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Pes cavus is defined as an abnormal elevation of the medial longitudinal arch of the foot. More than two-thirds of patients with pes cavus are found to have an underlying neurologic diagnosis driving a muscle imbalance within the foot. Expedient clinical diagnosis of underlying pathology is paramount to facilitate proper neuraxial imaging studies and a referral to pediatric neurology. Non-operative management is rarely sufficient and is typically indicated only in cases of mild deformity. Surgical management hinges heavily on physical and radiographic examination findings including the Coleman block test, which can help to determine the need for soft tissue or bony reconstruction. The goal of treatment in pes cavus is to obtain a painless, plantigrade, and supple foot.