A Lisfranc injury refers to a rare injury to a joint in the center region commonly known as the midfoot. Although a lesser known injury, an injury in this region of the foot can be highly debilitating for an athlete who depends on their lower extremities for so much of their athletic performance. These easily overlooked injuries have recently threatened Matt Schaub or adversely affected the careers of such well known athletes as Dwight Freeney of the Indianapolis Colts, Kevin Jones of the Detroit Lions and also Larry Johnson of the Kansas City Chiefs.
Who was Lisfranc?
This midfoot injury is named after Jacques Lisfranc de St. Martin, a field surgeon in Napoleon’s army on the Russian front. He became well known for his proficiency in amputating the foot at the junction of the end of the foot (otherwise known as the forefoot) and the midfoot. He routinely performed such amputations in less than 1 minute for treating gangrene in Napolean’s soldiers which at the time, before the advent of antibiotics could be life threatening. Injuries to this region in athletes first became recognized in horseman when they would fall from their horse with their foot remaining in the stirrup. This causes a substantial twisting injury to the ligaments of Lisfranc’s joint.
Where is the Lisfranc joint?
Lisfranc’s joint is located at the junction of the forefoot and the midfoot. Specifically, Lisfranc’s ligament refers to a specific ligament that originated from the medial cuneiform (one of the small bones in the midfoot region) and attaches to the base of the 2nd metatarsal (second long bone of the forefoot). This small, but important ligament helps stabilize the midfoot and it’s relationship with the forefoot. It also helps to preserve the arch of the foot, along with the curved shape of the bones themselves. There are also other ligaments of lesser importance in this region that contribute to the stability of the foot. Over time, the term Lisfranc injury has expanded to include any injury between the various joints between the forefoot and midfoot regions. This does not only include specifically Lisfranc’s ligament and has come to be known as the “tarsometatarsal complex”.
How is the joint typically injured?
Typically a Lisfranc injury occurs when there is a severe twisting force on the joints connecting the forefoot and midfoot. The forefoot is stuck in place and the force occurs through the athlete’s entire body when all their weight twists around the fixed forefoot. This classically occurs when a horseman falls off a horse and their foot stays locked in the stirrups. This same mechanism of injury can occur during a windsurfing accident. The windsurfer’s foot remains in the board’s stirrup while the surfer falls off the board. These injuries more commonly occurs when someone’s forefoot is stuck in the turf or ground and they unexpectedly rotate when making a cut, changing directions or are being tackled. This last type of injury is influenced by the friction between the playing surface and the athlete’s shoewear.
What about a Lisfranc injury and football?
Another mechanism by which a Lisfranc injury occurs is when an athlete, typically an offensive lineman in football, sustains a direct blow compression injury through their foot. The lineman is blocking an opposing defender while moving forward such that only their forefoot is on the ground while their heel is raised in the air. If another player falls on the blocker’s heel, a significantly large axial force occurs through the lineman’s Lisfranc joint. Furthermore, if any twisting motion also occurs, the injury can be more severe.
What are different types of Lisfranc injuries?
A Lisfranc injury can be described in various ways. One way is to differentiate them based on whether the injury is purely due to ligament rupture, or whether a small fleck of bone is pulled off (avulsed) from the ligament’s attachment to the bones of the foot. Also in the most severe high energy injuries, there may be a dislocation of the joints of the midfoot and/or multiple fractures present. A Lisfranc injury can also be classified based on which direction the involved bones move (displace) during the injury once the involved ligaments are torn.
How is a Lisfranc injury diagnosed?
A Lisfranc injury is initially diagnosed based on the history and description of the athlete’s acute injury. Often an athletic trainer at the practice or competition may see the injury occur in real time and have an immediate suspicion for the injury. The athlete will describe the immediate onset of pain in the midfoot region. There may be difficulty or even an inability to put weight on the injured foot. Over the course of the ensuing day, swelling and bruising often occurs that when serious may even become evident on the bottom of the foot. On a physical exam, the injured athlete will be tender over Lisfranc’s joint and any others involved in the injury. In the most severe of injuries, those that involve a large direct crushing force to the foot, the swelling may be so severe that an emergent evaluation in an emergency room is necessary and possibly even immediate surgery. This is however extremely rare in the setting of athletic injuries.
What imaging studies are important for a Lisfranc injury?
If a Lisfranc injury is suspected based on the description of the injury and the physical evaluation, further work-up is warranted with imaging studies. Any suspected injury should be evaluated studied with plain radiographs of the foot. It is important to take these x-rays with the patient standing on the injured foot if possible. The weight placed on the foot may cause spreading to be seen between the bones on the radiograph that might be missed on non-weightbearing x-rays. This helps to identify the injured ligaments. Another option is to take the x-rays while applying a force to the forefoot in an attempt to recreate the mechanism of injury. This may also demonstrate widening between the involved bones of the foot. An ultrasound evaluation is another simple, non-invasive way to image the injured structures in a similar dynamic fashion.
When an injury occurs that involves a fracture in this region a CT scan is best for evaluating the complex bony detail of the region. Another useful advanced imaging modality is a MRI scan. MRI is helpful in detailed evaluation of ligamentous structures, and it can see bruising in the small bones of the foot (edema) which indicate an acute injury. This can be extremely helpful when a purely ligamentous injury, without a fracture, has occurred as both of these findings are not seen on the other imaging studies.
What is the prognosis of a Lisfranc injury for an athlete?
A Lisfranc injury is a very serious, often season and sometimes career threatening injury. Untreated, a Lisfranc injury can lead to chronic, debilitating pain in the midfoot. The injury also is a cause of secondary arthritis of the involved joints which is possible even with the appropriate care (surgical or not), but is considerably higher if not treated in a timely fashion.
How is a Lisfranc injury treated in an athlete?
Treatment necessitates evaluation by an orthopaedic surgeon who routinely takes care of these injuries. This may include a sports medicine trained surgeon or an orthopaedist who specifically treats foot and ankle injuries. If after appropriate testing determines that the injury is considered a stable injury, then it may be treated with a period of non-weightbearing followed by gradual return to normal activites as detailed below. If the injury is unstable, or even if the suspicion is there for it to be unstable, then acute surgical treatment is warranted.
What is a typical course of non-operative treatment?
For a stable Lisfranc injury, treatment begins with a period of immobilization either in a removable boot or frequently a cast that includes the foot and the leg below the knee (a short leg cast). This typically lasts 6 to 8 weeks with the patient using crutches and not allowed to put weight on the injured extremity. At the same time, it is important to elevate the injured leg to decrease the swelling and therefore the pain from the injury. Icing the foot can be done also for pain and swelling if a boot is used and direct access to the foot is possible. Pain medications, usually in the form of anti-inflammatories, are also taken. In the case of a more minor injury, the duration of limited weight-bearing and immobilization may be shortened at the treating physician’s discretion.
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What does surgery for a Lisfranc injury consist of?
If the injury is found to be unstable, then surgery is warranted. The timing of surgery depends on the amount of swelling and the status of the skin overlying the injured foot. If there is too much swelling or the skin is in poor condition from the injury, a short period of elevation and swelling control is warranted prior to surgery. This will decrease the chance of complications from surgery such as infection or wound breakdown, both of which have serious consequences.
Surgery typically involves rigidly stabilizing the injured joints. The specific midfoot joints that are stabilized depend on the specific ligaments that are injured and may vary somewhat on a case by case basis. The majority of the time, stabilizing the injured region requires one or a few relatively small incisions, the placement of screws and in some cases wires. By holding the involved joints rigid, the torn ligaments are allowed to heal.
There is some evidence that permanently fusing the joints of the foot that are injured may be preferential in some cases. The rationale is that the initial Lisfranc injury damages the cartilage of the joint which predisposes an athlete to the development of arthritis. By fusing the injured joints, the cartilage is removed and there is no chance of arthritis developing. One concern in an athlete however is that there may be less motion in the midfoot region after a fusion than a repair. Also following a fusion, the motion normally present at the fused midfoot joints is transferred to the uninvolved joints. This added stress can lead to the development of arthritis elsewhere.
What happens after surgery on the Lisfranc joint?
Postoperatively following a typical Lisfranc joint repair, the patient must be non-weightbearing on the operative foot. This period of restricted weight-bearing and relative immobilization is typically 6-8 weeks. Subsequently, the amount of weight-bearing allowed is gradually increased over the next few weeks. Physical therapy is initiated and sports-specific training is begun. At some point, once the torn ligaments have been given sufficient time to heal, the screws used to fix the Lisfranc injury are removed as a minor operative procedure. This again allows normal motion and function to take place in the athlete’s midfoot region. It also avoids breaking of the screws by a repetitive fatigue mechanism with impact loading that occurs during weight-bearing on the repaired foot. Although the actual timing is somewhat controversial, this usually occurs somewhere between 3 and 6 months after the first operation takes place.
Lisfranc Injury Recovery Time?
Stable Lisfranc injuries that do not require surgery may cause an athlete to miss 2 months or more of their season. However, most athletes are able to successfully return at some point. Those injuries that are unstable, and require surgical repair, are serious injuries that almost always cause the injured athlete to miss the remainder of their season. It is also not uncommon for a high level athlete to not be able to return to the same level of athletic performance even in following seasons. Two well-known examples are Eric Rhett and Duce Staley both of whom had surgery for a serious Lisfranc injury and never successfully returned to their pre-injury form.
Injury to the Tarsometatarsal Joint Complex. Michael C. Thompson and Matthew A. Mormino. J. Am. Acad. Ortho. Surg., July/August 2003; 11: 260 – 267. Current management of tarsometatarsal injuries in the athlete. Myerson MS, Cerrato RA. J Bone Joint Surg Am. 2008 Nov;90(11):2522-33.
Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study. Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Foot Ankle Int. 2009 Oct;30(10):913-22.