The midfoot consists of bones and joints attaching the front of the ankle to the forefoot. Injuries to this area of the foot also called a midfoot sprain, can cause damage to the joints, ligaments, and tendons. This damage can vary from a mild ligament sprain to a bone fracture or joint dislocation. One particular injury called the Lisfranc sprain is potentially serious and can lead to long-term arthritis. So, how do we grade mid-foot injuries and avoid missing the more serious Lisfranc injury?
Causes of a midfoot sprain
Generally, injuries can vary from low-energy injuries such as a foot twist or fall in sport to high-energy injuries such as a fall from a height or a car accident.
Overall, low-energy injuries are the most likely to be missed. For example, one common injury is when an athlete stumbles forward over a flexed foot or an opponent falls on top of a foot planted on the ground.
Midfoot sprain symptoms
Usually, mid-foot injuries cause pain and swelling in the middle part of the foot. Also, weight-bearing can be difficult without crutches or a boot. In more severe cases, significant bruising and deformity occur if fractures or dislocation occur.
If pain and swelling do not settle, you need to see a doctor specialising in picking up severe mid-foot injuries.
Midfoot sprain vs. Lisfranc sprain: How can you tell the difference?
Sometimes, it can be difficult to distinguish between a simple sprain of the mid-foot ligaments or a more severe Lisfranc ligament or joint injury.
Lisfranc joint consists of bones and ligaments on the inside of the mid-foot. The most critical ligament is the Lisfanc ligament between the medial cuneiform bone and the base of the second toe bone. If this ligament is sprained or torn, the mid-foot might be unstable. The picture below shows the strong Lisfranc ligament spanning the bones in the midfoot.
Overall, we suspect a Lisfranc sprain or injury with the following symptoms:
- More severe midfoot pain and swelling
- bruising at the top of the foot and under the foot in the medial arch
- No relief in foot pain after a week of rest
- Crutches are needed to walk even after a period of rest
- twisting of your foot by your doctor causing pain
- severe pain when performing a heel lift or coming up on your ‘tip-toes.’
Lisfranc injury diagnosis
Generally, a Lisfranc injury is diagnosed by clinical assessment combined with foot imaging. Overall, imaging is needed to confirm or rule out a Lisfranc injury.
Lisfranc injury radiology
In severe cases of a mid-foot injury, a plain X-ray is all that is required to pick up a bad fracture or dislocation. However, a Lisfranc sprain can be missed on an X-ray in mild cases. Generally, we suggest weight-bearing X-rays to pick up the abnormal alignment of the joints. Abnormal alignment can mean the Lisfranc ligament is completely torn, also known as a Lisfranc sprain. For example, the X-ray above shows malalignment of the mid-foot bones on the right compared to the left.
A standing CT scan has replaced the weight-bearing X-ray in some specialised centres
If an X-ray does not show an injury, an MRI can demonstrate pain or tear of the ligament.
Treatment of Lisfranc injury
Overall, treatment depends on whether the Lisfranc joint or ligament is affected. However, all but the mildest injuries need to see a surgeon to consider surgical fixation. If we miss a Lisfranc injury, then the consequences for the person can be disastrous.
Lisfranc injury non-surgical treatment
Generally, we treat Lisfranc injuries conservatively if there are no fractures or dislocations and the Lisfranc ligament is intact. We often call these injuries a Lisfranc sprain. Usually, we use a boot with crutches and non-weight-bearing for six weeks, followed by weight-bearing in a stable shoe with an orthotic. We follow up closely to ensure the midfoot bone does not move.
After six weeks, you can start therapy to reduce swelling, improve range of motion and regain balance and strength in your foot. We suggest using therabands and then moving to weight-bearing exercises as the injury heals. Also, massage and joint mobilisation will help accelerate recovery.
Shoe inserts for Lisfranc injury
A mid-foot shoe insert can help reduce the load on the mid-foot, especially when returning to walking, running, and sports. Specialised podiatry service can help make up a shoe orthotic to suit your foot type.
Surgery for Lisfranc injury
Generally, we suggest surgery if the Lisfranc ligament completely tears or there are fractures or poor alignment of the bones. This means the injury is more severe and requires fixing.
The most common fixing procedure is opening the mid-foot and placing a screw to stabilise the bones. The screw acts like the Lisfranc ligament to keep the bones together and in the right place. Usually, we place the screw across the joints to keep the joints stable.
After surgery, the foot is placed in a boot with crutches for six weeks, followed by increased weight bearing for another 3-to four weeks.
Sometimes, we remove the hardware at 5-6 months to prevent irritation of the joints or tendons.
Running after Lisfranc injury
Overall, we suggest running only after a lengthy rehab program. Generally, you need to regain movement, balance, and strength before walking and running. We also recommend jumping (or plyometric exercises) as you move toward a return to sport. Sometimes, return to sport can take up to 6 months.
Final word from Sportdoctorlondon about Lisfranc sprain
A foot sprain is a common but potentially serious injury in sport. If your midfoot pain fails to settle after 1-2 weeks of rest, ice, and ibuprofen, you must see your doctor. Importantly, we should not miss a more serious Lisfranc injury as the consequences, such as early midfoot arthritis, can be devastating.
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