Lateral and anterior knee pain (hypothesized to be from knee hyperextension, varus of the knee from supinated foot) from iliotibial band syndrome.Achilles tendinosis/Insertional Achilles tendinitis/adventitious bursitis.Heel pain including plantar fasciitis (hypothesized to be from poor shock absorption).Midfoot arthritis and associated anterior tarsal tunnel syndrome (deep peroneal nerve irritation).Stress fracture of sesamoid under the 1 st metatarsal head.Stress fractures on 5 th metatarsal, medial malleolus.Pain and calluses on the lateral foot (5 th metatarsal head and base, lateral heel).The following are the common conditions associated with pes cavus. Specific secondary or associated conditions and complications As they engage in physical activities or sports, these individuals may become symptomatic. Subtle cavus feet in otherwise normal individuals may not trigger pain or functional impairment other than excessive wear of the footwear laterally or callus formation on the lateral foot (5 th metatarsal heads and base, lateral heel). Pes cavus varies a great deal in severity of deformity, pain, and other musculoskeletal symptoms. Forefoot valgus with 1 st ray lower than the rest of the forefoot (1c) Subtle cavus feet showing high arch, “peek a boo heel sign” when observed from the front (medial heel is shown bilaterally, 1b). These individuals do not have neurological disorders with normal neurological examination (Figure 1a & 1b). peroneal tendinitis, lateral ankle sprain). They may develop pain associated with various musculoskeletal conditions on the lateral foot (e.g. Subtle cavus feet can be noted in normal individuals without neurological disorders. Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time) This can lead to infection and sometimes amputation. In cavus foot associated with neuropathy, the heavy callus and the plantar ulceration are common on the 1 st and 5 th metatarsal heads due to high plantar pressure and reduced sensation in these areas.
In the early stages, the foot is flexible, but becomes more contracted as the disease progresses due to chronic muscular imbalances. A high foot arch then forms as the peripheral nerves are denervated more proximally in the foot causing fibrotic muscles to retract. Clawing of foot occurs as result of interphalangeal joints flexed by the flexor digitorum longus while the metatarsal phalangeal joints are extended by the extensor digitorum longus. Imbalance between relatively weak peroneus brevis and preserved posterior tibialis muscle leads to inversion of calcaneus and adduction of foot. The extensor hallucis muscle which dorsiflexes the toe would then be unable to balance the combined plantarflexing forces of peroneus longus, posterior tibialis, and triceps surae muscles. This forefoot valgus position further drives the hindfoot into inversion. The relatively weak tibialis anterior is overpowered by the strong peroneus longus muscle which plantarflexes the first 1 st ray and pronates the forefoot (making forefoot valgus). Patho-anatomy and PhysiologyĬavus deformity of Charcot Marie Tooth disease is hypothesized to stem from asymmetric foot weakness anterior-laterally due to selective denervation of the tibialis anterior and peroneus brevis muscles of the legs.
Severe pes cavus is 30% idiopathic in nature with 70% likely secondary to neurological causes, with most having origins with Charcot Marie Tooth disease (hereditary sensory motor neuropathy). Pes cavus occurs in about 8-15% of the general population. Idiopathic subtle cavus feet without neurological disordersĮpidemiology and Risk factors for Prevention.Malunion of calcaneal or subtalar fracture.Posterior compartment syndrome of the leg.Hereditary sensory motor neuropathy (Charcot Marie Tooth disease)
Regardless of the etiology of the neuropathy, intrinsic muscle atrophy and imbalance among different muscles group of the leg leads to features of pes cavus including high arch, clawing of the toes, and equinus deformity. Pes cavus cases can resultfrom hereditary or acquired peripheral neuropathies. The presentations may merely be a result of abnormal biomechanics associated with cavus feet and identification and management of cavus feet is essential for successful treatment and avoidance of recurrence of symptoms. peroneal tendinitis) rather than deformity itself. Patients often present with painful conditions which result from pes cavus (e.g. Pes cavus may have concomitant hindfoot varus, equinus, forefoot adduction, forefoot valgus, and claw toe. Variations of pes cavus deformities exist and may be associated with acquired, hereditary, and congenital neurological or musculoskeletal conditions. Pes cavus is commonly characterized by its elevated longitudinal medial plantar arch of the foot and is also known as “claw foot, hollow foot, or cavovarus foot”.
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