Cavovarus Foot Deformity: Alignment, Radiology, Correction, and Reconstruction

Cavovarus Foot Deformity:

• What is Cavovarus Foot Deformity?
• Alignment
• Radiology
• Correction
• Reconstruction

What is Cavovarus Foot Deformity?

Cavovarus foot deformity is a complex orthopedic condition characterized by a high arch (cavus) combined with inward turning of the heel (varus). This deformity can result from various underlying causes, including neurological disorders (such as Charcot-Marie-Tooth disease), trauma, or idiopathic (unknown) origins. The condition often leads to instability, pain, callus formation, and difficulties with balance and walking. Over time, it may cause abnormal stress on the lateral foot, ankle instability, and early arthritis if not treated appropriately.

Cavovarus deformity can be flexible or rigid. In the early stages, soft tissue imbalance dominates, and correction is easier through orthotics or physical therapy. However, chronic cases may involve bony deformities, joint contractures, and tendon imbalance that require surgical correction. Understanding its anatomy, biomechanics, and underlying pathology is crucial for successful management and long-term outcomes.

Alignment

Proper alignment evaluation is the cornerstone in diagnosing and managing cavovarus deformity. Clinicians assess the position of the hindfoot, midfoot, and forefoot both clinically and radiographically. The deformity typically involves plantarflexion of the first ray, hindfoot varus (inversion), and an elevated medial longitudinal arch. In standing position, the heel appears tilted inward, and weight distribution shifts to the lateral border of the foot.

During clinical examination, the “Coleman block test” is often used to determine if the deformity is flexible or rigid. This test helps differentiate whether the varus component is due to a flexible forefoot deformity or a fixed hindfoot malalignment. Understanding the alignment relationships between the forefoot, midfoot, and hindfoot guides the choice of conservative or surgical treatment options.

Radiology

Radiologic evaluation plays a vital role in the diagnosis and surgical planning of cavovarus foot. Weight-bearing X-rays (anteroposterior, lateral, and oblique views) are used to assess bone alignment, arch height, and deformity severity. Key measurements include the Meary’s angle (longitudinal arch alignment), calcaneal pitch, and talocalcaneal angles. These values help determine whether the deformity is flexible, rigid, or associated with joint degeneration.

Advanced imaging, such as CT or MRI, may be necessary in cases involving complex deformities or prior trauma. MRI can reveal soft tissue abnormalities, including peroneal tendon tears, ligament instability, or muscle atrophy associated with neuromuscular causes. Radiologic findings guide the surgeon in planning osteotomies, tendon transfers, and fusion procedures for optimal correction and functional restoration.

Correction

Correction of cavovarus deformity depends on the severity and flexibility of the foot. In mild, flexible deformities, non-surgical options like custom orthotics, bracing, and physical therapy can help rebalance muscle forces and realign the foot. Orthotic inserts with lateral posting and first-ray cutouts reduce varus and redistribute pressure more evenly across the sole.

For more advanced or rigid deformities, surgical intervention may be required. Procedures can include soft tissue releases, tendon transfers (such as peroneus longus to brevis), and osteotomies to correct bony malalignment. The goal of correction is to achieve a plantigrade, stable foot that allows even weight distribution, normal gait, and reduced pain. A well-planned surgical correction considers both bone and soft tissue structures for balanced realignment.

Reconstruction

Reconstruction of a cavovarus foot deformity is a comprehensive surgical approach that may involve multiple procedures to restore normal foot alignment, balance, and function. Common reconstructive surgeries include calcaneal osteotomy (to correct hindfoot varus), midfoot or first metatarsal osteotomy (to address forefoot plantarflexion), and tendon transfers to rebalance muscular forces.

In severe or rigid deformities, triple arthrodesis (fusion of the subtalar, talonavicular, and calcaneocuboid joints) may be necessary to achieve a stable, plantigrade foot. Postoperative care includes immobilization, gradual weight-bearing, and physical therapy to restore function. Successful reconstruction not only improves foot mechanics but also enhances quality of life by reducing pain, instability, and disability. Long-term outcomes are favorable when both structural correction and muscle balance are achieved.