The Lisfranc injury

By James Lehman

During my 33 years of patient practice, I enjoyed the opportunities to care for professional rodeo athletes. Some of the saddle bronc participants suffered with a mid-foot injury when thrown from a bucking horse. Unfortunately, this type of injury is commonly misdiagnosed by clinicians.

Lisfranc injuries are named after Jacques Lisfranc, a French surgeon in the early 1800s. In the army, a lot of the soldiers would get thrown from their horses, and their foot would get caught in the stirrup. This would cause an injury to the middle of the foot.

The midfoot is critical in stabilizing the arch and in walking (gait). During walking, the midfoot transfers the forces generated by the calf muscles to the front of the foot. The Lisfranc joints are located between the first metatarsal, second metatarsal, medial cuneiform, and intermediate cuneiform. To lessen ambiguity, some investigators have suggested that the term “Lisfranc joint complex” should be used to refer to tarsometatarsal articulations and that the term “Lisfranc joint” should be applied to medial articulation involving the first and second metatarsals with the medial (first) and middle (second) cuneiforms. The Lisfranc joint complex includes the bones and ligaments that connect the midfoot and forefoot. Lisfranc injuries include ligament sprains and tears, as well as fractures and dislocations of bone.

These injuries can happen with a simple twist and fall. This is a low-energy injury. It is commonly seen in football and soccer players. It is often seen when someone stumbles over the top of a foot flexed downwards. In athletes, injury typically is due to an axial load sustained with foot plantar flexed and slightly rotated.

These are the most common symptoms of the Lisfranc Injury:  

• The top of foot may be swollen and painful.
• There may be bruising on both the top and bottom of the foot. Bruising on the bottom of the foot is highly suggestive of a Lisfranc injury.
• Pain that worsens with standing or walking.
• The pain can be so severe that crutches may be required.

The clinician should observe discoloration (ecchymosis) on the bottom of the foot, which is very suggestive of a Lisfranc injury. Palpation of the foot should begin distally and continue proximally to each tarsometatarsal articulation. Tenderness along the tarsometatarsal joints supports the diagnosis of midfoot sprain with the potential for segmental instability. Passive stress testing of ligaments with grasping of heel and twisting of midfoot will increase pain of sprained ligaments. A provocative maneuver that involves passive flexion and extension of the individual toes, which stresses the midfoot. Ipsilateral heel rise test is a provocative maneuver that reveals pain with subtle Lisfranc injuries such mild sprain injuries.

The diagnosis of high energy Lisfranc injuries is straightforward, as physical exam will reveal swelling and obvious deformity, including widening or flattening of the forefoot. A positive gap sign, or abnormal space between the first and second toes, is also suggestive of a tarsometatarsal joint injury or intercuneiform disruption. The initial radiographs of a suspected Lisfranc joint injury should include weight-bearing anteroposterior and lateral views, as well as a 30-degree oblique view.

A non-weight bearing x-ray does not show any abnormal widening with the Lisfranc injury. The tear of the Lisfranc ligament is more evident in this weight bearing stress x-ray, showing a widening of the joint. Flattening of the longitudinal arch, dorsal displacement, or both at the second TMT joint may be observed on lateral weight bearing radiographs.

In order to demonstrate the incidence of misdiagnosis of the Lisfranc joint injury, I offer the following case report.

A 20 year-old male injured his left foot when thrown from sled. He landed with full weight on his left foot, which was folded under him. The ER examination including radiographic study of left foot on day of injury presented an impression of negative for fracture. A soft cast with foot placed in slight plantar flexion was prescribed. The anteroposterior non–weight-bearing radiograph of the left foot of the patient showed no evidence of malalignment or any other joint disruption.

The injured student was examined at the student clinic three days post-trauma with edema and ecchymosis noted on lateral foot. The patient was unable to bear weight. The soft cast removed and replaced with an elastic wrap.

He did not improve with the previous interventions and was still symptomatic expressive seven days following the incident. He was examined in the sports medicine clinic, now seven days post-trauma. He was unable to bear weight on left foot, the edema extended from the midtarsal area distally into the toes, and ecchymosis was observed along the metatarsophalangeal joint line to the lateral calcaneus. Marked dorsal tenderness was noted over second through fourth tarsometatarsal joints and second through fifth metatarsophalangeal region with minimal tenderness upon palpation of plantar aspect of left foot, and the pedal pulse was present. Patient was able to dorsiflex all toes against resistance

The left ankle demonstrated physical findings of a grade one anterior talofibular ligament sprain. Review of day one radiographic study revealed a subtle dorsal displacement of the base of the second metatarsal. A weight bearing radiographic study revealed a three millimeter separation of the first and second metatarsal bases and a bony fragment (fleck sign) in Lisfranc joint. The lateral non–weight-bearing radiograph showing dorsal displacement of the proximal base of the second metatarsal in the left foot of the patient.

A “step-off” point was noted (i.e., the dorsal surface of the second metatarsal was higher than the dorsal surface of the middle cuneiform). The anteroposterior weight-bearing radiograph of the left foot of the patient demonstrated the medial margin of the second metatarsal base and the medial edge of the middle (second) cuneiform were malaligned. The patient was then referred to an orthopedist. Treatment was open reduction and internal screw fixation, followed by a period of non–weight-bearing.

Another well-known example is Allen Craig, former member of the St. Louis Cardinals, who suffered from this type of injury and destroyed his promising career as a professional baseball player. To observe, click here, here, and here.

References:

Myerson M. The diagnosis and treatment of injuries to the Lisfranc joint complex. Orthop Clin North Am. 1989; 20: 655–64.

Hatch RL, et al. Diagnosis and Management of Metatarsal Fractures. Am Fam Physician. 2007 Sep 15; 76(6):817-826. Available from: https://www.aafp.org/afp/2007/0915/p817.html.