What is the initial conservative treatment for a patient with pes cavus foot type experiencing anterior ankle pain while running?

Conservative Treatment for Pes Cavus Foot with Anterior Ankle Pain During Running

Custom foot orthoses are the most effective initial conservative treatment for patients with pes cavus foot type experiencing anterior ankle pain while running. 1

Understanding Pes Cavus and Anterior Ankle Pain

Pes cavus (high-arched foot) is characterized by an abnormally high medial longitudinal arch that can lead to:

• Decreased shock absorption
• Increased plantar pressure
• Rigid foot structure
• Muscle imbalances

When combined with running, these characteristics can lead to anterior ankle pain due to:

• Increased impact forces
• Limited ankle dorsiflexion
• Altered biomechanics during gait
• Possible anterior impingement

Initial Assessment

When evaluating a patient with pes cavus and anterior ankle pain:

1. Rule out fractures using the Ottawa Ankle Rules if acute trauma is suspected 2
2. Assess pain location and characteristics:
   • Anterior ankle pain may indicate anterior impingement or tibial stress injury
   • Pain relief when barefoot suggests pressure-related issues
3. Evaluate biomechanics:
   • Assess for muscle imbalances (particularly inversion-to-eversion and plantarflexion-to-dorsiflexion ratios) 3
   • Check for limited ankle dorsiflexion
   • Observe running gait pattern

Treatment Algorithm

First-Line Treatment

1. Custom Foot Orthoses

   • Demonstrated superior effectiveness for cavus foot pain (improvement of 8.3 points on pain scales and 9.5 points on function scales compared to controls) 1
   • Should provide:
     • Shock absorption
     • Arch support
     • Pressure redistribution
     • Correction of biomechanical imbalances

2. Activity Modification

   • Temporarily reduce running volume and intensity
   • Implement a walk-run program starting with short running intervals (1-5 minutes) 2
   • Alternate running days to allow for recovery 2
   • Avoid hard surfaces and hills initially 2

3. Footwear Modifications

   • Recommend shoes with:
     • Adequate cushioning
     • Neutral support (avoid motion control)
     • Wide toe box
     • Proper fit for high-arched feet

Second-Line Interventions

If symptoms persist after 4-6 weeks:

1. Running Technique Modification

   • Consider forefoot running technique to reduce impact forces 4
   • Increase cadence and decrease stride length 2

2. Strengthening Program

   • Focus on:
     • Ankle dorsiflexors and evertors (often weak in pes cavus)
     • Intrinsic foot muscles
     • Hip and core stability

3. Stretching Program

   • Target:
     • Gastrocnemius-soleus complex
     • Plantar fascia
     • Posterior tibialis

Additional Interventions

For persistent symptoms:

1. NSAIDs

   • For short-term pain management
   • Use lowest effective dose for shortest duration 5

2. Physical Therapy

   • Address biomechanical issues
   • Gait retraining 2
   • Manual therapy for joint restrictions

Progression and Return to Running

1. Gradual Progression

   • Increase running time/distance by 10% weekly 2
   • Increase distance before increasing speed 2
   • Maintain pain levels below 3/10 during activity 2

2. Return to Running Criteria

   • Complete resolution of pain during and after activity
   • Full range of motion compared to uninjured side
   • Successful completion of sport-specific functional tests 5

Monitoring and Follow-up

1. Regular Assessment

   • Follow up within 1-2 weeks if symptoms persist 5
   • Monitor for changes in pain patterns or new symptoms

2. Orthotic Adjustments

   • May require modifications based on response and wear patterns
   • Consider pressure mapping to evaluate effectiveness

When to Consider Referral

Consider referral to a podiatric foot and ankle specialist if:

• No improvement after 6-8 weeks of conservative treatment 2
• Symptoms worsen despite appropriate management
• Suspicion of anterior tibial stress injury requiring imaging 2

Common Pitfalls to Avoid

1. Ignoring biomechanical factors - Pes cavus is often associated with specific muscle imbalances that must be addressed 3

2. Progressing too quickly - Gradual return to running is essential to prevent recurrence or worsening of symptoms 2

3. Inadequate orthotic prescription - Generic insoles may not provide sufficient support for the high-arched foot 1

4. Overlooking footwear - Inappropriate footwear can negate the benefits of other interventions

5. Focusing only on local symptoms - Hip and core weakness can contribute to distal symptoms and should be addressed

By following this comprehensive approach to conservative management of anterior ankle pain in patients with pes cavus foot type, most patients can successfully return to running with reduced pain and improved function.