Dr. Lam gives us insight on a Lisfranc injury. What are the treatment options and recovery time?

This last Sunday, Jimmy Garoppolo was carted off the field with a suspected season-ending injury.

What is a Lisfranc Injury?

Lisfranc (midfoot) injuries result if bones in the midfoot are broken or ligaments that support the midfoot are torn. The severity of a Lisfranc injury can vary widely – from a simple injury involving one midfoot joint to a complex injury involving one midfoot joint to a complex injury involving many midfoot joint and broken bones. Midfoot fracture dislocations are named after French surgeon Jacques Lisfranc de St. Martin, who served in the Napoleonic army in the 1800s and observed midfoot injuries in cavalry soldiers.

A simple Lisfranc injury can be easily mistaken for a sprain especially if the injury is a result of a straightforward twist and fall.

However, injury to the Lisfranc joint is not a simple sprain that should be “walked off” or expected to heal quickly. Even a simple Lisfranc injury is a severe injury that may take many months to heal and may require surgery to treat.

Anatomy

The midfoot is the middle region of the foot, where a cluster of small bones forms the arch on the top of the foot. From this cluster, five long bones (metatarsals) extend to the toes.

The bones are held in place by strong ligaments known as the Lisfranc joint complex, that stretch both across and down the foot. However, there is no connective tissues holding the first metatarsal to the second metatarsal. A twisting fall can break or shift (dislocate) these bones out of place.

The Lisfranc midfoot joint complex has very little motion and is critical in stabilizing the arch for push off during walking (gait). During walking, the midfoot transfers the forces generated by the calf muscles to the front of the foot. If a Lisfranc injury is left untreated, instability of the arch can persist, resulting in the collapse or flattening of the foot.

The midfoot will be affected if the bones are broken (fractured) or the ligaments are torn. Injuries can vary, from a simple injury that affects only a single joint to a complex injury that disrupts multiple different joints and includes multiple fractures.

Lisfranc injuries tend to damage the cartilage of the midfoot joints. Cartilage covers the ends of the bones in the joints, allowing the joints to move smoothly. If severe midfoot injuries are not properly treated, damage to the cartilage and increased stress at the midfoot joints can result in arthritis and collapse of the arch, which requires complex surgery to correct. Even with successful surgery for the Lisfranc injury, arthritis can still develop in later life.

What is the Cause?

A low-energy Lisfranc injury can happen with a simple twist and fall. It is also commonly seen in football and soccer players when one player lands on the back of another player’s foot while the foot is flexed downward in the push-off position.

More severe injuries occur from direct trauma, such as a fall from a height or a motor vehicle collision from a height or a motor vehicle collision. In these high-energy Lisfranc injuries, multiple foot fractures and joint dislocations can occur, along with injuries to the back and other limbs.

What are the Symptoms?

These are the most common symptoms of Lisfranc Injury:

• The top of foot may be swollen and painful.
• There may be bruising on both the top and bottom of the foot. Bruising on the bottom of the foot is highly suggestive of a Lisfranc injury.
• There may be pain in the midfoot that worsens with standing, walking, or attempting to push off on the affected foot. The pain can be so severe that weightbearing is not possible, and crutches may be required.

You should seek care from a surgical podiatrist if standard treatment for a sprain (rest, ice, elevation) does not relieve pain and swelling, or if you are unable to bear weight after the injury.

What are the Treatment Options?

Treatment for a Lisfranc injury depends on the severity of the injury.

Nonsurgical Treatment

If there are no fractures or dislocations in the joint and the ligaments are not completely torn, nonsurgical treatment may be all that is necessary for healing. A nonsurgical treatment plan includes wearing a non-weightbearing cast or boot for 6 to 8 weeks. You must be very strict about not putting weight on your injured foot during this period. This then progresses to weightbearing in a removable cast boot or an orthotics.

Your doctor will want to follow up with you regularly and take additional X-rays to make sure your injury is healing well. During the course of follow up, if there is any evidence that the bones in the injured joint have moved, surgery will be needed to put the bones back in place.

Surgical Treatment

Surgery is recommended for injuries with displaced fractures (broken bones) or with abnormal positioning (instability) of the joints. The goal of surgical treatment is to realign the joints, return the fractured bone fragments to a normal position, and restore stability to the midfoot.

These procedures can be used to treat Lisfranc Injuries:

Open reduction internal fixation (ORIF). In this procedure, the surgeon makes an incision on top of the foot, positions the bones correctly (reduction), and secures the bones in place with plates or screws. Because the plates or screws will be placed across joints that normally have some motion, some or all of this hardware may need to be removed at a later date. This can vary from 3 to 5 months after surgery, and is at the surgeon’s discretion.

Occasionally, the hardware may break before it is removed. This is not unusual when screws or plates span bones that have some movement. Metal can fatigue and fall under these conditions, just as a paperclip will fail if bent repeatedly. The surgery is often successful even if some of the hardware breaks.

Midfoot fusion. In some patients and types of Lisfranc injuries, fusion of the injured midfoot bones ma be recommended as the surgical treatment. The goal of a fusion surgery is essentially to realign the injured bones and have them heal together so that a joint no longer exists between them. Because the midfoot joints have very little motion to begin with, fusion can be an appropriate treatment to eliminate pain and restore function to the midfoot.

In this procedure, the surgeon removes cartilage from the bones and uses metal plates, screws, or staples to compress the bones together so that they heal to one another. The hardware will not typically need to be removed because the joints are fused and will not move after they heal.

Rehabilitation. After surgery (ORIF or fusion), a period of non-weightberaring for 6 to 8 weeks is typically recommended in a cast or cast boot. Weightbearing is started while the patient is in the boot if the x-rays look appropriate after 6 to 8 weeks. The amount of weight a patient can put on their foot, as well as the distance the patient is allowed to walk, is at the surgeon’s discretion.

Recovery

The goal in every patient is to have a pain-free, stable midfoot and return to all pre-injury activities. This goal can be achieved with either ORIF or fusion surgery in all types of patients. However, it is important to note that:

• The overall recovery process for resuming all activities may take 6 months to 1 year in some patients.
• Some patients may have persistent midfoot pain even with a successful surgery.
• Some athletic patients never return to their pre-injury levels of sport after these difficult injuries.
• Despite excellent surgical reduction and fixation, arthritis may occur from the damage to the cartilage. This may result in chronic pain and may require additional surgery in the future.

Are you experiencing symptoms from a possible Lisfranc injury?

Contact Dr. Lam’s office at (239) 430-3668 (FOOT) or visit www.NaplesPodiatrist.com to schedule an examination.

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