Palpation of the foot produces maximum tenderness at the base of the first and second metatarsals. A diminished dorsalis pedis pulse (the artery courses over the proximal head of the second metatarsal) can indicate a more severe dislocation. On physical exam, Lisfranc injuries may be manifest as plantar ecchymosis - bruising along the sole of the midfoot (Figure 2). Unstable Lisfranc injuries result in displacement of some or all of the tarsometatarsal joint with associated complete ligament disruption and/or significant fractures of the metatarsal base(s). Therefore, even stable injuries are painful and have a prolonged recovery period. However, stable Lisfranc injuries still cause significant discomfort because the ligaments of the midfoot are normally subject to marked forces (1-3 times greater than body weight) during normal standing and walking. Stable Lisfranc injuries typically have no apparent fractures, or fractures that are non-displaced. Stable Lisfranc injuries are characterized by a ligamentous injury that is not severe enough to allow the tarsometatarsal joints to displace. As such, pain in the midfoot region, swelling and bruising on the center plantar surface, and pain with weight-bearing may be the only findings that suggest the diagnosis of Lisfranc injuries.Ī Lisfranc injury may be stable or unstable. Gross subluxation or lateral deviation of the foot is rare with this injury occurring only in the most severe cases of Lisfranc injuries.
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A similar force is created during high speed motor vehicle collisions, where the foot is often driven into the floorboard (hyperflexing it) as the driver attempts to brake to avoid the crash. It is also seen more commonly in football players: a force directed down onto the planted foot by a falling player or tackle from behind can lead to hyperplantarflexion at the Lisfranc joint. Sporting activities that require the use of foot straps, such as windsurfing and horse-back riding seem to place people at high risk of this injury.
These injuries can be caused by a low-energy injury such as a twisting fall, or by a high-energy injury such as a fall from a height. Patients with acute Lisfranc injuries will present with a history of a traumatic injury to the foot. Biomechanical studies have shown the Lisfranc ligament to be significantly stronger and stiffer than the plantar and dorsal cuneometatarsal ligaments, making it the main stabilizer of the midfoot. There is an oblique ligament, designated the Lisfranc ligament, which traverses from the plantar-lateral aspect of the medial cuneiform to the plantar-medial aspect of the second metatarsal. This creates a point of weakness between the first and the other metatarsals. Additional dynamic stability of the tarsometatarsal joint is offered by the posterior and anterior tibial tendons and peroneal tendons.Īll of the bones of the midfoot are attached to their neighbors by ligaments with one exception: there is no ligament connecting the first and second metatarsal.
Thus, dislocation of the metatarsals or cuneiforms typically also involve fracture of the second metatarsal. The keystone of this arch is the base of the second metatarsal, which is tightly recessed between the medial and lateral cuneiforms, locking the tarsometatarsal complex and preventing medial/lateral translation (Figure 1). Bony congruence is also critically important to stability of the tarsometatarsal joint - namely, the articulation of the cuneiforms and bases of the metatarsals. This joint is stabilized by strong ligaments, particularly the plantar ligaments which support the arch and markedly limit motion through the joints of the midfoot. The midfoot (navicular, cuneiforms, and cuboid tarsal bones) meets the metatarsals at the tarsometatarsal joint, also known as the Lisfranc joint complex (Figure 1). Because these untreated injuries can be disabling, it is essential to diagnose them as they occur. Some Lisfranc injuries are subtle and can go undetected at first. Symptoms include marked pain, swelling, and inability to bear weight. Midfoot trauma including Lisfranc injuries are relatively rare, but when they occur they can be severe. An injury to the tarsometatarsal joint is known by the eponym “Lisfranc injury.” These types of injuries include sprains of the midfoot ligaments, fractures, or a combination of the two.
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