Diagnosing a Lisfranc Ligament Injury
Introduction
Injuries at the Lisfranc joint are noted to occur at an incidence rate of 14 per 100,000 persons a year (1). Up to 20% of Lisfranc injuries are misdiagnosed or missed altogether on initial evaluation (2).
Illustrated Lisfranc Joint Complex (5)
The Lisfranc joint or tarsometatarsal joint is an important stabilizer of the midfoot, connecting the five metatarsals with the 3 cuneiforms and cuboid (3).
Illustrated Lisfranc Joint Cross-Section (5)
The Lisfranc ligament is a combination of three individual ligaments within the joint complex: interosseus, dorsal and plantar ligaments. The interosseus ligament (considered the “Lisfranc ligament proper”) is the strongest of the three and connects the 2nd metatarsal with the medial cuneiform (4).
Lisfranc injuries occur with high energy trauma such as MVAs but more commonly with low energy trauma seen in sports-related injuries or falls/missteps (1). The mechanism of action often results from a compressive axial force applied onto a plantar-flexed foot such as a competitor stepping on the plantar-flexed foot of an opponent (5).
Diagnosis
Patients will likely present with tenderness or swelling around the Lisfranc joint area. Patients may be unable to plantar-flex with the affected foot (5). A clinical exam sign that can be visualized is plantar ecchymosis which is suggestive of a Lisfranc ligament injury.
Plantar ecchymosis at the mid-foot is strongly suggestive of Lisfranc injury (5).
One special test to aid in diagnosis of a lisfranc ligament is a pronation-abduction test. The test is performed by stabilizing the hindfoot and simultaneously pronating and abducting the forefoot to elicit pain (5).
Pronation-abduction test (5)
A Lisfranc joint squeeze test can also suggest a Lisfranc ligament injury. The test is performed when the examiner places the palm on the dorsum of the midfoot and applying a compressive force with the thumb and digits (5).
Lisfranc Joint squeeze test (5)
Non-weight bearing X-Rays routinely miss subtle Lisfranc injuries reported at 20-50% of the time (7). Weight bearing views can increase the space between the 1st and 2nd metatarsal. A positive test would be widening of 2-5mm (9).
Non-weight bearing (A) vs weight bearing (B) radiographs demonstrating widening of Lisfranc space (8)
A “Fleck sign” may be evident with Lisfranc ligament avulsion in which a bony fragment of the 2nd metatarsal or medial cuneiform is present in the space between the 1st and 2nd metatarsals (11).
“Fleck sign” on radiograph indicating Lisfranc ligament avulsion (10)
MRI has high sensitivity and negative predictive value for diagnosis and should be considered in patients with high clinical suspicion despite negative films (12). The Lisfranc ligament is highly visible with axial, transverse oblique and coronal MR images but more difficult to visualize in the sagittal plane (13).
MRI revealing tear of the Lisfranc ligament and surrounding edema in the Lisfranc space and joint (5)
Conclusion
A Lisfranc ligament injury should be considered in an athlete complaining of pain and tenderness along the midfoot. These injuries are common with low impact trauma on a plantar-flexed foot. Weightbearing plain radiographs are useful but MRI can provide more accurate diagnosis when suspicion remains high.
This review was written by Dr. Jesse Mcilwaine a second year resident at NCH Healthcare in Naples, Florida who will be applying for a sports medicine fellowship next cycle.
– More Foot Pain: https://www.sportsmedreview.com/by-joint/foot/
– Read More @ Wiki Sports Medicine: https://wikism.org/Lisfranc_Injury
References
1) Stødle, A. H., Hvaal, K. H., Enger, M., Brøgger, H., Madsen, J. E., & Ellingsen Husebye, E. (2020). Lisfranc injuries: Incidence, mechanisms of injury and predictors of instability. Foot and Ankle Surgery, 26(5), 535–540. https://doi.org/10.1016/j.fas.2019.06.002
2) Goossens M, De NS. Lisfranc’s fracture-dislocations: etiology, radiology, and results of treatment. A review of 20 cases. Clin Orthop Relat Res. 1983;176:154–162.
3) Desmond, E. A., & Chou, L. B. (2006). Current Concepts Review: Lisfranc injuries. Foot & Ankle International, 27(8), 653–660. https://doi.org/10.1177/107110070602700819
4) Solan, M. C., Moorman, C. T., Miyamoto, R. G., Jasper, L. E., & Belkoff, S. M. (2001). Ligamentous restraints of the Second tarsometatarsal joint: A biomechanical evaluation. Foot & Ankle International, 22(8), 637–641. https://doi.org/10.1177/107110070102200804
5) Beutler, A., & Taylor, C. (2023). UpToDate: Tarsometatarsal (Lisfranc) joint complex injuries. Retrieved March 17, 2023.
6) Ross, G., Cronin, R., Hauzenblas, J., & Juliano, P. (1996). Plantar ecchymosis sign: A clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. Journal of Orthopaedic Trauma, 10(2), 119–122. https://doi.org/10.1097/00005131-199602000-00008
7) Yan, A., Chen, S. R., Ma, X., Shi, Z., & Hogan, M. C. (2021). Updates on Lisfranc complex injuries. Foot & Ankle Orthopaedics, 6(1), 247301142098227. https://doi.org/10.1177/2473011420982275
8) Lattermann, C., Goldstein, J. L., Wukich, D. K., Lee, S., & Bach, B. R. (2007). Practical management of lisfranc injuries in athletes. Clinical Journal of Sport Medicine, 17(4), 311–315. https://doi.org/10.1097/jsm.0b013e31811ed0ba
9) Shapiro, M. S., Wascher, D. C., & Finerman, G. A. (1994). Rupture of lisfranc’s ligament in athletes*. The American Journal of Sports Medicine, 22(5), 687–691. https://doi.org/10.1177/036354659402200518
10) Yim, H. S., Hong, S. H., & Sung, K. S. (2016). Lisfranc joint injuries: Diagnosis and treatment. Journal of the Korean Fracture Society, 29(4), 283. https://doi.org/10.12671/jkfs.2016.29.4.283
11) Myerson, M. S., Fisher, R. T., Burgess, A. R., & Kenzora, J. E. (1986). Fracture dislocations of the tarsometatarsal joints: End results correlated with pathology and treatment. Foot & Ankle, 6(5), 225–242. https://doi.org/10.1177/107110078600600504
12) Kreulen, C., Giza, E., Escobedo, E., Bateni, C., & Doherty, M. (2018). Role of MRI in the diagnosis of injury to the Lisfranc ligament complex. Foot & Ankle Orthopaedics, 3(3). https://doi.org/10.1177/2473011418s00297
13) Castro, M., Melão, L., Canella, C., Weber, M., Negrão, P., Trudell, D., & Resnick, D. (2010). Lisfranc joint ligamentous complex: MRI with anatomic correlation in cadavers. American Journal of Roentgenology, 195(6). https://doi.org/10.2214/ajr.10.4674
