Bob Schroedter

DPT745T Management of LE Disorders

March 3, 2010

LISFRANC INJURIES IN THE PERFORMING ARTIST

Background
Lisfranc is an eponymous articulation named after the French gynecologist
and field surgeon in Napoleons army, Jacques Lisfranc de St. Martin, who was
known for surgically treating and amputating feet at these tarsometatarsal
joints1. The injury originally resulted from riders falling off their horse with
their foot remaining in the stirrup, causing extreme plantarflexion and
abduction rotation of the forefoot14.
Dance injury stats
Ankle and foot injuries comprise the majority share of injuries in dance,
between 26.6% and 53.4%3,8,17. In particular, Lisfranc injuries account for a
small subset of these, where in the general population fracture-dislocations
rates have been estimated as 0.2% of all fractures (1 in 55,000
persons/year)5.
Lisfranc defined
The base of the second metatarsal is tightly recessed within the mortise
formed by the three cuneiform bones 16. This configuration locks the entire
TMT complex and prevents lateral dislocation of the forefoot on the midfoot,
making the second MT a keystone of the joint16. As there is no transverse
ligament between the first and second MT, the Lisfranc ligament, which
extends obliquely from the medial cuneiform to the base of the second MT,
constitutes a major component of the soft tissue stability in this region. A
Lisfranc fracture-dislocation may occur when a break in the 1 st or 2nd MT
bases disrupts the TMT ligaments7.
Etiology
Mechanisms of injury are divided into high- and low-velocity injuries 7. Highvelocity Lisfranc injuries are sustained in high-speed motor vehicle accidents,
where the foot gets forced into hyperplantarflexion with a varus or valgus
component7. Low-velocity injuries, as that which occur in athletes and
dancers, results from a bending stress when the foot is fixed in a stirrup or
strap (sailboarding, equestrian) a hyperplantarflexed foot which sustains a
downward force onto the heel (football, soccer) or which lands or takes off
from a jump with excessive force (soccer, dance) 7,11,16.
Diagnosis
No specific clinical tests to confirm the extent of injury, so a high degree of
suspicion is given to any painful midfoot injury 9,16. Comparisons should be
made with the contralateral foot. Typically there will be pain during the pushoff phase of running and occasionally during walking and relev
(plantarflexion over the MT heads). Other possible signs include:
Midfoot pain lasting >5 days post-injury 16
Tenderness with or without swelling on the dorsal midfoot 16

Ecchymosis on the plantar surface 9

Positive eversion-abduction test16
Flattening of the longitudinal arch 11
Gross instability, crepitus or step-off deformity at base of 2 nd MT or
medial cuneiform in severe cases7,11

Radiographic imaging should incorporate three views of the foot: A-P, 30

oblique, lateral. Telltale signs include 7,16:
A-P: Displacement >2mm between base of the 1st and 2nd MT
Oblique: Misalignment between medial cortex of the 4 th MT and medial
border of cuboid
Lateral: Misalignment of the dorsal cortical line of the 1 st MT to the
medial cuneiform
The strongest predictor of instability of the midfoot was disruption of the
plantar ligament between the medial cuneiform and the bases of the second
and third metatarsals as seen on MRI, with a Sn=0.94, Sp=0.75, +LR=3.76,
-LR=0.0813.
Classification
Injuries can vary from mild sprains to fracture dislocations. Useful
classification is described for subtle Lisfranc injuries 12.
Non-conservative treatment
Anatomic reduction and stable internal fixation is the hallmark goal of
successful operative treatment10. However, controversy exists on the ideal
approach to achieve functional and good subjective patient outcomes,
arthrodesis or open reduction-internal fixation 15. The tendency is to develop
more TMT arthritis with ORIF, even with restoration of normal alignment,
which requires addressing later on with arthrodesis 6,10. Stage 2 or 3 Lisfranc
injuries (displaced and clearly unstable) require surgery and NWB in a cast or
cast boot postop. Between 8-12 weeks PWB is allowed and FWB progressed
after 12 weeks with a custom-molded orthosis 7.
Conservative treatment
Stage 1 Lisfranc injury is considered functionally stable and can be treated
nonoperatively12.
Additionally, following guidelines have been suggested 16:
Encourage healing of the Lisfranc ligament and other soft tissues at
their anatomical length
Some advocate for NWB cast up to 6 weeks and another 6 weeks in
WB cast
No return to dance for 4 months, even with a minor sprain
Custom-molded orthoses for maintenance of longitudinal arch height
through windlass, rearfoot control of overpronation, equalization of
plantar pressures on MT heads and maximizing 1st MTPJ extension

Manual therapy and exercise to normalize pelvic alignment, prevent

hip ADD+IR, improve TCJ dorsiflexion, strengthen intrinsic foot
musculature and increase proprioception with wobble board, Swiss ball
and Balance shoes
Taping to promote plantarflexion and prevent dorsiflexion of the 1 st ray
via mechanical bracing and altered afferent input for a positive change
in motor control

Prognosis
For a ballet dancer these injuries can be career-ending which is why delay in
diagnosis and treatment may be associated with continued instability and
poor prognosis2,4,5,16. Surgical treatment, despite restoration of anatomical
alignment can result in limitations in ability to plantarflex for relev or en
pointe.

REFERENCES
1. Jacques Lisfranc de St. Martin. Jacques Lisfranc de St. Martin
(www.whonamedit.com). Available at:
http://www.whonamedit.com/doctor.cfm/2572.html [Accessed March 3, 2010].
2. Della Valle C, Su E, Nihal A, Rosenberg Z, Trepman E. Acute disruption of
the tarsometatarsal (Lisfranc's) joints in a ballet dancer. J Dance Med Sci.
2000;4(4):128-131.
3. Gamboa JM, Roberts LA, Maring J, Fergus A. Injury patterns in elite
preprofessional ballet dancers and the utility of screening programs to
identify risk characteristics. J Orthop Sports Phys Ther. 2008;38(3):126-136.
4. Harrington T, Crichton KJ, Anderson IF. Overuse ballet injury of the base of
the second metatarsal. A diagnostic problem. Am J Sports Med.
1993;21(4):591-598.
5. Kadel N, Donaldson-Fletcher E. Lisfranc fracture-dislocation in a male ballet
dancer during take-off of a jump: a case report. J Dance Med Sci.
2004;8(2):56-58.
6. Kuo RS, Tejwani NC, Digiovanni CW, et al. Outcome after open reduction
and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000;82A(11):1609-1618.
7. Lattermann C, Goldstein JL, Wukich DK, Lee S, Bach BR. Practical
management of Lisfranc injuries in athletes. Clin J Sport Med. 2007;17(4):311315.
8. Liederbach M. General considerations for guiding dance injury
rehabilitation. J Dance Med Sci. 2000;4(2):54-65.
9. Loveday D, Robinson A. Lisfranc injuries. Br J Hosp Med (Lond).
2008;69(7):399-402.
10. Ly T, Coetzee J. Treatment of primarily ligamentous Lisfranc joint injuries:
primary arthrodesis compared with open reduction and internal fixation. A
prospective, randomized study. J Bone Joint Surg Am. 2006;88A(3):514-520.
11. Mantas JP, Burks RT. Lisfranc injuries in the athlete. Clin Sports Med.
1994;13(4):719-730.
12. Nunley JA, Vertullo CJ. Classification, investigation, and management of
midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med.
2002;30(6):871-878.
13. Raikin SM, Elias I, Dheer S, et al. Prediction of midfoot instability in the
subtle Lisfranc injury. Comparison of magnetic resonance imaging with
intraoperative findings. J Bone Joint Surg Am. 2009;91(4):892-899.

14. Seward J. Case review. A Lis Franc fracture-dislocation in a college soccer

player. Athletic Ther Today. 1997;2(5):24-25.
15. Teng AL, Pinzur MS, Lomasney L, Mahoney L, Havey R. Functional outcome
following anatomic restoration of tarsal-metatarsal fracture dislocation. Foot
Ankle Int. 2002;23(10):922-926.
16. Wadsworth DJS, Eadie NT. Conservative management of subtle Lisfranc
joint injury: a case report. J Orthop Sports Phys Ther. 2005;35(3):154-164.
17. Wiesler ER, Hunter DM, Martin DF, Curl WW, Hoen H. Ankle flexibility and
injury patterns in dancers. Am J Sports Med. 1996;24(6):754-757.