Pes cavus, defined as a high arch in the sagittal plane, occurs in various clinical situations. A cavus foot may be a variant of normal, a simple morphological characteristic, seen in healthy individuals. Alternatively, cavus may occur as a component of a foot deformity. When it is the main abnormality, direct pes cavus should be distinguished from pes cavovarus. In direct pes cavus, the deformity occurs only in the sagittal plane (in the forefoot, hindfoot, or both). Direct pes cavus may be related to a variety of causes, although neurological diseases predominate in posterior pes cavus. Pes cavovarus is a three-dimensional deformity characterized by rotation of the calcaneopedal unit (the foot minus the talus). This deformity is caused by palsy of the intrinsic foot muscles, usually related to Charcot-Marie-Tooth disease. The risk of progression during childhood can be eliminated by appropriate conservative treatment (orthosis to realign the foot). Extra-articular surgery is indicated when the response to orthotic treatment is inadequate. Muscle transfers have not been proven effective. Triple arthrodesis (talocalcanear, talonavicular, and calcaneocuboid) accelerates the mid-term development of osteoarthritis in the adjacent joints and should be avoided.