Lisfranc Injury

The “Lisfranc Joint” a name given to the tarsometatarsal joints in the midfoot joint complex, i.e. the joints between the five metatarsal bones of the forefoot and the cuneiform bones and cuboid bone in the midfoot through the dorsal tarsometatarsal ligaments (it could be argued that the dorsal metatarsal ligaments have a primary or secondary role in stabilising these joints). These joints have the important function of providing stability to the midfoot while maintaining the transverse arch of the foot. Please see images of the anatomy below:

The dorsal tarsometatarsal ligaments are highlighted.

The “Lisfranc Ligament” refers to the strong interosseous ligament (a ligament between bones) that connects the medial cuneiform and the base of the 2nd metatarsal along the dorsal aspect of this joint (on the top part of the foot). This ligament plays a significant role in stabilising the Lisfranc joint.

Injuries to the Lisfranc joint are thankfully uncommon, affecting approximately 1 in 55,000 people annually, accounting for around 0.2% of all fractures. It can also arise from severe, sudden trauma, such as a car accident. As a sporting injury, a Lisfranc injury usually arises when the foot is plantar flexed (see images above and below) and slightly rotated, and force is applied to the foot from above, leading to a range of possible degrees of injury, from partial sprain to complete rupture of the Lisfranc ligament, and in severe cases, there may be dislocation of the tarsometatarsal joints. See the image below for an illustrative example of how the injury may occur:

In a Lisfranc injury, patients will usually report experiencing pain in the midfoot area and that they are having difficulty bearing weight on the affected foot when standing, walking, or running. The pain is usually made worse by loading the forefoot, such as when standing on “tip toes”, doing a single-leg heel-raise test, or during the propulsive phase of the gait cycle. There is pain on combined eversion and abduction of the foot, with the rearfoot in a stabilised position. Often symptoms only appear several days after the injury occurred. Swelling and bruising at the midfoot may be visible. The medial longitudinal arch (instep) may be visibly reduced. In severe cases, there may be a tarsometatarsal dislocation with diastasis (separation) of the 1st and 2nd metatarsal bases (greater than 2mm).

While a Lisfranc injury can be diagnosed in clinic using a medical history and physical assessment techniques, having plain, weight-bearing radiographs (X-rays of the foot while standing) is considered essential for proper diagnosis and management of this condition. The main reason for this is that without X-rays, dislocations and distasis can be easily missed, making treatment significantly less effective, as this stage of the condition usually requires surgical correction.

A Lisfranc injury can be classified into 3 stages, each with its own indications for treatment:

Stage 1: dorsal capsular tear and sprain of the Lisfranc ligament without elongation of the ligament. No diastasis or arch height loss is found on X-ray.

Stage 2: dorsal capsular tear and sprain of the Lisfranc ligament with elongation of the ligament. Maybe diastasis of less than 5mm. Plantar capsule of joint remains intact. No loss of arch height.

Stage 3: dorsal capsular tear, sprain of Lisfranc ligament with significant elongation or rupture, plantar capsule of joint also affected, possibly involving multiple tarsometatarsal joints. Diastasis of greater than 5mm. Loss of arch height.

If left untreated, or treated improperly, these injuries can lead to prolonged disability. Restoring and maintaining the integrity of the Lisfranc ligament itself is key to recovery.

Treatment in stage 1 may include rest and immobilisation (casting) for 6 weeks, followed by long term management with foot orthoses along with therapeutic exercises to correct improper functioning of the foot and ankle, modification of activities for several weeks until fully recovered, and perhaps using acupuncture for pain relief.

Treatment in stage 2 and stage 3 both require surgical correction.

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