Treating Deformities in Athletes: Pes Cavus and Pes Planus

For years, it seems there has been a stigma associated with having deformities as an athlete. Through my 30 years of practice, I have noted scenarios in which surgeons thought it was medically necessary to correct an asymptomatic deformity in an athlete, soldier, or ballerina. I then had to address the outcomes of these procedures. Let’s be clear—no one can or should guarantee an athlete that if you correct a deformity, they will ever run as fast as they did before. Correcting a deformity should reduce daily pain, but we must accept that our surgery may never fully restore function. We all must remember we are dealing with feet that have compensated for their deformities or limitations.

Just look at what altered positions a forefoot varus creates that eversion must compensate for. The stress of that degree of eversion causes a whole host of issues. Sure, we can correct that, but in my observation, we cannot recreate a normal subtalar joint, midfoot or even normal ankle mechanics with surgery. Those joints weren’t necessarily normal from the start. Altering the positions of the foot, ankle, and leg won’t change an abnormally shaped joint, and in some cases our surgery may solve one issue but unmask another.

We surely can reduce the strain on the patient’s muscles by repositioning the foot. We can relieve tension on the Achilles tendon or the plantar fascia with a combination of procedures; but the outcomes will predictably stay the same—better, but not great. In my experience, performance will almost never be better than prior to surgery.

Within the Army, I have found getting a soldier back to full duty without any restrictions after flatfoot or cavus surgery is virtually impossible. We as surgeons must accept that. Symptomatic patients have accepted that they may never run again. They simply want relief from their day-to-day pain. We must strive to make daily pain and life better. If we are lucky, we can get patients back to recreational level sports, but in my experience, getting them back to collegiate or even professional activity is extremely rare in symptomatic individuals. However, when considering all of the above points, the idea of correcting an asymptomatic deformity in athlete is simply foolish.  

Wait long enough and eventually, foot deformities will likely start to have issues. How long will it take? During my career, I have seen teenagers develop pain while competing in high school. I have seen elite high school athletes struggle once in college. I have seen Division I athletes struggle at Basic Training or during their first duty assignment. I have seen soldiers as privates and then five years later progress to debilitating pain. I have seen soldiers start having pain two years prior to retirement. In so many cases, thanks to digital radiology, we can see serial imaging over the years and see no appreciable difference in their angles, just the development of pain.

We all have seen patients who claim their arches are falling. Then in other cases, you can see a patient with an everted foot slowly develop an abducted foot as compensation. The wear and tear of sports and the military surely plays a role in the development of symptoms. This is no different than the 50-year-old woman who has slowly gained weight over the years, has progressive posterior tibial tendon dysfunction, and sustained a posterior tibial tendon rupture walking up her stairs. We must remember that these conditions are progressive, and failure of compensatory mechanisms leads to another compensation or area of pain.

If one sees patients long enough, their symptoms will likely change. No one shows up stating, “My posterior tibial tendon has hurt for 10 years.” Most athletes state they have had the pain for a while, which was tolerable, then it changed location. Now it is in another location and they simply can’t run because of this area of pain.     

When Athletes Have Pain-Free Deformities

This column focuses on deformities—pes planus and pes cavus. It is truly amazing how many people have severe deformities but no pain, and can still function. The literature does not shed any light on this, either. Whether athletes are symptomatic or not, how can we help them? Do we need to do anything for a well-functioning, pain-free individual? Whether team athletes, cadets, or other key groups, screenings are very similar. We would make people hop, stand on one foot, crouch, or simply watch them walk. In many cases, we would make them jog. Essentially, we performed biomechanical examinations.

I found more athletes I saw, the more I questioned the literature. I do not believe every pes cavus foot needs a neurologic workup for Charcot-Marie-Tooth (CMT). I stopped ordering nerve conduction velocity (NCV) testing for cavus feet 25 years ago. Not every cavus foot has a clubfoot, and not every cavus foot has CMT. Family history is key. During my 30 years, I have diagnosed no more than 50 cases of CMT in soldiers. Half showed up telling me they had CMT. The other half stated a sibling had CMT. Only a handful actually required a workup. Putting that in perspective, a patient with undiagnosed CMT is very unlikely to walk into your clinic.  

On the flip side, do we need to start thinking that every teenager with pes planus has a tarsal coalition? Reviewing the literature one would think 60% of the population has tarsal coalitions. Well, the reality is they don’t. We aren’t here to argue how or why athletes develop flat feet. Nor are we dwelling on why so many professional athletes have flat feet. There are no absolutes in medicine, just like there is no one procedure to address every foot. Athletes will have adapted to and overcome their deformities and shortfalls early on. So, leave athletes alone if they are pain-free. I’m not going to debate prescribing orthotics here.  

A Closer Look at the Author’s Experience

As far as numbers, I have tracked deformities for 30 years. Over the past five years, I have kept reviews of every standing foot X-ray and cataloged X-rays based on all the typical findings: Meary’s angle, arch height, calcaneal inclination, cuboid abduction, talocalcaneal, talar head uncovering, and metatarsal inclination.

Based on those criteria, I was able to classify patients based on pes cavus or pes planus foot type. That involved over 10,000 foot X-rays. Of those cases deemed significant, we identified 271 cases with significant cavus foot types and 267 planus foot types. That should first shock most—more cavus than planus? Realistically, I didn’t include the 2000 or so “tweener” cases who were frankly pronators. There are clinically a lot of soldiers and athletes who are walking around with no arch clinically, but when you X-ray them the lateral view looks normal. There are a high number of cavus-looking feet on the lateral view, but are in fact in calcaneal valgus despite looking like a cavus foot with a high calcaneal inclination angle (Figure 1).

I want to show cases that are both clinically and radiographically significant for cavus and planus versus counting thousands of cases that don’t meet obvious X-ray criteria. These 271 and 267 cases, respectively, were significant. All of these cases involved either trainees or active duty military. So they were all active, and all having symptoms of some kind, thus why they were all X-rayed. I personally didn’t see every patient, but a large percentage. Interestingly, only a few of these cases ended up requiring surgery. I operated on a much higher percentage of those cases that fell into the “tweener” category that I was excluding. I believe that should become more obvious to surgeons—that more unstable feet are more likely to be more symptomatic than a stable flatfoot or rigid cavus. Thus, I have historically operated on the unstable foot versus a stable foot, and thus, why orthotics and bracing help to reduce symptoms and numbers of surgical cases.

As we start looking at specific case examples, the focus will be on the AP and lateral views. As one looks at the X-rays, it becomes very clear that no flatfoot or cavus foot are truly alike. We will see a wide range of faults per se. We will see everything from a very broad calcaneus, short talar bodies, abnormally shaped subtalar joints and a wide range of radiographic angles (Figure 2). We will show examples for each deformity and some of the common variations that we often see. Regardless of deformity, we will see frontal, sagittal, and transverse plane deformities. Assessing planal dominance is critical for deciding surgical treatment.  

The Athlete With Pes Planus

As we look at flat feet, we will see some commonalities, but we will also see significant variations between the AP and lateral views and clinical appearance. Just look at one soldier who clearly has two different types of flat feet as shown in Figure 3 and Figure 4. Radiographically, it is very difficult to diagnose equinus unless you see low calcaneal inclination or in some cases the heel off the ground as shown in Figure 5. Either way, a low calcaneal inclination angle is the first clue of pes planus.

Medial column collapse on the lateral view is the next focus, and we are all familiar with Meary’s angle and faults in the midfoot whether it be talonavicular, naviculocuneiform, or tarsometatarsal. We show progressive differences on the lateral views in Figure 6. As we focus on the AP view, we look at the talocalcaneal angle, talonavicular joint uncovering and then the midfoot and metatarsal alignment. Transverse planal dominance can progress if allowed as shown in Figure 7, Figure 8 and Figure 9.  

The Athlete With Pes Cavus

As we look at the cavus foot clinically, the focus always seems to be on arch height. Don’t be fooled: some patients, especially with Charcot-Marie-Tooth, have actually developed significant intrinsic atrophy, which creates a much higher arch than what X-rays will illustrate, as shown in Figure 10. The hallmark for all pes cavus is increased calcaneal inclination. As the deformity worsens, we will see changes in the midfoot and this leads to the many subsets of cavus deformities that we don’t need to address, but will show examples.

Either way, cavus feet, like flat feet, will have a wide range of calcaneal inclination, talocalcaneal, and Meary’s angles on lateral views (Figure 11). To complicate matters, just like with flatfoot, you will see frontal and transverse plane compensations. So you will see the pseudo-clubfoot (cavovarus) and metadductus foot types. As we look at the AP views, that is where you will see the transverse plane deformities and talocalcaneal angles being parallel as shown in Figure 12.         

In Summary

All pes planus and pes cavus feet are not the same, so why treat them the same? We must recognize the basics clinically and radiographically, but we must also understand the power of compensatory mechanisms. Not every flatfoot requires rearfoot and midfoot procedures. Not every deformity needs surgery. It is truly amazing to see professional athletes who can perform at such high levels with such horrible feet while a Basic trainee with the same foot will need to be medically discharged. Treat the patient, not the X-ray. 

Dr. Spitalny is a staff podiatrist at General Leonard Wood Army Community Hospital and Adjunct Faculty of the SSM Depaul Podiatry Residency Program in St. Louis, Mo.

Reference

1.    Paley D. Ankle and Foot Considerations. In: Principles of Deformity Correction. Springer;2002:571-645. Available at: https:doi.org10.1007978-3-642-59373-4_18.