Lisfranc injury of the foot: Not to be missed!
Foot injuries are not as commonly seen compared to some other sporting injuries. When they occur they need to be accurately diagnosed and managed to avoid ongoing problems, however this can be difficult when you consider the complex and intricate anatomy of the foot.
The Lisfanc joint complex refers to the tarsometatarsal joints of the foot (Fig 1) and the multiple ligaments which join these bones together. A Lisfranc injury refers to any injury that occurs to these joints or ligaments and can range from a mild strain of one of the ligaments, to separation of the bones and in severe cases, dislocation and fractures. These injuries can occur as a result of direct trauma to the foot, such as a crush injury, or as a result of landing from a jump awkwardly onto your toes, which creates longitudinal pressure along the foot. They can also occur during any other injury that applies a twisting mechanism to the foot.
Fig 1. Lisfranc injury (Courtesy of OrthoInfo: http://orthoinfo.aaos.org/topic.cfm?topic=A00162)
A recent casualty of this injury in Dane Swan from Collingwood, who twisted his right leg and foot in a very awkward position whilst landing on his leg. Unfortunately for him, he sustained multiple Lisfranc fractures, which is on the severe end of the spectrum for these types of injuries.
Severe injuries like Dane Swan’s are usually identified and managed appropriately very early. However there are many other midfoot injuries that occur innocuously, causing mild Lisfranc injuries that go undiagnosed, mostly because the individual will dismiss it as a “sprain that will go away”. As a general rule, any midfoot pain that persisting longer than five days should raise suspicion of a Lisfranc joint injury and should be examined by an appropriate professional.
The typical features of this injury include:
· Difficulty weightbearing on the injured foot, particularly with the push-off phase of walking or running
· Difficulty with running on the toes (or walking on the toes)
· Difficulty with doing a calf raise
Physical examination would reveal:
· Pain on midfoot palpation, particularly on the dorsum (top side) of the foot
· Pain with combined eversion and abduction of the forefoot whilst the hindfoot is stabilized
Plain film weightbearing Xrays of the both feet should be ordered. A Lisfranc injury is likely if the gap between the 1st and 2nd metatarsal bases of the injured foot is greater than 1mm when compared to the uninjured side. The plain film Xray should also detect any fractures. MRIs are more sensitive at detecting ligament injuries and should be ordered if Xrays appear normal.
Once diagnosed, appropriate management is paramount. Mild Lisfranc injuries (without joint instability) should be immobilized in a cast for 6 weeks, without weightbearing. After this, physiotherapy, strengthening and mobilization should occur with a graduated return to weight bearing as tolerated. Following this, a graded return to activity and sport can occur. Moderate to severe Lisfranc injuries that have signs of instability require surgical fixation. This also applies to fractures within the Lisfranc complex. A course of physiotherapy rehabilitation will need to occur afterwards.
The prognosis of this condition is variable depending on the severity of the injury. In general, a Lisfranc injury has a better prognosis when identified and managed early. A delayed diagnosis will generally result in a poorer outcome, even if managed correctly.
If you suspect that you have a Lisfranc injury, see a Sports Physician or Physiotherapist as soon as possible.
Daniel Di Mauro is a McKenzie credentialed physiotherapist with Advance Healthcare in St Albans. The clinic in St Albans provides physiotherapy, psychology and pain management services to to surrounding area including Sunshine, Altona and Keilor. Daniel has a specific interest in complex low back pain and also football and soccer injuries