Lisfranc Injuries: What they are and why we care about them

In the last two weeks, two players who are pretty important to their offenses have gone down with an injury that isn’t terribly common and is a very tough one to come back from: Lisfranc Injuries. With the prevalence slowly starting to rise and a lack of knowledge out there about what it is and how it affects a player, I wanted to spend some time talking about the injury itself, what it is, how it’s rehabbed, and what the prognosis is.

What is a Lisfranc Injury: I touched on this briefly in a preseason post about Matt Schaub (https://ziaddahdul.wordpress.com/2012/08/23/quarterback-preview-who-to-draft-and-who-to-avoid/), who suffered this injury in week 10 last season, causing him to miss the rest of the year. The Lisfranc complex is comprised of the small tarsal bones that form the top part of the arch of the foot in addition to the 5 metatarsals (long bones) that extend to connect to the toes. The term Lisfranc injury is very broad, and could mean fractured bones, torn ligaments, disrupted cartilage, and/or all of the above. In usual cases, there are fractures to the small bones that form the arch and/or tears to the ligaments that hold all of these joints together, which causes significant pain, swelling, and instability to the middle of the foot. The more small joints involved and the more bones that are fractured, the longer the healing process and the more involved the surgery is.

One caveat to this whole ordeal is when the 1st and 2nd metatarsals are involved, as the connection of the 1st metatarsal to the 2nd metatarsal is not held together by any connective tissue which can cause these bones to fracture or dislocate, changing the bony anatomy at the base of the big toe. Check out the images below, courtesy of the American Academy of Orthopedic Surgeons, for visual representation of what I just described:

The first image does a good job of showing you where the Lisfranc complex is and the common region where fractures and ligament tears occur. The second image shows you what it looks like when the 1st and 2nd metatarsal separate from each other, causing a widening of this joint and more pain and instability.

How does a Lisfranc Injury affect an athlete?

The main implication of an injury to this region is threefold:

1. Decreases the midfoot’s ability to stabilize the arch during walking: These small joints are what provides both the stability of the midfoot and the mobility of the midfoot. So how can it have such a profound effect on both? Well, if there is instability in a region such as the midfoot, our body’s first line of defense is to go into protection mode, which causes everything to stiffen up and get tight. When this happens, we lose the ability of these joints to move because not only is all the surrounding tissue and joints less mobile, there is also a lack of PROPER biomechanical mobility. These abnormal motions cause more strain to be put on surrounding joints and structures, which can cause issues in other regions of the body from the ankle up to the hip. Athletes, in particular, need to have the ability to move in the midfoot region, but in a pain-free and controlled fashion. When there is a Lisfranc injury, we lose the stability around the foot, which is a big reason why some guys never come back to their prior levels, as loss of force production and dynamic motion are the key culprits.

2. Impairs the transfer of forces from the calf to the front of the foot: In order for proper force production, the calf transfers forces from the muscle belly through the rear foot and so on forward to the fore foot. Now, what connects the rear foot to the fore foot? The wonderful midfoot! Without the ability to transfer forces properly, an athlete will lose his ability to properly push off when changing speeds (both accelerating and decelerating) in addition to tasks that involve planting and pushing off and jumping.

3. Can speed up arthritic processes in the small joints of the foot: Any time there is a change in bony alignment and anatomical positioning, there’s the likelihood that our joint mechanics are altered. When this happens, certain areas of the articular cartilage, which is on the ends of each bone, begin to develop different patterns of movement, which can result in certain areas of the joint grinding/rubbing where it shouldn’t be. This breakdown of cartilage is what happens in arthritic processes, which decreases the amount of “smoothness” on each end of the bone, causing irregular joint surfaces. Not only will this create problems in an athlete’s life later on down the line, but can also lead to early development of chronic foot pain, which can significantly affect effectiveness and mobility if they cannot tolerate pain well.

What’s the rehab process like?

This all depends on whether they determine if surgery is indicated or not, which will be decided once X-Rays and MRIs have been performed. If no surgery is indicated, the typical plan is for a cast or boot to be placed up to the ankle and the patient is advised to remain non-weight bearing for 6-8 weeks. So that means no pressure whatsoever is allowed to be placed through the foot, even with the boot or cast on it. If surgery is indicated, then the process lasts much longer depending on how many structures are involved and how much needs to be repaired. This typically involves hardware (screws/pins) being placed to stabilize the unstable joints and give the ligaments a sound environment for healing properly. After surgery, patients are also placed in a boot for 6-8 weeks, with weight bearing being slowly instituted on a gradual basis. After stability in the impaired joints are confirmed post-operatively, the pins/screws are typically removed to allow normal movement in the midfoot to occur.

The entire post-operative process can last anywhere from 3-6 months, but it all depends on the patient and the severity of the injury itself. The main goals of physical therapy are to restore range of motion (in a controlled manner), midfoot and ankle joint mobility, calf/ankle muscle length, and strength early on, with gradual progression to more intense exercises/manual techniques once the patient is ready. Only when the patient has restored full or near-full ROM and strength can they return to sport-specific activities.

What is the prognosis for someone who suffers a Lisfranc Injury?

This is where there isn’t a lot of agreement. Some players come back and don’t show any signs of injury, almost like nothing happened. Others are never the same. I think the player’s position and the severity of the injury are the two most important factors in predicting whether they will return to full strength. In someone like Matt Schaub’s case, speed and agility are not his game, so as long as he can restore close to normal mechanics and strength, his productivity won’t suffer. But for a RB like Cedric Benson and a WR like Santonio Holmes, speed and elusiveness and change-of-direction are key, so it’s much harder to predict how they will come back or if they even will be able to come all the way back. I think in the cases of both Holmes and Benson, timetable or not, they aren’t coming back this year, baring a super-quick recovery or less-serious-than-expected injury.