A Lisfranc injury refers to the little bones in your mid foot sustaining a fracture or being dislocated out of their natural alignment. A Lisfranc fracture is rare but serious and occurs two to four times more in men than women. The term Lisfranc injury is actually a broad umbrella term for a wide variety of different fractures or ligament tears that occurs in the mid region of the foot and is named after a French surgeon Dr Jacques Lisfranc which was first described in 1815!

As you simply land or step incorrectly , up to 20% of all Lisfranc injuries are misdiagnosed as a common ankle sprain. This making the initial diagnosed extremely important as if you leave it untreated it will cause long term disability , foot deformity , post-traumatic arthritis and chronic pain. Furthermore , research has indicated that 3.5% of all Lisfranc injuries are career ending in the high performing athlete if not correctly managed or diagnosed.

The foot can be divided into three main parts. namely: the forefoot, midfoot and hindfoot. Much like a puzzle, all the bones within your foot fit into one another. This makes the anatomy amazingly intricate and complex.

Forefoot

This is the front part of your foot, starting at the base of your toes. It is made up of five metatarsal bones and fourteen phalange bones. 

Midfoot

The midfoot region is made up of three small bones called cuneiforms (C1 – 3) which sit under the big toe and runs to your third toe. Next to it, you’ll find the cuboid – which is on the outer side of your foot. The last bone, called the navicular, fits in next to the cuboid but behind the three cuneiform bones. These bones help to form the arch of your foot.

Hindfoot

This area refers to your heel. It is made up out of the talus bone that fits perfectly onto your heel bone, known as the calcaneus. This is the part of your foot that joins to your lower leg and forms your ankle joint.

Lisfranc injuries involve the midfoot and forefoot. Specifically the joints between the toe bones (metatarsals) and cuboid and 3 cuneiform bones. This whole area can be split up into three zones (columns).

1. Outside zone (lateral column): Includes the cuboid bone and 4th and 5th metatarsals (toe bones).
2. Middle zone (middle column): Consists of cuneiform bones 2 and 3 and the 2d and 3d metatarsals (toe bones).
3. Inside zone (medial column): Includes the cuneiform 1 and its connection to the big toe (1st metatarsal).

Ligaments

Ligaments connect all these bones and give stability to keep them firmly in place. A Lisfranc injury always involve ligaments and bones. 

The Lisfranc ligament is the most important and most commonly injured ligament with a Lisfranc injury. It connects the medial cuneiform to the base of the second metatarsal. Basically, creating a strong foundation for the arch of your foot. This ligament consists of three bands namely: the dorsal ligament, the interosseous ligament and the plantar ligament.

Muscles

The muscles and fascia that provide further support and stability to the Lisfranc complex are:

• Peroneus longus
• Tibialis anterior
• Tibialis posterior
• Plantar Fascia

Despite being made up of 26 bones in total, the foot is poetry in motion. It is the first and last point of contact when you to walk, jump and run. Lets say you are performing a jump rope , as you are constantly putting force through your toes by jumping , the bones , ligaments and muscles are all working in unison – enabling you to jump up and down.

As you are jumping on your toes , the force is required to be absorbed , and distributed through your front foot , into your midfoot and eventually expanding into your hindfoot and into the rest of your body. By being able to transmit this force , the majority of force is largely concentrated at a specific point in your midfoot – this point is known as the Lisfranc complex. Your midfoot alone is also responsible for creating and maintaining your foot arch , absorbing force as you jump and giving stability to the entire foot structure.

It is therefore important that the structures of the midfoot are stable , strong and have the ability to transmit these forces through to the rest of the body. If this does not happen in a correct way due to a fault such as an incorrect landing , or an unstable intermetatarsal ligament – you will sustain a Lisfranc injury.

Lets say you are running joyfully down the hill and all of a sudden you feel your foot slipping , you twist and fall over it. The nature of a Lisfranc injury is caused by force going unevenly through the small bones of the midfoot. As the small bones of your midfoot is supposed to absorb this force , the positioning of your foot does not allow the force to be absorbed evenly. When this happens , the uneven distribution of force is caught between the small bones and ligaments , especially when you are in the “toe standing” position.

This position causes the ligaments to tear as they are unable to cope with the excessive or abrupt force due to the position of your foot. When this occurs , the bones tend to shift forward , outwards or apart from one another as the foot is placed in a position of maximal tension. The ligaments will tear , specifically the Lisfranc complex ligaments , which is a common complication of a Lisfranc fracture as force not only pulls the bones apart but the ligaments connecting the bones as well. As you feel the sudden onset of pain , the disruption of these structures will cause swelling , inflammation and a feeling of instability in your foot. There may well be a fracture of your midfoot bones as well as a sudden dislocation. You could still potentially walk on it , but as soon as the hours go by – it starts getting worse.

As the concepts remain the same , how you acquire the injury can differ. Lisfranc injuries can occur via two mechanisms , either indirect or direct trauma sustained to the foot. In both instances , the tension and force coming through the midfoot puzzle-like bones are too much for the bones , ligaments and muscles to handle causing them to move and tear apart from one another.

Lisfranc fractures make up about 18% of all ankle injuries sustained

Indirect injury

Indirect trauma occurs when your foot is caught in an extended and rotated position. A good example is if you were to sprain your ankle and get it caught under you as you fall on top of it. Other examples:

• Slipping and  falling over your foot
• Jumping and landing with your foot twisted underneath you
• Falling and landing from a significant height
• Getting tackled/shoved causing you to fall and sprain your foot

Direct injury

Lisfranc fractures are more commonly caused by high-energy accidents that puts a direct force through your foot.

• A heavy box or weight that falls directly onto your foot
• Someone steps/jumps directly onto your foot with a lot of force
• Motor vehicle/motorcycle crush accidents
• Falling off of your horse with your foot still in the stirrups
• Kicking something that is too hard or too heavy

Inflammation is the process that leads to swelling. This increase of fluid in the area helps to start the healing process. Usually, the inflammation response is bigger if there are more injured structures that your body has to attend to. So, a mild ligament sprain typically has less swelling than a fracture or dislocation.

Bruising is caused by bleeding in the tissue. Typically, a bone that’s fractured or a ligament that’s torn will cause more bleeding. This leads to more bruising. It can range from light blue to purple and black bruising depending on the severity.

Pain with weight-bearing

When you walk or stand on your foot, it has to be able to help carry a big portion (if not all) of your body’s weight. A Lisfranc injury causes pain in your foot and toes. So, you can imagine that stepping on your foot and putting pressure on all those foot joints and ligaments will be painful. A ligament thats sprained will cause significant pain when you put pressure on it, but might feel a lot better the moment you rest. Whereas, a fracture or dislocation will cause a lot more pain and you might feel that you cannot step on your foot at all. At it’s worst, you will need crutches, so that you can walk without stepping on your foot at all as your foot will not be strong enough to support your weight.

Mobility and foot movement

A Lisfranc injury will limit your foot and toe movement in some way. If it is only a ligament sprain, chances are you would still be able to move your foot up and down, but with some pain. Whereas, a fracture-dislocation leaves you feeling like your foot is stuck in one place and you can’t bear the thought of moving your foot or even wiggle your toes as it’s just too painful.

Instability

An important implication of a Lisfranc injury is that it leaves your midfoot and arch feeling unstable. A Lisfranc sprain affects the ligaments that are supposed to keep the joints in place. It affects your balance and your foot feels like it needs support. Whereas a Lisfranc dislocation physically thrusts the joint out of position. You might feel a palpable ‘bump’ at the top or bottom of your mid foot. Or, if someone applies pressure to your midfoot, it would allow way more movement than it should. That’s why you would feel like you are unable to step on it, because there is no support coming from your foot arch.

The diagnosis of a Lisfranc injury can be tricky to the untrained eye. But, at Well Health Pro, we have the expertise, knowledge and experience to safely identify what kind of foot injury you have. Given the complex anatomy of the foot – there is no one specific test that enables us to immediately diagnose a Lisfranc fracture.

Our initial assessment is important to diagnose such an injury. First, we’ll focus on a subjective assessment to listen to your story and gather all the necessary information about your history and symptoms. Then, we do a physical assessment that includes tests for mobility, strength, range and weightbearing. It is equally important to observe swelling and bruising as well as palpating the area. We always test other muscles, joints and nerves in the surrounding area in case it is a whole different injury.

Now, we can diagnose your Lisfranc injury with more confidence. This is so important, because up to 40% of Lisfranc fractures are completely misdiagnosed. 

X-ray views are a good tool to help with diagnosing a Lisfranc fracture. It is able to show abnormalities to the bone structue (like fractures) and joint position (like dislocations). However, you won’t be able to see ligaments or muscles on an x-ray. Research has shown that an x-ray is only 84.4% correct in diagnosing a Lisfranc fracture. So, it is important that the medical professional you are getting treatment from should be looking at all aspects of your injury and ask for the correct x-ray views. 

Your physiotherapist can refer you to get x-rays taken if necessary.

A sonar (ultrasound) is an effective way to provide an image of the soft tissues in your foot. It will pick up levels of swelling and and any tears in ligaments, tendons or muscles. If you are diagnosed with a suspected Lisfranc sprain, this can be an effective way of confirming that. It can even be used in conjunction with an x-ray to provide an image of both bone injury and soft tissue injury.

Your physiotherapist can refer you for a diagnostic ultrasound test if necessary.

An MRI has a much bigger chance of correctly diagnosing a Lisfranc injury and fracture. It is able to visualise bones, joints, nerves, ligaments, tendons and levels of swelling/bleeding. However, it is an expensive test that needs a referral from a specialist doctor. It isn’t always necessary to go for an MRI immediately.

If necessary, your physiotherapist can refer you to the appropriate specialist for an MRI. 

As you have sustained a Lisfranc fracture , the possibility of it healing “on it’s own” is very uncommon. As the bones of the foot are fits into one another in perfect alignment , once there has been a disruption to their alignment – its not likely that it goes back into its natural position without intervention.

As there are ligaments supporting and holding these bones in place , the ligaments will also not heal to their full potential without any treatment. You cannot expect your Lisfranc ligaments to heal if the bone it’s attach to is fractured or out of place.The longer you wait , the worse it will become and more difficult it will be to correct.

Why is my foot worsening?

The metatarsal bones and ligaments play a massive role in distributing force and weight throughout the rest of your body. Let’s have a look at why your foot is worsening:

Delayed union and healing of the fracture

With incorrect immobilisation and continuing to weight bear on your Lisfranc fracture , you will not allow to fractured bones to heal correctly. The foot is responsible for distributing weight although putting weight on it too soon after sustaining a Lisfranc injury , will cause further damage. This only sets your recovery journey back as the bones need to be gradually intriduced into taking weight again. There is an optimal time in order to do so , and by exposing the fractured and injured structures too soon – will only cause delayed healing.

Instability of the foot

Your foot arch plays an important role in the stability of how you walk , step up , drive and run. Even though your injured ligaments and bones have healed you are still feeling unstable when performing these tasks. This is due to rehabilitation that did not cater to the stability of your foot arch. This can lead to compensatory mechanisms that develops over time and gets worse to a point where you will have secondary issues that were not there in the first place , like lower back pain. This can be avoided with the correct rehabilitation and optimal loading exercise prescription.

Swelling

Swelling is an indication of a inflammatory process happening inside the joint. Swelling is normal and expected within the acute to sub-acute phases of healing. After that phase which should last around 4 weeks at most – the swelling should subside. If you are still struggling with a foot that’s swollen , there’s in indication that one of the injured structures in your foot is still unhappy. This is not good , and should be dealt with immediately as it also indicated that there’s a structure that has not healed correctly.

We have the expertise to safely recommend the course of action you should take and are able to safely guide you through the process. Do not wait till it’s too late.

Incorrect diagnosis

A Lisfranc fracture mimicks a simple ankle sprain and thus has a great way of hiding away to the untrained eye. A diagnosis like this is missed in up to 40% of ankle injuries on the first assessment. That is why a clinically correct diagnosis is so important, as it leads to better treatment and optimal healing.

Waiting and immobilising too long

The longer you wait, the bigger your chances of causing permanent damage to your foot following a Lisfranc fracture. Even following surgery , we are able to start you on a clinically measured rehabilitative program to ensure hastened healing in the most appropriate time frame for you. We aid the healing process by performing techniques that allows the pain and swelling to decrease. We also prescribe exercises that aims at the smooth distribution of weight throughout your foot without causing any complications.

Wearing a moon boot to immobilise your foot so you do not put any weight on it , is an important step in your rehabilitation journey. However , it should not be worn for too long as this will to hamper your progress. The same can be said about walking with crutches.

Allow us to gradually wean you off your immobilisation period through a guided and safe process in which we are still able to perform rehabilitation techniques to strengthening you foot but also to allow optimal healing.

Post – traumatic arthritis

If your Lisfranc fracture required surgery , you will certainly develop some form of post surgical arthritis in you foot joint. This is a normal following any boney surgery and is not a red flag by any means , although if not educated and managed correctly – it can cause some discomfort , swelling and pain when walking. Understanding why and how this condition effects your livelihood is important as you return to your normal functional state as the better you understand it , the better you are able to manage it.

Medication

• Using anti-inflammatories and pain medication has a good place in the management of your Lisfranc fracture. However , medication will only provide short term temporary relief and will not aid your process of healing or rehabilitation of the foot. Taking medication for long periods of time is certainly not recommended as this will bring up complications such as stomach ulcers as well as giving you a false sense of recovery.

Through our years of expertise , we are able to confidently deliver the best clinically suited program and protocol for your Lisfranc injury. By giving you the necessary guidance , education and answers to your questions – we can safely say we are the best at instilling the confidence in you in order to successfully return to the activities that means the most to you.

Depending on the type of Lisfranc fracture you have , a conservative approach is only recommended after careful and thorough investigations. Nonetheless , we love what we do , and we are still able to provide you with a successful rehabilitative process. Be it for a surgical or non-surgical approach , we will get you back on your feet!

Lets browse through some of the interventions that will make up the basis of your physiotherapy journey:

Improving daily function and capacity

• By listening and assessing your daily tasks and functional capacity , it’s important to us as this will guide us in advising you on what to do and what to avoid within your specific phases of rehabilitation.

Managing your injury

• Instead of medication, heat and ice therapy can be used to control the affects of pain and inflammation. We will provide you with the answers and guidance needed as to when to use heat on your muscles or ice on your Lisfranc fracture.
• Your mobility is important , but so is the healing. We will guide you on how to walk , how and when to put weight through your foot and how to mange your moonboot.

Improve range of motion

• Manual therapy will be used to increase the mobility of your ankle and toes until you are able to move it fully and pain-free.
• Your foot’s stability folling your Lisfranc fracture will be affected. We are able to identify where the lack of stability is coming from and therefore able to isolate and perform therapy to get the stability back to where it needs to be.

Combination therapy

• We believe that the best results are obtained not by doing one thing , but using a combination of treatment interventions. We are able to flawlessly plan out a rehabilitation program that balance’s and incorporates the best type of strengthening , manual therapy and passive modalities such as laser therapy for you.

Proprioception and Balance

• Following your Lisfranc injury , your balance and your body’s ability to know where your limbs are (proprioception) will be affected. This is an important part of your rehabilitation , as something as simple as climbing stairs will be a massive challenge.

Surgery for a Lisfranc injury is only recommended when there is a displaced fracture or dislocation or both. It ultimately leads to instability of your midfoot and arch of your foot. And with an injury this severe, your body wouldn’t be able to recover by itself without the help of surgical fixation.

The main indications for surgery are:

• Displaced or transverse unstable fractures
• Lisfranc fracture dislocation injury with significant soft tissue swelling
• A dislocation with more than 2 mm shift out of position
• Delayed treatment and chronic deformity
• Severe midfoot instability and arch collapse
• Failed non-surgical treatment after 6 – 12 weeks (if the fracture has not healed after 6 – 12 weeks)

Rehabilitation is still a vital part of your recovery, whether you get surgery or not. You will see a physiotherapist in the hospital to start with the initial rehabilitation. This can include anything from helping you to walk with crutches to making sure you can climb a few stairs before you go home. There is still more work to be done and it is important to progress your rehabilitation according to your doctors guidelines.

This is where we come in. At Well Health Pro, we are well equipped to guide you through your journey to recovery.

• Jones fracture – Injury and fracture of your 5th metatarsal (toe bone). Usually happens in conjunction with a lateral ankle sprain. Pain and swelling on the outside of your foot.
• Ankle sprain – Typically happens when ‘rolling’ your ankle inward while you walk or run or jump. It sprains or tears the lateral (outside) ligaments of your ankle, causing pain and swelling around your ankle.
• Plantar fasciitis – Pain at the underside and around the arch of your foot involving fascia and tendons. Specifically worse when you take the first few steps in the morning and gets worse the further you walk. Caused through overuse.
• Navicular stress fracture – Chronic injury to the navicular bone (found in your midfoot). Typically happens in runners and people that started exercising at a high level too soon. It feels worse with impact, like walking,running or jumping, and better with rest.

• Lisfranc joint sprain
• Fracture of Lisfranc joint
• Midfoot sprain
• Metatarsal fracture
• Fracture-dislocation of midfoot