Lisfranc injuries refer to a specific group of injuries which lead to instability of the tarsalmetatarsal joint. The Lisfranc joint complex is formed by the three cuneiform bones and cuboid bone proximally with the five metatarsal bases distally linked by capsule-ligamentous structures. The main stabilising structure is named the Lisfranc ligament. The strength of this ligament is such that it’s disruption will lead to altered stability within the medial and middle columns of the foot. There is a wide spread of pathologic conditions involving the joint complex, ranging from subtle ligament injuries to complex fracture-dislocations with severe soft tissue damage.

Literature shows that these injuries are rare, accounting for only 0.2% of all fractures, although in 20% of cases they are not diagnosed, or diagnosed late. They are more likely to occur in males and are more common in the third decade of life. An untreated or inadequately treated Lisfranc injury results in multiple late complications, the severity of which depends on the severity of the primary injury. The most common complications are painful instability of the joint, progressive deformity and arthritis.

Lisfranc injuries can be caused by either direct or indirect trauma. The two commonest mechanisms from direct trauma are falls from height and road traffic accidents. The large majority of Lisfranc injuries however occur from indirect trauma – plantarward bending of the metatarsals associated with rotational stress, or abduction injuries where the forefoot is suddenly adducted relative to a fixed hindfoot.

Injuries to the Lisfranc complex are classified according to structures damaged and stability: Stage 1 – Lis franc diastasis <2mm, Stage 2 – Lisfranc diastasis 2-5mm, Stage 3 – Lisfranc diastasis >5mm. Stages can be further sub-categorised based on bony injury. Stable injuries are best treated non-operatively, while unstable injuries should be treated operatively. One of the most challenging issues concerning Lisfranc injuries is to adequately evaluate stability of the nondisplaced Lisfranc injuries and thereby properly select the right patients for nonoperative treatment. If >2mm of displacement exists at the Lisfranc joint the injury is considered unstable. In the presence <2mm of displacement the injury is considered stable. Stability is best assessed on a weight-bearing x-ray, sometimes repeat x-rays are required 10-14 days following the injury to allow pain to subside enough to facilitate a weight-bearing view. For the purpose of this protocol, we will be dealing with stable sprains of the Lisfranc ligament.

Below is a guideline of the multiple steps involved in navigating a successful Lisfranc injury rehabilitation with the goals of each outlined below:

• Phase 1: Acute
• Phase 2: Control and capacity
• Phase 3: Strength accumulation
• Phase 4: Sport preparation
• Phase 5: Return to play and maintain performance

Acute - Phase 1:

Initial management of a stable Lisfranc injury consists of non-weightbearing in a below knee cast for 6 weeks. This can feel like a long time for technically a ‘sprain’; however, it just further highlights the importance of this significant joint.

Following removal of the cast, a moonboot is required allowing full weight-bearing over a further 4-6weeks. Generally, most people return to full weight-bearing at 10 weeks post-injury. Occasionally individuals might find it more comfortable to move into a shoe with medial arch support.

Control and Capacity - Phase 2:

This phase of recovery is focused on returning normal gait pattern and starting to load the injured site in a controlled and predictable manner.

It is important that the Physiotherapist considers maintaining load through other key body areas that are required for the athlete, lest you run the risk of deconditioning, for example the adductors of a kicking sport athlete, or the shoulder musculature of an overhead athlete.

Strength Accumulation - Phase 3:

This phase of the rehabilitation process aims to build strength in the ankle-foot complex. This coupled with continued strengthening of the rest of the limb helps to form the strong foundation blocks to introduce sports specific movement and training in the next phase. This phase will likely be the longest of your rehabilitation, as it can take a while to perform a single-leg calf raise with load, due to discomfort alongside strength. Note that plyometrics are supplementary goals in this phase, and clinically these should not be introduced til 6 months post-injury.

Sport Preparation - Phase 4:

This phase of the rehabilitation process introduces running, higher loads and change of direction. This is done in a graduate method in a controlled, safe environment to ensure successful progression. This phase also incorporates sport specific movement back into rehab and integrates the athlete back into a sport/team environment.

Clinically and in literature, most athletes do not meet the requirements to return to sport til 6 months post-injury. A systematic literature review completed in 2020 showed that 96% of people that sustained a stable Lisfranc injury were able to return to their prior level of sport.

Return to Play and Maintain Performance - Phase 5:

Athletes are now well into running, hopping and changing directions in both a controlled unpredictable environment. This phase is about incorporating sport specific chaotic environments and unplanned reactions into rehab and integrating the athlete back into a sport/team environment.

Once you have been given the all clear from the medical team to return to sport it is important to keep fit and maintain your strength.

For more information on the Foundation Clinic Lisfranc Protocol email [email protected], or phone 07 579 5601