Lisfranc Foot Injury
Lisfranc injury is an injury that affects the midfoot where the tarsal bones make their joints with the metatarsal bones (toes).
The injury is named after Jacques Lisfranc a surgeon in Napoleons army, who developed an operation for amputation through these joints.
The injury arises when bones in the midfoot are broken or ligaments that support the midfoot are torn, or a combination of both occurs. The severity of the injury can range from partial sprains to the ligaments without displacement, to complete tears with separation of the 1st and 2nd metatarsal bones. This can further result in different patterns of tarsal and metatarsal displacement.
It is a relatively rare occurrence in the general population however, they are the 2nd most common cause of mid foot pain in athletes and are considered a red flag condition due to the debilitating consequences of a missed diagnosis.
The technical definition of a Lisfranc injury involves ligament sprains in the Lisfranc joint complex and the displacement of one or more of the metatarsal bones from the tarsus (a cluster of several articulating bones situated between the lower end of tibia and metatarsals). This can range from subtle subluxations to obvious fracture dislocations.
Lisfranc injuries can arise from a variety of situations and mechanisms, with both direct and indirect injuries possible. Direct injuries are the most common cause of the injury, such as a fall from a height or motor vehicle accidents, which result in soft tissue injury, multiple fractures and dislocations of the joints.
One-third of Lisfranc injuries are caused by indirect trauma, which are more commonly missed, as it could be a simple twist and fall from sports or household accidents, and could coexist with an ankle sprain.
The most common symptoms of Lisfranc injury include:
§ Bruising on both the top and bottom of the foot, while bruising on the bottom of the foot is highly suggestive of a Lisfranc injury.
§ Swelling in the mid-foot and across the bridge of the foot.
§ Mid-foot pain that worsens with standing, walking or attempting to push off on the affected foot.
On examination, pain may be recreated by palpation (touching) of the top of the involved tarsometatarsal joints. Provocative tests include:
· Piano-key test – one hand secures the metatarsals, while the other hand supporting the hind-foot superiorly, and passive dorsiflexion and plantar flexion is performed at the tarsometatarsal joint (Figure 3). Subluxation or pain suggests injury.
· Mid-foot compression with dorsal and plantar flexion of the first metatarsal head relative to the second metatarsal head
· Compression across the width of the foot to stress the space between the first and second metatarsals. Pain or a palpable click is suggestive of a Lisfranc injury.
· Passive pronation with abduction of the forefoot, while the hindfoot is held still.
Further investigation including X-rays, CT and MRI scanning are imperative in the diagnosis of this injury, as the consequences of an untreated fracture-dislocation can be severe. Signs of an unstable injury include a broadened foot and shortening in the anteroposterior plane. In these situations, it is important to consider the nearby neurovascular bundle, consisting of the dorsalis pedis artery and deep peroneal nerve, most of the time, an injury of this severity requires surgical correction.
Any evidence of dynamic instability or clear diastasis at the Lisfranc complex requires operative management. Post-operatively, patients should remain non–weight bearing for two to four weeks, with their foot immobilised in a short leg splint or cast. High-impact activity is discouraged until any internal fixations are removed; however, low-impact activity is encouraged as tolerated.
Chiropractic and physiotherapy intervention can help in the initial diagnosis of the injury and is an important part of the post-surgical management and rehabilitation. In cases where the injury has no evidence of instability or diastasis on weight-bearing radiographs your therapist may be able to treat conservatively without the need for surgery. A common treatment pathway is as follows:
· During the first 2 weeks, the foot should be immobilised in a short walker boot with protective weight-bearing.
· After the initial 2 weeks, once the tenderness over the joint line subsides, patient should be encouraged to weight-bear with the short boot as tolerated for the next six to eight weeks.
· Once the patient is pain-free under abducted stress, they can swap to a stiff-soled shoe with rigid orthotic support for the next six months
· Running on uneven surfaces and twisting activities should be discouraged for the first three to four months, to minimise the risk of recurrence.
· Deep core stability and hip strengthening exercises can be commenced early to provide better biomechanical support to the lower limb and reduce the risk of recurrence.
So that’s a brief overview of what a Lisfranc injury or mid foot sprain is and how they occur. If you have questions or comments, feel free to e-mail us at firstname.lastname@example.org and we will happily answer them for you.
If you suffer with pain through the top of the foot, call us on (08) 9486 8653 and our therapists will be happy to chat with you about the best management plan.