High Arches (Pes Cavus): Causes, Problems & Treatment

What Is Pes Cavus?

Pes cavus — a high-arched foot — is the structural opposite of flat feet: the medial longitudinal arch is excessively elevated, creating a foot that appears to have a high arch even when bearing full body weight. The typical pes cavus foot has associated features: a varus (inverted) hindfoot, plantarflexed first ray (the first metatarsal points more downward than normal), prominent metatarsal heads on the plantar surface, claw toes, and a shortened, rigid foot.

Unlike flat feet, which are common and usually idiopathic, high arches have a neurological cause in the majority of symptomatic adult patients — the most common being Charcot-Marie-Tooth disease (CMT), a hereditary peripheral neuropathy that produces characteristic peroneal muscle weakness and posterior calf tightness. Other neurological causes include spinal cord lesions, polio, and Friedreich's ataxia. Idiopathic and familial pes cavus exist but are less common. Any progressive pes cavus deformity warrants neurological evaluation.

Problems Caused by High Arches

The rigid, supinated pes cavus foot is a poor shock absorber — it transmits rather than dissipates impact. The mechanical consequences include:

• Metatarsalgia: The plantarflexed metatarsal heads bear excessive plantar load, producing pain and callus under the ball of the foot
• Plantar fasciitis: A cavus foot has a shortened, taut plantar fascia under chronic high tension — a strong risk factor for plantar fascia injury
• Lateral ankle instability: The inverted hindfoot positions the ankle in a varus posture that pre-loads the lateral ligaments — recurrent inversion sprains and chronic lateral instability are hallmarks of pes cavus
• Peroneal tendinopathy: The peroneals are under constant eccentric demand trying to evert the chronically inverted heel
• Stress fractures: Particularly of the fifth metatarsal (Jones fracture zone) and lateral column — the rigid foot concentrates repetitive impact at specific points rather than distributing it
• Claw toes: Imbalance between the intrinsic (weakened) and extrinsic (overactive) toe flexors creates PIP flexion and MTP extension deformity — corns, plantar callosities, and shoe-fitting problems follow

Treatment

Conservative (flexible pes cavus without progressive neurological disease): Custom orthotics with a lateral heel wedge correct the varus hindfoot position, redistributing load from the lateral to the medial column. A full-length accommodative shell with first-ray cutout (accommodating the plantarflexed first ray without adding dorsal pressure) is the standard design. Extra-wide shoes with adequate depth accommodate the claw toes. Physical therapy targets the specific muscle imbalances driving the deformity — particularly peroneal strengthening for the inverted heel and intrinsic foot muscle strengthening for the claw toes.

Surgical (rigid or progressive pes cavus): The goal of surgery is to create a plantigrade, balanced foot. Procedures are individualized to the specific deformity: first metatarsal dorsiflexion osteotomy (corrects the plantarflexed first ray), calcaneal osteotomy (corrects hindfoot varus), Achilles lengthening or gastrocnemius recession (corrects equinus), peroneus longus to brevis tendon transfer (corrects the muscle imbalance driving first ray plantarflexion), and claw toe correction. In Charcot-Marie-Tooth disease with severe rigid deformity, triple arthrodesis (subtalar + calcaneocuboid + talonavicular fusion) provides durable correction.

The Bottom Line

High arches are not just a cosmetic finding — the mechanical consequences of pes cavus include recurrent ankle sprains, metatarsalgia, plantar fasciitis, and stress fractures that significantly limit activity. Any progressive high-arch deformity warrants neurological evaluation. Conservative care with appropriately designed custom orthotics and lateral wedging manages most symptomatic flexible pes cavus effectively. Come in for a full biomechanical assessment — we will determine whether your symptoms are driven by the arch structure and what intervention will produce the most durable relief.

Related reading: pes cavus overview · orthotics and insoles · peroneal tendon problems