Raiyyan Tahsan

Raiyyan Tahsan
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TC(1021).(05).Orthopedics Case No 99:- High Arch Foot / Pes Cavus

High Arch Foot / Pes Cavus — বাংলায় সাজানো নোট

গুরুত্বপূর্ণ: Pes cavus সাধারণত structural/biomechanical deformity। তাই ওষুধ deformity ঠিক করে না; ওষুধ দেওয়া হয় pain, inflammation, neuropathic pain, muscle spasm, ulcer/infection complication control করার জন্য। Definitive management হলো proper shoe, custom orthosis, physiotherapy, brace, এবং severe/progressive case-এ surgery।

1. Definition — সংজ্ঞা

Pes cavus / High arch foot হলো এমন পায়ের deformity যেখানে medial longitudinal arch অস্বাভাবিকভাবে বেশি উঁচু থাকে। অনেক ক্ষেত্রে এর সাথে hindfoot varus, forefoot adduction/pronation, plantar-flexed first ray, claw toes থাকতে পারে।

Core meaning:
পায়ের arch বেশি উঁচু হওয়ায় body weight ঠিকভাবে distribute হয় না; বেশি চাপ পড়ে heel, lateral border, first/fifth metatarsal head-এ—ফলে pain, callus, ankle sprain, instability হয়।

2. Causes — কারণগুলো

A. Neurological causes — সবচেয়ে গুরুত্বপূর্ণ

Pes cavus-এর significant case-এ underlying neurological disease খুঁজতে হয়। Common causes:

  • Charcot–Marie–Tooth disease — CMT
    • সবচেয়ে common hereditary neuromuscular cause।
    • Bilateral pes cavus + distal weakness + family history থাকলে strongly suspect।
  • Cerebral palsy
  • Post-stroke spasticity
  • Spinal cord lesion / tethered cord / spinal tumor
  • Poliomyelitis
  • Friedreich ataxia
  • Muscular dystrophy
  • Peripheral nerve injury / peroneal nerve injury
  • Diabetic neuropathy / polyneuropathy
  • Spina bifida / myelomeningocele

B. Traumatic causes

  • Old calcaneal fracture malunion
  • Talar neck malunion
  • Distal tibial fracture malunion
  • Chronic ankle instability
  • Burn scar / compartment syndrome
  • Peroneal nerve injury

C. Congenital / idiopathic causes

  • জন্মগত high arch
  • Family tendency
  • Idiopathic subtle cavus foot
  • Untreated or undertreated clubfoot
  • Tarsal coalition
  • Rheumatoid arthritis / ankle osteoarthritis

3. Pathophysiology — সহজ ব্যাখ্যা

Pes cavus অনেক সময় muscle imbalance থেকে হয়। যেমন CMT-তে tibialis anterior, intrinsic foot muscle, peroneus brevis weak হয়ে যায়; কিন্তু peroneus longus ও tibialis posterior relatively stronger থাকে। এতে first ray plantar-flexed হয়, forefoot pronation হয়, hindfoot compensatory varus হয়। Result: rigid, high-arched, poor shock-absorbing foot.

4. Symptoms — লক্ষণগুলো

  • পায়ের arch খুব উঁচু দেখা যায়
  • দীর্ঘক্ষণ হাঁটা/দাঁড়ালে foot pain
  • Heel pain
  • Lateral foot pain — পায়ের বাইরের দিকে ব্যথা
  • Metatarsalgia — পায়ের সামনের অংশে ব্যথা
  • Painful callus/corn — বিশেষ করে first ও fifth metatarsal head-এর নিচে
  • Claw toe / hammer toe
  • জুতা ঠিকমতো fit না হওয়া
  • জুতার বাইরের অংশ দ্রুত ক্ষয় হওয়া
  • Repeated ankle sprain
  • Ankle instability
  • Running বা fast walking-এ difficulty
  • Plantar fasciitis
  • Achilles tendon pain
  • Stress fracture হতে পারে
  • Neurological cause থাকলে:
    • পায়ে numbness/tingling/burning
    • distal muscle wasting
    • weakness
    • frequent tripping/falling
    • reflex কমে যাওয়া

HSS অনুযায়ী cavus foot-এ uneven weight distribution থেকে pain, metatarsalgia, callus/corn, ankle sprain, stress fracture, plantar fasciitis, hammertoe/claw toe হতে পারে।

5. Clinical diagnosis — clinically কীভাবে diagnose করব

A. History

  • শুরু কবে?
  • এক পায়ে নাকি দুই পায়ে?
  • Progressive হচ্ছে কি?
  • Family history আছে কি?
  • বারবার ankle sprain হয় কি?
  • জুতা দ্রুত নষ্ট হয় কি?
  • Diabetes/neuropathy আছে কি?
  • Stroke, CP, polio, spinal disease history আছে কি?
  • Numbness, tingling, weakness, wasting আছে কি?

B. Inspection — দাঁড় করিয়ে পা দেখা

  • High medial arch
  • Hindfoot varus
  • Forefoot adduction/pronation
  • Plantar-flexed first ray
  • Claw toe / hammer toe
  • Callus: first/fifth metatarsal head-এর নিচে
  • “Peek-a-boo heel” sign — সামনে থেকে heel pad দেখা যায়
  • Gait: lateral border দিয়ে হাঁটা, unstable gait

C. Palpation

  • Metatarsal head tenderness
  • Plantar fascia tenderness
  • Peroneal tendon tenderness
  • Fifth metatarsal stress fracture tenderness
  • Ankle joint line tenderness

D. Specific clinical tests

1. Coleman block test — খুব গুরুত্বপূর্ণ

1-inch/2.5 cm block পায়ের lateral forefoot ও heel-এর নিচে দেওয়া হয়, first metatarsal head block-এর বাইরে ঝুলে থাকে।

  • Hindfoot varus correct হলে → flexible, forefoot-driven cavus
  • Correct না হলে → rigid hindfoot varus / fixed deformity
    এটা surgical planning-এর জন্য important।

2. Silfverskiöld test

Gastrocnemius tightness আছে কি না দেখার জন্য।

3. Neurological examination

  • Power: tibialis anterior, peroneus brevis/longus, intrinsic muscles
  • Reflex: ankle jerk
  • Sensation: pinprick, vibration, proprioception
  • Muscle wasting
  • Spine exam: scoliosis, spinal dysraphism sign

6. Investigations — specific

A. X-ray — first-line

Weight-bearing X-ray করতে হবে:

  • Foot AP view
  • Foot lateral view
  • Oblique view
  • Weight-bearing ankle X-ray
  • Calcaneal axial view / hindfoot alignment view

Important radiological measurements:

  • Meary’s angle
    • Normal প্রায় 0°
    • Cavus foot-এ first metatarsal plantar-flexed হয়ে angle বাড়ে
    • Severe cavus-এ >20° হতে পারে
  • Calcaneal pitch increased
  • Hibb angle increased
  • AP talocalcaneal angle decreased
  • Degenerative arthritis, fracture, stress fracture দেখা

B. MRI

  • Unilateral unexplained pes cavus হলে brain/spine MRI দরকার, কারণ spinal tumor/tethered cord exclude করতে হবে।
  • Peroneal tendon tear, ligament injury, osteochondral lesion, stress fracture সন্দেহ হলে foot/ankle MRI।

C. CT scan

  • Rigid deformity, arthritis, surgical planning-এর জন্য।

D. Neurological tests

  • Nerve conduction study + EMG
    • CMT/peripheral neuropathy suspect হলে।
  • Genetic testing
    • CMT/hereditary neuropathy সন্দেহ হলে।
  • Blood tests
    • FBS/HbA1c — diabetic neuropathy
    • Vitamin B12
    • TSH
    • ESR/CRP if inflammatory disease
    • RA factor/anti-CCP if RA suspected

7. Differential diagnosis

  • Pes planus — flat foot
  • Equinovarus foot / clubfoot
  • Diabetic Charcot foot
  • Tarsal coalition
  • Peripheral neuropathy
  • CMT
  • Cerebral palsy-related foot deformity
  • Post-traumatic varus foot
  • Plantar fasciitis alone
  • Metatarsalgia without cavus
  • Peroneal tendon pathology

8. Complications — বাংলায় ব্যাখ্যা

  • Repeated ankle sprain: পায়ের outer side দিয়ে weight পড়ে, তাই ankle বারবার মচকায়।
  • Chronic ankle instability: ligament loose/weak হয়ে persistent instability হয়।
  • Painful callus/corn: pressure point বেশি হওয়ায় শক্ত চামড়া হয়।
  • Metatarsalgia: forefoot pressure বাড়ে।
  • Plantar fasciitis: plantar fascia tight থাকে।
  • Stress fracture: metatarsal/ankle bone-এ repeated load পড়ে।
  • Peroneal tendonitis/tear
  • Claw toe deformity
  • Ulceration: diabetic neuropathy থাকলে pressure ulcer হতে পারে।
  • Fixed rigid deformity: early management না করলে flexible deformity rigid হয়ে যায়।
  • Ankle/foot arthritis: long-term malalignment থেকে degenerative change হয়।
  • Surgical complication: nonunion, tendon transfer failure, DVT, recurrence—বিশেষ করে progressive neurological disease থাকলে।

9. Treatment / Management

A. Non-pharmacological management — main treatment

  • Patient education
    • Pes cavus-এ drug deformity ঠিক করে না।
  • Footwear
    • Wide toe-box shoe
    • Cushioned sole
    • Lateral stability support
    • High heel এড়িয়ে চলা
  • Custom foot orthosis
    • Pressure redistribute করে
    • First metatarsal recess, lateral posting, heel cushioning দরকার হতে পারে
    • RCT ও Cochrane review-এ painful pes cavus-এ custom orthosis pain/function improve করেছে।
  • Physiotherapy
    • Calf stretch
    • Plantar fascia stretch
    • Peroneal strengthening
    • Intrinsic foot muscle exercise
    • Balance/proprioception training
  • Brace
    • Ankle instability/neuromuscular weakness থাকলে AFO/Arizona brace।
  • Callus care
    • Podiatry debridement
    • Pressure off-loading
  • Surgery — severe/progressive/rigid/painful case
    • Plantar fascia release
    • Tendon transfer
    • First metatarsal dorsiflexion osteotomy
    • Calcaneal osteotomy
    • Midfoot osteotomy
    • Arthrodesis/fusion in rigid arthritic foot
      Surgery patient-specific; single universal operation নেই।

10. Pharmacological treatment — Bangladesh prescription-style list

Note: নিচের dose adult general dose। Patient-এর age, pregnancy, renal/liver disease, peptic ulcer, anticoagulant use, asthma, hypertension, CKD, cardiac risk অনুযায়ী adjust করতে হবে। NSAID একসাথে দুইটা দেওয়া যাবে না।

1. Paracetamol — mild to moderate pain

  • Generic name: Paracetamol
  • Therapeutic category: Analgesic, antipyretic
  • Pharmacological class: Non-opioid analgesic; not NSAID
  • Purpose in Pes cavus: mild foot pain, heel pain, walking-related pain
  • Adult dose: 500–1000 mg orally every 6–8 hours PRN
  • Max dose: generally 3 g/day safer limit; liver disease/alcohol use থাকলে কম
  • Duration: 3–5 days PRN; persistent pain হলে reassess
  • Side effects: nausea, rash; overdose → severe hepatotoxicity
  • Interactions: alcohol, warfarin long-term high dose, other paracetamol-containing cold/flu medicine
  • BD available brands with strength: Napa 500 mg, Fast 500 mg/1000 mg/XR 665 mg, Ace 500 mg, Reset ER 665 mg, Tamen XR 665 mg, Feva 500 mg, Feva One 1000 mg, Pyrex 500 mg, Tamino 500 mg. MedEx lists many paracetamol brands and strengths including Fast 500 mg/1000 mg/XR 665 mg and Napa 500 mg.

2. Ibuprofen — inflammatory pain / sprain-type pain

  • Generic name: Ibuprofen
  • Therapeutic category: NSAID
  • Pharmacological class: Non-selective COX inhibitor
  • Purpose in Pes cavus: painful plantar fasciitis, tendonitis, ankle sprain, inflammatory mechanical pain
  • Adult dose: 200–400 mg orally every 6–8 hours after meal PRN
  • Max dose: 1200 mg/day for short symptomatic use; physician-supervised higher dose only selected cases
  • Duration: 3–5 days; prolonged use avoid
  • Side effects: gastritis, GI ulcer/bleeding, dizziness, renal impairment, BP rise, fluid retention
  • Interactions: aspirin, warfarin/DOAC, clopidogrel, steroid, ACE inhibitor/ARB, diuretic, lithium, methotrexate, other NSAID
  • Contraindication caution: peptic ulcer, CKD, severe heart failure, third trimester pregnancy, NSAID-sensitive asthma
  • BD available brands with strength: Advel 200/400 mg, Flamex 200/400 mg, Profen 400 mg, Reumafen 200/400 mg, Intaflam 400 mg, Serviprofen 400 mg. MedEx lists ibuprofen indications for mild–moderate pain/inflammatory pain, dosage 200–400 mg, NSAID therapeutic class, interactions, and BD brands.

3. Naproxen sodium — longer acting NSAID

  • Generic name: Naproxen sodium
  • Therapeutic category: NSAID
  • Pharmacological class: Non-selective COX-1/COX-2 inhibitor
  • Purpose in Pes cavus: persistent inflammatory foot pain, tendonitis, bursitis, plantar fasciitis-type pain
  • Adult dose: 250–500 mg orally twice daily after meal
  • Max dose: 1000 mg/day
  • Duration: 5–7 days, then reassess
  • Side effects: heartburn, abdominal pain, dyspepsia, nausea, diarrhoea, renal impairment, fluid retention
  • Interactions: anticoagulants, antiplatelets, steroid, ACE inhibitor/ARB, diuretic, lithium, methotrexate, other NSAID
  • BD available brands with strength: Sonap 250/500 mg, Anaflex 250/500 mg, Diproxen 250/500 mg, Ecless 250/500 mg, Nuprafen 250/500 mg, Roxen 250/500 mg, Xenapro 500 mg. MedEx lists naproxen indication for tendonitis/bursitis/pain, adult dose 500–1000 mg/day, NSAID class, and many BD brands including Sonap 250/500 mg.

4. Etoricoxib — COX-2 selective NSAID

  • Generic name: Etoricoxib
  • Therapeutic category: NSAID
  • Pharmacological class: Selective COX-2 inhibitor
  • Purpose in Pes cavus: short-term moderate inflammatory pain when non-selective NSAID not suitable, but cardiac/BP risk must be considered
  • Adult dose: 60 mg once daily; severe short-term pain sometimes 90 mg once daily under physician decision
  • Duration: shortest possible, usually 3–7 days
  • Side effects: dyspepsia, edema, hypertension, dizziness, renal impairment, increased cardiovascular risk
  • Interactions: warfarin, ACE inhibitor/ARB, diuretic, lithium, methotrexate, rifampicin, other NSAID
  • Avoid/caution: uncontrolled hypertension, ischemic heart disease, stroke history, CKD
  • BD available brands with strength: Setorib 60/90/120 mg, Cox-E 60/90/120 mg, Etoxib 60/90/120 mg, SB-Eto 60/120 mg, Starcox 60/90 mg, Temcox 60 mg. MedEx lists etoricoxib 60/90/120 mg brands such as Setorib and SB-Eto.

5. Diclofenac topical gel — local pain

  • Generic name: Diclofenac sodium topical gel
  • Therapeutic category: Topical NSAID
  • Pharmacological class: Local COX inhibitor
  • Purpose in Pes cavus: local heel/forefoot/tendon pain; systemic NSAID avoid করতে চাইলে useful
  • Adult use: thin layer apply painful area 2–4 times/day
  • Duration: 5–7 days; open wound/ulcer-এর উপর লাগাবেন না
  • Side effects: local burning, rash, dermatitis; systemic GI/renal effect rare but possible with large area/long use
  • Interactions: oral NSAID + topical NSAID long-term একসাথে avoid; anticoagulant caution
  • BD available brands with strength: Voligel 1%, Voligel Max 2%, Volicool 1%, Volifen 1%, Voltagel DS 2%, Voltafen 1%, VOLINAC 1%, VOLINAC Max 2%, VOLINI 1%. MedEx gel list shows these diclofenac preparations and strengths.

6. Gabapentin — neuropathic pain

  • Generic name: Gabapentin
  • Therapeutic category: Neuropathic pain medicine / adjunct antiepileptic
  • Pharmacological class: Gabapentinoid; alpha-2-delta calcium-channel ligand
  • Purpose in Pes cavus: burning, tingling, electric-shock pain due to neuropathy/CMT/diabetic neuropathy; deformity pain নয়
  • Adult dose: Day 1: 300 mg HS; Day 2: 300 mg BD; Day 3: 300 mg TDS; titrate according to response
  • Usual range: 900–1800 mg/day in 3 divided doses
  • Duration: trial 2–4 weeks; benefit না হলে taper/stop
  • Side effects: dizziness, somnolence, fatigue, ataxia, weight gain, peripheral edema, dry mouth
  • Interactions: antacid reduces absorption; alcohol/sedatives increase drowsiness; renal impairmentে dose reduce
  • BD available brands with strength: Gaba 300 mg, Gabapen 100/300 mg, Gabastar 100/300 mg, Gabantin 100/300 mg, Gabamax 300 mg, Gabahil 100/300 mg. MedEx lists gabapentin indication for neuropathic pain, titration dose, interactions, side effects, therapeutic class, and brands.

7. Pregabalin — neuropathic pain

  • Generic name: Pregabalin
  • Therapeutic category: Neuropathic pain medicine / antiepileptic-related drug
  • Pharmacological class: Gabapentinoid; alpha-2-delta calcium-channel ligand
  • Purpose in Pes cavus: neuropathic burning/tingling pain, especially CMT/diabetic neuropathy-associated pain
  • Adult dose: 50–75 mg at night or BD; titrate to 75 mg BD after 3–7 days if tolerated
  • Usual range: 150–300 mg/day; maximum often 600 mg/day specialist-supervised
  • Duration: 2–4 week trial; stop করতে হলে taper
  • Side effects: dizziness, sleepiness, edema, weight gain, blurred vision, cognitive slowing
  • Interactions: alcohol, benzodiazepine, opioid, sedatives → CNS depression; renal impairmentে dose adjust
  • BD available brands with strength: GABA-P 25/50/75 mg, Gaba-P CR 82.5/165/330 mg, Gabarol 25/50/75/100/150 mg, Lyric 25/50/75/150 mg, Lyrinex 50/75 mg, Myrica 25/50/75/100 mg, Pregaba 25/50/75/100/150 mg, Pregaben 50/75/150 mg. MedEx lists many pregabalin brands and strengths in Bangladesh.
  • NICE neuropathic pain guidance recommends amitriptyline, duloxetine, gabapentin, or pregabalin as initial options for neuropathic pain, except trigeminal neuralgia.

8. Amitriptyline — chronic neuropathic pain, night pain

  • Generic name: Amitriptyline hydrochloride
  • Therapeutic category: Neuropathic pain adjuvant / antidepressant
  • Pharmacological class: Tricyclic antidepressant
  • Purpose in Pes cavus: chronic neuropathic pain, night burning pain, sleep disturbance with neuropathic pain
  • Adult dose: 10 mg at night; increase gradually to 25 mg at night if needed
  • Duration: 2–4 week trial; chronic use needs review
  • Side effects: dry mouth, constipation, urinary retention, blurred vision, drowsiness, weight gain, postural hypotension, QT prolongation
  • Interactions: SSRI/SNRI/MAOI, tramadol, linezolid, alcohol, sedatives, anticholinergic drugs, QT-prolonging drugs
  • Avoid/caution: glaucoma, BPH/urinary retention, arrhythmia, recent MI, elderly fall risk
  • BD available brands with strength: Tryptin 10/25 mg, Amilin 10/25 mg, Amit 10/25 mg, Amitip 10/25 mg, Reptylin 10/25 mg, Tripsina 10/25 mg. MedEx lists amitriptyline as tricyclic antidepressant and these BD brands.

9. Duloxetine — neuropathic pain with mood component

  • Generic name: Duloxetine hydrochloride
  • Therapeutic category: Neuropathic pain medicine / antidepressant
  • Pharmacological class: SNRI
  • Purpose in Pes cavus: neuropathic pain, diabetic neuropathy-type pain, pain with anxiety/depression component
  • Adult dose: 30 mg once daily for 1 week, then 60 mg once daily if needed
  • Duration: 4-week trial; stop করলে gradual taper
  • Side effects: nausea, dry mouth, insomnia/somnolence, sweating, BP rise, sexual dysfunction, liver enzyme elevation
  • Interactions: MAOI, SSRI/TCA/tramadol/linezolid → serotonin syndrome risk; alcohol/liver disease caution; CYP1A2/2D6 interactions
  • BD available brands with strength: Diliner DR 20/30 mg, Dulox 20 mg, Duloxen 20/30 mg, Xinolax DR 20/30/60 mg, Loxetine 20/30 mg, Stresin 30 mg. MedEx lists duloxetine delayed-release brands such as Diliner DR and Dulox.

10. Mecobalamin — only if neuropathy/B12 deficiency suspected

  • Generic name: Mecobalamin / Methylcobalamin
  • Therapeutic category: Vitamin B12 preparation / neurotropic vitamin
  • Pharmacological class: Coenzyme form of vitamin B12
  • Purpose in Pes cavus: B12 deficiency neuropathy, diabetic/alcoholic/drug-induced neuropathy support; deformity correct করে না
  • Adult dose: 500 mcg orally TDS after meal; injection 500 mcg IM/IV 3 times/week in selected deficiency/peripheral neuropathy cases
  • Duration: 4–8 weeks then reassess B12 level/clinical response
  • Side effects: nausea, diarrhoea, rash, headache
  • Interactions: absorption reduced by omeprazole/H2 blocker, colchicine, neomycin; oral contraceptive may reduce serum concentration
  • BD available brands with strength: Mecobal 500 mcg tablet/injection 500 mcg/ml, Mecol 500 mcg, Mecolagin 500 mcg chewable/injection 500 mcg/ml, Mecolin 500 mcg, Mecomin 500 mcg, MB 12 injection 500 mcg/ml. MedEx lists mecobalamin indication in peripheral neuropathy, dose, interactions, side effects, and BD brands.

11. Baclofen — spasticity-associated cavus only

  • Generic name: Baclofen
  • Therapeutic category: Skeletal muscle relaxant
  • Pharmacological class: GABA-B agonist; centrally acting muscle relaxant
  • Purpose in Pes cavus: cerebral palsy/stroke/spinal lesion-related spasticity; routine mechanical cavus painে নয়
  • Adult dose: 5 mg TDS initially; titrate slowly to 10 mg TDS if needed
  • Duration: specialist-guided; sudden stop করা যাবে না
  • Side effects: drowsiness, dizziness, weakness, hypotonia, nausea, confusion
  • Interactions: alcohol, benzodiazepine, opioid, sedatives → excessive CNS depression
  • BD available brands with strength: Flexilax 5/10 mg, Flexifen 5/10 mg, Beklo 5/10/25 mg, Liofen 5/10 mg, Bacofen 5/10 mg, Lospan 10/25 mg, Maxolax 5/10 mg, Myorel 5/10/25 mg. MedEx lists baclofen for spasticity/muscle spasm and many BD brands.

12. Tizanidine — painful muscle spasm/spasticity

  • Generic name: Tizanidine hydrochloride
  • Therapeutic category: Skeletal muscle relaxant
  • Pharmacological class: Central alpha-2 adrenergic agonist
  • Purpose in Pes cavus: painful muscle spasm or neurological spasticity; routine high arch deformity painে নয়
  • Adult dose: 2 mg TDS initially; severe spasmে 2–4 mg TDS; max specialist-guided
  • Duration: short course 5–7 days for spasm; chronic spasticity specialist-guided
  • Side effects: somnolence, dizziness, dry mouth, hypotension, bradycardia, weakness, raised transaminase
  • Major interactions: ciprofloxacin/fluvoxamine contraindicated; alcohol/sedatives increase sedation; QT-prolonging drug caution
  • BD available brands with strength: Relentus 2 mg, Sirdalud 2 mg, Tizan 2 mg. MedEx lists tizanidine indication, dose, interactions, contraindications, and side effects.

13. Pantoprazole — gastroprotection when NSAID risk exists

  • Generic name: Pantoprazole sodium
  • Therapeutic category: Anti-ulcerant
  • Pharmacological class: Proton pump inhibitor
  • Purpose in Pes cavus: NSAID-induced gastritis/ulcer risk থাকলে gastroprotection; Pes cavus-এর drug নয়
  • Adult dose: 20–40 mg once daily before breakfast
  • Duration: NSAID course চলাকালীন; high-risk patientে clinician-guided
  • Side effects: headache, diarrhoea/constipation, nausea; long-term useে B12/Mg deficiency, fracture/infection risk
  • Interactions: long-term PPI may reduce B12 absorption; warfarin/clopidogrel interaction clinically consider
  • BD available brands with strength: Pantonix 20/40 mg, Pantolok 20/40 mg, Pantogut 40 mg, Pantopan 20 mg, Pantopra 20/40 mg, Pantodac IV 40 mg/vial. MedEx lists pantoprazole as PPI used for NSAID-induced ulcer and BD brands/strengths.

14. Antibiotic — only if ulcer/cellulitis/infection develops

Routine Pes cavus-এ antibiotic দেওয়া যাবে না।
যদি ulcer, pus, cellulitis, fever, diabetic foot infection থাকে, তখন culture/clinical severity অনুযায়ী antibiotic। Mild skin-soft tissue infectionে doctorরা কখনও use করেন:

  • Generic name: Amoxicillin + Clavulanic acid
  • Therapeutic category: Antibiotic
  • Pharmacological class: Broad-spectrum penicillin + beta-lactamase inhibitor
  • Purpose: infected pressure ulcer/cellulitis; prophylaxis নয়
  • Adult dose: 500 mg + 125 mg orally every 8 hours after meal
  • Duration: usually 5–7 days; diabetic foot/osteomyelitis হলে longer specialist plan
  • Side effects: diarrhoea, nausea, rash, candidiasis, cholestatic hepatitis rare
  • Interactions: warfarin INR rise, allopurinol rash risk, methotrexate toxicity risk
  • BD available brands with strength: Moxaclav 500+125 mg / 875+125 mg, Aristomox CV 500+125 mg / 875+125 mg, Clamox suspension/injection, Clavoxil 250+125 mg / 500+125 mg, Co-Clav 500+125 mg. MedEx lists these amoxicillin-clavulanate brands and strengths and warns not to use antibiotic without prescription.

Bangladesh doctors commonly prescribe — practical list

Pes cavus patient prescription-এ commonly symptom অনুযায়ী যেগুলো দেখা যায়:

  1. Paracetamol — simple mechanical pain
  2. Topical diclofenac gel — localized heel/forefoot/tendon pain
  3. Ibuprofen / Naproxen / Etoricoxib — inflammatory pain, plantar fasciitis, ankle sprain, tendonitis
  4. Pantoprazole/Omeprazole — NSAID-induced gastric protection
  5. Pregabalin / Gabapentin — neuropathic burning/tingling pain
  6. Amitriptyline / Duloxetine — chronic neuropathic pain, night pain
  7. Mecobalamin — B12 deficiency/peripheral neuropathy support
  8. Baclofen / Tizanidine — spasticity-associated cavus, CP/stroke/spinal lesion
  9. Antibiotic — only infected ulcer/cellulitis হলে, never routine

Prevention — কীভাবে prevent/control করবেন

  • Early diagnosis: bilateral/progressive cavus হলে neurological evaluation।
  • Proper cushioned footwear ব্যবহার।
  • Custom orthosis ব্যবহার করলে pressure point কমে।
  • High-impact running/jumping কমানো যদি pain থাকে।
  • Calf stretch + plantar fascia stretch daily।
  • Balance/proprioception exercise ankle sprain prevent করে।
  • Callus নিজে blade দিয়ে কাটবেন না; podiatry care।
  • Diabetes থাকলে:
    • daily foot inspection
    • HbA1c control
    • barefoot walking avoid
    • ulcer হলে early doctor consult
  • Children/adolescent progressive cavus হলে early ortho + neurology referral।
  • Unilateral sudden cavus বা weakness/numbness থাকলে brain/spine MRI consideration।

Overview / Summary

Pes cavus হলো high-arched foot deformity, যা অনেক সময় neurological disease—especially CMT—এর sign হতে পারে। Diagnosis mainly clinical: high arch, hindfoot varus, claw toes, callus, lateral foot pain, recurrent ankle sprain; Coleman block test flexible vs rigid deformity বোঝায়। Investigation-এর first-line হলো weight-bearing X-ray; neurological suspicion থাকলে NCS/EMG, genetic test, MRI brain/spine দরকার। Main treatment হলো orthosis, footwear, physiotherapy, brace; drug শুধু pain/inflammation/neuropathic pain/spasticity/infection complication control করে।

Actionable Plan / Steps

  1. Ortho/Foot-ankle specialist দেখান যদি pain, recurrent sprain, progressive deformity, claw toe বা callus থাকে।
  2. Weight-bearing foot + ankle X-ray করুন।
  3. Bilateral/progressive/high arch + weakness/numbness/family history থাকলে Neurology referral + NCS/EMG।
  4. Pain থাকলে first-line: shoe modification + custom orthosis + physiotherapy।
  5. Medicine choose করবেন symptom অনুযায়ী:
    • simple pain → paracetamol
    • inflammatory pain → short NSAID/topical NSAID
    • neuropathic pain → pregabalin/gabapentin/amitriptyline/duloxetine
    • spasticity → baclofen/tizanidine
    • ulcer/infection → doctor-guided antibiotic only
  6. Red flag: sudden one-sided deformity, rapidly progressive weakness, ulcer, fever, severe numbness, diabetic foot wound → urgent referral।

Reference List

Textbook references

  1. Apley & Solomon’s System of Orthopaedics and Trauma, latest edition — Foot deformities; cavus foot principles.
  2. Campbell’s Operative Orthopaedics, latest edition — Cavovarus foot reconstruction, tendon transfer, osteotomy.
  3. Harrison’s Principles of Internal Medicine, latest edition — Peripheral neuropathy, Charcot–Marie–Tooth disease overview.
  4. Davidson’s Principles and Practice of Medicine, latest edition — Neuromuscular disorders and peripheral neuropathy.

Guideline / clinical source

  1. NICE CKS — Neuropathic pain drug treatment: initial options include amitriptyline, duloxetine, gabapentin, pregabalin.
  2. StatPearls/NCBI Bookshelf — Pes Cavus evaluation and management.
  3. HSS — Cavus foot symptoms and treatment.
  4. MedEx Bangladesh — BD brand names, generic information, drug class and dosing references.

Peer-reviewed journal / DOI

  1. Burns J, Crosbie J, Ouvrier R, Hunt A. Effective orthotic therapy for the painful cavus foot: a randomized controlled trial. J Am Podiatr Med Assoc. 2006;96(3):205–211. DOI: 10.7547/0960205.
  2. Burns J, Landorf KB, Ryan MM, Crosbie J, Ouvrier RA. Interventions for the prevention and treatment of pes cavus. Cochrane Database Syst Rev. 2007. DOI: 10.1002/14651858.CD006154.pub2.
  3. Qin B, Wu S, et al. Evaluation and Management of Cavus Foot in Adults: A Narrative Review. Journal of Clinical Medicine. 2022;11(13):3679. DOI: 10.3390/jcm11133679.

Md.Rafiqul Islam Lipu,Date:-15-06-2026 Monday,Time:-07-18-12 Pm

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