Pes cavus, derived from the Latin for “hollow foot,” is a structural deformity of the foot characterised by an abnormally elevated medial longitudinal arch. Unlike the more commonly discussed flatfoot (pes planus), pes cavus presents a high-arched configuration that fails to adequately distribute body weight across the plantar surface. The condition affects approximately 10% of the general population and can range from mild and asymptomatic to severely disabling, depending on its underlying cause and degree of progression. Because pes cavus is frequently associated with underlying neurological pathology, effective treatment demands a thorough understanding of its aetiology, biomechanical consequences, and the full spectrum of conservative and surgical interventions available.
Aetiology and Clinical Assessment
Approximately 60–80% of pes cavus cases have an identifiable neurological cause. Charcot-Marie-Tooth (CMT) disease, a hereditary peripheral neuropathy, is the most prevalent underlying condition. Other neurological associations include Friedreich’s ataxia, cerebral palsy, spinal cord tumours, spina bifida, and poliomyelitis. A smaller proportion of cases are idiopathic or result from residual clubfoot deformity. The imbalance between extrinsic and intrinsic foot musculature — often peroneus brevis weakness combined with relative peroneus longus and tibialis posterior overactivity — drives the characteristic deformity: forefoot plantarflexion, hindfoot varus, and claw toes.
A comprehensive clinical assessment is essential before any treatment decision is made. This includes a full neurological workup, gait analysis, and careful evaluation of foot flexibility. The Coleman block test is a key clinical tool: by placing a block under the lateral forefoot and allowing the first ray to drop, the clinician can determine whether the hindfoot varus is flexible (corrects on the block) or rigid (does not correct). This distinction is fundamental, as flexible deformities are more amenable to conservative care and certain joint-sparing surgical techniques, while rigid deformities often require more extensive bony correction.
Conservative Treatment
For mild to moderate pes cavus, conservative management remains the first line of treatment. The goals are to relieve pain, accommodate the deformity, improve function, and slow progression. Orthotics play a central role. Custom-moulded foot orthoses are designed to offload pressure from the lateral border of the foot and the metatarsal heads, where calluses and stress fractures commonly develop. A well-fitted orthosis can redistribute plantar loading, reducing pain during weight-bearing activities and decreasing the risk of lateral ankle instability, which is a frequent complication due to the varus hindfoot alignment.
Footwear modification is closely linked to orthotic management. Patients benefit from shoes with a wider toe box, a firm heel counter for stability, and adequate depth to accommodate custom insoles. In more severe cases, extra-depth shoes or custom-moulded footwear may be required. Ankle-foot orthoses (AFOs) are indicated when there is significant foot drop, ankle instability, or co-existing neurological weakness that makes normal gait unsafe.
Physiotherapy addresses the muscular imbalances and functional limitations associated with pes cavus. Stretching of the plantar fascia and Achilles tendon is frequently prescribed, as tightness in these structures contributes to the elevated arch and forefoot loading. Strengthening exercises targeting the peroneal muscles and intrinsic foot musculature can help to slow the progression of deformity in neurological cases. Balance and proprioceptive training is also valuable, given the inherent instability associated with a high-arched foot and the elevated risk of ankle sprains. Physiotherapy alone is unlikely to reverse a structural deformity, but it plays an important adjunctive role in managing symptoms and maintaining function.
Surgical Treatment
When conservative measures fail to provide adequate relief, or when the deformity is rigid and progressive, surgical intervention becomes necessary. The surgical approach is tailored to the specific components of the deformity and the patient’s overall neurological status. Operations are broadly categorised into soft tissue procedures, osteotomies, and arthrodesis (joint fusion).
Soft tissue procedures are typically used in younger patients with flexible deformities, aiming to correct muscular imbalances and relieve contractures without permanently altering bony architecture. The Steindler stripping procedure involves releasing the intrinsic muscles and plantar fascia from their calcaneal attachment to reduce forefoot plantarflexion. Tendon transfers are another key soft tissue technique: the peroneus longus to brevis transfer, for example, can address the muscular imbalance driving forefoot depression and hindfoot varus in CMT disease. Plantar fascia release, either open or endoscopic, is commonly performed to reduce arch rigidity and forefoot pain.
Osteotomies are performed when bony realignment is required but joint preservation is desirable. The Dwyer calcaneal osteotomy is one of the most widely used procedures in pes cavus surgery: a lateral closing wedge of bone is removed from the calcaneus to correct hindfoot varus and shift the weight-bearing axis medially. First metatarsal dorsiflexion osteotomy corrects the plantarflexed first ray, redistributing forefoot load away from the medial column. These procedures may be performed in isolation or in combination, depending on the components of the deformity. In adolescents and young adults, osteotomies are generally preferred over fusion because they preserve motion and allow for future revision if neurological progression worsens the deformity.
Claw toe deformities, which arise from intrinsic muscle weakness and extrinsic extensor tendon overactivity, are a common comorbidity requiring surgical attention. Procedures including proximal interphalangeal joint arthroplasty, flexor-to-extensor tendon transfer, and metatarsal head resection can address symptomatic claw toes that cause painful plantar callosities or dorsal pressure sores from footwear.
In severe, rigid, or long-standing deformities — particularly in skeletally mature adults — triple arthrodesis (fusion of the subtalar, talonavicular, and calcaneocuboid joints) may be the most appropriate surgical option. This procedure provides robust, reliable correction of complex hindfoot deformity and eliminates pain from arthritic joints. The trade-off is permanent loss of subtalar and midtarsal motion, which can lead to adjacent joint degeneration over time. Triple arthrodesis therefore tends to be reserved for patients with significant rigidity, arthritic changes, or failed prior surgery.
Postoperative Rehabilitation and Long-term Management
Surgical outcomes in pes cavus depend heavily on postoperative rehabilitation. Following osteotomy or soft tissue procedures, a period of non-weight-bearing immobilisation is typically required, followed by gradual progression to full weight-bearing. Physiotherapy resumes once the surgical site has healed, focusing on restoring strength, range of motion, and gait pattern. Custom orthotics are frequently continued after surgery to maintain correction and prevent recurrence.
Long-term follow-up is essential, particularly in neurological cases where the underlying disease may progress. In patients with CMT disease or other hereditary neuropathies, regular reassessment allows for timely adjustment of orthotic management or consideration of further surgical intervention if the deformity recurs or worsens. Patient education regarding footwear, skin inspection, and activity modification contributes meaningfully to long-term outcomes.
The treatment of pes cavus requires a structured, individualised approach that begins with accurate diagnosis of both the deformity and its underlying cause. Conservative management through orthotics, physiotherapy, and appropriate footwear remains the cornerstone of care for the majority of patients. When surgical intervention is indicated, the choice of procedure must reflect the flexibility of the deformity, the patient’s age and neurological status, and the specific anatomical components driving the pathology. With careful assessment and a systematic treatment strategy, most patients with pes cavus can achieve meaningful improvements in pain, function, and quality of life.