Physical Therapy for a Lisfranc Injury [Infographic]
A Lisfranc injury can involve a sprain or tearing of the ligaments of the midfoot or a fracture or dislocation of the metatarsal and tarsal bones of the midfoot, leading to significant pain, dysfunction, and difficulty walking or running. The Lisfranc joint is located at the junction of the forefoot and midfoot, where the metatarsal bones connect to the rest of the foot. A Lisfranc injury can occur when there is a severe twisting force placed on the joints connecting the forefoot and midfoot, which can occur among athletes like football players. Physical therapy after a Lisfranc injury can help you manage pain and swelling, improve lower extremity mobility and strength, restore normal walking ability, and ensure a safe return to activity and sports competition.
Lisfranc Complex Anatomy
The foot and ankle are the foundation of your movement, balance, and the equal distribution of your body’s weight. The Lisfranc joint is located at the junction of the forefoot and midfoot, where the metatarsal bones connect to the rest of the foot. The Lisfranc ligament complex encompasses the Lisfranc ligament and the first and second metatarsals’ TMT ligaments. The Lisfranc ligament is a small but important ligament that helps stabilize the midfoot and preserve the arch of the foot, allowing you to walk, run, and move with ease. In fact, the ligaments of the midfoot experience forces 2-3 times body weight when standing or walking.
How Lisfranc Injuries Occur
A Lisfranc injury can involve a sprain or tearing of the ligaments of the midfoot or a fracture or dislocation of the metatarsal and tarsal bones of the midfoot, leading to significant pain, dysfunction, and difficulty walking or running. A Lisfranc injury can range from a mild sprain to a severe fracture.
A Lisfranc injury can occur when there is a severe twisting force placed on the joints connecting the forefoot and midfoot. This can occur when the forefoot is stuck in place and a force occurs through the athlete’s entire body in such a way that all their weight twists around the fixed forefoot. This may happen in sports like football when the forefoot is stuck in the turf and ground and the athlete unexpectedly rotates when making a cut, change of direction, or is tackled. A Lisfranc injury can also occur if you slip and twist while stepping off the curb, a fall from a height, or the impact of the foot on the brake pedal during a car accident.
Common symptoms of a Lisfranc injury can include:
Immediate onset of pain in the midfoot
Difficulty or even inability to put weight on the injured foot that is exacerbated by heel raises
Swelling on the top of the foot
Bruising on the top and bottom of the foot
Instability or abnormal widening of midfoot
Pain that worsens with movement or when pressure is applied to the midfoot
Visible deformity in the foot
If a Lisfranc injury is misdiagnosed and not treated effectively initially, an untreated Lisfranc injury can lead to chronic, debilitating pain in the midfoot, progressive midfoot instability, foot arch collapse, abduction of the forefoot, and post-traumatic osteoarthritis in the foot.
Physical Therapy for Lisfranc Injuries
Physical therapy after a Lisfranc injury can help you manage pain and swelling, improve lower extremity mobility and strength, restore normal walking ability, and ensure a safe return to activity and sports competition. A stable injury to the midfoot where the Lisfranc ligaments are stretched or partially torn can be treated without surgery, using immobilization, progressive weight-bearing, and physical therapy to return to sport.
An unstable or displaced Lisfranc injury that involves complete tearing of the midfoot ligaments and fractures and displacement of the bones of the midfoot require surgery to restore joint alignment, stabilizing the joint with screws, pins, and plates to allow the bones and ligaments to be put back in proper position and held in place for healing. A second surgery is often done to remove the hardware once the injury is healed, followed by a comprehensive physical therapy program for up to a year to restore full function to the foot and a safe return to sport.
Physical therapy treatment for a Lisfranc injury can include:
Early immobilization of the foot to allow for healing, using a cast or boot with crutches to keep weight off the injured foot
Pain management using ice and massage to reduce pain and inflammation and manage swelling as well as electrical stimulation to help muscles relearn to contract properly
Range of motion exercises to prevent joint stiffness once initial pain and swelling have subsided, such as ankle pumps and gentle foot and ankle stretches. The therapist may also use manual therapy joint mobilizations of the foot and ankle.
Targeted strengthening exercises of the muscles around the Lisfranc joint for stability and support, including toe curls, heel raises, and resistance band exercises.
Proprioception and balance training as foot injury can affect your proprioception (awareness of the body’s position and space) and balance. Balance exercises are performed on stable and unable surfaces.
Gait analysis and training to relearn how to walk properly with a correct gait pattern following injury
Functional training is implemented as you progress in the rehabilitation program, involving exercises tailored to your specific needs and sport-specific movements
Patient education on proper footwear, activity modification, and self-management techniques
Gradual return to sport is monitored by the physical therapist who assesses readiness and ensures a safe progression for a gradual return to sports movement, practice, and competition. Return to sport activities can include agility and plyometric drills.
Research has shown that athletes who receive proper treatment for a Lisfranc sports injury can typically resume sports activities within an average timeframe of 28-35 weeks and often achieve a level of performance comparable to their pre-injury status. A 2021 meta-analysis found that 93-94% of athletes returned to some level of sports activity after a Lisfranc injury and surgery, and a significant proportion (74-88%) were able to resume their pre-injury level of sports participation.
A recent 2023 study analyzed the return to play rate and performance level of NFL players after a Lisfranc injury, assessing Lisfranc injuries from 2009-2020. During this period, a total of 33 NFL athletes sustained a Lisfranc injury, most of which were experienced by offensive lineman (24.2 %), followed by running backs (21.2%). Overall, of the 33 players who suffered a Lisfranc injury, 27 players (81.8%) returned to play after injury at a median of 11 months. Most of the players remained in the NFL for at least two-three seasons after injury.
Have you experienced a Lisfranc injury in your foot? Work with a physical therapist to restore function, strength, and mobility in your foot and return to activity safely!
