Like my fellow fantasy football participants, I am getting pumped up about the upcoming draft and start of the NFL season! Since last year, we have done our due diligence to construct our team rosters. We have gathered as much information as possible on new player acquisitions, studied the players’ strengths and weaknesses, and paid attention to the preseason games. We have also paid strict attention to the NFL injury reports.
As a reconstructive foot surgeon, a lot of my friends and patients seem to think I have an inside track on the injured players. All I can tell them is to visit the NFL injury reports like I do and look in a crystal ball. One disheartening fact is that there are already 140 players on the list. Nearly 21 percent of the players have lower extremity injuries.
Following their game against the Jacksonville Jaguars, the Bears had to place tight end Zach Miller on injured reserve because of a season-ending Lisfranc foot injury. This midfoot injury can be quite serious and in some cases career-ending. Although the Bears have not revealed the severity of the injury, it is disheartening to Miller and to the Bears, who saw him emerge as a playmaker.
Since I recently joined the fantasy football corps, I have become more aware of players being put on the injured reserve list because of a Lisfranc injury. This is a complex topic that deserves an explanation.
Explanation of Lisfranc injury
The Lisfranc injury is a midfoot injury to the bones and connecting ligaments. The injury occurs at the midfoot by the cluster of small tarsal bones (Navicular, three Cuneiform bones [medial, middle, and lateral] and Cuboid) that are positioned between the hindfoot (Talus [lower ankle] and Calcaneus [heel]) and the forefoot (Metatarsals [five long bones] that connect to the Phalanx [toes]).
The cluster of bones in the midfoot functions as a unit. They are connected by primary stabilizers (Interosseous ligaments that connect the bases of the second metatarsal to the fifth metatarsal on both plantar and dorsal aspects) and secondary stabilizers (plantar fascia, peroneus longus and intrinsic muscles of the foot). There is no connecting tissue that secures the first metatarsal to the second metatarsal. The Lisfranc Ligament extends from the plantar aspect (bottom of foot) of the medial Cuneiform to the base of the second metatarsal. The Lisfranc ligament is a large oblique ligament that is critical to stabilize the second metatarsal, and to maintain the structure of the midfoot arch. The part of the foot is referred to as the Lisfranc Joint Complex. Normally, the complex is very stable and has minimal motion.
A Lisfranc injury can present itself as a sprain, fracture or dislocation. A sprain usually occurs when the ligaments are stretched at the bottom of the foot, causing the mid foot to become unstable. A fracture can be a bone fragment (avulsion) or a fracture in the bone or bones of the midfoot. Dislocations cause the bones in the Lisfranc joint to be forced out of their normal location.
There are three primary classifications used to describe fifteen patterns of the displacement, but they are not used for determining a treatment or prognosis. They describe the type of displacement and illustrate how complex the injury can be. The classifications are referred to as the Quenu & Kuss Classification, Hardcastle Classification and Myerson Classification.
Causes of Lisfranc injuries
Lisfranc injuries occur from high impact traumas and excessive forces (indirect or direct). The primary causes of this injury are from motor vehicular accidents (MVAs), falls from heights and athletic injuries.
The direct Lisfranc injuries typically occur from crush injuries, i.e., when a person’s foot is run over by a vehicle, or from a head on collision that applies significant force to the drivers foot. Another type of direct injury can occur when an object falls on top of the midfoot.
The indirect Lisfranc injuries are generally caused by a dramatic rotational force on the forefoot if it is pointing down in a planter flexed position. This often occurs when a person falls from heights like a ladder or stairs. Runners can experience a direct injury if they fall in a hole (like a storm drain or uneven terrain). Horseback riders are also prone to this type of injury if they fall off the horse with their foot aught in the stirrup. Football players, especially lineman, are at risk if a falling player crushes down on their heels when their feet are in a plantar flexed position. Indirect Lisfranc injuries commonly occur in snowboarding, wakeboarding and kite surfing because the appliance bindings are perpendicular over the metatarsals when they fall. Baseball catchers are prone to this injury because the position requires dramatic pivoting, and their heel is exposed to runners sliding into home. Kick boxers and ballet performers are also subject to this injury because their maneuvers require violent twists, impacts and awkward landings.
The typical symptoms of the Lisfranc injury include swelling throughout the midfoot, tenderness over the tarsometatarsal joint, bruising in the bottom of the foot (medial plantar area), abnormal widening of the foot and pain in the middle or throughout the foot when applying pressure or standing. Motion and instability may also be present. Excessive pain can be associated with compartment syndrome in tissues of the foot.
According to an article in the America Family Physician, Lisfranc fractures and dislocations are commonly misdiagnosed as sprains. The diagnosis of a direct injury is usually more reliable than an indirect injury. The gap between the base of the first and second metatarsal is usually more visible, and so are the spacings in the dislocations. Other suspicious signs that make it easier to diagnose include disruptions to the skin and compromising blood supply.
Indirect injuries are more difficult to detect. Usually swelling, pain and poor mobility problems are apparent; however, there may be an absence of bruising in the midfoot area. Often, the patient and practitioner assume that the injury is a sprain because the patient is still mobile.
Radiography can appear to be normal in many cases even though the Lisfranc may be present. According to a study by the American Journal of Roentgenology, non-weight bearing X-rays are accurate half of the time and 85 percent of the time if they are when they are weight bearing. Often it is necessary to take several different sets of X-rays to confirm the diagnosis. These include: AP (anteroposterior) X-rays that go from front to back; standard views include Dorsal Plantar, Oblique and Lateral X-rays (to check alignment of the midfoot-forefoot junction, fractures and stress fractures). Both weight-bearing and non-weight bearing X-rays should also be taken for comparative purposes.
The Lisfranc injury can be subtle and not always result in a displacement. A radiological follow-up should be arranged if there is a clinically suspected ligament. A computer tomography (CT) can be useful for diagnosis and planning for surgery. Magnetic resonance imaging (MRI) can be used to confirm the presence of ligament damage.
Most often, Lisfranc injuries require surgery. Non-operative treatment is done when there is no evidence of displacement or bone injury. In these instances, the patient is immobilized in a cast for 8 weeks. The outcome depends on the amount of reduction that occurs during immobilization.
Operative treatment is usually done whenever a dislocation is present and exceeds 2 mm, and if there are bone dislocations. Surgical procedures can include:
* Open reduction and internal fixation;
* Arthrodesis of the first, second, and third tarsometatarsal joints;
* Midfoot arthrodesis.
Open Reduction and Rigid Internal Fixation is usually done when there is evidence of instability. Single or dual longitudinal incisions are usually made between the first and second rays. Transarticular screws or K-wires are applied to reduce the intercuneiform instability. Post-operative care includes monitoring early midfoot range of motion and wearing a protective weight-bearing boot for 8-10 weeks. The K-wires are removed within 6-8 weeks, and the screw within 3-6 months. In some cases, screws may be left in permanently. Patients are expected to return to full activity in 9-12 months.
Midfoot Arthrodesis of the first, second, and third tarsometatarsal joints is done in more extreme cases to primarily eliminate pain and attain full stability. This procedure exposes the TMT joints and strips the cartilage off the joint surfaces. Cortical screws are used to fuse the joints. Post-operative care includes a cast or splint for 6 weeks. A removable boot will be worn for 6-12 weeks as weight bearing progresses. Shoes can be worn in 12 weeks after surgery.
The good news about Lisfranc injuries is that they are not common and occur in less than 2 percent of all fractures. Early and accurate diagnosis is critical. Fractures or dislocations left untreated can present serious problems like joint degeneration, arthritis, poor mobility, sever pain, and compartment syndrome (nerve and vessel damage).
If you suffer from a midfoot injury, seek the counsel of a Board Certified Surgeon of the Foot and Ankle and in Reconstructive Rearfoot Surgery to get a diagnosis and care plan. Contact Dr. John Sigle at 787-2700 to schedule an appointment in Springfield or Decatur. Visit the free patient library at myfootandanklecenter.com.
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