I remember the first time I ever heard about ‘lisfranc injuries’ (Click the link if you need some lisfranc background) I was at a Northern Hospital in-service on placement as a student. A great deal of the presentation did not make sense to me at the time, but the key point seemed to be “this is a career ending injury, and you’d be lucky to run again.” Being a Collingwood fan, and seeing the great Dane Swan’s career end in this way… it did certainly seem this injury is serious.
This mysterious foot injury popped up at random points in postgrad PD courses, but was often glossed over in the “not to be missed” pathologies listed in differential diagnoses of ankle sprains. There was not much incentive for me to dig further into this clinical entity considering it was also mentioned as “incredibly rare.”
But in the great words of (name) “rare things happen” – especially if you see thirty to fifty active sporting patients a week. Basic maths dictates “lizzy” was going to walk, well hop, into the consulting room.
Coincidently, I ended up managing three lisfranc injuries simultaneously! Two of which happened to be former teammates of mine. This led to some digging!!
The key things I learnt managing lisfranc injuries are as follows.
Diagnosis can be missed: Be suspicious in the foot
The first of the three lisfranc injuries I managed occurred when a former teammate of mine was playing interstate. He did not have the normal level of medical support around, and thus diagnosis was not made for weeks, resulting in less-than-ideal acute management.
Luckily with a few key pieces of information, my clinical suspicion was peaked enough to refer him to a sports doc colleague and for further investigations. These early key pieces of information were:
- Video of injury mechanism – The vision wasn’t perfect, but was clear enough to show the athletes foot ‘get caught under’ his body when being tackled. With the final frame prior to tackling showing his foot ‘toes down’ in the turf… not as good sign
- Large amounts of bruising – The athlete mentioned large amounts of foot bruising. Be sure to get a photo or specific descriptions of the exact area of bruising. You should have a low threshold for imaging if there is significant bruising of the foot, especially plantar aspect.
- Pain running in an arc – The athlete initially rested and allowed for acute pain and swelling to resolve. Running in a straight line was manageable, but noted running on an arc, with the affected foot on the inside of the arc was very painful. Call it the “arc sign” if you will, but this pronation moment on midfoot seems to expose lisfranc instability nicely for those coping with some higher level activity. It now forms part of my clinical assessment of suspected lisfranc injuries in the clinic.
This wasn’t the end of the learning curve. My other former teammate sustained a foot injury whist being tackled, and arrived with an MRI already performed. The scan showed a potentially intact but injured (high signal) lisfranc complex.
To operate or not?
Tough to know without testing the ligament’s integrity… turns out some smart radiologists had thought of this. The weightbearing CT scan to the rescue.
A weightbearing CT scan is performed of both feet, and the gapping at metatarsals is measured. If this gapping on the affected foot is deemed too large, a surgeon will undertake fixation of the structure.
lisfranc "tight rope" appears to be a smoother recovery anecdotally
Keep in mind, this is an n=3 experience, so an incredibly underpowered viewpoint. However, from the small case series I experienced, the tightrope surgery appears to offer a smoother return to high level activity. It appears the omission of a second surgery to remove metal work plays a role, as well as the natural ‘give’ of the thread over the rigidity of the metal allow for a more comfortable rehab journey in the sub-acute time frame.
Acute post op is brutal! – Set expectations
A lot of orthopaedic surgeries appear not as painful or disabling as patients expect going into them. This one does not seem to be one of those! Based on the photos and colourful descriptions I received through text messages, this one hurts!!
Swelling and bruising appears to be significant, as well as strict post op non-weightbearing status really challenges patients physically and psychologically.
It’s best to set expectations here. False hope will only make this phase worse. Regularly checking in over the phone or text and offering support is helpful here.
Getting onto the forefoot is a challenge
After weeks of no weightbearing then being in a boot for more weeks, there’s some serious work to do! As expected, the rehab focused a lot on the affected foot, ankle and entire lower limb. The biggest sticking point I found was restoring the normal ‘foot rocker’ action and developing tolerance and confidence to spend time on and load into the forefoot. Initially this is limited by pain, but then remains a challenge following due to apprehension and maladaptive habits. I would suggest normalising load through the forefoot as early as safe and tolerated, based on surgeon’s orders. Even if it’s sitting or bilateral.
Footwear is important
All three athletes have returned to sport, two to football and one to endurance sport. It is important to recognise the difference between “return to sport” and “return to performance.” All three noted the affected foot “does not feel the same” as it did preinjury. This is both okay and normal. Surgery is not magic. This is where footwear selection is important. Enlisting the help of a good podiatrist is the best bet, but even just encouraging the use of more supportive, stiffer footwear will reduce stress on the affected region. Not only in sport (consider “career saver” footy boots), but also supportive shoes during ADLs.
Have any questions? Feel free to send Dave an email on dave@enhancesportsphysio.com.au. If you’d like assistance diagnosing or treating injuries, we’d love to help. You can book online by clicking here.