Lisfranc Joint Injuries

Lisfranc joint injuries involve damage to the ligaments, bones, or both in the midfoot, particularly the five metatarsals with their corresponding three cuneiforms and cuboid. This injury is named after Jacques Lisfranc, a French surgeon who first described it in the 19th century. The Lisfranc joint complex is critical for maintaining proper foot alignment and function, making these injuries potentially serious and sometimes difficult to diagnose.

 

Types of Lisfranc Injuries

1. Ligamentous Injury (Sprain): Damage to the ligaments that support the Lisfranc joint without any fractures.
2. Fracture-Dislocation: A combination of broken bones and torn ligaments, often leading to misalignment of the metatarsal bones.
3. Pure Dislocation: The metatarsal bones are displaced from their normal position without any associated fractures.

 

Classification of Lisfranc Joint Injuries

 

Causes of Lisfranc Joint Injuries

Lisfranc injuries often result from a combination of factors, such as twisting and impact, and the severity of the injury can vary based on the force involved and the mechanism of injury.

• Direct trauma occurs as a result of simple crush injury to the tarsometatarsal joint region.
• Indirect trauma occurs secondary to a longitudinal force sustained while the foot is in plantarflexion and slightly rotated.

There are three common injury situations:

1. longitudinal compression
2. a backward fall with the foot entrapped
3. fall on the point of the toe

 

Clinical Features

• patient typically reports pain localized to the midfoot region
• pain is usually severe, especially during weight-bearing activities
• significant swelling over the dorsum  of the foot is noticed often within hours of the injury
• the extent of swelling may be such that it obscures the normal contours of the foot
• patient will have a significantly antalgic gait (limping to avoid pain)
• in more severe injuries, particularly those involving fracture-dislocations, a visible deformity may be present
• noticeable gap between the base of the first and second metatarsals, or a step-off in the alignment of the metatarsal heads
• tenderness is usually present over the tarsometatarsal joints

 

Diagnosing Lisfranc Joint Injuries

As a physiotherapist, diagnosing a Lisfranc joint injury involves a combination of patient history, physical examination, and an understanding of the typical mechanisms of injury. 

Patient History:

• Mechanism of Injury: Ask about how the injury occurred. A history of trauma, such as a twist, fall, or direct blow to the midfoot, can be indicative of a Lisfranc injury.
• Symptoms: Inquire about the onset of pain, swelling, bruising, and any difficulty with weight-bearing or walking.
• Previous Injuries: Review any history of previous foot injuries or conditions that might predispose the patient to a Lisfranc injury.

Observation:

• Swelling: Look for swelling over the midfoot, particularly on the dorsum (top) of the foot.
• Bruising: Note any bruising, especially on the plantar (bottom) aspect of the foot, which is a key indicator of a Lisfranc injury.
• Deformity: Observe for any obvious deformity or changes in the alignment of the metatarsal bones.

Physical Examination:

• Palpation:

Gently palpate the midfoot, especially along the tarsometatarsal joints. Tenderness over the Lisfranc joint complex is a significant finding.

• Neurovascular Examination 

It is mandatory as the dorsalis pedis artery can be compromised in the initial injury or by subsequent swelling of the foot.

Clinical Test

• Squeeze Test:

Squeeze the foot from both sides at the midfoot. Pain elicited during this test can suggest a Lisfranc injury.

• Midfoot Instability Test:

Stabilize the hindfoot with one hand and attempt to move the forefoot up and down or side to side with the other hand. Instability or excessive movement may indicate ligamentous damage.

• Single-Leg Heel Raise Test:

Ask the patient to perform a single-leg heel raise. Pain or inability to perform this test could suggest midfoot injury.

Functional Assessment:

Assess the patient's balance on one foot. Difficulty balancing or increased pain indicate a midfoot injury. Pain with combined eversion and abduction of the forefoot while the calcaneus is held still, also elicit pain.

Imaging Studies:

X-rays:

• Standard weight-bearing X-rays are typically the first imaging step. If a Lisfranc injury is suspected Diastasis between the first and second metatarsal  bases of greater than 2 mm is present.
• Presence of "fleck sign," is a strong indicator of a Lisfranc ligament injury, particularly one involving the ligament between the medial cuneiform and the base of the second metatarsal. It appears as a small, floating bony fragment near the Lisfranc joint.

 

Differential Diagnosis

• Midfoot Sprain
• Metatarsal Fractures (Stress Fracture, Acute Fracture)
• Cuboid Syndrome
• Navicular Stress Fracture
• Plantar Fasciitis
• Tarsal Coalition
• Charcot Foot
• Arthritis (Osteoarthritis, Rheumatoid Arthritis)
• Peroneal Tendonitis
• Anterior Tarsal Tunnel Syndrome
• Gout

 

Physiotherapy Management of Lisfranc Joint Injuries

Phases of Physiotherapy Management

The rehabilitation process can be broadly divided into several phases:

Acute Phase (0-6 Weeks):

• Immobilization: The foot is typically immobilized in a cast. Non-weight-bearing (NWB) status is maintained, often with the use of crutches or a wheelchair.
• Pain and Swelling Management: Use of cryotherapy, elevation, and gentle compression as tolerated.
• Education: Instruct the patient on NWB techniques, safe use of assistive devices, and the importance of adhering to weight-bearing restrictions.
• Maintain General Fitness: Encourage upper body and contralateral limb exercises to maintain overall conditioning.

Early Rehabilitation Phase (6-12 Weeks):

• Weight-Bearing Progression: Transition from NWB to partial weight-bearing (PWB) and then to full weight-bearing (FWB) as per physician’s guidelines.
• Range of Motion Exercises: Begin with passive ROM exercises progressing to active ROM to restore mobility in the foot and ankle joints e.g. ankle pumps, toe curls, and alphabet exercises.
• Strengthening Exercises: Initiate isometric exercises for the foot and ankle muscles, progressing to isotonic exercises as tolerated.
• Proprioceptive Training: Gentle balance exercises to start retraining proprioception.
• Modalities: Use of therapeutic modalities like Therapeutic Ultrasound or Electrical Stimulation if indicated to assist in pain management and tissue healing.

Advanced Rehabilitation Phase (12-24 Weeks):

• Strengthening: Incorporate resistance training for foot intrinsic muscles, calf muscles, and other lower limb muscles e.g. towel scrunches, marble pickups, resistance band exercises for inversion, eversion, dorsiflexion, and plantarflexion.
• Stretching: Stretching exercises for the Achilles tendon, plantar fascia, and other relevant structures.
• Proprioceptive and Balance Training: Use of balance boards, single-leg stands, and dynamic exercises to improve stability.
• Gait Training: Focus on normalizing gait patterns, addressing any compensations.
• Cardiovascular Conditioning: Low-impact activities like swimming or cycling to improve aerobic fitness without overstressing the foot.

Return to Activity/Sport Phase (6 Months and Beyond):

• Sport-Specific Training: Drills and exercises tailored to the patient’s sport or activity.
• Plyometric Exercises: To develop power and agility.
• Functional Testing: Assess readiness to return to sport through functional tests.
• Education: On proper footwear, training techniques, and strategies to avoid re-injury.

Regular assessment is done to monitor pain levels, swelling, ROM, strength, and functional abilities regularly to track progress. Utilization of tools like the Foot and Ankle Ability Measure (FAAM) or the Lower Extremity Functional Scale (LEFS) to quantify improvements can be used by physiotherapist.