RICE & MICE: Lisfranc injuries

Thankfully, one of the injuries that hockey players are not prone to getting are Lisfranc injuries. Jets wide receiver Santonio Holmes will miss the remainder of the season with the dreaded injury and, unfortunately, many athletes just don’t come back 100 percent from damage to the Lisfranc area.

Lisfranc injuries are also called Lisfranc dislocations, Lisfanc fracture or Lisfranc fracture-dislocations, tarsometatarsal injury or just simply a mid-foot injury. It is named for Jacques Lisfranc de St. Martin, when he performed an amputation of the forefoot to the tarsometatarsal joints during the Napoleonic Wars. Ever since, the mid-foot where the metatarsal bones meet the tarsal bones has been called the Lisfranc joint complex.

One of the unique aspects of this injury is that it encompasses ligament sprains and tears as well as dislocations and fractures. A sprain of the Lisfranc ligament, can cause instability of the joint in the middle of the foot because the ligaments on the bottom of the mid-foot are stronger than the ligaments on the top of the mid-foot so when they are weakened there is instability in the mid-foot. A fractures can be a break in one or more of the bone in the Lisfranc joint and can be either  an avulsion fracture (a small piece of bone is pulled off) or a break through the bone. A dislocation in the joint is when one or more bones is forced out of the normal position.

Lisfranc injuries are often mistaken for simple, straightforward sprains because they can result from a seemingly benign or harmless twist and fall. In football, this injury commonly occurs when the forefoot is planted on the ground with the heel in the air and another player falls on the heel, causing a downward force through the foot. Lisfranc injuries may also occur as result of a fall or direct trauma (like dropping something on your foot). This injury can also happen when horseback riding if the foot gets caught in the stirrup when the rider falls or gets thrown.

These injuries can cause significant damage to the cartilage in the mid-foot and since cartilage doesn’t heal well, it is usually very difficult to restore functioning to pre-injury level. Cartilage covers the areas of the bone that articulate or lay and move against other bones, so disruption of the cartilage can cause dysfunction of the joint, arthritis and possibly flat foot or fallen arches.

Symptoms of a lisfranc injury can include swelling, pain, bruising, and pain with weight-bearing or inability to bear weight. Compartment syndrome can happen with this injury. When the foot is examines, there may be tenderness over the mid-foot, pain when the mid-foot is stressed by grasping the heel and twisting the forefoot and/or moving the toes up and down. With subtle injuries, there will be pain when doing a single leg heel rise (standing tip-toe on one foot).

Along with a clinical exam, x-rays may show fractures as well as mal-alignment of the Lisfranc joint complex, which could indicate an injury. Sometimes x-rays will be taken while standing in order to stress the joint and show subtle ligament injuries. MRIs are not routinely used to diagnose Lisfranc injuries. CT scans are not required for diagnosis, but they may be ordered to help a surgeon identify the areas of injury and may help in planning surgery.

Treatment of Lisfranc injuries depends on the severity of the injury. If the injury is a sprain, without complete rupturing of the ligaments, non-surgical treatment will likely be the best choice and can include non-weightbearing for up to six weeks and then progressing to a walking boot. During this time, x-rays may be done periodically to check the alignment of the affected bones. Surgery will be needed for any fracture injury and for bones that are subluxed or dislocated.

During surgery, the bones will be re-aligned and bones that are fractured will be reset. Sometimes, internal fixation using metal plates, pins or screws is needed to hold the bones in place. Some or all of this hardware may be removed 3-to-5 months after surgery, but hardware removal isn’t necessary. Because hardware is placed across a joint that moves, screws and plates may fail or break. This often doesn’t impact the effectiveness of surgery. In very severe injuries, where hardware cannot be used fixate the bones, surgical fusion may be used to heal the bones into a single piece of bone.

After surgery, there is usually a period of non-weightbearing followed by progression to weight bearing and eventually to strengthening exercises, running and sports specific activities and finally return to play. Some athletes never get back to pre-injury form and many Lisfranc injuries result in arthritis of the mid-foot.