PFATS Articles

Case Study of a Lisfranc Injury in an Offensive Lineman

Jeff Otte, MS, ATC/R, NREMT-B
Assistant Athletic Trainer
Minnesota Vikings

Introduction:
Lower extremity injuries, particularly those of the knee and ankle, are among the most common injures in athletics. Ankle and foot sprains are very prevalent among lower extremity injuries. During an NFL contest between the Minnesota Vikings and the Philadelphia Eagles, a 320 pound right offensive tackle suffered a Lisfranc fracture and dislocation. While blocking, the athlete suffered the injury during second quarter of the game. As the two lineman engaged, the offensive player was driven back and pushed out of position resulting in forced hyper-dorsiflexion of the right ankle and foot forcing the offensive lineman to take a large step back for balance. The circumstances of the injury, particularly the large weight of the player involved, required consideration during post-operative care.

Definition of injury:

(Image: Lisfranc action)

The Lisfranc joint, also called the tarsometatarsal joint, serves as the point of articulation of the first and second metatarsal heads with the first and second cuneiforms. This articulation contains the Lisfranc ligament, a band of ligamentous tissue that connects the medial cuneiform and the base of the second metatarsal. The Lisfranc joint is considered the “keystone” of the midfoot due to the wedging of the second metatarsal into the second cuneiform. The joint is also the focal point of all tarsometatarsal articulation.¹

Lisfranc joint and ligament injuries can result from both direct and indirect trauma.¹ This specific incidence of injury occurred due to indirect trauma as the force of both players bodies was transferred to the lineman’s stationary foot. The injury occurred as a result of the compression of the Lisfranc joint.

Evaluation and Assessment:
Initially, the athlete was seen limping off the field by the athletic training staff. During the initial on-field examination, tenderness was noted over the midfoot through his shoe. The athlete stated he felt a “pop” while blocking during the play and further explained his foot “gave out” causing him to fall to the ground. His shoe, sock, and ankle tape were removed to facilitate a thorough examination. He exhibited point tenderness over the midfoot, specifically the area of the navicular, cuneiforms, and the base of the metatarsals. The athlete was immediately referred to the team physician. Effusion was noted over the midfoot and he was unable to bear weight on the foot requiring transportation to locker room for x-ray evaluation. X-ray’s revealed a Lisfranc injury with an abnormal space between the bases of the first and second metatarsal. He was placed in an immobilization boot, given crutches and instructed on non-weight bearing ambulation for the trip home. The following day MRI and CT exams revealed:

Complete Lisfranc ligament rupture
1–1.5mm of lateral displacement of base of the second metatarsal
Fracture of the medial cuneiform

Treatment:

(Image: X-ray with Screws)

Team physicians determined that operative care was necessary and performed an Open Reduction Internal Fixation procedure seven days post injury. Specifically, two screws were used to fixate the injury. During surgery, an osteophyte was discovered and removed from the anterior talus along with a large loose body from the ankle joint.

Rehabilitation:
Phase 1: 0–6 weeks. Immobilization
The goal of this phase was to allow the repaired tissues to heal. Following surgery, the athlete was casted and instructed for non-weight bearing ambulation with crutches. At 14 days, follow-up x-rays were taken and the cast and sutures were removed. The wound was inspected and a cast was reapplied for maximal protection. Initial rehabilitation consisted of two weeks of rest followed by upper-body lifting with the strength and conditioning staff. At four weeks, lower body rehabilitation was initiated consisting of open chain hip and knee strengthening.

Phase 2: 6–13 weeks. Partial Weight Bearing
The second phase marked the beginning of partial weight bearing and the progression to on-field work prior to screw removal. Initially, the athlete was placed in a short leg walking cast and was instructed on partial weight bearing ambulation with crutches. At this point, the athlete began riding the exercise bike and continued open chain strengthening.

At nine weeks, he was taken out of the cast and placed in a pneumatic walking boot for ambulation. The athlete began straight ahead walking in chest high water using the hydroworx underwater treadmill. Additionally, ankle and foot ROM were initiated followed by marble pickups in addition to towel and sand curls for intrinsic foot strengthening. Care was taken not to stress the ankle excessively due to the osteophyte and loose body removal during surgery. At 12 weeks, ankle strengthening was initiated. Ankle strengthening exercises consisted of isotonic Thera-Band strengthening, balance training, and lateral stepping.

Phase 3: 13–22 weeks. Mobilization, Strengthening, and Function
At 13 weeks, the walking boot was removed and the athlete was placed in a custom orthotic with carbon fiber plate reinforcement. The athlete was progressed to closed chain weight bearing exercises and elliptical training. At 17 weeks, the athlete began straight ahead field jogging. From weeks 17–22, his on-field rehabilitation was gradually increased to include agility ladder drills, position specific drills, and heavy sled pushing. He also completed boxing training circuits with the strength and conditioning staff on a regular basis.

Phases 3: 22–25 weeks. Return to Partial Weight Bearing
A second surgical procedure to remove one of the stabilizing screws marked the beginning of phase three of the rehabilitation process. After safely removing the screw, the goal of this phase focused on allowing the injury to heal while applying safe but direct force to the healing tissue. During the second surgery, the intercuneiform screw was left in place. The athlete was placed back in the pneumatic walking boot for three weeks but was allowed to remove the boot for rehabilitation. The athletic training staff continued ROM exercises, open chain strengthening, and hydroworx pool therapy.

Phase 4: 25+ weeks. Return to Full Team Activity
The final stage of the rehabilitation of this Lisfranc injury involved returning the athlete to team participation. In order to facilitate team participation, that athletic training staff began by increasing the athlete’s workload during rehabilitation and progressing to on-field functional activity including working with the strength and conditioning staff. Finally, the athlete returned to team activity in a limited capacity.

At six months post operative and three weeks post screw removal, the walking boot was removed and the athlete began full weight bearing ambulation at all times. Immediately following boot removal, the athlete progressed to on-field straight ahead jogging in addition to his rehabilitation exercises in the athletic training room. Over the next three weeks, his on-field functional rehabilitation included the agility ladder, box drills, plyometrics, and position specific drills. He returned to the strength and conditioning program for on-field rehabilitation after working with the athletic training staff for three weeks. The athlete participated in the strength and conditioning staff’s off-season program gradually increasing his workload through weight room resistance training and on-field conditioning. He participated in mini-camp on a limited basis whereas he participated in all individual drills, however, he did not participate in the team portion of practice. He was cleared for full activity prior to the beginning of our June developmental camp 32 weeks after surgery.

Conclusion:
While this Lisfranc injury resulted in significant lost time during the 2004 season, the player has been cleared for full participation in the 2005 season. While the physician and our athletic training staff guided the athlete through the rehabilitation process, it was the athlete’s hard work that paved the way for success.

References:

Burroughs, K.E., Reimer, C.D., Fields, K.B. Lisfranc Injury of the Foot: A Commonly Missed Diagnosis. Amer Fam Physician. 58:118–129, 2001.