Chapter 25 Pes Cavus

First identified by Little in 1853

Clinical Problems
1) abnormal weight bearing forces
2) instability of the foot and ankle
3) restricted mobility
4) difficulty in fitting shoes

Its primarily a sagittal plane deformity

2 Types:
1) Rigid
2) Flexible

"High Arch" may be noted in stance exam or only in non-weight bearing, if present in
stance represents a more rigid deformity may be result of neuromuscular imbalance.

Complete Definition – pes cavus is primarily sagittal plane deformity consisting of

plantar flexion of forefoot on the rearfoot, possibly secondary multiplanar forefoot and
rearfoot deformities, it may be rigid or flexible, and is possibly associated with
neuromuscular disorders.

1 study showed 75% had associated neuromuscular disease, 16.3% incidence occurring in
women > men.

Specific diagnostic tests include EMG and NCV.

Broken into congenital or acquired conditions.

Congenital –
Spina Bifida, myelodisphasias, familial degeneration nerve disorders, hypertrophic
interstitial neuropathy, CP, MD, congenital syphilis, scoliosis, TEV, myelomeningocele
CMT, Freidrich’s ataxia, Roussy Levy syndrome.

*The earliest signs of Hereditary Sensory/Motor neuropathy (HMSN) occurs in

lumbricules and interossei.

Other Associated Disorders: dystonic musulorum deformons and fibromatosis

Acquired –
Tumors, trauma, infection, psychiatric conditions, choristoma of sciatic nerve, tarsal
coalition, spinal conditions of the first 2 segments.

1) CMT – Peripheral muscular atrophy

 - Most common (HMSN) cause associated with this disorder.
- Slowly progressive disease, appears in adolescent/young adult atrophy begins
distally in feet/legs and later involves hands
- Decrease NCV possible
- Cavus from anterior muscle group weakness, PB involved early – PL is later and
can be used at tendon transfer
- Stork leg
- Strong familial history
- Sensory deficit is mild

2) Roussy Levy –
- Similar to CMT –
- Important distinction = tremors in hands and ataxia
- Autosomal dominant
- Considered intermediate between CMT and FA
- Atrophy mirrors CMT but disease less severe and less rigid
- Decrease DTR's

3) Fredrich's Ataxia (FA)

- Hereditary, with onset in late childhood
- Recessive
- Child develops staggering gait and unsteady stance
- Loss sensation and DTR's
- Most patients die secondary to myocardial disease by early adulthood
- Surgery may not be indicated secondary to short life span
- Also see increase sensitivity to muscle relaxants

4) Dejerine-Sottas Syndrome – Hypertrophic Interstital Neuropathy (HIN)

- Rare
- Recessive
- Progressive muscle weakness begins in childhood
- Pain and parasthesis in feet with pes cavus
- Symmetric weakness of distal extremities
- Palpable enlargement of nerves
- Diagnosis confirmed by nerve biopsy

5) Cerebal Palsy (CP)

- May be numerous foot deformities with pes cavus being one
- Rearfoot and ankle are primary levels of deformity
- Fixed non-progressive brain lesion with onset perinatal
- Patients may have multiple levels of paralysis/spasistity
- Must test function of each muscle
- Surgical considerations based on case
- Surgery may greatly increase ambulatory capacity

6) Progressive Muscular Dystrophy

 - Rapid myopathy with loss of weight bearing in second decade
- Myocardium limits life to third decade
- Release of contractures may aid in wheelchair transfer
- Myotonic MD begins distally with foot disorders

7) Poliomyelitis
- Until 20th century was primary cause of pes cavus
- Infantile form is leading cause of post cavus
- Affects anterior horn cells in spinal cord
- Leads to weakness of DF and PF and claw toes

Classification pg 765

Biomechanics

Plantar flexion of forefoot on rearfoot or Dorsi flexion of rearfoot on forefoot

1) Anterior Cavus
4 types:
A) Metatarsus cavus
B) Lesser Tarsus cavus
C) Forefoot cavus
D) Combined Anterior cavus

A) Metatarsus Cavus –
- Declination of mets with apex at Lis Franc's
- Palpable bone dorsally usually at first met cuneiform joint
- More rigid

B) Lesser Tarsus Cavus –

- Apex over lesser tarsus
- Variable in terms of rigidity

C) Forefoot Cavus –
- Occurs at Chopart’s
- Dorsal lateral head of talus is pathognemonic sign in NWB
- More flexible
- Use Hibbs and Meary's angles for evaluation
Meary's = center of talus and first met
Hibb's = calcanenus and first met
- On lateral view where they intersect represents the apex of deformity
 D) Combined Anterior Cavus –
- Excessive plantar flexion occurring at 2 or more axises

Compensation may occur by:

1) Retraction of toes at MPJ
2) Plantar bulking of MPJ
3) Forefoot reduction if flexible
4) Ankle dorsiflexion

1) Retraction of toes at MPJ

- Unopposed EDL pull
- May occur non-weight bearing in swing phase – ie extensor substitution
- Due to cavus EDL is elongated which give constant passive pull

2) Plantar Bulking at MPJ –

- Secondary dorsiflexion of toes forces met heads into plantar flexion
- This exaggerates anterior cavus

3) Lesser tarsal sagittal plane flexibility (LTSPF)

- Weight bearing forces may reduce deformity in flexible form
- If completely compensated foot may appear normal in weight bearing
- No STJ pronation occurs this is pure sagittal plane at the lesser tarsus

Pseudoequinus
- Dorsiflexion of ankle can compensate for anterior cavus
- This leads to increase CIA
- If there is not enough ankle dorsiflexion remaining for gait the result is
Psuedo Equinus

Pseudoequinus Definition – functional limitation of ankle dorsiflexion caused by

premature dorsiflexion secondary to anterior cavus

Posterior Pes Cavus

- Excessive dorsiflexion of rearfoot compared to forefoot
 - See inverted calcaneous in stance but don't confuse with compensated forefoot
valgus
- Lesions occur at first and fifth met heads; midfoot pain; ankle instability

Associated Conditons
Forefoot Varus
Forefoot valgus
Plantar flexion of first ray
Met Adductus
Equinius
Rearfoot varus

Principles of Surgical Judgement

Must Classify intone of the following:

Type I: Forefoot deformity
- Flexible uni-planar deformity
- Treatment - MPJ releases, PIPJ fusions, & tendon transfers
Type II: Multiplanar
- More rigid especially in frontal plane
- Most common presentation
- Treatment - met/calcaneal osteotomies in addition to type I treatment
Type III: Advanced multiplanar
- NM imbalance
- Treatment - same as I & II with mid tarsal and tarsal fusions/osteotomies

*Must consider etiology whether progressive/non-progressive may need to fuse earlier if

progressive disease*

Type I –
- Flexible
- Deformity disappears on stance
- May have rigid/flexible hammer toes

Type II –
- May be apparent weight bearing
- Deformities for Type I may present as well
- Callous lesions on first and fifth mets
- Treatment – dorsiflexion osteotomy of 1st met/ Dwyer with tendon transfers
and/or lengthenings

Type III –
- Marked deformity in multiplanes
- Gait abnormalities and instability
- Painful plantar lesions
- Treatment = Cole or arthrodesis
 - Decision for diagnosis of type II vs III often made if patient complains of
painful lesions vs instability

Application
Rigid vs Flexible
- Rigid requires osteotomy/release –
- if any component is compensating may not need surgical correction
- In types II and III rearfoot assessed first
- Two planes may exist – sagittal (dorsiflexion of rearfoot compared to
forefoot) and/or frontal (rearfoot varus)

See flow chart pg 777

Soft Tissue Releases

Plantar Fasciotomies –
- Release plantar fascial contracture
- Reserved for pediatrics
- Only adjunctive in adults

Subcutaneous Fasciotomy –
- Peds with moderate plantar fascial contracture with little muscle involvement
- Blade inserted flat against skin then rotated 90 degrees with sharp against
fascia
- Cut 2 levels 2.5 cm apart with pressure from index finger on heel
- Then forefoot dorsiflexed
- BK walking cast changed every 2-3 weeks with forefoot dorsiflexed on
rearfoot

Steindler Stripping
- Peds with contracture of plantar fascia and musculature
- No effect on fixed deformities
- Care of Nuerovascular bundle
- Sagittal plane release only
- If multiplanar – need more incision along medial side of calcaneous distal to
approx. 3.75 cm anterior to medial tubercle
- Release plantar fascia/ abductor hallcis, FDB, Abductor DQ, and long plantar
ligament
- The foot forced in corrected position
- After care same as SubQ Fasciotomy

Mid line approach

- Midline incision from 1 cm distal to tuberosity to the base of mets
- Excise aponeurosis widely, abductor hallucis, FDB, abductor digiti quinti,
quadratus plantae, and the long plantar ligaments are detached from there
origin
 - Keep all dissection directly on bone to avoid NV bundles
- BK wlaking cast for 12-16 weeks

Plantar Medial Release for fixed ant cavus

- Release of intrinsic plantar musculature, long and short plantar ligs, spring lig,
calcaneonavicular portion of the bifurcate lig, and plantar fascia.
- Lengthening of the long flexors and PT tendon is preformed if bowstringing is
noted intraop.
- If posterior cavus is noted to be rigid, cut all capsular and ligamentous
attachments between talus and calcaneous except the post talocalcaneoal
ligament.
- These procedures are followed by serial casting

Tendon Transfers
- Provide better results for patients older than 10 years
- There must be adequate ROM across the joint in which the tendon is to be
transferred in order for the transfer to be successful
- These procedures aren’t meant to correct the deformity but to establish a more
normal equilibrium

Extensor Tendon Transfers

When transferred to the met heads or lesser tarsus, it has 3 effects:
1) relieves deforming forces at the digits
2) helps compensate for forces causing type I pes cavus
3) helps maintain dorsiflexory power at the ankle

- Helps to load the midtarsal joint by dorsiflexing the forefoot on the rearfoot
attempting to balance extensors and flexors
- PIPJ fusions may be necessary when performing ETT

Jones Suspension
- Isolated transfer of EHL to the head of the 1st met
- May be used for overpowering of Peronoues Longus of FHL
- Must have adequate ROM of the 1st ray and absent ankle equines
- Should fuse hallux IPJ
- Be careful not to produce iatrogenic limitus
- Jones is effective for correction of hallux malleus but not predictable for
submet 1 lesions

Heyman Procedure
- Transfer of all 5 long extensor tendons to their met heads.
- Original gave no resolution to the distal stump, the PI modification sutures
distal stumps to the short extensor tendons the 5th also goes to the fourth
- High complication rate – not used much anymore
 - Should fuse PIPJ and release the MPJ to assure adequate stabilization of the
toe.

Hibbs Procedure
- Original procedure included extensor transfer to 3rd cuneiform plantar fascial
release and plantar muscle release and possible Achilles tendon lengthening
- PI includes transfer of extensors to 2nd or 3rd met base or cuneiform, Jones of
EHL and either anastamosis of distal stumps to EDB or PIPJ fusions. Plantar
stripping is omitted to maintain stability of the toes and Achilles tendon
lengthening is rarely needed

Split Tibialis Anterior Tendon Transfer

- Effective in flexible pes cavus deformities
- Lateral half of TA is split and anastamosed with peroneous tertis tendon near
its insertion at the met base.
- This gives a pronation force as the foot prepares for heel strike
- This procedure is recommended when EHL and EDL are weak but TA is at
full strength.
- Rarely used as a sole procedure but as a adjunctive with osseous procedures.

Peroneus Longus Transfer

- Helps in producing dorsiflexory force at the ankle and decreases the
plantarflexion of the 1st met
- Procedure is decribed in Chapter 45 but typically one half is sutured to the TA
and the other half is sutured to PT near their insertions

Tibialis Posterior Tendon Transfer

- Can be released from its insertion and re-routed to the dorsum of the foot as
described in Chapter 45
- However this may result in sever pes valgus if the rearfoot can pronate past
perpendicular. If so may need to do triple or TN fusion for stability. If STJ
can’t pronate past perpendicular stabilization may not be necessary.

Peroneal Anastomosis
- Suturing the PL and PB at the level of the lateral ankle
- Used to decrease plantarflexion of 1st ray and increase eversion.
- As with STAT it is used as an adjunctive procedure. Should not be used as a
stand alone procedure.
- Can also anastamose at the level of PB insertion

Peroneus Longus and Tibialis Posterior Transfer to Calcaneous

- Used for significant weakness of Achilles Tendon or to neutralize a
calcaneous gait. However severe Pes planus may ensue by loosing these
tendons, so triple may be needed.
- PL is sectioned at level cubiod where it passes deep in the foot the distal
stump can be sutured to the PB tendon.
 - Penetration is made in the intramuscular septum from lateral compartment to
the superficial posterior compartment and the tendon is sutured into the lateral
calcaneous near the lateral aspect of the achilles.
- Tibialis Posterior is sectioned near its insertion at the navicular. The distal
stump may be sutured to the FDL tendon.
- Penetration through the deep transverse intermuscular septum into the
superficial post compartment and the tendon is sutured into the medial aspect
of the calcaneous near the insertion of the Achilles tendon medially.
- The two tendons are anchored into the calcaneous and sutured with foot in
mild plantarflexion.

Osseous Surgical Procedures

Midtarsal Osteomies

Cole –
- Addresses apex at midfoot
- Anterior tarsal resection – dorsal midfoot wedge osteotomy to reduce sagittal
plane anterior pes cavus with little frontal plane correction
- Dorsal wedge laterally from cuboid and medially from navicular/cuneiform
joint
- Medial and lateral incisions normally but 1 dorsal incision has be described
- Width of wedge depends on severity of deformity
- Fixated with pins, staples, or screws
- May need plantar fascitomy
- Post op non weight bearing , BK cast for 8 weeks, then weight bearing cast for
4-6 weeks
- Can add DF wedge of first met or Dwyer if rearfoot involved

JAPAS
- Midtarsal V osteotomy of midfoot
- No bone excised
- Apex of V oriented proximally at apex of deformity usually in navicular
- Lateral arm through cubiod and medial arm through cuneiform
- Osteotomy is displaced dorsally
- Fixation with 2 pins
- If first ray dorsiflexion is needed you can pass medial arm through the first
met base
- Plantar fasciotomy should be preformed
- Post op same as Cole
- Harder to perform than Cole with increased complications

Truncated Tarsometatarsal Wedge Arthodesis

- Wedges across Lis Franc's
- Amount of wedge depends on degree of deformity
- Can correct sagittal and frontal deformities
 - Contraindicated in patients with rearfoot varus, STJ abnormalities or calluses
proximal to Lis Franc's
- Other concerns CMT and paliolmylitis
- Technically difficult
- Wedges are truncated not triangular

McElvenny – Caldwell Procedur

- Eelevation of first met with arthodesis of first met cuneiform joint
- Procedure preceded by series of casts that put heel in valgus and supinates
forefoot in peds patients
- Relaxes soft tissue
- No age limitation
- Fixation 2 screws - 1 distal to medial in met base 2nd proximal to lateral in
cuneiform
- Can fuse navicular cuneiform joint if necessary
- Post OP cast for 9 weeks
- If pt needs triple it should be preformed first because it can drastically change
the amount of bone section needed distally

Metatarsal Osteotomies
- Multiple met osteotomies give latitude for correction of anterior cavus with
correction allowed in sagittal, frontal, and transverse planes if needed
- Rarely need plantar fascial releases
- Preformed through 3 dorsal incisions- 1st over first met base, 2nd between
2nd and 3rd met bases, 3rd between 4th and 5th met bases
- The met needing the least correction is done first
- If transverse plane correction needed do 5th met first to allow for lateral
translation
- Fixation with screws
- Non weight bearing cast 6-8 weeks
- Advantages:
o 1) function of rearfoot and midfoot joints are preserved
o 2) less disability –
- Disadvantages:
o extensive soft tissue dissection
o if rearfoot varus can’t return to perpendicular must realign

Tarsal Osteotomies

Dwyer
- Closing wedge of lateral body of calcaneous for rigid rearfoot varus
- Not indicated for rearfoot varus secondary to forefoot valgus
- Effective in peds after 3 years
- Reocurrence associated with neuromuscular disease
- Expose lateral body of calc. including upper and lower surfaces a wedge is
removed laterally just inferior and posterior and parallel to PL tendon
 - Fixation staple
- Post op – cast 6-8 weeks
- Tachdjian recommended not to perform prior to 8 years

Dorsiflexory Calcaneal Osteotomies

- A cresentic biplane osteotomy at posterior aspect of calcaneous
- Posterior calcaneous is rotated dorsally and laterally
- Decrease CIA (ie sagittal) as well as frontal plane deformity
- The problem is that it increases pseudo equinius
- Use caution

Tarsal Arthodesis
Triple Arthrodesis
- Hoke described fusion of the STJ and TN Ryserson added CC hince triple
- Aids in Type III pes cavus
- Increases stability
- May be combined with tendon transfers, met osteotomies and digital
procedures
- assess ankle stability
- To correct one may: 1) wedge resect or 2) sliding maneuvers –
- The initial Midtarsal joint resection is minimal until STJ is completed
- Care must be taken to PF calc. and talus in relation to forefoot and not to DF
talus
- If calc. is displaced forward slightly, it creates a wedge effect encouraging DF
of FF on RF
- Once STJ is complete its temporary fixed with pins
- Then wedges are taken from Midtarsal joint as needed
- Frontal plane slides can be used to correct forefoot varus/valgus
- If unsuccessful may need met osteotomy
- Temp. fix MTJ with pins
- Fixate STJ then MTJ
- Post op includes compression dressings and drains
- BK non weight bearing cast for 3 months or
- BK weight bearing cast after 2 months
- If you have rigid internal fixation can place patient in bivalved cast or splint
after 4 weeks to allow for patient and passive ROM

Repair of Digital Deformities

Hammer Toes and Claw Toes are common with pes cavus – if you people don't
know how to fix a toe by now, you should not be studying for this test.