Orthopaedic Foot and Ankle Surgery
The University of Chicago
Section of Orthopaedic Surgery and Rehabilitation Medicine
5841 S. Maryland Ave. sMC 3079 s Chicago s Illinois 60637
Phone 773.702.6984 Fax 773.702.0076
What Is Cavus Foot Deformity? (“High Arches”)Cavus foot deformity is also known as “pes cavus” or, more simply, high-arches. The arch is the main supportive structure of your foot. The height of the arch can vary from person to person. But, when a person with a cavus foot stands up, the arch seems to be higher off the ground than normal. In addition, the heel may point inwards and the toes may be drawn inwards. The toes in some cases can be curled up so much that they may resemble claw toes.
While the most noticeable thing about a cavus foot is the high arch, it is important to understand that this condition is likely caused by other deformities in the foot. For instance, the front part of the foot is drawn downwards more than normal in all cavus feet. And, the big toe in particular, is drawn down the most. These conditions are caused by an imbalance in the foot muscles. The result of that imbalance is that the person's arch tips upwards, and the foot tilts a bit to the outside. This makes it seem as if the arch is very high.
But, as with most conditions, there are several ways the condition can make itself known. For instance, some people with cavus feet may also have weak calf muscles. In this case, the heel may point downwards and this, too, makes the arch appear higher than normal. In other people, the Achilles tendon at the back of the ankle becomes tight, and this draws the heel up which puts more pressure on the ankle and the balls of the foot.
In most cases, at the early stage of cavus foot, the tilt in the heel is relatively flexible. After time though the joints may become stiff and the tilt may no longer be flexible.
Causes of Cavus Foot Deformity?
High arches seem to be based on an imbalance of muscles in the foot, but no one is sure why that imbalance occurs. It seems that the soft tissue on the sole of the foot, called the plantar fascia, ligaments, tendons and the joint capsules of the foot just get tighter. And, the tighter they get, the higher the arch appears.
Cavus foot may run in families. It may also be caused by other medical conditions that cause muscle weakness such as Spina Bifida or muscular dystrophy, and polio. Or the condition may be part of a progressive neurological disease.
Symptoms of Cavus Foot Deformity?
The most obvious symptom is the very high arch in the foot. For people who also have a neurological disorder, the arch might seem to get higher over time.
If you find normal shoes uncomfortable, this might also be a symptom. You will notice that lacing the shoes will be the problem as there will not be enough room. Pains on the outside border of the foot with calluses on the bottom outside border indicate excessive pressure caused by the cavus deformity.
Frequently sprained ankles and stumbling while walking may also be noticed because the alignment of the foot tips you toward the outside of your foot.
Treatment options
The first treatment is always conservative. Treatment options depend on how flexible or fixed the foot alignment is. If it is a flexible cavus foot, it can be treated with Orthotics and physical therapy. If it is a more rigid cavus foot, you may need to wear a brace.
If you have a cavus foot that doesn’t get better with conservative management, surgery is an option.
There are many surgical options. One may be doing things to correct the muscle imbalance by lengthening tendons, ligaments and other structures that are tight. This is most successful in patients that have flexible cavus feet.
Sometimes the surgery involves bony work to realign the foot to make it more square to the ground. It may involve a first tarsometatarsal (TMT) osteotomy. This procedure means putting the 1st metatarsal bone in a better position so that it doesn’t tip you outward. You may also need a calcaneal osteotomy to move the heel over to put it back under the ankle and make your foot more square to the ground.
At times the surgery may combine the bony work and the soft tissue work. Sometimes the cavus foot is so rigid it requires a triple arthrodesis.
The surgery takes approximately 3 hours. It is a surgery that involves a lot of bone and soft tissue work. There are also multiple incision to fix all of the problems. Because of the involvement of the procedure, you will be admitted to the hospital for an overnight stay following surgery. You will also go home in a short leg cast that you will stay off of for 4-6 weeks.
Post operative management
Pain management
The first 3-5 days after surgery will be the most uncomfortable. You will have both swelling and pain. During this time it is very important that you decrease your activity level, elevate the operated foot above heart level, and use ice therapy. You will notice when you put your foot down, it will begin to swell immediately and you will experience a throbbing pain. To treat this, elevate and ice and it should go away. Over the next two weeks, you will be able to increase the amount of time you can have your leg down. It is still important to keep your leg elevated as much as possible.
After surgery, you will be given a prescription for pain medication. You should not need any refills. If you are out of pain medication, perhaps you are being too active and need to decrease your activity level. Before taking a pain pill, we suggest that you elevate and ice for a period of 20 minutes, if this does not adequately control your pain, than you should take some pain medicine.
There are many factors that affect your healing time. The most important is to be patient and do not put any weight on your foot for the first 4-6 weeks after surgery. This is the amount of time it takes for the soft tissue and bony work to heal. This means you must use assistive devices, like crutches, a walker or roll-a-bout to get around. We do not want you to use a wheel chair because your entire body gets weak and it will lengthen your recovery time.
Another factor is smoking. YOU MUST NOT SMOKE while you are recovering. It will delay your healing. This includes second hand smoke. Smoking decreases the blood flow to your surgical site. This means that oxygen and nutrients essential for healing are decreased and will lengthen your recovery. It is also possible that the bones will not heal, or your wound will not heal and the skin dies. In the event that the bones do not heal, you will require additional surgery to get the bones to heal.
Another factor is swelling. This is something that can be avoided by elevating your foot above heart level. Swelling can also be controlled with ice therapy. Icing for 20-30 minutes in intervals will significantly decrease your swelling. The best thing to use for ice therapy is crushed ice or frozen vegetables because they can conform around your cast or splint. By eliminating swelling, you can reduce or eliminate your pain.
you elevate and ice your foot 20-30 minutes for pain control first. If elevation and ice do not adequately control the pain, you may then take your pain medication. It is important to only take your pain medication when you need it. Just because the prescription says you may take it every 4-6 hours, does not mean that you have to.
Casting
After surgery you will be placed in a cast or splint. There is a handout on cast care. One important thing is to wiggle your toes 10 times an hour while awake to prevent stiffness. If you had soft tissue work only, you will be casted for 4 weeks. If you had bone work, you will be casted for 6 weeks. It takes 4 weeks for the soft tissue work to heal, and 6 weeks to see signs of bone healing.
Two weeks after surgery, you will return to the clinic. Your cast will be removed, and your stitches will be taken out. We will inspect the incision and steri-strips (like band aids) will be placed on the skin. You will be placed in a lighter weight fiberglass cast. You must still remain non-weight-bearing.
Four-to-Six weeks after surgery you will return to the clinic for a cast removal and x-rays. If x-rays demonstrate that the bone is healing, you will not need another cast, and will be placed in a CAM Boot, which is like a big ski boot. A CAM Boot is a boot that can be removed for bathing and physical therapy. It must still be treated like a cast and worn at all times, including at night. If the x-rays demonstrate that the bone still needs time to heal, then you will be put in a cast for another 4 weeks. Then x-rays will be taken again to assess the bone healing, and the decision for casting or a CAM Boot will be made.
Physical Therapy
When you are placed in a CAM Boot, you cannot walk on it right away. You will begin at 30-50 pounds of weight bearing with crutches/walker. This is simply putting the leg down and supporting the weight of the leg only. You will now start physical therapy 2-3 times a week for 6-12 weeks to progress to full-weight-bearing without crutches. After full weight bearing has been achieved, you will be weaned out of your CAM Boot into your regular shoes.
During therapy, you will work on strengthening, mobility and gait training. At three months, after surgery you should be independent with activities of daily living, but should expect continued swelling. You will continue to work on the therapy you have learned at home.
At 10-12 weeks after surgery, you will return for a clinic appointment. X-rays will be taken to see how well the bones have healed. You may be able to return to work without any restrictions.
One of the most common issues after this surgery is swelling. It lasts for many months after the surgery, sometimes up to a year. This is normal, and not a cause for concern, however it can become bothersome. You will need to wear a good lace-up tie shoe to accommodate for the swelling you will experience. It requires patience.
It is important to remember that you may still have good and bad days after your treatment is completed. It can take up to six months to return to your normal level of activity. Although there will be some bad days, over time you will get progressively better. We will see you back at the six month anniversary of your surgery. At nine to twelve months, the foot should “feel normal”, range of motion is greatly improved, swelling is decreased and there are no problems with the foot with normal activities.
At any time during your treatment, you may call the office at (773) 702-6984 or the nurse at (773) 834-0355 with any questions or concerns.