Midfoot Injuries

MIDFOOT INJURIES
By:  Robert H. Sheinberg, D.P.M., D.A.B.F.A.S., F.A.C.F.A.S.

Lisfranc injuries are challenging injuries that cause disruption to the ligaments in the middle portion of the foot.  They are more common in sports activities such as football.  When the foot is pointed down and something lands on the back of the heel the midfoot area collapses.  This causes a disruption of the ligaments in the midfoot and often the bones around them.  These injuries can also occur from something as simple as falling forward while wearing a shoe with a heel.  Coming off of a step and falling forward can also cause injuries to the midfoot region.  A disruption of the ligaments in the midfoot is rare with direct trauma to the area.  Direct trauma often causes a fracture to the bones in the midfoot region. 

Lisfranc injuries cause an immediate swelling and pain throughout the midfoot area both on the top and bottom of the foot.  It is often accompanied by a black and blue area on the bottom of the foot, which usually accompanies more traumatic events.  Patients often experience diffuse swelling and difficulty weightbearing.  These injuries need to be evaluated and addressed immediately.

X-rays are taken to evaluate the midfoot region.  X-rays are always best taken with the patient putting weight on the foot to get a full evaluation of the extent of injury.  When inconclusive, MRIs and often CT scans are necessary to evaluate the injury.  When the ligaments are disrupted or the bones have fractured, the midfoot bones start to separate.  This could lead not only to short-term problems but long-term injuries of the midfoot area which cause the foot to start to look and function in a deformed way.  This progressive deformity will often cause an inability for the patient to not only exercise but perform activities of daily living.  It is a progressive deformity that if often unattended can be disabling. 

Acute treatment of Lisfranc injuries is to fully evaluate the extent of the injury.  When the bones have separated most often open reduction and internal fixation is performed.  This will allow the bone to be put back to its proper anatomical position and allow healing of the ligaments.  Most commonly we place the patient twelve weeks nonweightbearing.  We avoid putting screws across the joints, which is commonly performed to avoid injuries to the joint surface.  Small K-wires are more than enough to hold the position of the joints during the healing process.  Any pins that are placed across the joint surfaces are removed at approximately twelve weeks.  The main screw going from the inside of the cuneiform to the second metatarsal would stabilize the Lisfranc ligament will often remain.  This may add further stability to the midfoot.  Screws may have a tendency to loosen over time or even break.  This provides no long-term problems.

Lisfranc injuries are often associated with arthritis at some point in the future despite the most perfect anatomic reduction.  Sometimes the arthritis is very subtle and can be treated with anti-inflammatories and an orthotic placed in a person’s shoe.  If the problems persisted, then fusing one or two of the small joints in the midfoot may provide complete relief of all symptoms and a full return to all activity.