Introduction

Lisfranc injury is defined as damage or injury to the long bones of the foot (Lisfranc joint). The injury can be in the form of a dislocation, fracture, or sprain(called a ligament tear).¹ The midfoot bones fracture or the supporting ligaments are damaged. This condition, named after French surgeon Jacques Lisfranc de St. Martin, who first documented these injuries in cavalry soldiers during the Napoleonic era, is still an essential medical challenge.² These can occur in football or soccer when a player tumbles on the back of another player's foot while it is stretched downward in the landing position.² Therefore, the title is from the battlefield to modern sports.

Anatomy

The midfoot is composed of tiny bones that form the arch on the top of your foot. Five longer bones, known as metatarsals, stretch from this location to your toes. These bones are bound together by powerful ligaments, which act as stiff straps to keep the foot stable. The bones and ligaments form the Lisfranc joint complex. This area of the foot doesn't move much, but it's crucial for maintaining your arch's health and helping your foot push off the ground when walking.

One weakness in this location is the lack of a ligament linking the first and second metatarsals. This makes injuries more likely to occur here, particularly during a fall or a violent foot twist. Lisfranc injuries can result in ligament tears, shattered bones, or both. Sometimes only one joint is injured, while more severe accidents might result in many joints and fractures. Even if surgery is performed, the damage might result in long-term complications such as a collapsed arch, arthritis, and difficulty walking. That is why early detection and good treatment are critical.^2,3

The Lisfranc joint complex consists of the three cuneiform bones (C1 to C3) and the cuboid bone (Cu) proximally, as well as the five metatarsal bases (M1 to M5) distally joined together by a ligamentous capsule structure.⁴

Mechanism of injury

A Lisfranc injury may take place in two ways: through direct contact or by twisting the foot.

Direct impact occurs when something strikes the centre of the foot with great force, as in an automobile accident or a fall from a height. This can fracture or dislocate the bones in the centre of the foot.

Twisting injuries are more common. These occur when the foot bends or twists in an odd manner. For example, if the front part of the foot bends while the back remains static, ligaments can be torn or bones shifted out of position. This can happen during sports or in accidents, such as when a horse rider falls and gets their foot hooked in the stirrup.

Both sorts of injuries can have a major impact on how your foot functions and should be treated promptly.⁵

Symptoms

• Swelling and soreness on the top of the foot, especially in the centre (midfoot) area
• Bruising on the top and bottom of the foot
• Bruising on the sole is a clear indication of a Lisfranc injury
• Pain while standing, walking, or pushing off with the afflicted foot
• Walking or weight-bearing may be impossible due to intense pain
• There is no improvement with basic sprain treatment (rest, ice, elevation)
• Use crutches if discomfort stops you from putting weight on your foot^1,2,3

Diagnosis

To diagnose a Lisfranc injury, your doctor will first discuss your symptoms and then carefully examine your foot. Although some of the physical examinations may be painful, they are harmless and will not exacerbate the injury. Here's what the doctor will usually check:

• Bruising on the bottom of the foot - This is a clear indication of a torn ligament or broken bone in the midfoot
• Tenderness in the midfoot - If pressing on the middle of the foot causes discomfort, this could indicate a Lisfranc injury
• Twist test: The doctor may gently twist the front of your foot while holding the heel to see if it creates pain
• The doctor can examine for midfoot pain by sliding your toes up and down on a piano note
• Heel rise test: You may be asked to stand on one foot and rise to your toes. Pain during this exam may suggest a latent injury^1,2,3

Imaging tests⁶

To confirm the diagnosis and determine its severity, your doctor may order the following scans:

• X-rays might reveal damaged bones or misalignment in the midfoot. Standing X-rays (taken while you are standing) can identify ligament injuries that would otherwise go undetected
• Comparison X-rays - X-rays of the healthy foot are occasionally taken to compare with the injured one
• MRI (Magnetic Resonance Imaging) - This scan produces a clear image of soft tissues such as ligaments. It helps to detect injuries that X-rays may miss
• A CT (Computed Tomography) scan provides a more complete, three-dimensional image of the bones, allowing surgeons to plan surgery if necessary^5,6
• These tests assist your doctor in determining the severity of the injury and the most appropriate treatment for optimal

Complications

Several complications might arise if a Lisfranc injury is not properly treated or if healing does not go as planned. This may include:

• Post-traumatic arthritis is the most prevalent and significant consequence, occurring in up to 45-72% of cases, particularly when joint alignment is not correctly restored following surgery
• Chronic pain refers to ongoing pain in the midfoot, which is frequently associated with arthritis or poor healing
• Foot abnormalities, such as collapsed arches, can disrupt walking and balance
• Screw-related concerns - Screws used in surgery can break or loosen (approximately 16% of the time)
• Spontaneous fusion - In around 7.8% of instances, nearby joints fuse on their own, limiting mobility
• Wound and soft tissue issues occur in 3.6% of patients
• Compartment syndrome is an uncommon but significant consequence (2.6%) characterised by elevated pressure in the foot, which can injure muscles and nerves
• Implant infection was reported in 1.5% of cases
• Reflex sympathetic dystrophy is a pain disorder affecting nerves (1%)
• Deep vein thrombosis (DVT) - Blood clots in the leg veins, which occur in 0.5% of cases
• These problems underline the necessity of a correct diagnosis, good surgical technique, and attentive monitoring during recovery

Treatments

Treatment for a Lisfranc injury is determined by the severity of the damage. The primary purpose is to alleviate discomfort, protect the joint, and encourage normal healing to prevent future issues.

Non-surgical treatment

Doctors may offer non-surgical treatment for modest injuries that do not involve shattered bones, joint dislocations, or substantial ligament tears. This includes:

• Ice and elevation: To minimise swelling, keep the foot elevated above the heart level as much as possible. Apply ice (wrapped in a towel) for approximately 20 minutes many times per day
• Immobilisation entails wearing a cast or boot to keep the foot stable and prevent additional injury. Crutches are commonly used to avoid putting weight on the foot
• Pain relief: Ibuprofen and paracetamol are two over-the-counter medications that can aid with pain and swelling. For more severe pain, doctors may prescribe drugs; always follow their directions carefully

Surgical treatment

Surgery is required if the injury creates instability in the Lisfranc joint (e.g., dislocation or fracture). The goal is to straighten and stabilise the bones so they can recover properly. Lisfranc surgery involves the use of plates and screws to hold the bones in place. Following surgery:

• You must refrain from putting weight on the foot for 4 to 8 weeks
• A cast or boot is worn for several weeks to protect the area
• In some cases, the screws or plates may be removed later, after the foot has healed

Recovery can take several months, and regular follow-ups with your doctor are essential to track progress.

Conclusion

Lisfranc injuries, while frequently neglected, can have devastating long-term effects if not recognised and treated quickly. These midfoot injuries, which originated in combat medicine and are now common in modern sports, emphasise the significance of early detection and treatment. Lisfranc damage, whether caused by direct trauma or a twisting injury, can have serious consequences for mobility and quality of life.

With a thorough physical examination and proper imaging, an accurate diagnosis is feasible. While some stable injuries can be managed conservatively with rest and immobilisation, more severe instances frequently necessitate surgical intervention to straighten and stabilise the foot. Even after treatment, problems such as arthritis, persistent pain, and foot abnormalities might develop, emphasising the importance of regular monitoring and rehabilitation.

Ultimately, early intervention, informed decision-making, and a patient-specific strategy are critical to reducing complications and regaining normal function in people with Lisfranc injuries.