What is the next step in managing a patient with bilateral cavus and burning pain on the top of both feet after a long hike, with X-ray confirmation and existing orthotics?

Management of Bilateral Cavus Foot Pain After Long Hike

For a patient with bilateral cavus feet, burning pain on the top of both feet extending up the shins after a long hike with tight shoes, the next step should be to prescribe open-backed shoes, appropriate orthotic modifications, NSAIDs, decreased activity, and stretching exercises to reduce pain and improve function. 1

Initial Assessment and Management

• The patient's symptoms suggest an overuse injury exacerbated by tight footwear, with the existing cavus foot deformity as a predisposing factor 2
• The burning pain pattern extending from the top of the feet up the shins indicates possible tendinopathy and/or nerve irritation related to the high-arched foot structure 3
• Despite the patient already using orthotics, they may need adjustment or replacement to better accommodate the cavus foot structure 1

Immediate Interventions

• Footwear modifications: Recommend open-backed shoes to reduce pressure on irritated areas 1
• Activity modification: Advise temporary reduction in weight-bearing activities, particularly hiking 1
• Pain management: Prescribe NSAIDs to reduce inflammation and pain 1
• Cryotherapy: Recommend ice application to painful areas to reduce inflammation 1

Orthotic Management

• Orthotic evaluation: The existing orthotics should be assessed for proper fit and function, as they may need adjustment given the recent exacerbation 4
• Orthotic modifications: Consider customized modifications to better accommodate the bilateral cavus deformity and redistribute pressure 1, 4
• Heel lifts: May be beneficial to unload tension on affected tendons, particularly if Achilles tendinopathy is contributing to symptoms 1

Exercise Therapy

• Stretching exercises: Prescribe regular calf-muscle and anterior compartment stretching to reduce tension 1
• Eccentric strength training: Particularly important if tendinopathy is present, as it promotes tendon healing 1
• Deep transverse friction massage: Can be recommended to reduce pain in affected tendons 1

Follow-up Plan

• If symptoms improve within 6-8 weeks, continue the prescribed treatments until symptoms fully resolve 1
• If no improvement occurs after 6-8 weeks, referral to a podiatric foot and ankle surgeon is appropriate for further evaluation 1

Potential Advanced Interventions

• If symptoms persist, additional treatments may include:
  • Immobilization with a cast or fixed-ankle walker-type device 1
  • Consideration of neurological causes if symptoms persist, as cavus foot can be associated with hereditary neuropathies 5
  • Physical therapy focusing on gait retraining and muscle balance restoration 3

Common Pitfalls to Avoid

• Ignoring neurological causes: Bilateral cavus feet can be associated with underlying neurological conditions that should be considered if symptoms persist 5
• Inadequate footwear modification: Continuing to use tight shoes will perpetuate symptoms 1
• Focusing only on orthotics: While important, orthotics alone may not resolve symptoms without addressing activity modification, stretching, and strengthening 4
• Premature return to activity: Returning to hiking before adequate healing can lead to symptom recurrence 1

The management approach should address both the acute pain from the recent hike and the underlying cavus foot deformity to prevent future episodes and improve long-term function 3, 4.