What are the treatment options for a patient with a high arched foot (pes cavus)?

Treatment of High Arched Foot (Pes Cavus)

Custom foot orthoses are the first-line treatment for symptomatic pes cavus, providing significant pain relief and functional improvement within 3 months. 1

Initial Conservative Management

Orthotic Therapy (Primary Treatment)

• Custom foot orthoses should be prescribed as the definitive treatment for painful cavus feet, as they demonstrate superior efficacy compared to simple insoles, reducing foot pain by 8.3 points and improving function by 9.5 points on validated scales at 3 months 1
• Custom orthoses significantly reduce plantar pressure across all foot regions (mean reduction of 3.0 N·s/cm²) compared to sham insoles 1
• Physical functioning improves by 7.0 points with custom orthoses versus control interventions 1
• Semirigid orthotic devices are particularly effective for high-arched feet, as they improve shock absorption capacity and reduce the risk of femoral and tibial stress fractures that are more prevalent in cavus foot structure 2

Footwear Modifications

• Appropriate therapeutic footwear must be fitted by a specialist who understands pressure reduction principles for cavus foot deformities 3
• Shoes should have adequate height to accommodate toe deformities, with internal width equal to foot width at metatarsophalangeal joints, and length 1-2 cm longer than the foot 3
• Patients should never walk barefoot indoors or outdoors and must avoid wearing shoes without socks 3
• Shoes require firm support with comfortable fit, evaluated in standing position at end of day when feet are most swollen 3

Activity Modification and Supportive Care

• Patients should remain on light duty with activity limitation for an initial 6-week period 4
• Avoid flat shoes and barefoot walking during treatment 4
• Use heel cushions, arch supports, and appropriate padding/strapping 4
• NSAIDs may be used for pain management during the initial treatment phase 5, 4
• Stretching exercises and cryotherapy should be initiated immediately 5

Evaluation and Monitoring

Initial Assessment

• Comprehensive foot evaluation should be performed at least annually to assess for progression of deformity 3
• Examine for associated deformities including hammertoe, claw toe, bunions, or arthritic changes that commonly accompany pes cavus 3
• Assess for neurological causes, as posterior pes cavus is frequently related to neurological diseases, particularly Charcot-Marie-Tooth disease in pes cavovarus 6
• Radiographs should be obtained as first-line imaging to identify structural abnormalities 5

Follow-up Timeline

• If improvement occurs within 6 weeks, continue conservative treatments and light duty restrictions until symptoms fully resolve 4
• If no improvement after 6 weeks, refer to podiatric foot and ankle surgeon while continuing initial treatments 5, 4
• The 2-3 month mark represents the critical decision point for escalating treatment 5, 4

Advanced Conservative Interventions (After 6 Weeks Without Improvement)

• Night splinting may be added to the treatment regimen 5, 4
• Limited corticosteroid injections can be considered (avoid near Achilles tendon) 5, 4
• Casting or fixed-ankle walker devices may be necessary for severe cases 5, 4
• Orthotic treatment to realign the foot can eliminate risk of progression during childhood in pediatric cases 6

Surgical Considerations

• Extra-articular surgery is indicated only when response to orthotic treatment is inadequate 6
• Muscle transfers have not been proven effective for pes cavus 6
• Triple arthrodesis should be avoided as it accelerates mid-term development of osteoarthritis in adjacent joints 6

Return to Full Activity Criteria

Full duty or normal activity should only resume when all three criteria are met: 4

• Pain has resolved with conservative treatment measures
• Patient can ambulate without significant discomfort
• Appropriate footwear modifications and orthotics are in place to prevent recurrence

Critical Pitfalls to Avoid

• Do not return patients to full activity prematurely before inflammation resolves, as this risks prolonging symptoms and may necessitate immobilization or surgery 4
• Avoid overdebridement of calluses in cavus feet, as this can increase tenderness and complications 3
• Do not use simple off-the-shelf insoles as definitive treatment when custom orthoses are indicated 1
• High arch support heights, while generally beneficial, may induce excessive midfoot pressure if not properly calibrated 7