When an athlete or athletic person can return to sports or exercise is one of the most common questions sports medicine surgeons receive. In this Ask Dr. Geier column, I address this question for a difficult and increasingly recognized foot injury in athletes – a Lisfranc injury.

Jaydin asks:
Dr. Geier,
I’m a 16-year-old football player from Corona del Mar High School dealing with a Lisfranc tear in my right foot. It’s been 6 weeks with a walking boot on and I’m getting ready to take it off. What do you suggest it the best recourse for physical therapy and rehabbing my foot?
Thank you!

That is a great question. Before I address physical therapy and return to sports, let me explain the injury. A Lisfranc injury is an injury to the midfoot that often affects athletes in sports that involve sprinting and quickly changing directions, like football and soccer. Specifically the athlete injures ligaments between small bones in the midfoot or suffers a fracture of these bones.

How does an athlete suffer a Lisfranc injury?

While severe Lisfranc injuries involving multiple bones and ligaments in the midfoot can result from high-energy trauma, treatment of those injuries is beyond the scope of this column. In sports, a Lisfranc injury usually involves disruption of the ligament that connects one of the metatarsals (the long bones in the foot) to a bone in the arch of the foot.

Also read:
Ask Dr. Geier: MCL injuries
Ask Dr. Geier: Return to sports after ACL surgery

The athlete might suffer the injury trying to push off his foot when someone falls on him or his lower leg. Or he might awkwardly twist his foot while changing directions. The athlete often notices pain on top of the arch of the foot, and the top of his foot often shows swelling or bruising. He will likely have difficulty bearing weight as well.

Location of foot pain from a Lisfranc injury

X-rays and MRI

X-rays often demonstrate these injuries if the ligament injury leads to widening of the space between the first and second metatarsals. Often the surgeon will find tenderness in this part of the foot on physical exam despite x-rays that do not demonstrate obvious widening and will order an MRI to better evaluate the ligaments.

Treatment options

Since these bones and joints stabilize the arch of the foot, Lisfranc injuries can lead to long-term pain and degenerative changes if the joints don’t heal in an anatomic position. If a ligament injury occurs but the bones are nondisplaced, the surgeon will often place the patient in a cast or boot for about six weeks and require him to remain strictly nonweightbearing. If the radiographic studies demonstrate displacement, the surgeon often performs surgery to properly align the bones and hold them with screws or combination of plates and screws.

Also read:
Ask Dr. Geier: Return to activity after meniscus surgery
Ask Dr. Geier – Biceps tendon ruptures

Progression to running and sport-specific exercises

Whether the injury is treated surgically or nonoperatively, the athlete remains nonweightbearing until he heals. The surgeon generally then allows progressive weightbearing before transitioning to normal shoes. Many surgeons choose to remove the hardware before progression to running as the screws can break over time. Physical therapy can help to increase range of motion of the foot and ankle and promote return of lower extremity strength. Once the surgeon clears the patient for more aggressive activity, the physical therapist can help with functional and sport-specific activities. Overall this process from injury to full return to sports and exercise can take 4 to 6 months.

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