Pes cavus

Last updated
Pes cavus
Other namesHigh instep, high arch, talipes cavus, cavoid foot, supinated foot
Charcot-marie-tooth foot.jpg
High arch in foot of a person with a hereditary neuropathy
Specialty Medical genetics, Podiatry

Pes cavus, also known as high arch, is an orthopedic condition that presents as a hollow arch underneath the foot with a pronounced high ridge at the top when weight bearing.

Contents

This foot type is typically characterized with cavus—the elevation of the longitudinal plantar arch (e.g., the bottom arch of a foot), plantar flexion of the foot, forefoot pronation, hindfoot varus, or forefoot adduction. A high arch is the opposite of a flat foot and is somewhat less common.

Signs and symptoms

Pain and disability

As with certain cases of flat feet, high arches may be painful due to metatarsal compression; however, high arches—particularly if they are flexible or properly cared-for—may be an asymptomatic condition.[ citation needed ]

People with pes cavus sometimes—though not always—have difficulty finding shoes that fit and may require support in their shoes. Children with high arches who have difficulty walking may wear specially-designed insoles, which are available in various sizes and can be made to order.[ citation needed ]

Individuals with pes cavus frequently report foot pain, which can lead to a significant limitation in function. The range of complaints reported in the literature include metatarsalgia, pain under the first metatarsal, plantar fasciitis, painful callosities, ankle arthritis, and Achilles tendonitis. [1]

There are many other symptoms believed to be related to the cavus foot. These include shoe-fitting problems, [2] lateral ankle instability, [3] lower limb stress fractures, [4] knee pain, [5] iliotibial band syndrome, [6] back pain [7] and tripping. [2]

Foot pain in people with pes cavus may result from abnormal plantar pressure loading because, structurally, the cavoid foot is regarded as being rigid and non-shock absorbent and having reduced ground contact area. There have previously been reports of an association between excessive plantar pressure and foot pathology in people with pes cavus. [8]

Cause

Pes cavus can occur from four primary causes: neurological conditions, trauma, undertreated clubfoot, or idiopathic with other underlining conditions. [9]

Bilateral presentation (i.e., in both feet) often occurs due to a hereditary or congenital source, whereas a unilateral presentation (i.e., in one foot) is often the result of trauma. [9]

Pes cavus is primarily caused by an underlying neurological process or is idiopathic (unknown) in its cause. [10] [9] Among adults with symptomatic pes cavus, two-thirds have a neurological condition most commonly within the hereditary motor and sensory neuropathies (HMSNs). [11] These can include the Hereditary Motor and Sensory Neuropathy Type 1 (Charcot-Marie-Tooth disease) and Friedreich's Ataxia.

The cause and deforming mechanism underlying pes cavus is complex and not well understood. Factors considered influential in the development of pes cavus include muscle weakness and imbalance in neuromuscular disease, residual effects of congenital clubfoot, post-traumatic bone malformation, contracture of the plantar fascia, and shortening of the Achilles tendon. [12]

Among the cases of neuromuscular pes cavus, 50% have been attributed to Charcot-Marie-Tooth disease, CMT, [13] which is the most common type of inherited neuropathy with an incidence of 1 per 2,500 persons affected. [14] Also known as hereditary motor and sensory neuropathy (HMSN), it is genetically heterogeneous and occasionally idiopathic. There are many different types and subtypes of CMT, and as a result, it can present from infancy through to adulthood. CMT is a peripheral neuropathy, affecting the distal muscles first as weakness, clumsiness, and frequent falls. It usually affects the feet first, but can sometimes begin in the hands. Charcot-Marie-Tooth disease can cause painful foot deformities such as pes cavus. Although it is a relatively common disease, many doctors and laypersons are not familiar with it. There are no cures or effective courses of treatment to halt the progression of any form of Charcot-Marie-Tooth disease at this time. [15]

The development of the cavus foot structure seen in Charcot-Marie-Tooth disease has been previously linked to an imbalance of muscle strength around the foot and ankle. A hypothetical model proposed by various authors describes a relationship whereby weak evertor muscles are overpowered by stronger invertor muscles, causing an adducted forefoot and inverted rearfoot. Similarly, weak dorsiflexors are overpowered by stronger plantarflexors, causing a plantarflexed first metatarsal and anterior pes cavus. [12]

Pes cavus is also evident in people without neuropathy or other neurological deficit. In the absence of neurological, congenital, or traumatic causes of pes cavus, the remaining cases are classified as idiopathic because their aetiology is unknown. [16]

Diagnosis

On weightbearing projectional radiography, pes cavus can be diagnosed and graded by several features, the most important being medial peritalar subluxation, increased calcaneal pitch (variable) and abnormal talar-1st metatarsal angle (Meary's angle). [17] Medial peritalar subluxation can be demonstrated by a medially rotated talonavicular coverage angle. [17]

Types

The term pes cavus encompasses a broad spectrum of foot deformities. Three main types of pes cavus are regularly described in the literature: pes cavovarus, pes calcaneocavus, and 'pure' pes cavus. The three types of pes cavus can be distinguished by their aetiology, clinical signs and radiological appearance. [19] [2]

Pes cavovarus

Pes cavovarus, the most common type of pes cavus, is seen primarily in neuromuscular disorders such as Charcot-Marie-Tooth disease and, in cases of unknown aetiology, is conventionally termed 'idiopathic'. [20] Pes cavovarus presents with the calcaneus in varus, the first metatarsal plantarflexed, and a claw-toe deformity. [19] Radiological analysis of pes cavus in Charcot-Marie-Tooth disease shows the forefoot is typically plantarflexed in relation to the rearfoot. [2]

Pes calcaneocavus

In the pes calcaneocavus foot, which is seen primarily following paralysis of the triceps surae due to poliomyelitis, the calcaneus is dorsiflexed and the forefoot is plantarflexed. [19] Radiological analysis of pes calcaneocavus reveals a large talo-calcaneal angle.[ citation needed ]

Subtle pes cavus

In 'pure' pes cavus, the calcaneus is neither dorsiflexed nor in varus and is highly arched due to a plantarflexed position of the forefoot on the rearfoot. [21]

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. [22]

Despite various presentations and descriptions of pes cavus, not all incarnations are characterised by an abnormally high medial longitudinal arch, gait disturbances, and resultant foot pathology.[ citation needed ]

Management

Non-operative

Suggested conservative management of patients with painful pes cavus typically involves strategies to reduce and redistribute plantar pressure loading with the use of foot orthoses and specialised cushioned footwear. [23] [24] Other non-surgical rehabilitation approaches include stretching and strengthening of tight and weak muscles, debridement of plantar callosities, osseous mobilization, massage, chiropractic manipulation of the foot and ankle, and strategies to improve balance. [25]

Operative

Surgical treatment is only initiated if there is severe pain, as the available operations can be difficult.

There are also numerous surgical approaches described in the literature that are aimed at correcting the deformity and rebalancing the foot. Surgical procedures fall into three main groups:[ citation needed ]

  1. soft-tissue procedures (e.g. plantar fascia release, Achilles tendon lengthening, tendon transfer);
  2. osteotomy (e.g. metatarsal, midfoot or calcaneal);
  3. bone-stabilising procedures (e.g. triple arthrodesis). [26]

Epidemiology

There are few good estimates of prevalence for pes cavus in the general community. While pes cavus has been reported in between 2 and 29% of the adult population, there are several limitations of the prevalence data reported in these studies. [1] Population-based studies suggest the prevalence of the cavus foot is approximately 10%. [27]

History

The term pes cavus is Latin for 'hollow foot' and is synonymous with the terms talipes cavus, cavoid foot, high-arched foot, and supinated foot type.

Pes cavus is a multiplanar foot deformity characterised by an abnormally high medial longitudinal arch. Pes cavus commonly features a varus (inverted) hindfoot, a plantarflexed position of the first metatarsal, an adducted forefoot, and dorsal contracture of the toes. Despite numerous anecdotal reports and hypothetical descriptions, very little rigorous scientific data exist on the assessment or treatment of pes cavus. [28]

See also

Related Research Articles

<span class="mw-page-title-main">Charcot–Marie–Tooth disease</span> Neuromuscular disease

Charcot–Marie–Tooth disease (CMT) is a hereditary motor and sensory neuropathy of the peripheral nervous system characterized by progressive loss of muscle tissue and touch sensation across various parts of the body. This disease is the most commonly inherited neurological disorder, affecting about one in 2,500 people. It is named after those who classically described it: the Frenchman Jean-Martin Charcot (1825–1893), his pupil Pierre Marie (1853–1940), and the Briton Howard Henry Tooth (1856–1925).

<span class="mw-page-title-main">Foot</span> Anatomical structure found in vertebrates

The foot is an anatomical structure found in many vertebrates. It is the terminal portion of a limb which bears weight and allows locomotion. In many animals with feet, the foot is a separate organ at the terminal part of the leg made up of one or more segments or bones, generally including claws and/or nails.

<span class="mw-page-title-main">Calcaneus</span> Bone of the tarsus of the foot

In humans and many other primates, the calcaneus or heel bone is a bone of the tarsus of the foot which constitutes the heel. In some other animals, it is the point of the hock.

<span class="mw-page-title-main">Plantar fascia</span> Aponeurosis of the sole of the foot

The plantar fascia or plantar aponeurosis is the thick connective tissue aponeurosis which supports the arch on the bottom of the foot. Recent studies suggest that the plantar fascia is actually an aponeurosis rather than true fascia. It runs from the tuberosity of the calcaneus forward to the heads of the metatarsal bones.

<span class="mw-page-title-main">Flat feet</span> Foot arch deformity

Flat feet, also called pes planus or fallen arches, is a postural deformity in which the arches of the foot collapse, with the entire sole of the foot coming into complete or near-complete contact with the ground. Sometimes children are born with flat feet (congenital). There is a functional relationship between the structure of the arch of the foot and the biomechanics of the lower leg. The arch provides an elastic, springy connection between the forefoot and the hind foot so that a majority of the forces incurred during weight bearing on the foot can be dissipated before the force reaches the long bones of the leg and thigh.

<span class="mw-page-title-main">Tarsus (skeleton)</span> Bones of the foot

In the human body, the tarsus is a cluster of seven articulating bones in each foot situated between the lower end of the tibia and the fibula of the lower leg and the metatarsus. It is made up of the midfoot and hindfoot.

Neuropathic arthropathy refers to a progressive fragmentation of bones and joints in the presence of neuropathy. It can occur in any joint where denervation is present, although it most frequently presents in the foot and ankle. It follows an episodic pattern of early inflammation followed by periarticular destruction, bony coalescence, and finally bony remodeling. This can lead to considerable deformity and morbidity, including limb instability, ulceration, infection, and amputation.

<span class="mw-page-title-main">Sever's disease</span> Medical condition

Sever's disease, also known as calcaneus apophysitis, is an inflammation at the back of the heel growth plate in growing children. The condition is thought to be caused by repetitive stress at the heel. This condition is benign and common and usually resolves when the growth plate has closed or during periods of less activity. It occurs in both males and females. There are a number of locations in the body that may get apophysitis pain. Another common location is at the front of the knee which is known as apophysitis of the tibial tuberosity or Osgood–Schlatter disease.

<span class="mw-page-title-main">Calcaneal spur</span> Medical condition of the heel

A calcaneal spur is a bony outgrowth from the calcaneal tuberosity. Calcaneal spurs are typically detected by x-ray examination. It is a form of exostosis.

<span class="mw-page-title-main">Arches of the foot</span> Load-bearing curves in the tarsal and metatarsal bones of the feet

The arches of the foot, formed by the tarsal and metatarsal bones, strengthened by ligaments and tendons, allow the foot to support the weight of the body in the erect posture with the least weight.

Foot and ankle surgery is a sub-specialty of orthopedics and podiatry that deals with the treatment, diagnosis and prevention of disorders of the foot and ankle. Orthopaedic surgeons are medically qualified, having been through four years of college, followed by 4 years of medical school or osteopathic medical school to obtain an M.D. or D.O. followed by specialist training as a resident in orthopaedics, and only then do they sub-specialise in foot and ankle surgery. Training for a podiatric foot and ankle surgeon consists of four years of college, four years of podiatric medical school (D.P.M.), 3–4 years of a surgical residency and an optional 1 year fellowship.

The Ponseti method is a manipulative technique that corrects congenital clubfoot without invasive surgery. It was developed by Ignacio V. Ponseti of the University of Iowa Hospitals and Clinics, US, in the 1950s, and was repopularized in 2000 by John Herzenberg in the US and Europe and in Africa by NHS surgeon Steve Mannion. It is a standard treatment for clubfoot.

<span class="mw-page-title-main">Hereditary motor and sensory neuropathy</span> Medical condition

Hereditary motor and sensory neuropathies (HMSN) is a name sometimes given to a group of different neuropathies which are all characterized by their impact upon both afferent and efferent neural communication. HMSN are characterised by atypical neural development and degradation of neural tissue. The two common forms of HMSN are either hypertrophic demyelinated nerves or complete atrophy of neural tissue. Hypertrophic condition causes neural stiffness and a demyelination of nerves in the peripheral nervous system, and atrophy causes the breakdown of axons and neural cell bodies. In these disorders, a patient experiences progressive muscle atrophy and sensory neuropathy of the extremities.

<span class="mw-page-title-main">Hereditary neuropathy with liability to pressure palsy</span> Medical condition

Hereditary neuropathy with liability to pressure palsy (HNPP) is a peripheral neuropathy, a condition that affects the nerves. Pressure on the nerves can cause tingling sensations, numbness, pain, weakness, muscle atrophy and even paralysis of the affected area. In normal individuals, these symptoms disappear quickly, but in sufferers of HNPP even a short period of pressure can cause the symptoms to occur. Palsies can last from minutes or days to weeks or even months.

<span class="mw-page-title-main">Orthotics</span> Medical specialty that focuses on the design and application of orthoses

Orthotics is a medical specialty that focuses on the design and application of orthoses, sometimes known as braces or calipers. An orthosis is "an externally applied device used to influence the structural and functional characteristics of the neuromuscular and skeletal systems." Orthotists are professionals who specialize in designing these braces.

Roussy–Lévy syndrome, also known as Roussy–Lévy areflexic dystasia, is a rare disorder of humans that results in progressive muscle wasting. It is caused by a mutation of the genes that code for proteins necessary for the functioning of the myelin sheath affecting the conductance of nerve signals and resulting in loss of muscles' ability to move. The condition affects people from infants through adults.

Distal hereditary motor neuropathy type V is a particular type of neuropathic disorder. In general, distal hereditary motor neuropathies affect the axons of distal motor neurons and are characterized by progressive weakness and atrophy of muscles of the extremities. It is common for them to be called "spinal forms of Charcot-Marie-Tooth disease (CMT)", because the diseases are closely related in symptoms and genetic cause. The diagnostic difference in these diseases is the presence of sensory loss in the extremities. There are seven classifications of dHMNs, each defined by patterns of inheritance, age of onset, severity, and muscle groups involved. Type V is a disorder characterized by autosomal dominance, weakness of the upper limbs that is progressive and symmetrical, and atrophy of the small muscles of the hands.

<span class="mw-page-title-main">Calcaneal pitch</span>

The calcaneal pitch is an angle used mainly in the diagnosis and severity grading of flat feet and pes cavus.

X-linked Charcot–Marie–Tooth disease is a group of genetic disorders and a type of Charcot–Marie–Tooth disease characterized by sensory loss associated with muscle weakness and atrophy alongside many other symptoms.

Subtalar arthroereisis is a common treatment for symptomatic pes planus, also known as flatfoot. There are two forms of pes planus: rigid flatfoot (RFF) and flexible flatfoot (FFF). The symptoms of the former typically necessitate surgical intervention. The latter may manifest fatigue or pain, but is typically asymptomatic.

References

  1. 1 2 Burns J. Landorf KB. Ryan MM. Crosbie J. Ouvrier RA. Interventions for the prevention and treatment of pes cavus. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006154. doi : 10.1002/14651858.CD006154.pub2
  2. 1 2 3 4 Aktas S, Sussman MD. The radiological analysis of pes cavus deformity in Charcot Marie Tooth disease. J Pediatr Orthop 2000; 9: 137-40
  3. ↑ Barrie JL, McLoughlin C, Robem N, Nuttal R, Lishman J, Wardle F, Hopgood P. Ankle instability in pes cavus. J Bone Joint Surg Br 2001; 83-B: 339
  4. ↑ Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Risk factors for recurrent stress fractures in athletes. Am J Sports Med 2001; 29: 304-310
  5. ↑ Dahle LK, Mueller M, Delitto A, Diamond JE. Visual assessment of foot type and relationship of foot type to lower extremity injury. J Orthop Sports Phy Ther 1991; 14: 70-74
  6. ↑ Williams DS, 3rd, McClay IS, Hamill J. Arch structure and injury patterns in runners. Clin Biomech 2001a; 16: 341-7
  7. ↑ Builder MA, Marr SJ. Case history of a patient with low back pain and cavus feet. J Am Podiatr Med Assoc 1980; 70: 299-301
  8. ↑ Burns J. Crosbie J. Hunt A. Ouvrier R. Novel Award: The effect of pes cavus on foot pain and plantar pressure. Clinical Biomechanics. 20(9):877-82, 2005.
  9. 1 2 3 Seaman, Travis J.; Ball, Thomas A. (2024), "Pes Cavus", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   32310476 , retrieved 2024-09-07
  10. ↑ Burns, Joshua; Landorf, Karl B; Ryan, Monique M; Crosbie, Jack; Ouvrier, Robert A (2007-10-17). Cochrane Neuromuscular Group (ed.). "Interventions for the prevention and treatment of pes cavus". Cochrane Database of Systematic Reviews. 2010 (12). doi:10.1002/14651858.CD006154.pub2. PMC   8915727 . PMID   17943889.
  11. ↑ Meier, Robert; Cornell, Ken (January 2023). "Orthotic Management of the Cavovarus Foot". Podiatry Management: 97.
  12. 1 2 Burns J. Redmond A. Ouvrier R. Crosbie J. Quantification of muscle strength and imbalance in neurogenic pes cavus, compared to health controls, using hand-held dynamometry. Foot & Ankle International. 26(7):540-4, 2005.
  13. ↑ Brewerton D, Sandifer P, Sweetnam D. "Idiopathic" pes cavus: An investigation into its aetiology. BMJ 1963; 2: 659-661.
  14. ↑ Skre H. Genetic and clinical aspects of Charcot-Marie-Tooth disease. Clin Genet 1974; 6: 98-118
  15. ↑ Shy ME, Blake J, Krajewski K, Fuerst DR, Laura M, Hahn AF, Li J, Lewis RA, Reilly M. Reliability and validity of the CMT neuropathy score as a measure of disability. Neurology 2005; 64: 1209–1214
  16. ↑ Manoli A, Graham B. The subtle cavus foot, "the underpronator," a review. Foot Ankle Int 2005; 26: 256–63
  17. 1 2 3 4 5 "Pes Cavus". University of Washington, Department of Radiology. Last modified: 2016/08/14
  18. ↑ Detailed explanations and references are located in the Calcaneal pitch article.
  19. 1 2 3 Meehan PL. The cavus foot in: Morrisy, RT, (Eds), Lovell and Winter's Pediatric Orthopaedics, J.B. Lippincott, Philadelphia, 1990
  20. ↑ Giannini S, Ceccarelli F, Benedetti MG, Faldini C, Grandi G. Surgical treatment of adult idiopathic cavus foot with plantar fasciotomy, naviculocuneiform arthrodesis, and cuboid osteotomy. A review of thirty-nine cases. J Bone Joint Surg Am 2002; 84-A: 62-9
  21. ↑ Jahss MH. Evaluation of the cavus foot for orthopedic treatment. Clin Orthop Relat Res 1983; 181: 52-63
  22. ↑ Coleman SS, Chesnut WJ. A simple test for hindfoot flexibility in the cavovarus foot. Clin Orthop Relat Res 1977; 123: 60-2
  23. ↑ Burns J. Crosbie J. Ouvrier R. Hunt A. Effective orthotic therapy for the painful cavus foot: a randomized controlled trial. Journal of the American Podiatric Medical Association. 96(3):205-11, 2006
  24. ↑ Wegener C. Burns J. Penkala S. Effect of neutral-cushioned running shoes on plantar pressure loading and comfort in athletes with cavus feet: A crossover randomized controlled trial. American Journal of Sports Medicine. 36(11):2139-2146, 2008
  25. ↑ Manoli A, Graham B. The subtle cavus foot, "the underpronator," a review. Foot Ankle Int 2005; 26: 256-63
  26. ↑ McCluskey WP, Lovell WW, Cummings RJ. The cavovarus foot deformity. Etiology and management. Clin Orthop Relat Res 1989; 247: 27–37
  27. ↑ Sachithanandam V, Joseph B. The influence of footwear on the prevalence of flat foot. A survey of 1846 skeletally mature persons. J Bone Joint Surg Br 1995; 77: 254-7
  28. ↑ Burns J. Landorf KB. Ryan MM. Crosbie J. Ouvrier RA. Interventions for the prevention and treatment of pes cavus. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006154. doi : 10.1002/14651858.CD006154.pub2.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.