What Causes High Arches?
The size of the arch of the foot is variable. Some people have very flat arches, and some people have big arches. These can both be normal. Treatment is only required if the arch is associated with pain, deformity or high pressure on one area of the foot.
If the arch of the foot is high, there may be problems associated with this. If the heel is pointing inwards, it may rub on shoes, and there may be a large amount of pressure on the outer border of the foot, which leads to pain and hard skin. Sometimes, there is pain, especially with activity, and sometimes there are deformities of the toes, including clawing and hammering.
Sometimes the high arch can run in families. This may be part of a generalised disorder, involving nerves that go to muscles – a disease called Hereditary Sensory and Motor Neuropathy. Sometimes, there is no nerve disorder and this is just a familial trait, but this requires assessment.
If you have high arches, it is best to see an orthopaedic surgeon who specialises in foot and ankle surgery. You should have x-rays taken in a standing position – this will demonstrate whether the arch is really exaggerated, and will help to decide what treatment may be required, if any.
How is the Surgery Performed?
The nature of the surgery depends on what is causing the deformity. The problem may lie in the back of the foot, the forefoot or both, and a combination of procedures is often required.
If younger patients, the big toe is pointing down too much, pushing the heel inwards. If the joints in the back of the foot are mobile, lifting the big toe may allow the heel to be corrected, but this is seldom performed alone.
If the deformity of the heel is fixed, then different surgery is necessary. The heel bone may need to be broken and reset to allow the foot to become flatter. The bone is allowed to drift up, backwards and to the outer side of the foot.
Often the surgery has to be broken down into different stages. If there is an imbalance in tendons, then a transfer of a tendon from one side of the foot to the other is necessary. This is especially used when there is a dropped foot that results in frequent sprains. The shifting of the heel and lifting the big toe metatarsal are often required too at the same time or at another time.
Sometimes, the foot cannot be corrected with these simple measures, and several joints will require a fusion operation – a triple fusion. This involves the fusion of three joints in the back of the foot that will correct the foot deformity but at the cost of loss of side to side movement in the back of the foot which is useful for compensating when walking on uneven ground.
Often, surgery is required for claw toes or metatarsalgia if these exist, and would be performed at the same time.
Surgery is carried out under general anaesthetic, but can be carried out with local anaesthetic injections behind the knee or around the ankle. The injections are normally given while you are asleep for your comfort. They can give good pain relief for the first day after the operation. You can go home the same day in the evening.
Risks of Surgery
Bleeding, infection, poor bone healing, poor skin healing, injury to tendons, injury to nerves, recurrence, and a need for further surgery.
There is a small risk of blood clots in the legs or lungs (DVT and PE), and there are also risks from anaesthesia – the process of being put to sleep for your operation.
Risks of Anaesthesia
The injection behind your knee is given using an ultrasound machine to guide the needle. There is a less than 1% chance of injury to the nerve. General anaesthetic also carries risks. These risks are proportional to your general health. You will need to be assessed for your fitness for surgery and an Anaesthetist will be able to advise you on your individual risk.
What Happens After Surgery?
If you have had any bony surgery in the back half of the foot, you will require plaster treatment for six weeks. If you have only had bony surgery in the forefoot, then you may be able to manage with a special shoe that only allows weight bearing through the heel.
You will have had injections to numb your foot so that you are not in pain after the operation. This injection will wear off after 18-24 hours, so you must take regular painkillers so that you are not in severe pain when the injection wears off. Ibuprofen and Diclofenac should not be used for more than a few days after the operation as they can interfere with bone healing.
The pain will settle over a few weeks. You may see blood stains on the dressings. This is normal and not a cause for alarm. If blood is dripping from the dressings however, return to hospital.
The foot will be swollen as well as sore. You should keep the foot elevated as much as possible for the first two weeks. Keep walking down to a minimum – going to the toilet or for meals. Letting the leg hang down will cause the foot to become more swollen. Most of the swelling will settle within the first few months, but swelling can continue for up to one year.
If you are resting on your sofa, keep your foot elevated on the back rest or arm rest. If you are resting in bed, then place a few pillows under the foot to keep it elevated.
You will normally be in plaster for a total of six weeks after surgery. During this time, you should not weight bear on this foot. You will need crutches or a walking frame to get about.
Two weeks after the operation, you will have your plaster removed, and the stitches removed. You will then have a further plaster applied for four more weeks.
After this, you will have an xray and if this is satisfactory, you will be given a removable plastic boot, in which you can put your weight through the operated foot. You will use this for a further six weeks. This can be removed for washing, performing exercises and at night.
If you have only had forefoot surgery, then you will be able to return to normal footwear at six weeks, if the swelling allows this.
If you are in plaster for a prolonged period, you will be at risk of developing a blood clot in your leg. You will be given injections to thin the blood to cut this risk down. These can be self-administered, even in the elderly. You can stop taking these as soon as you progress to a plastic boot.
While you are in plaster, you can perform exercises to keep the leg muscles above the knee strong, as these will become weaker as you are not weight bearing.
You can remove the plastic boot to wash, and perform exercises depending on your operation. If you have had a triple fusion, you will still be able to perform up and down movement of the ankle.
After twelve weeks, you will be seen in the clinic and a further xray will be taken. From this time, you will start to wean yourself off the plastic boot, and have physiotherapy.
RETURNING TO WORK
You will be unable to weight bear while in plaster. I advise that you do not return to work before the plaster is removed, especially if you are on your feet all day at work. Most people will be off work for four months as a minimum, but if you have a workplace with disabled access that allows you to use crutches and you are sitting down most of the day, you may be able to return to work while wearing the plastic boot. Remember that not everyone is the same, and some people take a longer time to recover from their surgery. Please request a sick note before you leave hospital, if you need one.