Lisfranc injuries, although rare, are significant due to their potential for severe consequences if not properly diagnosed and treated. Named after French surgeon Jacques Lisfranc, who described them in the 1800s, these injuries affect the midfoot region, specifically the tarsometatarsal (TMT) joints and associated ligaments.
What is a Lisfranc Injury?
A Lisfranc injury involves the disruption of the ligaments that connect the metatarsal bones to the tarsal bones in the midfoot. This complex structure is essential for maintaining the arch of the foot and providing stability during movement. Despite being relatively uncommon, with an incidence of approximately one in 55,000 people in the US, mismanagement can lead to severe outcomes such as arch collapse, post-traumatic arthritis, and long-term disability.
Anatomy of the Lisfranc Joint
The Lisfranc joint complex comprises several bones, including the metatarsals, cuneiforms, and the cuboid. The second TMT joint, acting as the keystone of the midfoot arch, plays a crucial role in stability. The rigidity and minimal motion of the joints in this area are contrasted by the more flexible lateral column of the foot, which adapts to uneven surfaces and exhibits lower rates of arthritis.
Causes and Types of Lisfranc Injuries
Lisfranc injuries can result from both high-energy and low-energy mechanisms. High-energy injuries, often seen in motor vehicle accidents and falls, tend to have worse prognoses. Low-energy injuries are commonly associated with sports like basketball, football, and rugby, typically occurring due to an axial or rotational load on a plantar-flexed foot.
Classification of Lisfranc Injuries
The most widely used classification system for Lisfranc injuries is the Myerson classification, which includes four main types:
- Type A: Total incongruity
- Type B: Partial incongruity
- Type C: Divergent
- Type D: Subtle, nondisplaced injuries (further divided into D1 and D2, with D2 being purely ligamentous or involving bony avulsions)
Nunley and Vertullo also proposed a classification system focusing on athletic Lisfranc sprains, which considers clinical findings and the presence of longitudinal arch collapse.
Diagnosis of Lisfranc Injuries
A high index of suspicion is necessary when patients present with acute midfoot pain, inability to bear weight, and swelling. Specific tests, such as the piano key test and the abduction stress test, can help identify instability. Imaging is crucial, with X-rays being the first step, though they can miss up to 20% of Lisfranc injuries. CT scans are more sensitive and can reveal fractures and joint malalignments missed on plain radiographs. MRI may be utilized if symptoms persist despite negative X-ray and CT findings.
Treatment Options
Conservative Management: For stable injuries without significant displacement, immobilization for 2 to 8 weeks is recommended, followed by radiographic monitoring to ensure proper healing.
Surgical Intervention: Unstable injuries often require surgical fixation. Options include reduction and internal fixation (ORIF) or primary arthrodesis (fusion). While both methods have shown good outcomes, fusion may require fewer subsequent surgeries.
Post-Surgical Rehabilitation
Post-surgical rehabilitation typically involves:
- Immobilization for 6 to 8 weeks
- Gradual weight-bearing at around three months
- Physiotherapy for edema control and strength restoration
Outcomes and Prognosis
Outcomes for Lisfranc injuries range from fair to excellent, with 85-93% of patients reporting good to excellent results post-treatment. However, some may experience chronic discomfort, midfoot deformities, and post-traumatic arthritis. Timely and appropriate treatment is crucial for optimal recovery. In athletes, studies have shown a high rate of return to sport, with 90% of NFL players and 94% of European soccer and rugby players resuming their previous level of activity within an average of 11 months and 25 weeks, respectively.
Conclusion
Lisfranc injuries, though rare, demand careful attention due to their complex nature and potential for serious complications. Proper diagnosis, appropriate imaging, and timely intervention are essential for ensuring good outcomes. Whether managed conservatively or surgically, the prognosis for most patients is positive, with many athletes successfully returning to their sport. If you suspect a Lisfranc injury, early consultation with a healthcare provider is critical for effective management and recovery.
If you have any foot or ankle pain following a acute sporting incident or activity, physiotherapy assessment may be beneficial to assess, treat, or triage your injury.
References
Chen, J., Sagoo, N., & Panchbhavi, V. K. (2021). The Lisfranc injury: a literature review of anatomy, etiology, evaluation, and management. Foot & Ankle Specialist, 14(5), 458-467.