A Lisfranc (midfoot) injury is a common injury seen in practice but are often misunderstood and misdiagnosed due to the complex presentation and symptoms. Originally named after the French surgeon Jacques Lisfranc who served in the Napoleonic army in the 1800s, he observed that these midfoot injuries were often suffered by soldiers in the cavalry army.
The Lisfranc complex itself sits within the middle region of the foot and is comprised of a small cluster of bones that form the arch on the top of the foot, before extending to the five metatarsals.
Damage to the Lisfranc complex should not considered as a simple sprain that will heal easily, as even minor sprains take months to heal and often require surgical management.
What is a Lisfranc Injury?
A Lisfranc injury occurs when patients have a tear of the ligaments in the midfoot, or have fractured the bones of the foot. These injuries can vary dramatically from tears that involve a single joint to a complex injury that disrupts multiple joints and includes multiple fractures.
Due to the nature of these injuries and their potential to go undiagnosed in the acute stages post injury, they are high risk of causing osteoarthritis due to the potential damage to the cartilage of the bones. These injuries are also at risk of developing arthritis post-operatively, prompting the need for early diagnosis and planning.
Causes of a Lisfranc Injury:
Lisfranc injuries are often seen in sports that involve jumping, sudden direction changes, and contact. They can be classed into low-energy and high-energy mechanisms of injury. High-energy mechanisms typically occur in motor vehicle accidents and high falls where there is significant force being transferred through the midfoot. Low-energy mechanisms are those that we see in sport and can occur when the body is twisted over a planted foot or when an opposing player lands on the back of a flexed foot.
Symptoms of a Lisfranc Injury:
As these injuries are often misdiagnosed, it is important to recognise the signs and symptoms early to ensure appropriate management.
The most common symptoms of a Lisfranc injury are:
Localised pain over the top of the midfoot.
Bruising that can be seen on both the top and bottom of the foot. Bruising on the bottom of the foot is highly indicative of a Lisfranc injury.
Difficulty walking - quite often patients will have difficulty with toe off due to potential instability. This is also seen when patients attempt to perform a calf raise.
Patients can experience significant pain with weight bearing.
Swelling on the top of the foot.
Diagnosing a Lisfranc Injury
Here at Rehab Advantage, our physiotherapists will perform a comprehensive subjective and objective assessment to diagnose a potential Lisfranc injury. This will be done through a combination of hands-on and functional tests to determine the severity and extent of damage.
If you suspect a Lisfranc injury it is important to undergo the relevant diagnostic imaging to determine the extent of damage and help guide management.
X-Rays: key to visualise fractures and the alignment of the bones of the foot. Patients may also be referred for a weight bearing X-ray as these injuries are worsened in standing.
Magnetic Resonance Imagining (MRI): as stable Lisfranc injuries are hard to diagnose from X-rays, MRI scans are used to assess the extent of damage to the soft tissue structures around the bone.
Computerised Tomography (CT) scan: provide a more detailed image than X-rays and allow the potential to create cross-sectional 3D renderings of the injured site which can aid to evaluate the extent of the injury.
Treatment Options:
Depending on the extent of damage to both the bony and soft tissue structures of the foot, operative or non-operative management may be considered.
Patients will generally be recommended for non-operative management when there has been no dislocation of the joint, no fractures and minimal soft tissue damage. A non-operative treatment plan will generally involve a short period of non-weight bearing before a graded exposure back to weight bearing and loading. Rehabilitation timelines for non-operative Lisfranc injuries are between 4-6 months.
Operative management is recommended for more significant injuries and those that involve dislocations, fractures and extensive soft tissue damage that cause abnormal alignment of the joints of the midfoot. Surgery is used to realign the joints, restore stability to the midfoot and stabilise any fractured bone fragments. Return to play timelines following surgically managed Lisfranc injuries vary from 6-9 months and are dependent on the surgical technique used. Surgical techniques may vary depending on surgeon, however the most common techniques are:
Open reduction internal fixation (ORIF) - involving an incision on the top of the foot to allow the surgeon open access to reduce and secure the bones of the foot with plates or screws. This type of procedure provides good fixation, however due to the plates and screws crossing multiple joints a second surgery is required to remove the hardware once ligament and bony healing has occurred.
Midfoot fusion - for some patients, a midfoot stabilisation may be recommended. The goal of a fusion surgery is to realign the injured bones and allow them to heal together so that a joint no longer exists between them. This type of surgery leads to increased stiffness of the midfoot as there is no joint to allow movement.
Tightrope repair - a more novel procedure where a polyethylene rope is used to reduce the bones back together. This technique allows faster return to play due to the elimination of a second surgical procedure which is seen in ORIF managed injuries.
Both operative and non-operative Lisfranc injuries require extensive periods of rehabilitation to restore normal function, strength and mobility of the midfoot. Due to these injuries requiring prolonged periods of non-weight bearing, rehabilitation focused on reconditioning of the whole leg is crucial to prevent the further risk of injury once athletes have returned to sport. Inadequately managed Lisfranc injuries pose a high risk of developing osteoarthritis, chronic pain, instability and long-term foot dysfunction which also emphasises the need for a structured rehabilitation plan.
Conclusion
Lisfranc injuries can be serious and are often misdiagnosed in the early stages post injury. By understanding the causes and symptoms of this injury you can ensure an early diagnosis is made and an appropriate management plan is developed. So, if you are an athlete or just an active individual and you suspect a Lisfranc injury, don’t wait—book an appointment with one of our physiotherapists to set you on the right path and get you back to the sport and activities you love.