Brian C. Toolan, MD
Orthopaedic Foot and Ankle Surgery
The University of Chicago
Section of Orthopaedic Surgery and Rehabilitation Medicine
5841 S. Maryland Ave. MC 3079  Chicago  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 xrays. 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.