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Cavus foot

39 citationsUpdated Sep 2026

Overview

Pes cavus is defined by an elevated medial longitudinal arch secondary to forefoot plantar flexion or, less frequently, excessive calcaneal dorsiflexion [20]. The primary structural problem is forefoot plantar flexion, often more marked in the first ray, which results in forefoot pronation [20]. For the lateral half of the foot to contact the ground, the hindfoot deviates into varus [20]. Two-thirds of patients have an underlying neurologic disorder, most commonly Charcot-Marie-Tooth disease [20]. Subtle cavovarus foot alters mechanics, leading to lateral ankle instability, peroneal tendon tears, and stress fractures [3]. Patients may report instability, such as ankle sprains [20].

Evaluation requires a neurologic examination and family history [20]. Unilateral involvement suggests a focal diagnosis, such as spinal cord anomaly or nerve injury, while bilateral involvement with a positive family history is common with Charcot-Marie-Tooth disease [20]. Asymmetry may occur despite bilateral involvement [20]. Hindfoot flexibility is assessed via the Coleman block test [20]. Weight-bearing radiographs are required, with an increased Meary angle (normal 0° to 5°) and calcaneal pitch greater than 30° indicating deformity [20]. MRI of the spine is indicated with unilateral involvement [20].

Treatment prioritizes joint-sparing procedures, with hindfoot flexibility guiding surgical decisions [20]. Non-operative management of childhood neurologic cavovarus foot avoids surgery in half of cases or delays it by a mean 4.5 years [1]. Joint-sparing surgery is optimal for flexible cavovarus foot, even in Charcot-Marie-Tooth disease [2]. Arthrodesis is reserved for severe rigid or degenerative cases [2]. Specific interventions include plantar release, tendon transfers, and osteotomies tailored to deformity rigidity [20]. Selective plantar-muscle denervation may prevent progressive deformity and improve stability [10]. Extra-articular midfoot osteotomy with joint-sparing fixation is effective for rigid deformity with low arthritic degeneration rates [14]. Neutral-cushioned running shoes reduce plantar pressures in athletes [25].

Anatomy & Pathophysiology

Definition and Epidemiology

A pes cavus is defined as a foot with an elevated medial longitudinal arch secondary to forefoot plantar flexion or, less frequently, excessive calcaneal dorsiflexion [20]. Approximately 10% of skeletally mature individuals have cavovarus foot alignment, with most of these individuals being asymptomatic [42]. Cavus foot is rarely found in the absence of an underlying neuromuscular condition [29]. While rarely found in early childhood, the condition is fairly frequent after 8–10 years of age [29]. In a study of more than 2700 patients with Charcot-Marie-Tooth disease, 71% had foot deformities, with pes cavus and hammer toes being the most common [41].

Neuromuscular Pathophysiology

The primary structural problem in cavus foot is forefoot plantar flexion, where the first ray is often more markedly plantarflexed, resulting in forefoot pronation [20]. For the lateral half of the foot to be in contact with the ground, the hindfoot must deviate into varus [20]. First ray plantar flexion may result from a weak tibialis anterior relative to the peroneus longus, but is more commonly caused by intrinsic weakness and contracture [20]. In Charcot-Marie-Tooth disease, atrophy and contracture of the intrinsic musculature occur due to denervation, leading to collagen replacement of the intrinsic muscles [30]. The elevation of the longitudinal arch in Charcot-Marie-Tooth disease is produced by contracture of the plantar fascia, which increases pressure on the metatarsal heads [30]. Varus of the hindfoot in Charcot-Marie-Tooth disease is caused initially by plantar flexion of the first ray and forefoot equinus [30]. The posterior tibialis and peroneus longus remain strong relative to the weak peroneus brevis and anterior tibialis, leading to depression of the first ray and increased varus [30]. The peroneus longus is believed to remain relatively stronger than the peroneus brevis because it is normally approximately twice as strong as the brevis [30]. Toe deformity in Charcot-Marie-Tooth disease results from nonfunctional intrinsic muscles, causing the long toe flexors to create flexion deformities of the interphalangeal joints and hyperextension through the metatarsophalangeal joints [30]. Loss of intrinsic function, as seen in hereditary motor sensory neuropathy or diabetic neuropathy, predictably leads to claw toes [61]. In Charcot-Marie-Tooth disease, the forefoot is pulled into equinus relative to the hindfoot, and the first ray becomes plantarflexed [41]. The long toe extensors attempt to assist the weak anterior tibial tendon in dorsiflexion but contribute to metatarsal plantarflexion, pronating the forefoot into a valgus position with mild adduction of the metatarsals [41]. As the forefoot becomes more rigidly pronated, the hindfoot assumes a varus position, creating a "tripod" weightbearing mechanism on the heel and the first and fifth metatarsal heads [41]. Neuromuscular imbalance between a nonfunctioning peroneus brevis muscle and its antagonist, the posterior tibialis muscle, pulls the hindfoot into varus [42]. Forefoot-driven varus can occur when a relatively weak anterior tibialis muscle is overpowered by its antagonist, the peroneus longus muscle, plantarflexing the first ray [42].

Traumatic and Acquired Pathophysiology

Muscle contractures created by deep posterior compartment syndrome cause the tibialis posterior and flexor digitorum longus muscles to pull the foot into an equinus and cavovarus position [23]. Severe scarring after burns, crush injuries, or venous stasis may pull the foot into the cavovarus position [23]. A talar neck fracture malunion can leave the distal portion of the talar neck in a shortened, dorsally and medially translated position, resulting in a fixed varus position of the subtalar, talonavicular, and calcaneocuboid joints [23]. Injury to the deep branch of the peroneal nerve or L5 nerve root resulting in peroneal muscle weakness leaves the action of the tibialis posterior and long toe flexor muscles unopposed, causing hindfoot and forefoot varus [23]. Heel varus may subject the peroneus brevis tendon to repetitive injury, resulting in a degenerative tear and possible rupture, which can progress to a significant cavovarus foot [23].

Clinical Manifestations and Biomechanics

Subtle cavovarus foot is a mild malalignment that alters foot mechanics, leading to conditions such as lateral ankle instability, peroneal tendon tears, and stress fractures [3]. One of the most common symptoms of cavus foot is anterior ankle pain, sometimes associated with toe walking [29]. The forefoot in a cavus foot is severely plantar flexed on the hindfoot, requiring marked ankle dorsiflexion to compensate [29]. When the cavus deformity becomes too severe, ankle dorsiflexion is blocked, leading to anterior ankle impingement and pain [29]. The inability to dorsiflex further compromises forefoot clearance, eventually allowing only the metatarsals to contact the floor [29]. This inability to dorsiflex can be misinterpreted as an ankle plantarflexion contracture, leading to unnecessary heel cord release [29]. Plantar callosities under the first and fifth metatarsal heads are common in cavovarus foot [32]. A "peek-a-boo" heel, where the medial heel pad is visible from behind, signifies hindfoot varus [32]. In Charcot-Marie-Tooth disease, pressure is abnormally distributed with excess loading along the lateral border of the foot, on the first metatarsal head, and on the tips of claw toes [30]. Chronic overloading of the talonavicular joint due to a pes cavus deformity with restricted motion in the adjacent talonavicular joint is frequently seen in physically active patients with stress fractures [80].

Radiographic Anatomy and Assessment

On weight-bearing lateral radiographs, an increased Meary angle is defined as the long axis of the talus intersecting the long axis of the first metatarsal dorsally, with a normal value of 0° to 5° [20]. An increased calcaneal pitch, defined as the intersection of a line running along the undersurface of the calcaneus and the floor greater than 30°, indicates a calcaneocavus foot [20]. In patients with Charcot-Marie-Tooth disease, the Meary angle averages 18 degrees, compared to normal values ranging from 0 to 5 degrees [30]. Varus in Charcot-Marie-Tooth disease is seen as parallelism of the talus and calcaneus on the lateral radiograph [30]. The lack of hindfoot equinus in Charcot-Marie-Tooth disease can be documented by measurement of the calcaneal pitch, which usually reveals dorsiflexion of the calcaneus and the presence of forefoot equinus with the apex of the deformity in the midfoot [30]. Hindfoot varus can be assessed using the AP-talocalcaneal angle, and midfoot cavus by the lateral talar–first metatarsal angle [32]. Foot supination can be quantified by metatarsal overlap on radiographs [32]. The Coleman block test is performed by placing a 1-inch block under the lateral border of the foot to assess hindfoot flexibility [20]. If lateral foot elevation and first ray plantar flexion succeed in everting the hindfoot, the deformity is connoted as forefoot-driven hindfoot varus [32]. If the hindfoot deformity does not correct with passive manipulation or the Coleman block test, the deformity is considered hindfoot-driven varus or fixed varus [42]. Fixed varus indicates that the Chopart joints are locked in varus and that a hindfoot corrective osteotomy is required [42].

Classification

Phenotypic Presentation: Subtle cavovarus foot represents a mild malalignment that alters foot mechanics [3]. This deformity predisposes patients to lateral ankle instability, peroneal tendon tears, and stress fractures [3]. Heel varus subjects the peroneus brevis tendon to repetitive injury, resulting in degenerative tears and possible rupture [23]. Loss of the peroneus brevis tendon can progress to a significant cavovarus foot [23].

Etiological Mechanisms: Muscle contractures created by deep posterior compartment syndrome cause the tibialis posterior and flexor digitorum longus muscles to pull the foot into an equinus and cavovarus position [23]. Injury to the deep branch of the peroneal nerve or the L5 nerve root resulting in peroneal muscle weakness leaves the action of the tibialis posterior and long toe flexor muscles unopposed, causing hindfoot and forefoot varus [23]. Knee dislocation with permanent injury to the peroneal nerve may lead to an equinocavovarus position of the ankle or foot [23].

Other Considerations: The aim of treatment for pes cavus in children and adolescents is to preserve a painless, plantigrade, mobile foot by correcting bone deformity while preserving movement and using rebalancing techniques wisely [22]. Arthrodesis is reserved as a salvage procedure for pes cavus in children and adolescents [22].

Clinical Presentation

Cavus foot serves as a clinical marker for underlying neuromuscular disease, necessitating a thorough search for the etiology upon diagnosis [29]. In adults with Charcot-Marie-Tooth disease, foot and ankle weakness constitutes the primary factor impacting quality of life [30]. A neurologic examination and detailed family history are essential components of the evaluation [20]. Unilateral involvement suggests a focal diagnosis, such as a spinal cord anomaly or nerve injury, and warrants MRI of the spine [20]. While bilateral involvement is typical, asymmetry may still be present in Charcot-Marie-Tooth disease [20]. Patients with bilateral cavovarus feet have a 78% probability of being diagnosed with Charcot-Marie-Tooth disease, a probability that increases to 91% when a family history of the condition is present [30]. A neurologic or neuromuscular etiology should be expected when clinical features include a family history of cavus feet, rapid onset and progression, marked asymmetry, very severe deformity with marked clawing, focal wasting, or spasticity [42]. Nonneurologic causes of cavovarus foot include congenital clubfoot, posttraumatic varus malunion, missed compartment syndrome, burn contractures, and idiopathic etiology [42].

Clinical Signs and Symptoms

Anterior ankle pain arises because the severely plantar-flexed forefoot requires marked ankle dorsiflexion to compensate, leading to impingement when dorsiflexion is blocked [29]. Common physical findings include calluses beneath the metatarsal heads and heel skin [29], as well as plantar intrinsic wasting [32]. In Charcot-Marie-Tooth disease, contracture of the plantar fascia increases pressure on the metatarsal heads, resulting in painful callosities along the lateral border of the foot and beneath the metatarsal heads [30]. Inspection from the side reveals an elevated medial longitudinal arch [32], while inspection from behind demonstrates heel inversion on standing [32]. Neuromuscular cavovarus foot often presents with clawing of the hallux and lesser toes [42]. The foot may exhibit a bean-shaped appearance due to the combination of hindfoot varus and forefoot adductus [42].

Physical Examination Maneuvers

Hindfoot flexibility is assessed using the Coleman block test, which involves placing a 1-inch block under the lateral border of the foot [20]. If lateral foot elevation and first ray plantar flexion succeed in everting the hindfoot, the deformity is driven by the plantarflexed first ray [32]. When hindfoot varus corrects with the Coleman block test, the deformity is classified as forefoot-driven varus or flexible varus [42]. In individuals with cavovarus deformity, hindfoot varus is considered nonstructural if it corrects with the block test, indicating that surgical procedures directed at correcting the hindfoot deformity are not necessary [29].

Radiographic Findings

Weight-bearing radiographs are required for the evaluation of cavus foot [20]. On lateral views, an increased Meary angle is defined as the long axis of the talus intersecting the long axis of the first metatarsal dorsally, with a normal value of 0° to 5° [20]. In patients with Charcot-Marie-Tooth disease, Meary angle values average 18 degrees [30]. An increased calcaneal pitch is defined as the intersection of a line running along the undersurface of the calcaneus and the floor, with a value greater than 30° indicating a calcaneocavus foot [20]. Lateral radiographs of cavovarus foot often show the fibula located posterior to the posterior border of the distal tibia at the level of the ankle [42]. On AP radiographs of the foot, metatarsals are often adducted and the forefoot is rotated into supination [42]. On AP radiographs of the ankle, the talus may tilt into varus as a result of lateral ankle ligament insufficiency [42]. The Coleman block lateral radiograph is a mediolateral weight-bearing view used to evaluate the flexibility of the hindfoot, rotational correction in the ankle, and degree of correction of forefoot supination [30].

Investigations

Clinical Examination

A neurologic examination and a family history are essential for the evaluation of cavus foot [20]. Calluses beneath the metatarsal heads and heel skin are common clinical findings [29]. When cavus deformity is severe, ankle dorsiflexion is blocked, leading to anterior ankle impingement and pain [29]. This presentation can be misinterpreted as an ankle plantarflexion contracture, potentially leading to unnecessary heel cord release [29]. Hindfoot varus in individuals with a cavovarus deformity is nonstructural if it can be corrected with the "block test" [29].

Imaging

Diagnosis of cavus foot requires a thorough search for the underlying cause and may require neurologic consultation, spinal MRI, and electromyographic (EMG) studies [29]. Cavus foot is frequently accompanied by hindfoot varus deformity, toe clawing, and demonstrable weakness of ankle or foot muscles [29].

Plain radiography: Calcaneal pitch is defined as the intersection of a line running along the undersurface of the calcaneus and the floor [20].

Treatment

Non-Operative

Non-operative management is effective for childhood neurologic cavovarus foot, avoiding surgery in half of cases followed to the end of growth or delaying intervention by a mean of 4.5 years [1]. For mild, flexible, and painless cavus foot, treatment consists of Achilles tendon stretching and an eversion/dorsiflexion strengthening program [20]. In mild cavus foot that is progressive or symptomatic, plantar release with or without a peroneus longus to brevis transfer is indicated [20]. Conservative measures include shoe modifications or inserts for accommodation, which do not correct the condition [29], and neutral-cushioned running shoes to reduce plantar pressures in athletes [25]. A simple splint straightens clawed toes, improves walking, and has not caused skin necrosis or other complications [27]. An orthotic that recesses the first ray and elevates the entire lateral foot is reserved for cavovarus deformities with flexible hindfoot varus [32]. In Charcot-Marie-Tooth disease, nonoperative treatment including serial casting and botulinum toxin has generally been unsuccessful [41]. Botulinum toxin injections are safe and well tolerated but do not affect deformity progression [41], and high-dose ascorbic acid is ineffective in altering the natural history of the disease [41].

Operative

Indications: Joint-sparing procedures are preferred whenever possible for cavus foot [20]. The flexibility of the hindfoot is a key determinant in surgical decision making [20]. For children and adolescents, the aim is to preserve a painless, plantigrade, mobile foot by correcting bone deformity while preserving movement [22]. Arthrodesis is reserved as a salvage procedure for children and adolescents [22] and is indicated for severe rigid cavus foot or degenerative cases [2]. In patients with myelomeningocele, arthrodesis should be avoided due to the susceptibility of insensate feet to skin breakdown and ulceration [83].

Surgical Approach / Technique: Percutaneous plantar fascia release is insufficient to correct cavus foot; at minimum, an open release and soft-tissue rebalancing are needed [20]. Achilles tendon lengthening should not be performed concomitantly with plantar fasciotomy, as an intact Achilles tendon provides the resistance necessary to stretch contracted plantar tissues [20]. Plantar release is useful for correcting residual cavus deformity from clubfoot in older children and for improving alignment in feet with cavus deformity resulting from poliomyelitis, provided there is no significant equinus or calcaneal deformity [21]. Selective plantar-muscle denervation may prevent progressive increase of pes cavus, improving foot balance, performance, stability, and position [10]. In selected cases of calf-muscle paralysis, hamstring transplant prevents calcaneocavus deformity in the growing child and can develop considerable power of plantar flexion [15, 16]. For varus caused by peroneal weakness, tibialis anterior and/or posterior tendon transfer to the peroneal muscles is indicated [20]. For clawing of the hallux, an extensor hallucis longus transfer to the first metatarsal (Jones procedure) is indicated [20]. In equinocavovarus deformity where the hindfoot is correctable into valgus, isolated soft-tissue surgeries can correct the deformity [89]. A split transfer of the tibialis anterior tendon to the lateral cuneiform maintains active dorsiflexion while reorienting the force vector out of varus [89]. If the tibialis anterior tendon is weak, a split tibialis posterior tendon transfer to the peroneus brevis should be used [89]. The cavus component can be addressed with a plantar fascia release through either a plantar or a medial incision [89]. If both cavus and equinus are present, their correction should be staged because the surgeon cannot control the contributions of each procedure if done concurrently [89]. Soft tissue surgery consisting of plantar fascia release or extensive plantar release, including capsulotomies with tendon transfer, may be sufficient to postpone or avoid triple arthrodesis when done early in the disease in young patients with Charcot-Marie-Tooth disease [30].

Osteotomies: Dorsiflexion osteotomy of either the first metatarsal or cuneiform is indicated for moderate rigid medial cavus [20]. Dorsiflexion osteotomies of the cuboid and cuneiforms are indicated for rigid medial and lateral cavus [20]. A closing or sliding calcaneal osteotomy is indicated for rigid hindfoot varus [20]. A surgical procedure combining plantar fasciotomy, naviculocuneiform arthrodesis, and cuboid osteotomy provides good correction of adult idiopathic cavus foot without compromising the range of motion of the foot [4]. Anterior tarsectomy is indicated in moderate or supple anterior or mixed pes cavus, with good scores for activity, walking distance, footwear use, and gait, though the impact on pain was disappointing [7]. Extra-articular midfoot osteotomy combined with adjacent joint sparing internal fixation is effective and safe for the treatment of rigid pes cavus deformity, with low rates of arthritic degeneration and joint stiffness in the adjacent joints [14]. Tarsal V-osteotomy for pes cavus has produced encouraging results in seventeen feet followed for two to six years [13]. In equinocavovarus deformity where the hindfoot is not correctable into valgus, tendon transfer should be coupled with a calcaneal lateral closing wedge osteotomy or a slide osteotomy [89]. Midfoot wedge resection may be required for forefoot equinus deformity in older patients with flail foot [53]. Osteotomies of the areas of fixed deformity (forefoot, midfoot, or hindfoot) are included in the surgical treatment of cavovarus foot [32]. For Charcot-Marie-Tooth disease with increased plantarflexion of the first metatarsal, increased supination, and a stiffer hindfoot, treatment includes first metatarsal osteotomy, midfoot/hindfoot osteotomies, and possible triple arthrodesis [41].

Arthrodesis: Triple arthrodesis is indicated for rigid cavovarus deformity in Charcot-Marie-Tooth disease [41]. It is an option when deformities are too severe to correct through reconstruction or when reconstruction fails in equinocavovarus deformity [89]. The addition of a lateral column lengthening to triple arthrodesis has been described to address severe deformity, resulting in good correction but a stiff foot at higher risk for skin breakdown [89]. Triple arthrodesis is contraindicated in patients with insensate feet as it causes rigidity that may lead to ulceration [51, 52].

Other Considerations: Subtle cavovarus foot alters foot mechanics, leading to lateral ankle instability [3], peroneal tendon tears [3], and stress fractures [3]. In Charcot-Marie-Tooth disease, contracture of the plantar fascia increases pressure on the metatarsal heads, leading to painful callosities along the lateral border of the foot and beneath the metatarsal heads [30]. Absent intrinsic function leads to flexion deformities of the interphalangeal joints and hyperextension through the metatarsophalangeal joints, resulting in a dorsally displaced position with metatarsal head prominence on the plantar aspect of the foot [30]. Foot and ankle weakness caused the greatest impact on quality of life in these patients [30]. In cavus foot, severe forefoot plantar flexion requires marked ankle dorsiflexion to compensate, which can lead to anterior ankle impingement and pain when dorsiflexion is blocked [29]. The inability to dorsiflex further compromises forefoot clearance, eventually allowing only the metatarsals to contact the floor [29]. This inability to dorsiflex can be misinterpreted as ankle plantarflexion contracture, leading to unnecessary and possibly harmful heel cord release [29]. Anterior tarsectomy for adult pes cavus yielded disappointing results regarding the impact on pain [7]. Extra-articular midfoot osteotomy combined with adjacent joint sparing internal fixation for rigid pes cavus deformity is associated with low rates of arthritic degeneration and joint stiffness in the adjacent joints [14]. Tarsal navicular fractures can result in pes cavus deformity as a complication [90] or pes planus deformity as a complication [90].

Recovery

Non-Operative Management: Non-operative management of childhood neurologic cavovarus foot has demonstrated efficacy, with surgery avoided in half of cases followed up to the end of growth [1]. In cases where non-operative management is effective for childhood neurologic cavovarus foot, surgery is delayed by a mean of 4.5 years [1]. Initial results suggest that better foot function is inevitable with less surgical management for idiopathic clubfoot [9]. Nonsurgical treatment for cavovarus deformity includes the utilization of laterally posted custom orthotic inserts with the posting extended to the midfoot to simulate a Coleman block test [36]. Nonsurgical treatment for cavovarus deformity includes physical therapy to optimize peroneal muscle strength and function [36]. A custom ankle-foot orthosis (AFO) can be considered for more severe cavovarus deformities involving the hindfoot or ankle [36].

Operative Management: Joint-sparing surgery is the best option for flexible cavovarus foot, including in patients with Charcot-Marie-Tooth disease [2]. Arthrodesis is indicated for severe rigid cavus foot or in degenerative cases [2]. Arthrodesis should be reserved for salvage procedures or in combination with tendon transfers in patients with severe deformity where joint-sparing surgery would fail or has failed [36]. Undercorrection is the leading cause of poor outcomes in patients who undergo cavovarus reconstruction [36]. Anterior tarsectomy is indicated for moderate or supple anterior or mixed pes cavus [7]. Anterior tarsectomy for adult pes cavus yields good scores for activity, walking distance, footwear use, and gait [7]. The impact of anterior tarsectomy on pain in adult pes cavus was disappointing [7]. The surgical procedure combining plantar fasciotomy, naviculocuneiform arthrodesis, and cuboid osteotomy allows alternating pronation and supination during gait [4]. Extra-articular midfoot osteotomy combined with adjacent joint sparing internal fixation for rigid pes cavus deformity has low rates of arthritic degeneration and joint stiffness in the adjacent joints [14]. Severe equinocavovarus deformities of the foot can be corrected without an open procedure using a hinged distraction apparatus [28]. Correction of severe equinocavovarus deformities using a hinged distraction apparatus allows most patients to return to employment and improves quality of life [28]. Selective plantar-muscle denervation for pes cavus results in improvement in foot balance, performance, stability, and position [10]. Plantar release is a useful technique for correcting residual cavus deformity from clubfoot in older children [21]. Plantar release is useful for improving alignment in feet with cavus deformity resulting from poliomyelitis, provided there is no significant equinus or calcaneal deformity of the hind part of the foot [21]. At minimum, an open release and soft-tissue rebalancing are needed to correct a cavus foot [20]. For varus caused by peroneal weakness, treatment includes adding tibialis anterior and/or posterior tendon transfer to the peroneal muscles [20]. For rigid medial cavus, treatment includes dorsiflexion osteotomy of either the first metatarsal or cuneiform [20]. For rigid hindfoot varus, treatment includes a closing/sliding calcaneal osteotomy [20]. For clawing of the hallux, treatment includes adding an extensor hallucis longus (EHL) transfer to the first metatarsal (Jones procedure) [20]. In selected cases of calf-muscle paralysis, a specific procedure will prevent calcaneocavus deformity from developing in the growing child [15]. In selected cases of calf-muscle paralysis, a specific procedure can develop considerable power of plantar flexion [15]. Hamstring transplant demonstrates that considerable power of plantar flexion can be developed in growing children with calf-muscle paralysis [16].

Outcomes and Complications: Functional outcomes were improved at a median of 15 years for feet treated with the Ponseti method compared with feet treated with posteromedial release (PMR) [5]. Advantages were seen in the Ponseti group over several domains compared to PMR at a median of 15 years [5]. In a study of clubfoot treatment results, 71% of feet had good results, 28% had a slight residual deformity, and one foot had a poor result [6]. Ponseti treatment does not result in a normal foot, but patient function is generally good irrespective of whether additional surgery is performed or the regimen is used for older children in a low-income country [17]. Serial manipulations and casts followed by limited surgery consisting of percutaneous Achilles tenotomy and pin fixation of the talonavicular joint provided good early results in terms of clinical appearance and radiographic measurements at a minimum of two years after correction for congenital vertical talus [18]. Treating physicians should be aware of the possibility of late recurrence in patients who have had complete correction of their clubfoot deformity, as demonstrated by a recurrence at age 8 years despite normal neurologic evaluation [37]. The anteroposterior and lateral talocalcaneal angles are not influenced significantly by the tenotomy in idiopathic clubfeet undergoing Ponseti treatment [38].

Key Evidence

  • [Paper] The study demonstrated efficacy for non-operative treatment of childhood neurologic cavovarus foot, with surgery either avoided in half of the cases followed up to end of growth or delayed by a mean 4.5 years. [1] (10.1016/j.otsr.2016.09.006)
  • [L5] Joint-sparing surgery is the best option in flexible cavovarus foot even in Charcot-Marie-Tooth disease, while arthrodesis is indicated in severe rigid cavus foot or in degenerative cases. [2] (10.1302/2058-5241.2.160077)
  • [L5] Subtle cavovarus foot is a mild malalignment that alters foot mechanics, leading to conditions such as lateral ankle instability, peroneal tendon tears, and stress fractures. [3] (10.5435/jaaos-22-08-512)
  • [L4] This surgical procedure provides good correction of adult idiopathic cavus foot without compromising the range of motion of the foot, allowing alternating pronation and supination during gait. [4] (10.2106/00004623-200200002-00008)
  • [L2] Functional outcomes were improved at a median of 15 years for feet treated with the Ponseti method compared with feet treated with PMR, with advantages seen in the Ponseti group over several domains. [5] (10.2106/jbjs.20.02014)
  • [L4] The results in 71 per cent of the feet were good; in 28 per cent a slight residual deformity persisted; and in one foot a poor result was obtained. [6] (10.1007/s11999-009-0720-2)
  • [L4] Anterior tarsectomy is indicated in moderate or supple anterior or mixed pes cavus, with good scores for activity, walking distance, footwear use, and gait, though the impact on pain was disappointing. [7] (10.1016/j.otsr.2009.03.013)
  • [L4] Plantar fasciotomy, midtarsal osteotomy, the Jones procedure, and dorsiflexion osteotomy of the first metatarsal yielded adequate correction of flexible cavus feet in patients with Charcot-Marie-Tooth disease in the absence of fixed hindfoot deformity. [8] (10.2106/jbjs.n.00794)
  • [L4] Initial results suggest that better foot function is inevitable with less surgical management. [9] (10.5435/00124635-200311000-00003)
  • [L4] The preliminary results suggest that selective plantar-muscle denervation may prevent the progressive increase of pes cavus, resulting in improvement in foot balance, performance, stability, and position. [10] (10.2106/00004623-195638030-00005)
  • [L4] The results in seventeen feet followed for from two to six years have been encouraging. [13] (10.2106/00004623-196850050-00005)
  • [L4] Extra-articular midfoot osteotomy combined with adjacent joint sparing internal fixation is effective and safe for the treatment of rigid pes cavus deformity, with low rates of arthritic degeneration and joint stiffness in the adjacent joints. [14] (10.1186/1749-799x-9-44)
  • [L4] In selected cases of calf-muscle paralysis, this procedure will prevent calcaneocavus deformity from developing in the growing child and can develop considerable power of plantar flexion. [15] (10.2106/00004623-198163070-00014)
  • [L4] The procedure prevents calcaneocavus deformity from developing in growing children with calf-muscle paralysis and demonstrates that considerable power of plantar flexion can be developed. [16] (10.2106/00004623-195840040-00014)
  • [L5] Ponseti treatment does not result in a normal foot but irrespective of whether additional surgery is performed or the regimen is used for older children in a low-income country, patient function is generally good. [17] (10.2106/jbjs.18.00948)
  • [L4] Serial manipulations and casts followed by limited surgery consisting of percutaneous Achilles tenotomy and pin fixation of the talonavicular joint provided good early results in terms of the clinical appearance of the foot and radiographic measurements at a minimum of two years after correction. [18] (10.2106/jbjs.f.01011)
  • [L4] Plantar release is a useful technique for correcting residual cavus deformity from club foot in older children and for improving alignment in feet with cavus deformity resulting from poliomyelitis, provided there is no significant equinus or calcaneal deformity of the hind part of the foot. [21] (10.2106/00004623-198264050-00026)
  • [L5] The aim of treatment is to preserve a painless, plantigrade, mobile foot by correcting bone deformity while preserving movement and using rebalancing techniques wisely, with arthrodesis reserved as a salvage procedure. [22] (10.1302/2058-5241.6.210021)
  • [L5] [23] (10.5435/00124635-200509000-00004)
  • [L2] Two popular types of neutral-cushioned running shoes were effective at reducing plantar pressures in athletes with cavus feet. [25] (10.1177/0363546508318191)
  • [L4] The splint is simple, efficient, and inexpensive; it straightens the toes, improves walking, and has not caused necrosis of the skin or other complications. [27] (10.2106/00004623-194931010-00026)
  • [L4] Severe equinocavovarus deformities of the foot can be corrected without an open procedure using this external fixation device, allowing most patients to return to employment and improving quality of life. [28] (10.2106/00004623-199604000-00008)
  • [L5] Management goals are to obtain a plantigrade, mobile, pain-free, stable, motor-balanced foot. [36] (10.5435/00124635-200305000-00007)
  • [L4] Treating physicians should be aware of the possibility of late recurrence in patients who have had complete correction of their clubfoot deformity, as this case demonstrates a recurrence at age 8 years despite normal neurologic evaluation. [37] (10.1097/01.blo.0000065837.77325.19)
  • [L4] The anteroposterior and lateral talocalcaneal angles are not influenced significantly by the tenotomy. [38] (10.2106/jbjs.f.00438)

References

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