Lisfranc Injuries (midfoot sprains)
Lisfranc
A Lisfranc injury, which occurs in the midfoot is commonly overlooked and misdiagnosed. The signs, symptoms, special tests and even imaging can be subtle. Initially, the pain can be mild causing dancers to continue performing and adding to the challenge of accurately diagnosing. In my career of treating dancers, I have seen a little more than a handful of Lisfranc injuries. So, on the surface that may sound uncommon. But let us consider how many ankle sprains are treated? We know it is common for a dancer to slip or roll an ankle in rehearsal, performance or class and just ice, wrap, tape and continue dancing.
This can be a debilitating injury leading to other issues as it can create such an instability in the foot.
Type of Lisfranc Injuries
Sprain - a stretching or tearing of the ligament in the Lisfranc complex. We specifically see injury to the ligament that attaches the base of the second metatarsal to the cunieform.
Fracture - a fracture may occur at the base of the metatarsal where the ligament attaches to.
Dislocation - the second metatarsal may dislocate in addition to the ligament tear and fracture. This occurs because nothing stabilized the 2nd metatarsal to the first.
Anatomy of Foot and Lisfranc Complex
The foot is divided into 3 sections – forefoot (toes and metatarsal bones), mid-foot (navicular, cuboid, cuneiform) and hindfoot (talus, calcaneus).
Connecting the metatarsals and providing support to the transverse arch are the intermetatarsal ligaments.
The intermetatarsal ligaments run between metatarsal 2-5, which supports the transverse arch.
There is no transverse ligament between metatarsal 1 and 2. Only an oblique ligament that runs from the base of the second metarsal to the medial cunieform (lisfranc ligament). This might account for the injuries that occur in this area.
Mechanism of Injury
The injury occurs due to a torsion or abduction of the forefoot with an axial load when the foot is in a plantarflexed position. This is seen in football or soccer when the cleat is stuck in the turf as a player changes direction.
There is not a lot of research in the area of dancers, however it is reported from patients from falling off pointe, missed jump landings, during spin, or takeoff for a jump. I have seen the following in the clinic.
Dancer with a history of ankle sprains and foot injuries while on pointe went into a pirouette and she slipped injuring the supporting or turning foot.
Dancer went into a turn with the back leg plantar flexed and possibly a little forefoot abduction. When she tried to push off the back foot she heard and felt a pop.
Dancers with no traumatic event injured due to possible wear and tear. If we think about the mechanics of a demi or pointe if there is weakness in the arch and the dancer is twisting/abducting the forefoot it can stress this area every time they go into pointe or demi pointe.
Clinical Findings
There is no special tests to perform on a chronic injury. However, you will see a diastis or separation from the cuneiform and metatarsal. Also, you can apply a dorsal push to the base of the 2nd metatarsal to see the laxity in the ligament.
To test the stability you want to stabilize the midfoot and apply a dorsal pressure at the base of the second metatarsal. Compare to the non-injured foot if the ligament is sprained you will see excessive movement in the dorsal direction.
You will need to confirm with imaging and to determine if there is a fracture or dislocation of the 2nd metatarsal.
Treatment
Non-surgical; stabilize the midfoot through taping or compression socks.
Work to strengthen the arch muscles; it is important to due this without engaging toes
Strengthen FHL muscle
Work on ankle and midfoot mobility (specifically into dorsi-flexion)
Demi in hooklying position focus on articulation of the foot and equal height of the demi
Progress demi exercises to seated
Progress demi exercises to standing in parallel
Balance exercises activating the midfoot/arch
Progress to pointe shoe (usually dancers feel more stable in their pointe shoe than in demi but keep in mind it is important that they have the strength and stability for demi)
Surgical: similar goals but will not need taping to stabilize midfoot
Summary
This injury can be a challenge for dancers to regain that strength and stability in the foot necessary for pointe/demi-pointe. Rehabilitation should focus on mobility in the ankle and midfoot, as well as strength and alignment into demi to overcome.
Another consideration is that it is important for pre-pointe assessments/strengthening to teach younger dancers. This type of program should be re-visited throughout a dancers career to ensure the strength and mobility in their foot.
Below are a few resources on this injury. More research needs to be done with dancers and their outcomes. However, the start is educating!
Please leave any comments or questions we love hearing your feedback.
References
Nunley JA,Vertullo,CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 2002; 30 (6): 871-878
Johnson A, Hill K, Ward J, Ficke J. Anatomy of the lisfranc ligament. Foot Ankle Spec. 2008 Feb;1(1):19-23. doi: 10.1177/1938640007312300.. PMID: 19825687.