Physical Therapy for a Lisfranc Injury

The Lisfranc joint is a complex joint in the midfoot where the metatarsal bones connect to the rest of the foot, providing stability to the foot, supporting the arch of the foot, and allowing you to walk and run with ease. A Lisfranc injury involves a fracture or dislocation of the metatarsal and tarsal bones of the midfoot or a sprain of the ligaments of the midfoot, leading to significant pain, dysfunction, and difficulty walking or running. Physical therapy after a Lisfranc injury and surgery can help you manage pain and swelling, improve lower extremity mobility and strength, restore normal walking ability, and safely return to activity and sports competition.

Anatomy of the Foot & Lisfranc Complex

The foot and the ankle are the foundation for your movement, balance, and equal distribution of your body’s weight. The Lisfranc joint is located in the middle of your foot where the metatarsal bones (the bridges to your toes) connect to the rest of your foot. The Lisfranc joint complex is a vital and complex part of the foot, providing stability to the surrounding areas; it is an area where many bones, ligaments, and tendons come together to hold your foot’s arch in shape and help the foot and arch to move properly, allowing you to walk, run, and move with ease.

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What is a Lisfranc Injury?

A Lisfranc injury involves a fracture or dislocation of the metatarsal and tarsal bones of the midfoot or a sprain of the ligaments of the midfoot, leading to significant pain, dysfunction, and difficulty walking or running. A Lisfranc joint injury is the second most common foot injury in athletes but is misdiagnosed in 1 of every 5 patients with a foot injury.

A Lisfranc injury can involve a sprain of the ligaments of the midfoot that can lead to pain and instability in the foot. A Lisfranc dislocation occurs when a bone (the metatarsal or tarsal bones of the midfoot) is forced out of its normal position. A Lisfranc fracture is a break in a bone of the midfoot that can also cause a tear or sprain of the Lisfranc joint’s connective tissues. 

Symptoms of a Lisfranc injury can include:

• Swelling on the top of the foot

• Severe foot and ankle pain

• Bruising on the top of the foot and below the foot

• Pain when weight-bearing that is exacerbated by heel raises

• Inability to walk on the affected foot

• Visible deformity in the foot

A Lisfranc injury can result from falling on your foot in an abnormal position, like stepping in a hole in the grass and twisting suddenly over your foot, causing the small bones in your foot to shift to one side and break. It can also occur when playing sports and landing hard on the foot or falling from a height where the impact of the fall affects the foot. It is more commonly seen among men in their 30s and athletes who play sports like football, soccer, and basketball where feet are vulnerable to being twisted, stepped on, or crushed.

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Physical Therapy for a Lisfranc Injury

Physical therapy after a Lisfranc injury can help you manage pain and swelling, improve lower extremity mobility and strength, restore normal walking ability, and safely return to activity and sports competition.

Treatment for a Lisfranc injury initially involves a cast or boot for the first 8 weeks to reduce stress on the hurt foot and prevent you from putting unnecessary weight on the injured foot. Surgery may be required if the fracture is severe to ensure proper anatomic alignment and positioning of the bones of the foot and Lisfranc joint.  Surgery can involve repositioning the bones of the foot with the help of plates or screws. Surgery, if needed, should occur soon after injury, followed by immobilization, and then targeted rehabilitation to restore function in the foot.

Physical therapy treatment for a Lisfranc injury can include:

• Instruction on using crutches or walkers during immobilization period in boot or cast

• Fitting and use of a brace to help stabilize the ankle and foot following removal of cast

• Therapeutic modalities like ice and heat to reduce pain and swelling or neuromuscular electrical stimulation to help muscles relearn to contract properly

• Manual therapy involves manual movement of the foot by the therapist in specific directions to improve mobility, scar tissue mobilization if there is a scar on your foot from surgery, and joint mobilizations of the foot and ankle joints to improve motion

• Gait analysis and retraining to restore normal walking ability

• Therapeutic exercise to restore function, strength, and mobility in the foot:

  • Range of motion exercises of the ankle and foot for improved movement

  • Flexibility exercises to improve the length of the muscles around the foot and ankle that may have become tight during the immobilization period

  • Targeted strengthening exercises of the foot and ankle complex

• Return to sport training that involves balance and proprioception exercises followed by agility and plyometric drills as the patient progresses to prepare for sport-specific movements

There are four rehabilitation phases to safely and gradually prepare them for a return to sport after a Lisfranc fracture:

1. Acute Post-Surgery Phase [first 8 weeks]: During this phase, the goal of the therapist is to protect the surgery site, manage pain and swelling, and maintain mobility to the surrounding joint. The therapist incorporates core and upper body strengthening as well as strengthening of the other leg, uses ice for pain and swelling, stretching of surrounding joints, and manual therapy to maintain mobility and reduce tightness.

2. Strengthening Phase [8-12 weeks]: At this phase, the therapist incorporates range of motion and early strengthening, stretching, and mobility exercises as well as instruction in movement mechanics and gait training. The therapist helps the patient transition from the boot to a jogger to an arch support as they exercise during this time.

3. Power Phase [3-6 months]: During this phase, the therapist works with the patient to prepare to return to sport, restore full strength and power in the foot and ankle, improve whole body strength and fitness, and help the patient transition from the removal of any surgical hardware to full function of the foot. It is during this phase that the therapist incorporates a more advanced strengthening program of the foot and ankle, aerobic conditioning, and agility, balance, and plyometric drills to help the patient achieve full function in the foot and safely return to sport.

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!