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Pes Cavus Deformity:

Pes Cavus Deformity Kentucky Podiatric Residency Program Crystal Kincaid OCPM Jeff Loveland Barry

Synonyms for Cavus Foot:

Synonyms for Cavus Foot Schaffer Foot Lotus Flower Foot Bolt Foot Claw Foot Vault Foot Hollow Foot Anterior Equinus Pes Cavo Varus Contracted Foot Talipes (Pes) Arcuatus Talipes Plantaris

What Is It?:

What Is It? Extraordinarily high plantar longitudinal arch Arch fails to flatten out with WB Forefoot is plantarflexed to rearfoot Primarily sagittal plane deformity

Etiology of Pes Cavus:

Etiology of Pes Cavus Neurological Congenital Iatrogenic Infection Idiopathic

Etiology :

Etiology Neurological - # 1 cause; estimated at about 75% Charcot Marie Tooth disease Friedrich’s Ataxia Roussy-Levy syndrome Poliomyelitis Cerebral Palsy Dejerine-Sottas’s interstitial hypertrophic neuritis


Etiology Congenital Spina Bifida Talipes Equinovarus Myelodysplasia Clubfoot Iatrogenic Post surgery or trauma Peroneal nerve injury Weak anterior muscles Overpowering posterior muscles


Etiology Infection Syphillis Poliomyelitis Idiopathic Must be considered

Presenting Complaints:

Presenting Complaints Pain and/or weakness Discomfort and fatigue of the foot Pain related to callus formation at the “ball” of the foot Deformity Trouble obtaining shoe gear Ankle Joint instability Lack of coordination


Evaluation Complete History Include developmental, familial, and a good medical history Neurological Exam Evaluate motor & sensory systems, assess reflexes and coordination tests. Musculoskeletal check strength, ROM, DTR, rotational deformities (hips, knees, tibia, etc.)


Evaluation Biomechanical Exam Include gait analysis Wide based gait with short steps  neurological High stepping  weak AJ DF Kelikian push-up test: test for flexible or rigid digital deformities Coleman Block Test Assess ankle equinus

Coleman Block Test:

Coleman Block Test Pt. Stands with 1st ray hanging over the edge If RF is vertical or pronated, then RF is compensating for a rigidly PF 1st ray As a compensation, RF inverts when FF is on the ground RF is 2° deformity

Biomechanics Rearfoot Varus:

Biomechanics Rearfoot Varus Block Test FF hanging off an edge Bisected Calcaneus is vertical STJ is Compensating No rearfoot frontal plane component Bisected Calcaneus is in varus STJ is partially Compensated or uncompensated Rearfoot frontal plane component

Biomechanics Rearfoot Varus:

Biomechanics Rearfoot Varus Tibial Varum Compensated Partial or Uncompensated

Other Diagnostic Tests:

Other Diagnostic Tests Electromyography (EMG) Nerve conduction velocity Muscle biopsy Nerve biopsy Blood Tests Blood smear shows acanthocytosis (Bassen-Kornzweig syndrome)


Radiographs AP Evaluate transverse plane deformities Metatarsus adductus Kite’s Angle T-N articulation AP Ankle deformity may not be at foot; ankle in varus

Metatarsus Adductus Angle:

Metatarsus Adductus Angle Is formed by a line perpendicular to the bisection of the lesser tarsus and a line representing the lesser metatarsus The lesser metatarsus is represented by the bisection of the dorsal longitudinal axis of the shaft of the second metatarsal Normal MA is less than 21 o As the foot becomes more adducted, this angle increases and a greater chance exists for abductus deformity at the first MPJ joint

Talocalcaneal Angle (Kite’s Angle):

Talocalcaneal Angle (Kite’s Angle) Is formed by the bisection of the longitudinal axis of the rearfoot and head and neck of the talus Normal is 15-30 o and 75% of talus head articluates with the navicular Supination is 16 o or less and greater than 75 % articulation


Radiographs Lateral Evaluate: Calcaneal inclination angle Talar declination angle Meary’s angle Hibb’s angle Metatarsal declination angle Evaluate sinus tarsi and cyma line

Calcaneal Inclination Angle:

Calcaneal Inclination Angle Best angle - changes little with supination or pronation Inferior pitch of calcaneus to WB surface of calcaneus to 5th metatarsal head Normal: 24.5° Moderate pes cavus: 31°- 40° Severe pes cavus : > 40°

Calcaneal Inclination Angle:

Calcaneal Inclination Angle

Talar Declination Angle:

Talar Declination Angle Is formed by the weight bearing surface of the foot and the bisection of the head and neck of the talus Normal is 21 o

Meary’s Angle:

Meary’s Angle Talometatarsal angle Bisection of talus intersects with bisection of the 1st met. Normal: lines should be parallel Abnormal: > 4° Intersects at apex of the deformity

Hibb’s Angle:

Hibb’s Angle long axis of calcaneus as it intersects with bisection of the 1st met. Intersects at apex of the deformity Represented by angle A

Pes Cavus Classification:

Pes Cavus Classification Anterior Can be Posterior Structural(Rigid) Combined Positional(Flexible)

Anterior Cavus Foot:

Anterior Cavus Foot Sagittal plane deformity Excessive PF of FF on RF Metatarsal Cavus (apex at Lisfranc’s joint) Lesser Tarsal Cavus Forefoot Cavus (apex at Chopart’s joint) Combined Cavus Foot (2 or more listed above)

Anterior Cavus Foot:

Anterior Cavus Foot Local = PF of 1st ray only Global = entire FF is PF Differentiating these two is important in determining proper surgical procedure

Anterior Cavus Foot:

Anterior Cavus Foot C.I.A. < 30° Meary’s angle > 10° Meary’s angle intersects at base of 1st metatarsal or Lisfranc’s joint

Rigid Anterior Cavus Compensation:

Rigid Anterior Cavus Compensation Pseudoequinus Functional limitation of AJ dorsiflexion caused by premature use of the AJ motion to compensate for pure sagittal plane anterior pes cavus deformity No STJ compensation

Flexible Anterior Cavus Compensation:

Flexible Anterior Cavus Compensation FF dorsiflexion at midfoot with WB forces Plantar buckling at MPJs Retraction of toes at MPJs

Posterior Cavus Foot:

Posterior Cavus Foot Primarily STJ deformity Less common than anterior pes cavus C.I.A. > 30° Meary’s angle < 10° Meary’s angle intersects proximal to Chopart’s joint

Posterior Cavus Compensation:

Posterior Cavus Compensation Sagittal plane A) Flexible: Plantarflexion Comp. No change in CIA B) Rigid: FF plantarflexion Comp. Decreased CIA

Combined Cavus Foot:

Combined Cavus Foot Anterior and Posterior components  C.I.A., talar declination angle, & met. declination angle

Combined Cavus Foot:

Combined Cavus Foot Primary Anterior C.I.A. ~ 30° Meary’s angle intersects at N-C joint Primary Posterior C.I.A. > 30° Talar varus Meary’s angle intersects at Chopart’s joint

Pes Cavus Rearfoot Varus:

Pes Cavus Rearfoot Varus Functional FF deformity with a rigid RF varus Coleman Block test used to determine if RF varus is 1° or 2° deformity

Treatment Goals:

Treatment Goals Correct the deformity Relieve pain Maintain a balanced foot

Principles of Treatment:

Principles of Treatment Underlying etiology MUST be determined The plane of the deformity is critical Cavus foot requires multilevel correction ie. Digits, Lisfranc’s joint, Midfoot, Rearfoot

Non Operative Treatment:

Non Operative Treatment Indications: mild pes cavus or when surgery is contraindicated Shoe modifications and inserts build up shoe AFO Physical Therapy Stretching

Surgical Correction:

Surgical Correction Soft tissue procedures indicated for flexible deformities often used in conjunction with osseous procedures Osseous procedures

Surgical Treatment Classification:

Surgical Treatment Classification Type I – Mild Pes Cavus Flexible, may appear normal w/ WB Tylomas and metatarsalgia Contracted digits w/ extensor substitution Surgery: MPJ release PIPJ fusions Hibbs procedure Other soft tissue releases

Surgical Classification:

Surgical Classification Type II – Moderate Pes Cavus More rigid and more evident clinically Primarily sagittal plane deformity Hammertoes, tylomas, metatarsalgia Surgery: DFWO of 1 st metatarsal Dwyer calcaneal osteotomy Digital procedures

Surgical Classification:

Surgical Classification Type III – Severe Pes Cavus Marked rigid deformity Gait abnormalities Multiplanar Surgery: Major tarsal fusions or osteotomies Digital procedures Triple arthrodesis

Soft Tissue Procedures:

Soft Tissue Procedures Plantar Fascia Release Steindler Stripping Garceau & Brahms Tendon Transfers Jones Hibbs STATT PT Tendon Transfer PL Tendon Transfer

Pes Cavus Treatment:

Pes Cavus Treatment Early deformity plantar release indicated in pt <10 y/o with signif pf of 1st ray plantar medial release indicated for rigid hindfoot w/fixed varus angulation plantar release w/medial tarsal structures tendon transfers indicated for supple inversion deformity w/ weak evertor lateral transfer of Tib Ant T to midtarsal area along 3rd ray

S.T. Procedures:

S.T. Procedures Steindler Stripping : release plantar fascia, abductor hallucis, FDB, abductor digiti quinti, and often the quadratus plantae muscle attachment to the heel Garceau & Brahms : selective plantar muscle denervation. Resect motor branches of medial and plantar nerve. Historical procedure

Tendon Transfers:

Tendon Transfers Jones Suspension : transfer EHL from the hallux to the 1st metatarsal indications: flexible PF 1st ray, weak Tib. Ant., helps DF ankle to  met declination angle Hibbs Suspension : transfer EDL from each toe out to the midfoot (lateral cuneiform or cuboid) indications: flexible anterior cavus, flexible claw toes, pts. with extensor substitution, pts. with weak tib. Ant./ EDL /EHL

Hibbs Suspension:

Hibbs Suspension

Split Tibialis Anterior Tendon Transfer (STATT):

Split Tibialis Anterior Tendon Transfer (STATT) Split Tib. Ant. in half. Lateral half is transferred to insert with the peroneus tertius, lat. cuneiform, or cuboid. Indications: weak anterior m., swing phase supination

Tendon Transfers:

Tendon Transfers Posterior Tibial Tendon Transfer : Very difficult. Out of phase transfer. Transfer Tib. Post. to dorsum of foot through EDL, peroneus tertius or Tib. Ant. tendon sheath. Indications: weak anterior muscle group TAL : only indication is spastic equinus

Peroneus Longus Tendon Transfer/ Lengthening:

Peroneus Longus Tendon Transfer/ Lengthening PL Transfer : transfer PL to dorsum of lesser tarsus through EDL tendon sheath or split through Tib. Ant. & peroneus tertius sheaths. STOP procedure : suture PL to PB indications: flexible 1st ray, heel varus PL Lengthening : decreases PF of 1st ray Indications: flexible 1st ray, weak tibialis anterior m.

Osseous Procedures:

Osseous Procedures Digital Reduction DFWO metatarsals COLE JAPAS Dwyer McElvenny-Caldwell Triple Arthrodesis

Digital Reduction:

Digital Reduction restore MPJ alignment PIPJ arthrodesis Extensor hood resection Extensor tendon lengthening flexor plate release Fixate (K-wire)

Metatarsal DFWO:

Metatarsal DFWO Proximal metaphysis dorsal distal to proximal plantar maintain hinge if possible fixation (screws or K-wires) Indications: local FF cavus rigid PF 1st met


COLE DFWO at MTJ base is dorsal & apex is proximal often do plantar release also preserves STJ & MTJ motion indications: anterior cavus


JAPAS V shaped MTJ osteotomy with apex proximal long incision, runs along EDL to the 3rd digit maintains length More normal looking foot




Dwyer lateral closing wedge osteotomy wider laterally than medially,  heel varus Indications: calcaneal varus posterior cavus non-reducible deformity Contraindications: reducible calcaneal varus 2° to PF 1st ray Important to do Coleman Block test here






McElvenny-Caldwell Fuse 1st metatarsocuneiform navicular joints in a DF position

Triple Arthrodesis:

Triple Arthrodesis T-C, T-N, C-C can correct all planal deformities common for severe cases of pes cavus Must decide the deformity 1st! Adducted FF? Correct at MTJ Sagittal plane deformity at MTJ? Cut wider wedge dorsally vs. plantarly RF varus? Fix at STJ (cut wider laterally than medially)

Triple Arthrodesis:

Triple Arthrodesis

Triple Arthrodesis:

Triple Arthrodesis

Pes Cavus:

Pes Cavus Disadvantages of midtarsal osteotomies Stiffness Non-unions Under/over correction Edema Neurovascular compromise

Important Points:

Important Points ID etiology ID apex of deformity Determine from examination the appropriate correction technique.


Bibliography Canale, S. Terry, M.D.. Campbell’s Operative Orthopaedics . Mosby. St. Louis, 1998. Hansen, Sigvard, M.D.. Functional Reconstruction of the Foot and Ankle. Lippincott Williams & Wilkins. Philadelphia, 2000. Jahass, Melvin, M.D.. Disorders of the Foot and Ankle, 2nd edition. W.B. Saunders Company. Philadelphia, 1991. Kelikian, Armen. Operative Treatment of the Foot and Ankle. Appleton & Lange. Stamford, 1999. McGlamry, E. Dalton, D.P.M.. Comprehensive Textbook of Foot Surgery. Lippincott Williams & Wilkins. Baltimore, 2001.


Bibliography Myerson, Mark, M.D. Foot and Ankle Disorders. W.B. Saunders Company. Philadelphia, 2000. Resnick, Donald, M.D.. Bone and Joint Imaging, 2nd edition. W.B. Saunders Company. Philadelphia, 1996. Sammarco, James, M.D., Taylor, Ross, M.D.. “Cavovarus Foot Treated with Combined Calcaneus and Metatarsal Osteotomies.” Foot & Ankle International. 22:1; 19-30. 2001.

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