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Pes cavus is an orthopedic foot deformity seen in children and adults. It is commonly characterized by its elevated longitudinal medial plantar arch and is also known as “claw foot, hollow foot, or cavovarus foot”.1,2 Variations of pes cavus deformities exist and may be associated with acquired, hereditary, and congenital neurological or musculoskeletal conditions. Pes cavus may have concomitant hindfoot varus or equinus, forefoot adduction or valgus, plantar flexion of the first ray, and claw toe [deformities].1 Patients often present with painful conditions which result from pes cavus (e.g., peroneal tendinitis) rather than deformity itself.


Pes cavus has four primary causes: neuromuscular, traumatic, congenital, and idiopathic. (rosenbaum) Regardless of the etiology, bony malalignment or intrinsic muscle atrophy and imbalance among different muscle groups of the leg leads to the features of pes cavus including high arch, clawing of the toes, and equinus deformity.

Common causes of pes cavus:1,3,4,5,6

Epidemiology and Risk factors for Prevention

Pes cavus occurs in about 8-15% of the general population.7,8,9 Severe pes cavus is 30% idiopathic in nature with 70% likely secondary to neurological causes, with most having origins with Charcot Marie Tooth (CMT) disease (hereditary sensory motor neuropathy).1,10

Pes cavus in the general population may be more prevalent than these numbers suggest as idiopathic cavus foot or subtle cavus foot has become increasingly accepted and diagnosed as a non-neurologic form of pes cavus.11

Risk factors for Pes Cavus are mostly genetic. Multiple genetic mutations are associated with CMT and inheritance can be autosomal dominant, autosomal recessive, or X-linked. Subtle pes cavus without neurologic disorder is also likely inherited although the specific genes and inheritance pattern are still unclear.6 Risk factors for other forms of pes cavus are related to the risk factors for the underlying disease.

Patho-anatomy and Physiology

Cavus deformity can result from forefoot pathology, hindfoot pathology or a combination of the two. It affects the foot in 3 dimensions. In a standing position, weight is normally distributed through the foot via a tripod created by the first metatarsal head, calcaneus, and fifth metatarsal head. With pes cavus this functional relationship is disturbed and, in an attempt to compensate and restore the tripod, the flexibility of the arch is reduced limiting its ability to provide shock absorption.6,11

Cavus deformity of neuromuscular origin such as in CMT disease is forefoot driven. It 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.1 The relatively weak tibialis anterior is overpowered by the strong peroneus longus muscle which plantarflexes the first 1st ray and pronates the forefoot (making forefoot valgus). This forefoot valgus position further drives the hindfoot into inversion (varus). 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. Imbalance between relatively weak peroneus brevis and preserved posterior tibialis muscle leads to further inversion (varus) of calcaneus and adduction of foot. During gait the more flexible pronation phase is shortened, and the first metatarsal reaches the ground before the hind foot reaches eversion.11 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.1 A high foot arch then forms as the peripheral nerves are denervated more proximally in the foot causing fibrotic muscles to retract. In the early stages, the foot is flexible, but becomes more contracted as the disease progresses due to chronic muscular imbalances. In cavus foot associated with neuropathy, a heavy callus and plantar ulceration are common on the 1st and 5th metatarsal heads due to high plantar pressure and reduced sensation in these areas. This can lead to infection and sometimes amputation.1,10,12,13

Hindfoot driven cavus deformity is usually from a trauma to the subtalar joint or talo-crural joint causing rear foot varus, supinated subtalar joint and rigid calcaneocuboid joint. This often co-exists with a shortened achilles and the pull of the achilles on a varus calcaneous worsens the cavus form. The equinus position also gives a mechanical advantage to the peroneous longus causing a plantar flexed first ray. The foot then fails to pronate with initial contact and remains rigid throughout stance phase.11

Subtle or idiopathic cavus deformity is due to similar muscle imbalances of non-neurologic origin: Peroneal overdrive relative to tibialis anterior, gastrocnemius tightness, under-pronation during gait, plantar flexed first ray with cause unknown. These elements should be evaluated on exam to aid diagnosis and treatment.11

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Foot pain may be the first presenting symptom for patients with idiopathic or neuromuscular forms of Pes cavus. Prognosis will depend on the etiology, severity, and age at presentation.6

Subtle cavus feet can be noted in normal individuals without neurological disorders. They may develop pain associated with various musculoskeletal conditions on the lateral foot (e.g., peroneal tendinitis, lateral ankle sprain). These individuals do not have neurological disorders and have a normal neurological examination (Figure 1a & 1b).

Figure 1a, 1b, and 1c.

1a) Subtle cavus feet showing high arch with hind foot varus
1b) “peek a boo heel sign” when observed from the front (medial heel is shown bilaterally)
1c) Forefoot valgus with 1st ray lower than the rest of the forefoot

Pes cavus varies a great deal in severity of deformity, pain, and other musculoskeletal symptoms. 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 (5th metatarsal heads and base, lateral heel). As they engage in physical activities or sports, these individuals may become symptomatic. Subtle pes cavus does not tend to progress but if the foot biomechanics are not properly addressed, they may present with increasing and recurrent foot pathologies over time.  Untreated chronic lateral ankle instability is a known cause of ankle joint OA.6

Cavus foot of neuromuscular origin however tends to be progressive along with the progression of the underlying disease. In CMT, the most common cause of cavus feet, deformities worsen with progressive demyelination of the peripheral nerves. Deformities are often slow to develop and can begin before puberty. Children are initially able to compensate with a flexible deformity often requiring foot orthoses and physical therapy but as they become more rigid overtime this can affect bone growth. Surgical treatment is often needed for these patients.6

Specific secondary or associated conditions and complications

The following are the common conditions associated with pes cavus.1,14,11

  • Pain and calluses on the lateral foot (5th metatarsal head and base, lateral heel)
  • Stress fractures on 5th metatarsal, medial malleolus
  • Stress fracture of sesamoid under the 1st metatarsal head
  • Midfoot arthritis and associated anterior tarsal tunnel syndrome (deep peroneal nerve irritation)
  • Peroneal tendinitis/tendinosis/subluxation
  • Heel pain including plantar fasciitis (hypothesized to be from poor shock absorption)
  • Lateral ankle sprain and chronic lateral ankle instability
  • Achilles tendinosis/Insertional Achilles tendinitis/adventitious bursitis
  • Lateral and anterior knee pain (hypothesized to be from knee hyperextension, varus of the knee from supinated foot) from iliotibial band syndrome.
  • Metatarsalgia
  • Medial tibial stress syndrome

Essentials of Assessment


Clues in History for Pes Cavus:

Patients often present with painful conditions mentioned above rather than the deformity itself. Any patient with metatarsalgia, frequent lateral ankle sprain, midfoot pain, stress fractures of 5th metatarsal, Achilles area pain, or heel pain should be examined for possible pes cavus. Patient’s report of excessive wearing of footwear on the lateral side also warrant thorough examination for pes cavus. The presentation of these conditions may merely be a result of abnormal biomechanics associated with cavus foot and identification and management is essential for successful treatment and to avoid recurrence.

Family history should also be discussed. A family history of similar deformities may be a clue to a hereditary neuromuscular cause. Taking into account the time course is also important. An acute onset of unilateral pes cavus is concerning for spinal cord involvement. Whereas chronic, mild lateral foot pain symptoms aggravated by activities is more consistent with subtle or idiopathic pes cavus.6

Physical Examination

A thorough lower extremity neurologic exam, musculoskeletal exam of the foot including static alignment and active range of motion, and skin exam should be performed. Goal of exam is to identify pes cavus deformity, assess severity, determine etiology and to evaluate musculoskeletal sequelae that may be causing pain or dysfunction. The clinician should evaluate:


  • Skin:
    • observe spine for signs of spinal dysraphism
    • Look for foot calluses or ulcers usually under 1st and 5th metatarsals with/without tenderness
  • Muscle bulk:
    • Muscle hypotrophy of Peroneus Brevis and Tibialis Anterior
  • Foot alignment: observe in standing and in supine
    • Elevated medial arch
    • Hindfoot varus (inverted calcaneus) (Figure 1a)
    • Peek-a-boo heel sign in standing (medial heels are seen from the front (Figure 1b))
    • Forefoot valgus (1st ray lower than the rest of the forefoot (Figure 1c)) which drives hindfoot into varus


  • Palpate bony landmarks of the foot, ankle and knee with particular attention to areas of pain commonly associated with pes cavus
    • 5th metatarsal
    • Sesamoids
    • Tarsal tunnel
    • Peroneal tendons
    • Plantar fascia
    • Anterior talofibular ligament
    • Medial tibia
    • IT band and lateral knee

Range of Motion:

  • Look for reduced passive range of motion of ankle dorsiflexion [Shortened gastrocnemius and Achilles’ tendon (may not be observed in calcaeocavus, e.g., pes cavus due to weakness of gastrocnemius in polio patients)]
  • Reduced subtalar pronation (relatively more range of motion of supination)


  • Manual muscle testing of dorsiflexion, inversion, eversion, and plantar flexion

Special Tests:

  • Coleman Block Test: evaluation for examining the flexibility (reducibility) of hindfoot varus. Place a block under the lateral side of the forefoot and examine whether hindfoot returns to neutral position from varus. If hindfoot remains to be in varus position, the hindfoot deformity is likely rigid and not correctable with orthosis.
  • Anterior drawer and varus stress to assess ankle stability

Neurologic exam:

Full neurological examination including sensation and deep tendon reflexes: If neurological impairment is noted in clinical examination, further work-up including electrodiagnostic study is warranted.1,3,15,16

Clinical functional assessment: mobility, self-care cognition/behavior/affective state

  • Gait evaluation is essential especially in cavus feet of neurological etiology. Clinicians look for
    • Steppage gait or foot drop (weak dorsiflexor tibialis anterior)
    • Toe hyperextension (compensate with extensors for weak dorsiflexor tibialis anterior) in swing phase
  • Functional tests are useful in subtle pes cavus to assess ankle stability and functional alignment
    • Single leg balance
    • Single leg heel rise
    • Single leg squat
  • Footwear evaluation
    • lateral wear of outsole
    • deformation of upper lateral aspect of shoe
    • excessive wear and pressure points on 1st and 5th metatarsal heads

Laboratory Studies

If hereditary neuropathy is suspected, electrodiagnostic study, nerve biopsy, and genetic testing is recommended.


Radiographs of foot (at least 3 views) are obtained for evaluation of pes cavus deformities including lateral ankle/foot, frontal view of hindfoot (Meary or Salzman), dorsoplantar of forefoot.3 All imaging of foot is taken in weight bearing position. This serves to evaluate for any fractures or degenerative changes that may be associated as well as to determine the presence of cavus by certain radiographic parameters:

  • Cavus:
    • Forefoot Cavus – Hibb’s Angle also known as Calcaneum to First Metatarsal angle >45 degrees
    • Meary’s Angle – Talus to Frist Metatarsal angle >5 degrees
    • Hindfoot Cavus – Calcaneus to ground angle > 30 degrees
  • Equinus:
    • Tibio-talar angle > 105 degrees

CT and MRI scans are not used often but they are useful for peroneal tendinopathy for future reconstruction of ligament, weakness in amyotrophic lower extremities from Charcot Marie Tooth disease, spinal cord involvement, and painful arthritis of the foot.3,10,17

Supplemental assessment tools

Electrodiagnostic Study (Edx):

Edx may reveal peripheral neuropathy or nerve root lesions. Other work ups include genetic testing and imaging of spine depending on the clinical and Edx findings.

Early predictions of outcomes

Neurogenic cavus feet are often more severe and progressive. Determining the underlying etiology of cavus feet early is therefore important for treatment and patient education on disease course. Conservative treatment especially when initiated in children can be effective in avoiding surgery or delaying it to allow only a single procedure once skeletally mature.18

In patients with subtle pes cavus Increased activities such as sports and laterally worn out shoes can result in increased morbidity from secondary conditions listed above.


A hard floor surface and rigid footwear exacerbate symptoms.

Soft flexible footwear accommodates the rigidity of cavus feet.

Elevated heel design is also recommended for accommodation of shortening of gastrocnemius.

Social role and social support system

Neurogenic cavus feet often have genetic predisposition and screening of family members may be needed. Understanding the progressive nature of neurogenic cavus feet and potential disability will help to plan for the future.

Professional issues

Neurogenic cavus feet also often accompanies foot drop. Patients with jobs requiring walking should be treated with orthoses and gait aids to help them maintain their mobility. Fall prevention and intervention education is also important.

Athletes and patients in physical jobs should be counseled on appropriate footwear. Clinicians should examine their footwear for work and leisure activities to ensure that their feet are properly supported. They should avoid sneakers with anti-pronation design (reinforced medial midsole, counter) which is popular and commonly used among runners. This type of sneaker is designed for individuals with pes planus and potentially drives the foot into further supination putting further stress on the lateral structures of the feet. Rather, shoes with extra depth or soft uppers and orthoses with a lateral counter are preferred. Ankle bracing may also be needed during work or sports if there is ankle instability present.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Currently no specific published guideline is available for pes cavus. However, there are published clinical practice guidelines for management of pediatric CMT which include recommendations for addressing pes cavus.19 There is also a published consensus statement for the surgical treatment of pes cavus in patients with CMT.20

Summary of guidelines:

  • Progressive resistance exercises of the ankle dorsiflexors to improve muscle strength and slow progression of weakness is a strong evidence based recommendation.
  • Conditional evidence based recommendation suggests avoiding the use of botulinum toxin in the lower limbs for management of flexible cavus foot
  • Consensus based conservative recommendations include:
    • Stretching of joints prone to contracture
    • Serial casting or serial night casting in children to improve ankle dorsiflexion ROM
    • AFO can be used in children with foot drop, trips and falls, and ankle instability
    • Foot orthoses should be used in children with foot pain
    • Well-fitting footwear is important for children with impaired mobility
    • Children should be referred to an orthopedic surgeon if they have: painful, disabling, or progressive pes cavus not responsive to conservative measures. Ankle contracture not responsive to stretching intervention.
  • Consensus based surgical recommendations include:
    • Tibialis posterior transfer should be used to correct severe foot drop with flexible hind-foot varus and can be combined with osteotomies or fusions to enhance ankle dorsiflexion
    • EHL transfer to first metatarsal can be used alone in children but should be combined with metatarsal osteotomy in adults
    • Calcaneal osteotomy is effective in correcting hind-foot valgus
    • Dorsiflexion osteotomy of the first metatarsal is recommended for plantar flexed first ray.
    • Tibialis anterior tendon transfer, ankle arthroplasty, plantar fascial release and peroneous longus tendon lengthening are not recommended

At different disease stages

Treatment differs depending on the etiologies and severity of pes cavus.

  • Acute

Treat for the associated conditions with NSAIDs, tape, and bandages.

Identify the biomechanical deficit and address them with orthosis

  • Subacute

Therapy focusing on stretching of gastrocnemius and subtalar range of motion to increase pronation range of subtalar and ankle dorsiflexion range. Strengthening of tibialis anterior.

  • Chronic

Check the status of orthosis and revise it as needed. Inspect footwear for lateral wear.

  • Palliative

Accommodative footwear and operative interventions for recalcitrant lateral ankle instability and plantar ulceration under metatarsal heads.

For individuals with idiopathic subtle cavus feet without neurological conditions, addressing the presenting symptoms and conditions is the first step of treatment. These individuals may have lateral ankle sprain, peroneal tendinitis, and other disorders mentioned above which may be triggered or exacerbated by pes cavus deformity. Standard conservative treatments such as therapy and orthoses are used. Choosing proper footwear especially athletic footwear (sneakers) during sports activities is essential as described above. Foot orthoses should be designed to address all components of the deformities (hindfoot varus, ankle or forefoot equinus, forefoot valgus) taking into account the flexibility of the deformities. If hindfoot varus is flexible, a lateral wedge combined with a heel lift is incorporated in the orthotic prescription. Forefoot valgus is an often ignored component of pes cavus. A small lateral forefoot wedge or depression on the insole at the location corresponding to the 1st metatarsal head can accommodate forefoot valgus. This design reduces the need for the hindfoot turning to varus. Individuals with severe deformities of idiopathic pes cavus with lateral ankle/foot instability with recurrent ankle sprain should be referred for possible operative intervention. Physical therapy focuses on stretching of gastrocnemius and restoring subtalar eversion.

Pes cavus from neurological disorders is often worsened as the primary disorder progresses. Patients with Charcot Marie Tooth disease presents with foot drop, heavy callus formation on the 1st and 5th metatarsal heads and clawing of the toes. These individuals often require AFO (typically posterior leaf spring orthosis) unilaterally or bilaterally. Foot orthoses can be placed inside an AFO with the design mentioned above to address forefoot valgus and reduce pressure on the 1st metatarsal head. As the disease progresses, patients may have further weakness in ankle plantarflexion and knee extension, a semisolid or solid AFO may be needed. Solid AFOs for both lower limbs are rarely recommended because they do not allow any motion of the ankle, subtalar, and midtarsal joints. Physical therapy emphasizes prevention of contractures (i.e., gastrocnemius), range of motion exercises, and gait training with AFO.1,3,9,12,18 Custom made orthotics reduce about 75% of the pain and redistributes pressure points around the foot.13

Operative intervention should be entertained in patients with recurrent plantar ulceration, lateral ankle and foot instability which affects mobility and quality of life. These may involve plantar fasciotomies, Achilles’ tendon lengthening, tendon repairs, tendon transfers, soft tissue releases, and osteotomies.1,3 Patient may still need to wear AFO after the operation. Recent surgical literature favors early and aggressive intervention to avoid progression of the deformity. The goal of surgical intervention is to correct the muscle imbalance however surgeons often have different preferences for which procedures to perform.21

Coordination of care

Parallel practice: Patients may be rehabilitating but still working or competing.
Coordinated: Employers, coaches, and family may need to be involved to promote a successful outcome.
Multidisciplinary: Athletic trainers, physical therapists, and orthotists may be involved.
Interdisciplinary: Foot-ankle trained orthopedic surgeons or podiatrists can be consulted in refractory cases. Surgeons should also be involved in the care team of the patient early in the course of neuromuscular pes cavus so that interventions can be timed appropriately to growth and prevention of further fixed deformities.

Patient & family education

Educate on the importance of foot and ankle stretching, appropriate training volume and intensity, appropriate shoe (and orthotic) wear. Different athletic shoes should be worn every 6 months and can be rotated for longer wear. In cases of neuromuscular cavus foot, educate the patient and family on the progressive nature of the disease.

Measurement of Treatment Outcomes including those that are impairment-based, activity participation-based and environmentally-based

The Foot Function Index (FFI) is a 0-10 scale of pain and foot function over time in standing, walking, etc. The Foot Health Status Questionnaire (FHSQ) is a 42-item questionnaire assessing quality of foot health. The Foot and Ankle Ability Measure (FAAM) is an activities-of-daily-living scale of foot health. These measures can be used to assess pain severity and to monitor response to treatment.

Translation into Practice:  practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Neurogenic cavus feet may progressively worsen with new weakness in ankle dorsiflexors or quadriceps. Thorough manual muscle testing at each visit should be performed including proximal muscles. A systematic approach should be used.

Early identification of subtle pes cavus and treatment of resulting biomechanical deficits may help prevent recurrent symptoms. There are no reliable tests of classifications for the diagnosis which can be subject to variability based on the experience of the clinician. Being aware of the “peek-a-boo” heel sign and practicing its evaluation on all patients presenting with foot pain improves reliability and makes it an important tool to diagnosis.11

Cutting Edge/ Emerging and Unique Concepts and Practice

New treatment techniques to address the sequelae of cavus foot include extracorporeal shockwave therapy (ESWT), ultrasound guided corticosteroid injection, percutaneous needle tenotomy, platelet rich plasma (PRP), prolotherapy, and potentially in the future, stem cell therapies to promote healing. Newer materials for orthotics and knowledge of different shoes for different activities are important. Research on efficacy of orthotics in pes cavus is limited but a recent study on the biomechanical effects of foot orthoses showed decreased peroneous longus EMG amplitude during walking in patients with cavus foot wearing orthoses with a lateral bar.22

Minimally invasive surgical techniques are also emerging. The first description of successful minimally invasive correction of cavus foot performed through a percutaneous technique was recently published in 2021. Advantages include, less fixation required, immediate post-operative weight bearing, performed under regional block making it safer for patients with co-morbidities. Complications include transient sural neuralgia.23 A 2022 article describes the emerging technique of using customized 3D printed surgical models to optimize correction in all 3 planes with a midfoot wedge osteotomy.24

A 2019 randomized controlled trial outlined a promising new treatment that combines static stretching with transcutaneous electrical stimulation of the plantar fascia. This combination is thought to facilitate gliding of deep connective tissue increasing flexibility. This is the first study of its kind and included 68 participants. They found this treatment had immediate and short-term impact on radiologic measurements of the medial longitudinal arch and helped to flatten the arch in adults with idiopathic cavus foot.25

Gaps in the Evidence-Based Knowledge

New techniques of pain management include different types of foot orthotics and ankle bracing. The role of PRP, prolotherapy, botulinum toxin, percutaneous needle tenotomy, stem cells needs to be evaluated. Comparison-outcome trials are needed to provide better data to evaluate treatment options. The current controversy in the reconstruction of these deformities is whether to proceed with osteotomies and tendon transfers or arthrodesis. Surgical correction of subtle cavus deformity is also controversial. However, it is becoming more studied as subtle cavus foot is more recognized and a 2020 retrospective analysis found that surgical correction of cavus deformity at the same time as the standard procedure for chronic lateral ankle instability improved functional and pain outcomes. More studies are needed on this topic.26


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Original Version of the Topic

David Berbrayer, MD. Pes Planus/Cavus. 09/15/2015.

Previous Revision(s) of the Topic

Mooyeon Oh-Park, MD, Yusik Cho, MD, Lawrence Chang, DO, MPH. Pes Planus/Cavus. 12/18/2019.

Author Disclosure

Mooyeon Oh-Park, MD
Nothing to Disclose

Areeb Chator, MD
Nothing to Disclose

Emma Desjardins, DO
Nothing to Disclose