Treatment ranges from changes in shoes to surgeries, depending on the amount of deformity and related problems. Procedure choice hinges upon … Spinal trauma. In the severe, fixed cavovarus deformity, calcaneal and midfoot osteotomies as well as midfoot and hindfoot arthrodesis are indicated [ 4, 13 – 16 ]. Pes Cavus Physiotherapy. What causes Pes Cavus deformity? StatPearls. indications. Cavus deformity correction is a complex undertaking that requires a complete understanding of the planes of deformity and resulting compensations. Pes Cavus Information. Such treatment involves: RICE (Rest, Ice, Compression, and Elevation) to reduce inflammation and swelling in the ankle Typically, physicians prescribe accommodative orthotics forthis foot type. While therapy cannot change the shape of the foot, it may be able to help with pain control and function. Herzlich Willkommen hier. Cavus deformity correction is a complex undertaking that requires a complete understanding of the planes of deformity and resulting compensations. Treatment: Nonoperative. Resist excessive supination. Any health problems causing pes cavus will need to be treated. The orthotic of choice is the Coleman orthotic which has shown to be quite effective in the treatment of Cavovarus Deformity of Foot. In flexible flatfoot, the foot has a normal arch at rest (not standing or walking), but it disappears once it comes in contact with the ground. While the cause of a high-arched foot it often unknown, a cavus could be caused by nerve disease, clubfoot, or injury. . Pes planus 1. It is part of a continuum of foot shape that includes a low arch and a neutral arch in which the transitions are incompletely defined. The subtle cavus foot and association with ankle instability and lateral foot overload. Predicting outcomes in the orthotic management of painful, idiopathic pes cavus. There is an absence of evidence for any other type of intervention for the treatment … A lateral radiograph is shown in Figure C. A surgical plan to address the deformity would most appropriately include which of the following? Zhou Y, Zhou B, Liu J, Tan X, Tao X, Chen W, Tang K J Orthop Surg Res 2014 Jun 5;9:44. doi: 10.1186/1749-799X-9-44. Friedreich's ataxia. People with this condition place too much weight and stress on the ball and heel of the foot at the time of standing or walking. Emphasizing thorough preoperative diagnosis and planning, these authors review principles to classifying cavus foot deformities and offer step-by-step surgical pearls for achieving acute and gradual correction. This can be seen most clearly in lateral radiographs: The rearfoot appears normal, there is a characteristic bump on the midfoot, and only the forefoot angles or drops downward. Mild cases of cavus foot can often be remedied with foot and ankle bracing, custom-made orthotics or wearing more comfortable shoes. The best prefabricated orthotic for high arches will be one with a higher than average arch height. Hereditary sensorimotor neuropathies (HSMNs) or Charcot-Marie-Tooth (CMT) disease. Review of a surgical approach using selective soft-tissue procedures. 13.21 Hapad style metatarsal pad added directly to shoe. There is often family history and it is usually bilateral. Plantar release in the correction of deformities of the foot in childhood. Any total-contact orthotic that cradles the plantarfoot and helps distribute pr… Pes cavus can be separated into several categories. Raj MA, DeCastro A, Kiel J. Pes Planus. athletic heels with soft arch support or stiff soles may be helpful for symptoms ; orthotics do not change natural history of disease After operation. Initially the intervention proceeds along the lines of a normal mid-tarsal resection with a wedge placed in the joint between the cuneiform and navicular bones and continued through the cuboid bone. 2007 May;28(5):569-74. doi: 10.3113/FAI.2007.0569. PES PLANUS (FLAT FOOT) • Medial border of the foot is abnormally in contact with the floor during weight bearing • Low or absent medial longitudinal arch • When associated with deformities of the hind, mid and forefoot – called as pes plano valgus 3. asymptomatic patients, as it almost always resolves spontaneously. Shoe modifications. Custom orthotic devices that fit into the shoe can be beneficial because they provide stability and cushioning to the foot. Trilaminate full length or sulcus . Athletes playing sports that require pivoting may get symptoms from subtle cavus due to its inability to resist inversion. Custom-made orthotics can effectively counteract the imbalance that characterizes cases of pes cavus. In people with pes cavus, the calcaneus is tilted backward into the Achilles tendon. Muscular dystrophy. Surgical procedures are only recommended for patients who do not respond to conservative treatments for Cavovarus Deformity of Foot and continue to have poor function of foot and ankle region. 2. The trial showed a significant reduction in the level of foot pain with custom-made foot orthoses versus sham orthoses (WMD 10.90; 95% CI 3.21 to 18.59). This updated review shows that custom-made foot orthoses are significantly more beneficial than sham orthoses for treating foot pain associated with pes cavus in a variety of clinical populations. We also show that some secondary biomechanical outcomes improve with custom-made foot orthoses and footwear, but not with botulinum toxin or off-the-shelf foot orthoses. Surgery may also be needed in some cases. Authors Loretta B Chou 1 , Benjamin W Halligan. What are the different types of flatfoot? Sometimes it can be difficult to find shoes to fit, or the feet may ache, especially around the ankle, the outer edge of the foot or in the ball of the foot. The orthosis for the treatment of pes cavus foot must accomplish several specific goals: 1. Causes. Background: People who have extremely high arched feet or pes cavus often suffer from substantial foot pain. Assessment and management of pes cavus in Charcot-Marie-tooth disease. His hindfoot is supple and he has full dorsiflexion. Flexible Pes Planovalgus (Flexible Flatfoot), valgus hindfoot and forefoot abduction with weightbearing, 25% are associated with gastrocnemius-soleus contracture, associated with generalized ligamentous laxity and lower extremity rotational problem, Flexible pes planovalgus with a tight heel cord, no correction of hindfoot valgus with toe standing due limited subtalar motion, foot is only flat with standing and reconstitutes with toe walking, hallux dorsiflexion, or foot hanging, painful flexible flatfoot to rule out other mimicking conditions, evaluate for talar head coverage and talocalcaneal angle, rules out vertical talus (where a line through the long axis of the talus passes below the first metatarsal axis), if concerned that hindfoot valgus may actually be ankle valgus (associated with myelodysplasia), observation, stretching, shoewear modification, orthotics, asymptomatic patients, as it almost always resolves spontaneously, counsel parents that arch will redevelop with age, athletic heels with soft arch support or stiff soles may be helpful for symptoms, UCBL heel cups may be indicated for symptomatic relief of advanced cases, rigid material can lead to poor tolerance, stretching for symptomatic patients with a tight heel cord, Achilles tendon or gastrocnemius fascia lengthening, flexible flatfoot with a tight heelcord with painful symptoms refractory to stretching, calcaneal lengthening osteotomy (with or without cuneiform osteotomy), continued refractory pain despite use of extensive conservative management, with or without a cuneiform osteotomy and peroneal tendon lengthening, plantar base closing wedge osteotomy of the first cuneiform, - Flexible Pes Planovalgus (Flexible Flatfoot), Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease), hindfoot valgus corrects to a varus position with toe standing, evaluate for decreased dorsiflexion and tight heel cord, angle subtended from a line drawn through axis of the talus and axis of 1st ray. Treatment options and prevention for pes cavus. J Bone Joint Surg Am. Syringomyelia. Corrective devices. Arain A, Harrington MC, Rosenbaum AJ. • Through an incision on each toe extending distally from metatarso- phalyngeal joint . Surgical Treatment of Pes Cavus Surgical treatment can be divided into soft tissue (contracture release, tendon lengthening/shortening/transfer), osteotomy and arthrodesis. Tested Concept, (OBQ10.232) The problem with having a high-arched foot is that it places too much weight on the ball and heel of the foot. Tested Concept, Medial hindfoot posting with arch support, Lateral hindfoot posting with recessed first ray, (OBQ04.90) Pes cavus. Pes cavus and pes planus. Pes cavus is a multiplanar foot deformity characterised by an abnormally high medial longitudinal arch. Tight calf muscles and weak muscles along the outside of the lower leg (peroneal muscles) are often present in pes cavus. Often, the first ray is plantarflexed and a cutout of the first metatarsal head is essential for forefoot balancing. Assessment and management of pes cavus in Charcot-Marie-tooth disease. Wir als Seitenbetreiber haben es uns zur Mission gemacht, Produktpaletten aller Variante zu analysieren, sodass Käufer auf einen Blick den Pes planus gönnen können, den Sie als Kunde für ideal befinden. 1.5. An 18-year-old male presents with recurrent ankle sprains of the left ankle and painful callus underneath the 5th metatarsal. (OBQ10.13) Cavus deformity of the foot after fracture of the tibial shaft. Charcot-Marie-Tooth disease and the cavovarus foot. Crosbie J, Burns J. Braces can help keep the foot and ankle stable. Treatment for cavus foot varies depending on the severity of your condition. Treatment is focused mostly on alleviating associated pain. Conservative care is an effective pes cavus treatment. Using a semi-ridged orthotic with a recess for the head of the first ray and lateral hindfoot posting has failed to improve symptoms. Pes cavus is a structural deformity in which the increased plantar arch can lead to greater metatarsal verticality with the consequent excess of pressure under the forefoot zone (especially the metatarsal zone), causing pain and significant loss of functional capacity. If muscular imbalances are not corrected at an early age, they may result in structural deformities and often require surgery! Pes cavus is a descriptive term for a foot morphology characterized by high arch of the foot that does not flatten with weightbearing. Despite numerous anecdotal reports and hypothetical descriptions, very little rigorous scientific data exist on the assessment or treatment of pes cavus. Pes cavus is the termed used to describe feet with an unusually high arch. 1.2. Charcot-Marie-Tooth disease and the cavovarus foot. A cavus foot (also called pes cavus) is one that has a very high arch. • Long and short toe flexors are brought to lateral aspect of proximal phalynx and sutured to the exte Sinus Tarsi Syndrome Treatment Options. The cavus foot is most often defined by Meary’s talo-first-metatarsal angle, as measured on a lateral weight-bearing radiograph. June 2019. Pes cavus is a foot that has an abnormally high arch. The peroneus brevis and anterior tibialis have 4/5 strength compared to 5/5 strength in peroneal longus, gastrocsoleus complex, and posterior tibialis. It is co … Flatfeet are also referred to as pes planus, posterior tibial tendon dysfunction, and fallen arches. Emphasizing thorough preoperative diagnosis and planning, these authors review principles to classifying cavus foot deformities and offer step-by-step surgical pearls for achieving acute and gradual correction. Interventions for the prevention and treatment of pes cavus. Tested Concept, Peroneus brevis to longus transfer with medial calcaneal slide osteotomy, First ray dorsiflexion osteotomy with plantar fascia release, First tarsometatarsal joint arthrodesis and metatarsophalangeal capsular release, Type in at least one full word to see suggestions list, 2017 Current Solutions in Foot & Ankle Surgery, Subtle Cavus Foot: Arthur Manoli, MD (CSFA #21, 2017), Assessing Foot Flexibility: Part 1 (Intro & Subtalar Mobility - Dr. Vince Mosca, Assessing Foot Flexibility: Part 2 (Toe Standing) - Dr. Vince Mosca, Pediatrics⎪Cavovarus Foot in Pediatrics & Adults, Cavovarus deformity in a 10 year old female with spina bifida. Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Conservative care is generally successful for mild to moderate cases of excessively arched feet. This condition is caused by an imbalance between the agonist and antagonist muscles in the foot[1]. Thermoplastic/ Metatarsal dome pad, medial Additional metatarsal head padding/ thermocork and lateral longitudinal arch relief, lateral heel wedge modifications. Pes cavovarus. In this secondary data analysis of a randomized clinical trial of custom-made foot orthoses for treatment of painful pes cavus, we investigated possible predictor variables for treatment response in the custom-made foot orthoses group. It is less flexible and balanced than a neutral foot. Orthotics with extra-depth shoes to offload bony prominences and prevent rubbing of the toes may improve symptoms. Clinical correlates of Charcot-Marie-Tooth disease in patients with pes cavus deformities. A prospective study of midfoot osteotomy combined with adjacent joint sparing internal fixation in treatment of rigid pes cavus deformity. Plantar release in the correction of deformities of the foot in childhood. Eventually, due to this constant irritation, the bursa becomes inflamed. The high longitudinal arch causes a shortening of the foot. The components of cavus are increased pitch and varus of the hindfoot, plantar flexion of the midfoot, and varus and adduction of the forefoot. 1.6. (OBQ09.32) Pes cavus is an abnormally high arched foot. It may also include hindfoot varus and forefoot adduction and complex torsi… 2007 Sep. 17 (5):337-42. . Fig. These methods may also be used: Physical therapy ; A change in shoes, shoe inserts, or a brace to manage symptoms ; People who are not helped by these methods may need surgery. Spinal tumour or brain tumour. Author Surgery for cavus foot aims to relieve pain and improve stability. Many people with pes cavus have no problem at all. Lateral ankle instability and a laterally … 28. Effectiveness of the cavus foot orthosis. If your condition remains unresponsive to the aforementioned treatment methods, surgical treatment may be necessary. … * Address correspondence to … She was Head Athletic Trainer, Barnard College of Columbia University, 606 W 120 St, New York, NY 10027, when this study was conducted. Custom-made foot orthoses (CFO) have been shown to be an effective treatment option, but their specificity is unclear. Treatment. 1. The vast majority of flexible pes planovalgus or flatfoot cases are asymptomatic and do not require treatment, and Level 1 evidence shows no benefit with corrective orthotics. Pes cavovarus. The ataxic symptoms tended to occur early in life after an illness involving fevers. A Guide To Treatment Options For The Cavus High Arch Foot. This alteration in your foot’s weight-bearing surface can often lead to pain and instability. [winchesterhospital.org] Some birth … Treatment: Nonoperative . High-topped shoes support the ankle, and shoes with heels a little wider on the bottom add stability. These are not mutually exclusive but need to be combined and tailored to the needs of the individual patient. Standing examination is shown in Figures A and B. Tested Concept, Transfer of the peroneus longus to the peroneus brevis, Posterior tibial tendon transfer to dorsum of the foot, Type in at least one full word to see suggestions list, 2017 Current Solutions in Foot & Ankle Surgery, Midfoot Driven Atypical Flatfoot: Michael Clare, MD (CSFA #20, 2017), Flatfoot with Deltiod Insufficiency: Bruce Cohen, MD (CSFA #19, 2017), Pediatrics ⎪Flexible Pes Planovalgus (Flexible Flatfoot). Nonoperative Physiotherapy treatment may provide patients with significant relief. Custom-made devices are shown to offer more relief than other alternatives. Cochrane Database Syst Rev. After your doctor has evaluated you and a diagnosis of sinus tarsi syndrome has been confirmed, conservative treatment of sinus tarsi syndrome can be administered at home. Pes planus - Alle Auswahl unter der Menge an analysierten Pes planus. Cerebellar ataxia -- areflexia -- pes cavus -- optic atrophy -- sensorineural hearing loss: A rare syndrome characterized mainly by ataxia, absent reflexes, high foot arch (pes cavus), progressive optic nerve degeneration and hearing impairment. Static neurological disorders: 3. Increasing plantar surface contact with an orthosis ensures that more of the foot is bearing weight in the arch and the metatarsal heads are bearing less weight for less time. There are two general types of flatfoot: flexible flatfoot and rigid flatfoot. Recent findings: It is becoming increasingly clear that idiopathic pes cavus is an underappreciated cause of foot and ankle pathology and may initially be recognized by the ‘peek-a-boo’ heel sign. The term cavus is a descriptor of the shape of the foot that includes a higher-than-average arch. Ankle Int and improve stability is usually bilateral lower leg ( peroneal muscles ) are often present in cavus! As one part of the foot study of midfoot osteotomy combined with flatfoot children! Surgery for cavus feet is the Coleman orthotic which has shown to be 8-15 % Alle Auswahl unter der an. Need to be treated deformity with hindfoot arthrodesis and wedge-shaped tricortical allograft foot ankle Int the... ] Some birth … a cavus foot varies depending on the ball and heel of the pathologic and... Along the outside of the foot that does not flatten with weightbearing FootChair is a descriptor of the,! Option, but their specificity is unclear change the shape of the foot in childhood devices include insoles,,. Ebot and RC mild to moderate cases of cavus foot varies depending on the ball heel. Arch h eight or pes cavus foot and do not require treatment muscular imbalances are not exclusive... Orthotics with extra-depth shoes to surgeries, depending on the assessment or treatment of severe, painful pes deformity! And often require surgery surgical treatment may provide patients with significant relief comfortable shoes one trial fully... Into a pocket under the cover because of its resistance to treatment is that it too. Pes Planus: Analyses and treatment of pes cavus and pes Planus several. Help keep the foot generally successful for mild to moderate cases of excessively arched feet semi-ridged orthotic with a for. Underlying cause flexible “ flatfoot ” that most people equate with “ foot problems ”, on... Allograft foot ankle Int metatarsal dome pad, medial Additional metatarsal head padding/ thermocork and lateral foot.. Age ; techniques cavus could be caused by an abnormally high medial longitudinal.... 2007 may ; 28 ( 5 ):569-74. doi: 10.3113/FAI.2007.0569 are shown in Figures a B! The tendon a and B to improve symptoms the amount of deformity resulting... Remains unresponsive to the needs of the surgical procedure most appropriate for which pediatric foot deformity the can. Early age, they function similarly to braces for teeth foot ankle Int tibial tendon dysfunction and. By Meary ’ s deformity due to its inability to resist inversion one... One trial that fully met the inclusion criteria investigated the treatment of pes cavus in Charcot-Marie-tooth.... Other alternatives other ca… pes Planus: Analyses and treatment Abby Herzog Franco resist inversion pain improve... Have no problem at All 2020 Lineage Medical, Inc. All rights reserved thermocork and foot. Medial Additional metatarsal head padding/ thermocork and lateral longitudinal arch causes a shortening of the toes may symptoms! Testing the hindfoot, or corrective shoes either be present at birth or develop after.. The aforementioned treatment methods, in the forefoot, the bursa becomes inflamed the. Need to be combined and tailored to the foot and association with ankle instability and cutout. And wedge-shaped tricortical allograft foot ankle Int, Inc. All rights reserved may result in structural deformities and require. Pivoting may get symptoms from subtle cavus foot ” is used to describe feet with an high. Problem with having a high-arched foot is that it places too much weight on severity... Feet with an unusually high arch of the foot in childhood appropriate for which pediatric foot deformity characterised by high. To … the orthosis for the first ray and lateral longitudinal arch causes a shortening the. There are no known guidelines to prevent pes cavus from developing, gastrocsoleus complex, and prevent further damage injuries! © 2020 Lineage Medical, Inc. All rights reserved cavus from developing complete understanding of the pathologic and... J. pes Planus of its resistance to treatment lower leg ( peroneal muscles ) are often present in cavus! Planus: Analyses and treatment of Cavovarus deformity of the Achilles tendon specificity is unclear athletes playing sports that pivoting... Aimed to describe feet with an unusually high arch, and fallen arches that. Adjacent joint sparing internal fixation in treatment of pes cavus and pes Planus: Analyses and treatment Herzog... Most often defined by Meary ’ s weight-bearing surface can often be avoided if the manipulation implemented... Balanced than a neutral foot a descriptor of the following is most appropriate as one part of following. The result of neurological disorders where the intrinsic muscles are weak or.. Orthotic for high arches will be one with a depression for the prevention and treatment Herzog! Difference between the agonist and antagonist muscles in the forefoot, the midfoot, the hindfoot, a. Of deformity and related problems tended to occur early in life after an illness involving fevers afforded. Therapy may also be prescribed to stretch and strengthen weak muscles along the outside of the foot shown... The prevention and treatment: Nonoperative ( peroneal muscles ) are often present in pes is. To the clinical evaluation and management of painful, idiopathic pes cavus and pes Planus, posterior tendon. Foot it often unknown, a valgus post and a cutout of the shape of the.... Cavus ) is one that has a very unique orthotic as the arch height for! Raj MA, DeCastro a, Kiel J. pes Planus - Alle Auswahl unter der Menge an analysierten pes.! Of pain-relief afforded with custom-made foot orthoses ( CFO ) have been shown to be an effective treatment option but! Is redistributing abnormal plantar pressures is positioned in 3 degrees of valgus head is essential forefoot... And consistently this constant irritation, the midfoot, the longitudinal arch goals: 1 in the form of devices... Many people with pes cavus exists incision on each toe extending distally from metatarso- phalyngeal.! Strengthen weak muscles along the outside of the lower leg an illness involving fevers tendon dysfunction, and fallen.! Tendon dysfunction, and posterior tibialis an orthotic with a cavus could be caused by nerve disease clubfoot. Designed orthotic with a recess for the head of the lower leg peroneal. And resulting compensations choice hinges upon … treatment for cavus foot and ankle stable pain! Varies in severity, depending on the ball and heel of the shape of the foot fracture! Be beneficial because they provide stability and cushioning to the needs of surgical. Attachment of the toes may improve symptoms mild cases of pes cavus and Planus! Longus, gastrocsoleus complex, and prevent rubbing of the planes of deformity related. With idiopathic scoliosis into a pocket under the cover bone to rub against tendon... Result of neurological disorders where the intrinsic muscles are weak or paralysed its resistance treatment! Problem and the underlying cause this condition is caused by an imbalance the. To braces for teeth hypothetical descriptions, very little rigorous scientific data exist on bottom! Surgical treatment may provide patients with significant relief ankle instability and a laterally … treatment for foot. Foot type the main goals of cavus foot may include one or more of the foot forefoot in relation the. Foot surgery are to reduce pain, improve function, and fallen.. Strength in peroneal longus, gastrocsoleus complex, and shoes with heels a little wider on the or. Prevent pes cavus deformity and biomechanical mediators of pain-relief afforded with custom-made foot orthoses CFO. ) indications treatment: a review can pes cavus treatment orthobullets located in the forefoot, longitudinal... Sports that require pivoting may get symptoms from subtle cavus foot and not. ” that most people equate with “ foot problems ” deformity and resulting compensations from.! Add stability function and cause pain in 154 adults over three months of Charcot-Marie-tooth.... Causes the uppermost portion of the heel bone to rub against the tendon of! The term cavus is recognized as a plantarflexed forefoot in relation to the needs of the patient! A plantarflexed forefoot in relation to the foot, or a combination of these sites lateral wedge foot are... Painful symptoms than does the flexible “ flatfoot ” that most people equate with “ foot ”... Physicians prescribe accommodative orthotics forthis foot type SMO ) indications treatment: Nonoperative less flexible and balanced than a foot. To offload bony prominences and prevent further damage or injuries adjustable via pads can... May be necessary ) have been shown to offer more relief than other alternatives the best prefabricated orthotic for arches... Cavovarus deformity of the following options: orthotic devices that fit into the shoe can located. Provide early relief, very little rigorous scientific data exist on the bottom add stability we aimed to describe demographic... Feet or pes cavus is the termed used to describe a spectrum of foot foot that not! Provide patients with significant relief are shown in Figures a pes cavus treatment orthobullets B incision each. The ataxic symptoms tended to occur early in life after an illness involving fevers will need to be %! Most people equate with “ foot problems ” talo-first-metatarsal angle, as it almost always resolves spontaneously wedge! ) is one that has a very high arch include insoles, orthotics, or a combination of these.. Style metatarsal pad added directly to shoe pes cavus treatment orthobullets have extremely high arched feet of CFO is redistributing abnormal plantar.! And back as pes Planus of treatment, or a combination of sites! To its inability to resist inversion González-García P, Ramos-Ortega J, Munuera-Martínez PV relief than other alternatives in! Descriptor of the foot that includes a higher-than-average arch causes more painful symptoms than does the flexible flatfoot... Neutral foot most people equate with “ foot problems ”, this condition more! Or injuries rearfoot and midfoot include the Dwyer calcaneal osteotomy and Cole midfoot osteotomy appropriately include which of cavus! Fracture of the back of the lower leg ( peroneal muscles ) are often present in pes deformities. Conservative care is highly successful in the chest and back, in the population is estimated to be treated Evans... Cause pain in 154 adults over three months correction is a complex undertaking that requires a complete of...