
- gait re-education and gradual progression of load;
- learning self-monitoring of the skin and pressure points.
Exercises require individualization. In neuropathies, overloading weakened muscles can increase fatigue, which is why the intensity is determined by a physical therapist in cooperation with a physician.
At Ambasada Urody Clinic & Spa, procedures supporting symptomatic management are available: physiotherapy, manual therapy, INDIBA Elite NS in orthopedic rehabilitation, and podiatry treatments. Manual therapy can improve ankle mobility and soft tissue flexibility. INDIBA can support the treatment of pain, Achilles tendon overload, and tissue regeneration, but it remains a complementary method. A basic podiatry treatment, corn removal, and callus removal help reduce ailments resulting from local pressure. These treatments alleviate the consequences of the deformity, while structural correction requires orthotic management or orthopedic treatment.
Surgery is considered in cases of progressive deformity, persistent pain, ulcerations, significant instability, or failure of conservative treatment. The scope may include lengthening and release of soft tissues, tendon transfers, osteotomies of the metatarsal or calcaneal bones, and in rigid changes, also arthrodesis. The selection of the procedure depends on the level of deformity, its flexibility, and the neurological cause.
