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he Cavus Foot in Athletes:undamentals of Examination and Treatment

arang N. Desai, DO, Randolph Grierson, DO, and Arthur Manoli, II, MD

Athletes with cavus feet present unique challenges to the orthopedic surgeon. Continuoushigh impact activity with this foot deformity leads to distinct injuries. Immediate recognitionof the athlete’s cavus feet and associated injuries allows prompt treatment and return tosport. If not recognized, treatment will often fail. Injuries include stress fractures, ankleinstablility, impingement syndromes, and tendon disorders. Appropriate treatment requirescorrection of the cavus deformity as well as the specific associated injuries. Nonoperativetreatment includes specialized orthotic shoe inserts. If a course of nonoperative treatmentfails, operative intervention is warranted. Operative treatment of the cavus deformity mayinclude a simple dorsiflexion first ray osteotomy or more complex reconstruction, includinga lateralizing calcaneal osteotomy. Correction or accommodation of the deformity as wellas the identification of the specific injury will likely lead to successful treatment and returnto a high level of competition.Oper Tech Sports Med 18:27-33 © 2010 Elsevier Inc. All rights reserved.

KEYWORDS cavus, cavovarus, ankle instability, “peek-a-boo” heel

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he cavus foot has been an enigmatic subject for manyyears. The belief that cavovarus feet are the result of

eurologic lesions is deeply ingrained in the adult and pedi-tric orthopedic literature. Several potential causes of thiseformity have been described. Many of these do includeeurologic conditions such as polio, Charcot–Marie–Toothisease, Fredreich’s ataxia, and cerebral palsy. Other com-on causes include the residual effects of clubfeet and com-artmental syndrome. Despite the popular belief that cavuseet are a result of neurologic conditions, the single largestopulation remains idiopathic. From our clinical observa-ion, these adult cavus feet are idiopathic, and often have aenetic component. Cavus foot deformities are common inthletes. These types of feet present unique injuries and chal-enges to the orthopedic surgeon. The deformity and associ-ted injuries should be recognized and treated appropriately.

The true incidence of cavus feet is unknown and multipleactors contribute to this. While in residency, pediatric or-hopedic training involves treating children with sequela ofeurologic disease. Many of these patients have severe cav-varus deformities. This has led to the notion that cavovarus

ichigan International Foot and Ankle Center, St Joseph Mercy Hospital,Pontiac, MI.

ddress reprint requests to Sarang N Desai, DO, Associated Orthopaedicsand Sports Medicine, 4031 W. Plano Parkway, Plano, TX 75093. E-mail:

tsndesaibonedr@hotmail.com

060-1872/10/$-see front matter © 2010 Elsevier Inc. All rights reserved.oi:10.1053/j.otsm.2009.10.002

eet are more common to children, and only occur in patientsith neurologic disease. The result is cavus feet being deleted

rom the adult differential diagnosis. Another contributingactor is that most orthopedic surgeons have been taught thetoo-many toes” sign as an easy way to diagnose a posterioribial tendon deficient foot.1 The “peek-a-boo” sign is a sim-lar easily performed test that diagnosis the cavus foot.2 Thiss a more recent discovery and is often not taught while inrthopedic training. Also, cavus feet are often bilateral, andherefore lack a normal foot for comparison. This can alsoake diagnosis more difficult.

valuationhe “peek-a-boo” sign was described in 1993 in an articleescribing lower extremity contractures.2 We have used thisest for 15 years and have found it highly sensitive for iden-ifying the subtle cavus foot. This test is performed with theatient standing, with the feet aligned straight. These patientsenerally have tight Achilles, and therefore have a tendencyo point their feet outward. We encourage the patients to lookown at their feet to ensure their feet point straight ahead.hen viewed from the front, the varus heel will be visualizededially in a cavus foot (Figs. 1 and 2). A foot with physio-

ogic heel valgus would not display this characteristic. Themount of heel visualized medially should be compared with

he contralateral limb. Two causes of a false positive “peek-

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28 S.N. Desai, R. Grierson, and A. Manoli II

-boo” sign include a very large heel pad and significantetatarsus adductus. Heel varus should be confirmed withosterior examination. When visualizing from the front, abulging” first metatarsal head fat pad may also be seen me-ially.After the identification of a varus heel, the Coleman block

est should be performed.3 This will identify whether theubtalar joint is supple and will also assess whether a plan-arflexed first ray is driving the heel varus. The Colemanlock test is performed by asking the patient to stand on aooden (or 1 in) block. The first ray is left off the blockedially. If the heel “corrects” to physiological valgus, the

arus hindfoot is supple and caused by a plantarflexed firstay.3 This is often referred to as forefoot driven hindfoot varusFig. 3). A strong contribution of the peroneus longus canlso be identified using another technique. This involveslacing one thumb under the first metatarsal head and thether thumb across the remaining metatarsal heads. The pa-ient is then asked to plantarflex the foot into the examiner’shumbs. With peroneus longus overdrive, there will be more

igure 1 Anterior standing examination shows bilateral “peek a boo”eels and prominent first metatarsal head fat pads.

fligure 2 Posterior examination reveals hindfoot varus bilaterally.

orce felt under the first metatarsal head as compared with theateral heads.4

Assessment of the Achilles mechanism is fundamental toavus foot evaluation. Part of that assessment involves per-orming the Silverskiold test that will isolate gastrocnemiusightness from the rest of the triceps surae. When the ankleannot be passively dorsiflexed to neutral with the knee ex-ended, but can be passively dorsiflexed to 5° of dorsiflexionith the knee flexed, gastrocnemius tightness exists.5

oot Morphologynd Biomechanicstight gastrocnemius and a plantarflexed first ray are central

o cavus feet.6 The repercussions of a plantarflexed first rayan be significant. A plantarflexed position of the first meta-arsal causes the medial aspect of the forefoot to strike theround first. When this occurs, the heel is forced into a varusosition to maintain a balanced three-point contact positionith the ground. Because of this, the hindfoot is unable to

each maximal eversion. This in turn decreases the ability ofhe subtalar joint to absorb and dissipate energy. The forefootnd hindfoot, although initially flexible, can progress to stiffhen rigid over time. The forefoot then becomes fixed in aronated position and the hindfoot in a varus position. Aight gastrocnemius can also significantly contribute to theavus posture. When the foot is in a planterflexed position,he peroneous longus is placed at a biomechanical advantagend the tibialis anterior at a disadvantage. With this relation-hip, the peroneous longus maintains the first ray in a plan-arflexed position.7 This position of the first ray is at first

igure 3 Coleman block test reveals correction of hindfoot varus intonatomic heel valgus.

exible, but over time can become stiff, and then rigid.

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The cavus foot in athletes 29

adiographic Evaluationt our institution, radiographs consist of standing anteropos-

erior (AP) of both ankles (same cassette), both feet (sameassette), and lateral views of each foot and ankle on the sameassette.8 There are multiple consistent radiographic abnor-alities common to cavus feet that can be identified. The

ateral view reveals a break in Meary’s line (axis of talus,edial cuneiform, and first metatarsal) as a result of the plan-

arflexed metatarsal. Also in the lateral view, one observes aigh arch with an increased measured distance between the

nferior medial cuneiform and inferior fifth metatarsal base.8,9

posteriorly positioned fibula may be seen due to an exter-ally rotated ankle axis, as well as a dorsiflexed calcaneus.10

lthough the calcaneus is dorsiflexed, the Achilles can still beight (Fig. 4).

With examination of the standing AP ankle (or foot) radio-raph, several features are consistent. There is a decrease in

igure 4 Standing lateral radiograph shows an increased distanceetween the inferior base of the fifth metatarsal and inferior medialuneiform. A break in Meary’s line and a posterior positioned fibulas also noted.

Figure 5 Standing AP radiograph of the feet showing met

pronation.

he normal talocalcaneal angle. The foot height measuredrom the top of the talar body to the floor will be greater in theavus foot compared to a normal contralateral side on theateral aspect.11 An AP radiograph of the feet will reveal fore-oot supination (Fig. 5).

Other useful radiographs may include internal oblique ofhe foot to evaluate for calcaneonavicular coalitions andetatarsal fractures. Computed tomography scans can iden-

ify subtalar coalitions and degenerative changes of the anklend tarsometatarsal joints.

ssociated Pathologieshere are many conditions associated with cavus feet thathould be considered and treated appropriately. We often seehese associated pathologies in athletes given the repetitiveigh-impact activity. These injuries can be debilitating andan cost an athlete a successful career if not treated promptly.

Patients with cavus walk on the outer border of their feetnd their plantarflexed first ray. In the forefoot, the patientay develop overload calluses under the first metatarsal head

nd fifth metatarsal head or base. This can lead to halluxesmoiditis. Jones fractures of the fifth metatarsal and fourthetatarsal stress fractures are common (Figs. 6-8). Other

ommon stress fractures are of the tibial or fibular shaft,avicular, and medial malleolus. These fractures can be elu-ive, and we have found bone scans to be helpful. Moreroximally, cavus feet are prone to peroneal tendon pathol-gy. This may include tendonitis, subluxation, dislocation,nd tears (Fig. 9).

The peroneus brevis is more prone to injury compared tohe peroneus longus. An os perineum may also fracture lead-ng to increased pain.12 Other common symptomatic footroblems include a tight Achilles and tight plantar fascia.13,14

Ankle instability and recurrent ankle sprains in a patientith cavus feet must be carefully considered. Standard re-airs or reconstructions of the lateral ligaments may fail with-

overlap due to hindfoot supination and relative forefoot

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30 S.N. Desai, R. Grierson, and A. Manoli II

ut correction of the varus heel and/or plantarflexed first ray.ong-standing cases of cavus feet and ankle instability may

ead to varus ankle arthritis.15 Stress fractures of the medialalleolus and navicular are also common (Fig. 10). External

otation of the talus and tibia can also result in knee pathol-gy. This posture of the lower extremity leads to excessivetress on the lateral structures of the knee. Patients may com-lain of pain along the lateral collateral ligament or iliotibialand.14,16,17 The varus strain may also result in medial com-artment arthritis in long-standing cases.Many other conditions may exist and should be recognized

igure 6 (A) AP radiograph displaying cortical hypertrophy consis-ent with fibular stress fracture. (B) Bone scan with increased uptaket the site of the fibular stress fracture.

n the comprehensive picture of the cavus foot (Table 1). g

reatmentn attempt to correct the apparent pathology without ad-ressing the concordant foot deformity will often lead toailure in treatment. This is particularly frequently observedith lateral ligament reconstruction without correction of the

avovarus deformity.A trial of nonoperative treatment should be instituted

pon diagnosis. This consists of a specific cavus foot orthotics well as a gastroc stretching program. We demonstrate howo perform these gastroc stretching exercises to each athleten the office. We recommend 20 repetitions 5 times a day forach extremity.

Many athletes come to our office stating they have triedrthotics, without alleviation of their symptoms, and in facthat their symptoms were made worse. When the orthotic isnspected, it is seen to be an orthotic designed for a plano-algus foot. We prefer a specific orthotic that has a few keyesign features. First, there is a recess to allow for the plan-arflexed first metatarsal head. This allows the possibility of ateast partial correction of the hindfoot, as demonstrated byhe Coleman block test. Even if the deformity is not flexible,he recess will accommodate the plantarflexed first ray, andherefore be more comfortable for the patient. Second, theres an elevated heel to allow for equinus. Other features in-lude a forefoot wedge that accommodates the valgus fore-oot and a reduced medial arch. We have found that an or-

igure 7 (A) Radiograph of fifth metatarsal stress fracture. (B) Radio-

raph of intramedullary screw fixation of stress fracture.

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The cavus foot in athletes 31

hoses that fits snuggly against the medial arch is not onlyainful for many athletes, but it does not allow for hindfootorrection. In our practice, 3 of 4 patients have improvedymptoms with this orthoses. It would be reasonable to con-ider the use of such an orthoses in a symptomatic athleteith a cavus foot shape.Appropriate shoe wear is also imperative for these patients.

he shoe should allow for the prominent midfoot. This is bestone with a soft wide laced upper. A flared heel that is slightlyigher than the forefoot will help provide inversion stability.tight Achilles with subsequent extensor recruitment often

auses clawed toes in these patients. An extra depth toe boxill accommodate these contracted toes. Medial posting

hould be avoided. Cosmetic cutaways and air chamberseaken the shoe and can increase hindfoot instability and

igure 9 Peroneal tears are common with cavus feet particularly tearsf the peroneus brevis.

igure 8 (A) Subtle left cavus foot with visible “peek-a-boo” heel. (B)RI confirming navicular stress fracture. (C) Radiograph displaying

igure 10 Cavus foot with medial malleolus stress fracture.

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32 S.N. Desai, R. Grierson, and A. Manoli II

hould therefore be avoided. A cushioned neutral runninghoe is recommended.

When a trial of conservative treatment fails, operative in-ervention should be considered. It is imperative to identifynd correct all aspects of the cavovarus foot deformity. Aareful examination should reveal a supple versus rigid de-ormity, which is paramount in the successful treatment ofhese patients. As mentioned previously, a contracted gastrocs almost universally found in the cavovarus foot. We prefero treat this with a modified Vulpius type lengthening. Aedial incision approximately 15 cm from the tip of theedial malleolus is created, and the sural nerve is first iden-

ified. The gastrocnemius tendon alone, and often the soleusascia, is then lengthened in a pie-crust manner.18,19

In the case of peroneal overdrive with a flexible first ray, aeroneus longus to brevis transfer is performed at the pero-eal tubercle. The distal stump of the longus is transferred tohe brevis tendon to avoid formation of a dorsal bunion. Toddress the plantarflexed first metatarsal, which drives a ca-us deformity, we prefer a dorsal closing wedge V-type os-eotomy secured with a 4.0-mm screw, notching the dorsalortex to prevent fracture.20,21 With a more pronounced fore-

able 1 Musculoskeletal Conditions Associated with the Ca-us Foot

Associated Conditions

FracturesMedial malleolusTibia shaftFibularNavicularBase of fourth metatarsalJones fracture of fifth metatarsalSesmoidOs peroneum

Soft-tissue injuriesPeroneal tears/dislocationsPlantar fasciitisIT band frication syndromeKnee lateral collateral tearsAnkle lateral ligament instabilitySubtalar instabilityAchilles tendonitisMTP synovitis

ArthritisVarus ankle arthritisMedial compartment kneeMidfoot

OtherTight gastrocnemius muscleSesmoid overload, AVNExertional compartment syndromeMetatarsus adductusCalluses under first and fifth metatarsal headsLarge peroneal tubercleLarge distal fibula

TP, metatarsophalangeal; AVN, avascular necrosis; IT, iliotibial.

oot pronation deformity, a V-type osteotomy of the second w

nd third metatarsals, and possibly the midfoot may be re-uired.As highlighted earlier, the cavovarus foot generally

rogresses from a supple deformity to a rigid deformity overime. In instances when the varus heel does not correct withColeman block test, a lateralizing calcaneal osteotomy iserformed along with a dorsiflexion osteotomy of the firstetatarsal. An oblique incision is made through the midpor-

ion of the calcaneal tuberosity, and the osteotomy is doneerpendicular to the axis of the tuberosity. Cuts created tooar posterior will penetrate Haglund’s prominence and bursa,hereas those too far anterior may enter the subtalar joint.he heel is translated 5-10 mm medially and secured with 2tacked 6.5-mm screws.

With an advanced cavovarus deformity, the magnitude ofhe deformity can become significant and the tissue stiff.

hen this occurs, a triple arthrodesis is required. The artic-lar cartilage of the calcaneocuboid, subtalar, and talonavic-lar joints are denuded, and they are secured with 6.5-mm

ag screws. The heel must be placed into mild valgus, and theorefoot derotated through the Chopart joints from its initialronated position.22 A common error is correcting heel varusithout correcting the forefoot deformity. When the heel isoved into valgus the first ray planterflexion increases, and

his must be addressed or the heel will move back into varusfter surgery.

As noted previously, many conditions may be associatedith the cavovarus foot shape. Some of these conditions may

equire operative treatment. Fractures are treated with rigidnternal fixation using solid screws, or excision for sesmoid,r os peroneum fractures. Jones fractures are common, and atur institution, we treat these with rigid internal fixation withr without bone grafting (Fig. 7).Recent literature has supported acute fixation of Jones frac-

ures.23 We also prefer to treat stress fractures of the navicularith rigid internal fixation (Fig. 8).We believe aggressive treatment of these stress fractures

rovides a more favoerable biomechanical environment forhe fracture to heal, and allows the athlete to return to athleticctivity faster. Along with internal fixation, we also addresshe cavus through either conservative or operative means asiscussed earlier. We often see athletes who have failed mul-iple operative procedures for these fractures. This can beevastating for the professional as well amateur athlete. The

mportance of correcting the cavus deformity cannot be over-mphasized.

Peroneal tendon tears, subluxation, or dislocation shoulde treated appropriately. An incision is made just posterior tohe posterior border of the fibula at the distal aspect of theuperior peroneal retinaculum. The retinaculum is opened atts fibular insertion. Longitudinal tears are repaired. An ex-ensively degenerated peroneus longus tendon is transferredo the peroneus brevis. If a shallow or convex groove is iden-ified, it is deepened. We prefer to do this by drilling multiple.0-mm holes in an oblong shape, and impacting this corticalone. The superior peroneal retinaculum is repaired throughdrill holes in the fibula, and 2 horizontal mattress stitches

ith a heavy nonabsorbable suture. In this way we achieve a

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The cavus foot in athletes 33

ecure repair, and also are able to advance a lax retinaculum.f the patient has greater tenderness at the peroneal tubercle,he incision is centered distally over the tubercle. Tears areepaired, and a large peroneal tubercle is removed.

With recurrent ankle sprains the lateral ligaments shoulde tightened with possible augmentation. We perform aodified Brostrum repair. After repairing the anterior talo-bular ligament in a vest-over-pants fashion, we then aug-ent the repair with a thick superficial layer of the inferior

xtensor retinaculum.23 Many of these patients also have as-ociated ankle impingement. This often manifests as eithernteromedial or anterolateral ankle pain. Anteromedially, ansteophyte off the anterior talus is frequently recognized (Fig.1). This osteophyte can impinge on the tibia during dorsi-exion of the ankle.24 This lesion can be removed through amall medial arthrotomy. If identified, an associated “kissingesion” on the tibia should also be removed. Anterolaterally, aypertrophied band of the anterior inferior tibiofibular liga-ent may cause pain.25 Patients may complain of discomfort

nterolaterally, often with a painful click caused by impinge-ent on the talus.26 This hypertrophied band is resected

hrough a small anterolateral arthrotomy.Midfoot arthritis is common with cavus feet. We initially

reat these with a graphite plate shoe insert. This decreaseshe motion at the midfoot articulations and has been success-ul in relieving pain in our experience. Failed conservativereatment may require a midfoot arthrodesis. Varus anklerthritis is common with the cavovarus foot. Tibiofibular oralcaneal osteotomies may be appropriate early with arthro-esis for advanced stages.15 If ankle arthroplasty is consid-red, the cavovarus deformity must be corrected first, or the

igure 11 Illustration showing the dorsal talar osteophyte commonith ankle impingement.

rosthesis may tip into varus.27

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2. Manoli A 2nd, Beals TC, Hansen ST Jr: Technical factors in hindfootarthrodesis. Instr Course Lect 46:347-356, 1997

3. Portland G, Kelikian A, Kodros S: Acute surgical management of Jones’fractures. Foot Ankle Int 24:829-833, 2003

4. Harper M: Modification of the Gould modification of the Broströmankle repair. Foot Ankle Int 19:788, 1998

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