Pes Cavus: Symptoms, Types, Causes and Treatment

Pes cavus, commonly known as high-arched foot, is a complex condition that can affect people of all ages, from children to older adults. Unlike the more familiar flatfoot, pes cavus presents unique challenges in diagnosis, management, and daily living. Whether you’re a patient, caregiver, or healthcare provider, understanding pes cavus is crucial for promoting foot health and overall well-being. This article delves into the symptoms, types, causes, and treatments for pes cavus, offering an evidence-based, accessible overview.

Symptoms of Pes Cavus

Pes cavus can range from a subtle high arch to a more pronounced foot deformity, often accompanied by discomfort and functional issues. Recognizing the signs early can lead to better management and improved quality of life.

Symptom	Description	Frequency / Risk	Sources
Foot Pain	Discomfort, often under forefoot/rearfoot	60% in affected individuals	1
High Arch	Visibly increased arch in the foot	Defining feature	2 3
Toe Clawing	Toes bent downward (claw toes)	Common in advanced cases	3 4
Instability	Ankle/foot instability, frequent sprains	Variable	3 8
Calluses	Thickened skin under high-pressure areas	Variable	1

Table 1: Key Symptoms

Foot Pain and Discomfort

Foot pain is one of the most frequent complaints among people with pes cavus, affecting up to 60% of individuals compared to 23% in those with normal feet 1. The pain is typically felt under the forefoot or hindfoot, where plantar pressures are disproportionately high due to the structural shape of the foot.

Pain severity can vary:

• Mild aching after long periods of standing or walking
• Sharp, localized discomfort during activity
• Chronic, persistent pain interfering with daily life

High Arch and Visual Deformity

The most obvious feature of pes cavus is a visibly elevated medial longitudinal arch, giving the foot a hollowed appearance 2 3. This can be apparent when standing or even when non-weight-bearing.

Toe Clawing

As the condition progresses, muscular imbalances may lead to clawing of the toes. This results in the toes bending downward, sometimes causing additional pain or difficulty in fitting shoes 3 4. Claw toes are especially prevalent in neurologically-driven pes cavus.

Instability and Balance Issues

The altered biomechanics of a high-arched foot can contribute to ankle instability, making individuals more prone to sprains and difficulty walking on uneven surfaces 3 8. This instability may be subtle at first but can become a significant problem if left unmanaged.

Skin Changes: Calluses and Corns

Due to the abnormal distribution of plantar pressure, people with pes cavus often develop calluses or corns beneath the metatarsal heads (ball of the foot) or heel 1. These skin changes are a direct result of increased force being transmitted through a smaller area of the foot.

Types of Pes Cavus

Not all high arches are the same. Pes cavus encompasses a spectrum of deformities, each with its own characteristics and implications for treatment.

Type	Defining Features	Common Causes	Sources
Direct Pes Cavus	High arch only, sagittal deformity	Idiopathic, neuromuscular	2 3
Pes Cavovarus	High arch + heel in varus/supination	Charcot-Marie-Tooth, muscle imbalance	2 3 5
Pes Equinocavovarus	High arch + foot drop + ankle equinus	Neurological disorders	3
Pes Calcaneovarus	High arch + hindfoot dorsiflexion	Rare, specific muscle imbalance	3

Table 2: Types of Pes Cavus

Direct Pes Cavus

This is the classic form, where the arch is elevated due to changes primarily in the sagittal plane—meaning the up-and-down orientation of the foot 2 3. The deformity can affect the forefoot, hindfoot, or both. Some individuals may have no symptoms, while others experience significant pain and dysfunction.

Pes Cavovarus

Here, the high arch is accompanied by a varus (inward) tilt of the heel, resulting in a three-dimensional deformity. This is often seen in association with neuromuscular diseases, most notably Charcot-Marie-Tooth (CMT) disease. The combination of arch elevation and heel inversion leads to significant instability and is more likely to progress over time 2 3 5.

Pes Equinocavovarus

This complex type combines a high arch with foot drop (inability to lift the foot) and equinus (downward-pointed) positioning of the ankle. It is typically due to severe neurological impairment, such as advanced CMT or cerebral palsy 3.

Pes Calcaneovarus

In this less common variant, the primary issue is excessive dorsiflexion (upward bending) of the ankle and hindfoot, with compensatory plantarflexion (downward pointing) of the forefoot. The result is a high arch with unique biomechanical challenges 3.

Causes of Pes Cavus

Understanding what leads to pes cavus is essential for both prevention and appropriate intervention. The origins of this condition are varied, ranging from inherited neurological disorders to unknown (idiopathic) causes.

Cause	Mechanism/Details	Prevalence/Notes	Sources
Neurological Disease	Muscle imbalance, nerve dysfunction	Most common in children	2 4 5 6
Idiopathic	Unknown, possibly subtle imbalance	Many adult cases	1 3 4
Congenital	Present at birth	Rare, often severe	6
Trauma/Other	Injury or local muscle damage	Uncommon	4

Table 3: Causes of Pes Cavus

Neurological Disorders

The majority of pes cavus cases, especially those seen in children and adolescents, are due to underlying neurological conditions. These include:

• Charcot-Marie-Tooth disease (CMT): A hereditary peripheral neuropathy that leads to progressive muscle weakness and imbalance, resulting in high arches and often toe clawing 2 3 5 10.
• Cerebral palsy: Damage to the central nervous system can create abnormal muscle tone and overactivity of foot invertors, contributing to the deformity 4.
• Other neuropathies: Conditions that impair nerve function to the foot muscles can set the stage for pes cavus development 6.

The driving force is usually an imbalance between muscles that lift and lower parts of the foot, with overactivity of the invertors (muscles that turn the foot inward) and underactivity of their antagonists 4 6.

Idiopathic Pes Cavus

In many adults, particularly when neurological evaluations are normal, the cause remains uncertain. These idiopathic cases may arise from subtle, undetectable muscle imbalances or genetic predisposition 1 3 4. They can be stable or slowly progressive.

Congenital and Other Causes

Some individuals are born with pes cavus, possibly due to developmental abnormalities or as part of syndromic conditions 6. Less frequently, trauma to nerves or local muscle groups can result in a cavus foot 4.

Treatment of Pes Cavus

Managing pes cavus is often challenging due to its underlying causes and potential for progression. However, a range of conservative and surgical options can help alleviate symptoms and improve function.

Treatment	Approach/Details	Effectiveness/Notes	Sources
Orthoses	Custom-made foot supports	Reduces pain, improves function	8 9
Physical Therapy	Exercises to maintain flexibility	Useful in mild/moderate cases	4 8
Footwear Modifications	Supportive shoes, cushioning	Adjunct to orthoses	8 9
Surgical Correction	Osteotomy, fasciotomy, tendon transfers	For severe/fixed deformity	4 7 11

Table 4: Treatment Options

Orthotic Management

Custom-made foot orthoses are the best-supported intervention for pes cavus-related pain and dysfunction. High-quality evidence shows that these devices significantly reduce pain and improve foot function compared to sham orthoses 9. Orthoses work by redistributing plantar pressure, providing shock absorption, and improving alignment.

• Soft orthoses are generally preferred for shock absorption.
• Permanent orthoses may be needed for more severe deformities 8.

Physical Therapy

Physical therapy focuses on:

• Stretching tight muscles and plantar fascia
• Strengthening weaker muscle groups to rebalance foot posture
• Balance and proprioception training

These interventions can help slow progression in early or moderate cases and are essential adjuncts to orthotic management 4 8.

Footwear Modifications

Supportive, well-cushioned shoes reduce focal pressure points and, when combined with orthoses, can enhance comfort and prevent skin breakdown 8 9. Shoes may be custom-fitted in severe cases or when claw toes are present.

Surgical Options

Surgical intervention is reserved for cases where conservative treatment fails or when the deformity is severe and rigid. Procedures vary based on the specifics of deformity:

• Osteotomy: Resection of bone to correct arch height and heel alignment. Lateral wedge osteotomy of the calcaneum is common for correcting heel varus and restoring plantigrade posture 4 7.
• Plantar Fasciotomy: Cutting the tight plantar fascia to relieve tension and facilitate correction 7 11.
• Tendon Transfers/Denervation: For selected cases, especially with muscle imbalance or spasticity 6 4.
• V-osteotomy of the tarsus: A newer technique for correcting anterior pes cavus, with encouraging preliminary results 11.

The choice of surgery depends on the severity, rigidity, and underlying cause of the deformity 4 10. Preservation of foot joint movement is prioritized to avoid long-term complications like arthritis 2 4 7.

Conclusion

Pes cavus is a multifaceted foot condition with diverse causes and presentations. Early recognition and tailored management can prevent long-term disability and improve quality of life. Here are the key takeaways:

• Common symptoms include foot pain, high arch, toe clawing, instability, and calluses.
• Types of pes cavus vary from simple high arches to complex deformities with heel varus or equinus.
• Causes are most often neurological, but idiopathic and congenital cases also occur.
• Treatment starts with custom orthoses and physical therapy, reserving surgery for severe or rigid deformities.

By understanding these elements, patients and clinicians can work together to achieve the best possible outcomes for those living with pes cavus.