A 25-year-old male recreational player presented for assessment of a left foot injury which had occurred three weeks previously. He described pushing off to sprint and feeling a sudden pop in the medial aspect of his left mid-foot. This was very painful and he was unable to continue. He developed swelling and bruising over the dorsal midfoot and had difficulty weight-bearing.
At the time of his assessment he had a grossly swollen foot with old bruising over the dorsum of the midfoot. There was a reduction in weightbearing dorsiflexion, mild pain performing a heel raise and with weightbearing eversion. There was localised tenderness over the dorsum of the first and second tarsometatarsal
X-rays of the injured foot are largely normal, with no fracture or obvious diastasis at the Lisfranc joint. MRI sequences show that there is thickening, increased signal and disruption of the Lisfranc ligament along with subchondral fractures involving the first, second and third tarsometatarsal joints and proximal lateral cuneiform. There is no discrete fracture line. There is normal alignment and no diastasis.
This player was managed in a walking boot and a medially posted orthotic for four weeks. At this point he was taken out of the boot and was able to walk comfortably in a sports shoe. He continued to use the orthotic to support the medial arch. After six weeks of treatment he was able to start a progressive running programme. He was able to return to team training approximately nine weeks after his injury. To do this he had to change to a boot with a firmer shank and use a custom orthotic in the boot. While he was able to play without major restriction he did continue to have some ongoing aching after football. He managed this with some ongoing icing, the use of topical NSAID and by limiting his running frequency. These symptoms resolved over a four month period.
The Lisfranc ligament runs from the base of the second metatarsal to the medial cuneiform.
In the general population injuries to this ligament are rare and are often associated with high velocity trauma, for example motor vehicle accidents or crush injuries. In a sporting context injuries can occur with less force. They typically occur due to an axial load on a plantarflexed and rotated foot. Injuries can range from a minor sprain of the Lisfranc complex (with no displacement) to complete injuries with wide diastasis between the first and second metatarsals. Players who have sustained a Lisfranc injury typically present with midfoot pain, difficulty weight bearing and a grossly swollen foot. Key examination findings are tenderness to palpation over the base of the second metatarsal and pain with passive plantarflexion or rotation of the midfoot. Weight bearing x-rays (AP, lateral, oblique), ideally with comparison views of the normal side, should be ordered to look for diastasis or evidence of a fracture. If the x-ray seems normal but clinical suspicion is high, CT imaging or MRI should be ordered. If there is no diastasis a period of immobilisation and support of the medial arch can be an effective treatment. In most other cases surgical stabilisation is needed. An early diagnosis and prompt treatment greatly improves prognosis.
A classification system (developed at the Duke FMCE) based on clinical findings, weight bearing x-rays and bone scan results has been described and is widely used (although MRI has largely replaced bone scans). Patients like this one, who have pain but no displacement, are defined as being grade one and are generally managed non-surgically. Patients with diastasis of less than 5mm on an AP view, but a normal lateral x-ray were defined as being grade two, while those with diastasis of more than 5mm on an AP view and/or diastasis or loss of mid-foot arch height were defined as being grade 3. Grade two and three injuries require surgical treatment in the vast majority of cases.
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