Pes Cavus (High Arch Foot): A Patient Guide

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Expert Patient Guide  ·  Foot & Ankle Surgery  ·  London, North London & Hertfordshire

Pes Cavus (High Arch Foot): A Patient Guide from a London Consultant Foot & Ankle Surgeon

A comprehensive patient guide by Mr Matthew Welck, Consultant Orthopaedic Foot & Ankle Surgeon, Royal National Orthopaedic Hospital (RNOH) Stanmore and Honorary Associate Clinical Professor at UCL — London, UK.

Contents

  1. What Is Pes Cavus?
  2. How Common Is It in the UK?
  3. What Causes Pes Cavus?
  4. What Are the Symptoms?
  5. Investigations
  6. Non-Surgical Treatment (Flexible vs Fixed)
  7. Surgical Options (Flexible vs Fixed)
  8. Why Choose Mr Welck?
  9. Frequently Asked Questions
  10. Book a Consultation
01

What Is Pes Cavus?

Pes cavus — also called high arch foot — describes a foot in which the medial longitudinal arch is abnormally elevated. It is the structural opposite of flat foot (pes planus). The forefoot is plantarflexed (pointed downwards) relative to the hindfoot, and the heel is often turned inwards (hindfoot varus). Many patients also develop claw toes and a tight Achilles tendon.

The most important clinical question is whether the deformity is flexible or fixed. A flexible high arch foot can still be passively corrected by the surgeon’s hands; the bones and joints remain mobile, and the abnormal posture is driven mainly by muscle imbalance and tight soft tissues. A fixed (rigid) deformity has become structurally locked in — the joints no longer move enough to be passively realigned. It directly determines whether joint-preserving surgery is realistic, or whether selective fusion is required.

Pes cavus matters because it changes how the foot loads the ground. Pressure is concentrated under the heel, the head of the first metatarsal, and the lateral border of the foot, while the midfoot bears far less. The result is overload pain, recurrent ankle sprains, stress fractures, and accelerated wear of the lateral ankle and subtalar joints. A specialist consultation with a Consultant Foot & Ankle Surgeon — such as Mr Matthew Welck in London — gives you access to the full range of modern treatment options, from bespoke orthoses to joint-preserving reconstruction. Mr Welck specialises in complex foot and ankle problems such as pes cavus.

02

How Common Is It in the UK?

Mild forms of high arch foot are surprisingly common. Population studies suggest that around 10% of UK adults have some degree of cavus posture, although the great majority are asymptomatic and need no treatment. The clinically important group — patients with pain, recurrent injury, or progressive deformity — is far smaller, and these patients benefit most from specialist input.

Pes cavus is over-represented in two groups. The first is patients with an underlying neurological condition, where progressive muscle imbalance gradually pulls the foot into a high arch. The second is athletes and active individuals, in whom even a mild cavus posture can cause repeated ankle sprains, peroneal tendon problems, and chronic lateral foot pain. Sports injuries clinics in London and North London therefore see pes cavus patients far more frequently than overall prevalence figures would suggest.

03

What Causes Pes Cavus?

A high arch foot is a sign, not a single disease. Identifying the underlying cause is essential, because it changes both the prognosis and the treatment plan. The main categories are:

  • Neurological — the most common cause in adolescents and young adults. Charcot-Marie-Tooth (CMT) disease is the classic example, but cerebral palsy, spinal dysraphism (such as tethered cord), prior poliomyelitis, spinocerebellar ataxia, and stroke can all produce a cavus foot. Any patient with new or progressive pes cavus, particularly if asymmetric, should be screened for a neurological cause.
  • Idiopathic — no identifiable cause. This is a diagnosis of exclusion, made only after a thorough clinical and, where indicated, neurological work-up.
  • Post-traumatic — malunion of calcaneal, talar or midfoot fractures; missed compartment syndrome of the leg or foot; and severe burns or crush injuries can all produce an acquired cavus deformity.
  • Congenital — residual deformity from clubfoot (talipes equinovarus), arthrogryposis, or other developmental conditions.
  • Iatrogenic — rarely, after surgery that disturbs the muscle balance of the foot.

Because a neurological cause is so common, a detailed family history (particularly for CMT), examination of the hands and the opposite foot, and — where appropriate — referral for nerve conduction studies, are core parts of the assessment. Identifying the cause early is one of the most important factors in long-term outcome.

04

What Are the Symptoms?

Pes cavus produces a recognisable cluster of symptoms. Patients commonly report:

  • Recurrent ankle sprains and a feeling that the ankle “gives way”, especially on uneven ground.
  • Pain along the lateral (outer) border of the foot, often worse with sport or prolonged standing.
  • Pain under the ball of the foot (metatarsalgia), particularly under the first and fifth metatarsal heads.
  • Hard skin (calluses) under the first and fifth metatarsal heads and along the lateral border.
  • Claw toes that catch in shoes and cause dorsal pain.
  • Stress fractures, classically of the base of the fifth metatarsal — a frequent presentation in runners and footballers.
  • A tight Achilles tendon and plantar fascia, with morning stiffness or post-activity pain.
  • Difficulty fitting shoes, with the heel slipping out and the forefoot feeling cramped.
  • Reduced sporting performance, fatigue, and a sense that the foot “doesn’t roll properly”.

Symptoms are often mistaken for simple ligament weakness, plantar fasciitis, or peroneal tendinopathy. When standard treatment for those conditions fails, the underlying cavus posture is frequently the missing diagnosis. This is one of the most common reasons sports physicians and physiotherapists in London refer patients for a specialist foot and ankle opinion.

05

Investigations

Investigation has two aims: to characterise the deformity itself, and to identify or exclude a neurological cause. A typical work-up includes:

  • Clinical examination — including assessment of the hindfoot, the Coleman block test (to determine flexibility), gait analysis, peroneal strength, ankle stability tests, and a focused neurological examination.
  • Weight-bearing X-rays — anteroposterior, lateral, and hindfoot alignment views. Key measurements include Meary’s angle (the talo–first metatarsal angle), calcaneal pitch, and the Hibbs angle.
  • Weight-bearing CT (WBCT) — the modern gold standard for understanding three-dimensional foot alignment. Increasingly used in pre-operative planning for pes cavus surgery. This is Mr Welck’s investigation of choice.
  • MRI — for assessment of peroneal tendons, ankle ligaments, cartilage, and bone marrow oedema where stress fractures are suspected.
  • Pedobarography (pressure mapping) — useful for orthotic design and for monitoring response to treatment.
  • Neurological referral — including nerve conduction studies and electromyography (EMG) where a neurological cause is suspected, and genetic testing for CMT in selected patients.

Combining structural imaging with a careful neurological assessment is what separates a generic foot examination from a specialist pes cavus work-up. It is also what allows treatment to be targeted, rather than reactive.

06

Non-Surgical Treatment

Most patients with pes cavus can be managed without surgery, particularly in the early stages and where the deformity is flexible. The treatment plan, however, depends fundamentally on whether the high arch foot is flexible or fixed, and the two groups are managed differently.

6.1  Flexible Deformity — Non-Surgical Treatment

When the deformity can still be passively corrected, the goal of non-surgical care is to rebalance load, support the lateral ankle, and address muscle imbalance before structural change occurs. Effective measures include:

  • Custom orthoses with a lateral forefoot and hindfoot wedge (a “reverse Coleman” design) and a recess under the first metatarsal head. These offload the lateral border, reduce metatarsalgia, and improve ankle stability.
  • Targeted physiotherapy focused on peroneal strengthening, intrinsic foot muscle activation, calf stretching, and proprioceptive retraining — particularly important for patients with recurrent ankle sprains and sports injuries.
  • Footwear modification — supportive trainers with a wide base, lateral flare, firm heel counter, and adequate forefoot depth to accommodate claw toes.
  • Ankle bracing for sport, ranging from lace-up supports to semi-rigid stirrup braces, which can dramatically reduce the rate of recurrent sprains.
  • Activity modification and load management, including running re-education and gradual return-to-sport programmes.
  • Selective injections (corticosteroid, platelet-rich plasma) for specific painful structures such as the peroneal tendons or plantar fascia.

6.2  Fixed Deformity — Non-Surgical Treatment

Where the deformity has become rigid, the aims of non-surgical treatment shift. The foot can no longer be realigned by orthoses alone, so the focus is on protection, comfort, and preserving function. Options include:

  • Accommodative (rather than corrective) orthoses, designed to cushion high-pressure areas under the first and fifth metatarsal heads and the lateral border.
  • Bespoke or extra-depth footwear to accommodate claw toes, the high dorsum, and a narrow heel.
  • Ankle-foot orthoses (AFOs) for patients with significant neurological weakness, foot drop, or instability.
  • Falls-prevention strategies and balance training, especially in patients with an underlying neuromuscular condition.
  • Structured pain management, including nerve-modulating medication where neuropathic pain is a feature.
  • Skin and callus care, often in shared follow-up with a specialist podiatrist, to prevent ulceration over high-pressure areas.

When non-surgical treatment is no longer controlling pain or functional limitation — or when deformity is progressing — surgery is considered.

07

Surgical Options

Pes cavus surgery is highly individualised. There is no single operation; instead, a combination of procedures is selected to correct the specific drivers of each patient’s deformity. The single most important pre-operative decision is, again, whether the deformity is flexible or fixed. Joint-preserving reconstruction is reserved for flexible feet, while selective fusion is needed for fixed deformity.

7.1  Flexible Deformity — Joint-Preserving Reconstruction

In flexible pes cavus, the goal is to rebalance the foot while preserving as many joints — and as much movement — as possible. Procedures are combined according to the deformity, and may include:

  • Dorsiflexion osteotomy of the first metatarsal to lift the plantarflexed first ray and restore tripod loading of the forefoot.
  • Lateralising (Dwyer) calcaneal osteotomy to correct hindfoot varus, often combined with a calcaneal Z-osteotomy in more complex deformity.
  • Tendon transfers to rebalance the foot — most commonly transfer of peroneus longus to peroneus brevis (to weaken the deforming force on the first ray and strengthen eversion), and transfer of the tibialis posterior tendon in selected neurological cases.
  • Achilles or gastrocnemius lengthening to address equinus contracture.
  • Toe correction — flexor-to-extensor (Girdlestone-Taylor) transfers, interphalangeal joint fusion, or Jones transfer of the extensor hallucis longus — to address claw toes.
  • Lateral ligament reconstruction where chronic ankle instability has developed.

Recovery from joint-preserving cavus reconstruction usually involves around six weeks non-weight-bearing in a cast or boot, followed by a graduated return to weight-bearing and a structured physiotherapy programme. Return to sport is typically achievable, but is staged carefully and depends on which procedures were performed.

7.2  Fixed Deformity — Reconstruction with Selective Fusion

When the hindfoot can no longer be passively corrected, soft-tissue work and osteotomies alone will not realign the foot. Selective fusion (arthrodesis) of the rigid joints is then required. Options include:

  • Triple arthrodesis — fusion of the subtalar, talonavicular and calcaneocuboid joints. The traditional powerful correction for fixed cavovarus deformity.
  • Modified or partial triple arthrodesis — for example, a double fusion sparing the calcaneocuboid joint where appropriate, to preserve some midfoot motion.
  • Combined osteotomy and fusion — pairing a calcaneal osteotomy or first metatarsal osteotomy with selective fusion to fine-tune alignment.
  • Tendon transfers in addition to fusion, to rebalance the muscles acting across the corrected foot and reduce the risk of recurrence.

Surgery for fixed pes cavus is complex reconstructive work. It is best undertaken by a specialist team experienced in deformity correction and in managing the underlying neurological conditions that often accompany this group of patients. With appropriate planning, the great majority of patients achieve a stable, plantigrade foot that fits in normal shoes and tolerates everyday activity comfortably.

08

Why Choose Mr Welck?

Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH) Stanmore — the largest dedicated orthopaedic hospital in the UK — and an Honorary Associate Clinical Professor at University College London (UCL). His practice covers London and North London and is focused on complex reconstructive foot and ankle surgery, including pes cavus.

  • Double fellowship-trained in foot and ankle surgery, including international fellowship experience.
  • More than 50 peer-reviewed publications, including work on weight-bearing CT, deformity correction, and ankle reconstruction.
  • Regularly invited national and international speaker; co-organiser of the Stanmore Foot & Ankle Course, one of the leading dedicated training events in the UK.
  • Active sports injuries practice, treating recreational and elite athletes with recurrent ankle sprains, peroneal tendon problems, and stress fractures linked to pes cavus.
  • Multidisciplinary team approach, working closely with specialist physiotherapists, podiatrists, orthotists, and neurologists for patients with neurological pes cavus.
  • Consulting locations across London and North London, including the RNOH Stanmore site, with rapid access to weight-bearing CT, MRI, and dedicated foot and ankle theatres.

Patients seeking a specialist foot and ankle surgeon in London for pes cavus, recurrent ankle sprains, or sports injuries can therefore expect detailed assessment, a clear explanation of flexible versus fixed deformity, and a treatment plan tailored to their specific anatomy and goals.

09

Frequently Asked Questions

Can pes cavus be cured without surgery?

Many patients with high arch foot are managed successfully without surgery, particularly when the deformity is flexible and identified early. Custom orthoses, targeted physiotherapy, footwear modification, and bracing can control symptoms for years. Surgery is considered when non-surgical treatment no longer maintains comfort or function, or when the deformity is progressing.

Is pes cavus hereditary?

It can be. The most common neurological cause — Charcot-Marie-Tooth disease — is inherited, and family members of an affected patient often have a high arch foot themselves. A careful family history, examination of relatives, and (where appropriate) genetic testing are part of a thorough assessment.

Will my pes cavus get worse over time?

Idiopathic pes cavus is often stable, while neurological pes cavus tends to progress. Regular review allows early detection of worsening deformity, peroneal weakness, or new instability — and earlier, less invasive intervention if needed.

Can I still play sport with a high arch foot?

Yes, the majority of patients can — and many elite athletes have a degree of pes cavus. The main barriers are recurrent ankle sprains, lateral foot pain, and stress fractures. With the right orthoses, peroneal strengthening, footwear, and (where indicated) bracing, most patients return to full sporting activity. When non-surgical management is not enough, joint-preserving surgery is designed specifically to restore the ability to play sport.

How long is recovery after pes cavus surgery?

It depends on the specific combination of procedures. Soft-tissue work and osteotomies typically involve around six weeks non-weight-bearing in a cast or boot, followed by a graduated return to weight-bearing and three to six months of rehabilitation before full sport. Surgery involving fusion takes longer, with bony healing usually monitored for around three months and full recovery measured in months rather than weeks.

Should I see a neurologist as well as a foot and ankle surgeon?

Often, yes. Because a high arch foot can be the first sign of an underlying neurological condition, a joint assessment is sometimes advisable — particularly when the deformity is progressive, asymmetric, or associated with weakness or sensory changes. The specialist team will arrange neurological referral and nerve conduction studies if indicated.

Why is the difference between flexible and fixed pes cavus so important?

Because it changes everything. A flexible high arch foot can usually be reconstructed while preserving the joints of the foot — restoring shape and function with osteotomies, tendon transfers, and soft-tissue rebalancing. A fixed deformity has lost that flexibility and almost always needs selective fusion to achieve a durable correction. Getting this distinction right at the first consultation is one of the most important steps in pes cavus care.

Who is the best foot and ankle surgeon in London?

There is no single “best” foot and ankle surgeon, and the UK Advertising Standards Authority does not allow that claim. The right surgeon for you is one who is on the GMC Specialist Register for Trauma & Orthopaedic Surgery, holds a recognised subspecialty fellowship in foot and ankle surgery, is a member of the British Orthopaedic Foot & Ankle Society (BOFAS), and treats your specific condition regularly. Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH) Stanmore — a tertiary referral centre — and an Honorary Associate Clinical Professor at UCL.

How do I choose a foot and ankle surgeon?

Look for four things: GMC Specialist Register entry in Trauma & Orthopaedic Surgery; a dedicated subspecialty fellowship in foot and ankle surgery (not general orthopaedics); active membership of BOFAS or an equivalent specialist society; and regular practice in the specific procedure you may need (for example, total ankle replacement, ankle ligament reconstruction, or pes cavus reconstruction). For complex or revision surgery, a tertiary referral hospital such as the RNOH adds the benefit of a multidisciplinary team including specialist radiology, neurology, and rehabilitation.

Where can I have an ankle replacement in London?

Total ankle replacement is a specialist procedure performed by a small number of surgeons in the UK. In London and the South East, ankle replacement and revision ankle arthroplasty are offered at the Royal National Orthopaedic Hospital (RNOH) Stanmore, where Mr Matthew Welck consults. The same team also assesses ankle fusion (arthrodesis) and joint-preserving alternatives where appropriate, so the right operation can be matched to the right patient.

Can patients from North London or Hertfordshire be seen?

Yes. The RNOH Stanmore site sits between North London and Hertfordshire and is a regional and national referral centre. Patients from across North London (Barnet, Enfield, Harrow, Camden, Islington), Hertfordshire (Watford, St Albans, Hemel Hempstead, Borehamwood, Radlett), and the wider Home Counties are seen routinely, both on the NHS via GP or consultant referral and privately on request.

Do you see private and NHS patients?

Yes. Mr Welck consults privately at clinic locations across London and North London, and runs a tertiary referral practice through the RNOH Stanmore. Patients can be seen privately or referred through the NHS where eligible.

10

Book a Consultation

If you have a high arch foot, recurrent ankle sprains, lateral foot pain, or a sports injury that is not settling with standard treatment, a specialist consultation can help establish the diagnosis and identify the right plan for you. To request an appointment with Mr Matthew Welck, Consultant Foot & Ankle Surgeon in London and North London, please visit matthewwelck.com or contact the practice directly.

This guide is provided for general information only. It is not a substitute for individual medical advice. Treatment decisions should always be made in consultation with a qualified Consultant Foot & Ankle Surgeon following a full clinical assessment.

About the Author
Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH) Stanmore, the UK’s largest specialist orthopaedic hospital, and an Honorary Associate Clinical Professor at University College London (UCL). His specialist practice covers the full spectrum of adult foot and ankle disorders, with a particular focus on ankle arthritis and ankle replacement, sports injuries of the foot and ankle, ligament reconstruction, complex foot deformity (including pes cavus), and revision surgery. He works as part of a multidisciplinary tertiary referral team and accepts NHS and private referrals from across London, North London, Hertfordshire, and the wider UK.

Last reviewed: November 2026 by Mr Matthew Welck, Consultant Orthopaedic Foot & Ankle Surgeon, RNOH Stanmore.

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