If you’ve found this page, I’m guessing you are not in the best of moods right now. On February 9th of this year, neither was I. Three months ago I suffered a moderately severe Lisfranc fracture. If you too have just been told by your doctor that you’ve suffered this rare type of foot injury, you are most likely googling like mad, trying to figure out what the next few months of your life will look like. In this post I’ll talk about my experience, and give you some helpful tips to make the recovery as successful as possible.
What is a Lisfranc Fracture?
Basically, a Lisfranc is an injury of the bones or ligaments in the middle of your foot. A Lisfranc fracture is when one, two, or even all 5 of your metatarsals (the bones connecting your toes to the middle of your foot) break away from something called the “tarsus.” The silly French name comes from the first recorded case of the injury when a guy fell off a horse in 1815.
Interestingly, Lisfranc fractures are quite rare. I was told only about 1/50,000 foot injuries are of this kind. Usually, they only occur in very high energy impacts like car crashes. Occasionally, they happen in freak ways like in my case. Due to the rarity of this type of injury, it’s critical to get a few opinions, because the medical literature is not in agreement on proper treatment.
Should I be Concerned?
There is a wide gradient of injuries that can occur in the Lisfranc region. In the best of cases, you could have merely a sprain of the midfoot, or a fracture of a single metatarsal. If you do have a fracture, the important thing in determining the severity of the break is the displacement of the bones. Displacement is how out of alignment the bones are from their proper location. Breaking multiple metatarsals with little to no displacement can sometimes be a better prognosis than breaking a single metatarsal with major displacement. The reason is because bones that are severely misaligned will in most cases require surgery to put back in alignment. You don’t want to have surgery if you can avoid it.
If you have been googling for a few hours already, you no doubt have found countless horror stories out there. There are cases of people slashing all 5 metatarsals, feet being crushed, and even cases of amputation. It’s important to remember that these are worst case scenarios, and your story can be way less unfortunate. Even in some of these worst case scenarios there are full recoveries.
The problem with injuries of the Lisfranc area is that the middle of your foot carries all of your weight. This means that small misalignments of the bones can lead to major long term complications. In many cases, these injuries can lead to long term chronic arthritis, and joint pain. The likelihood of your injury resulting in long term complications is directly related to the magnitude of the displacement of the bones.
Three months ago I broke my second and third metatarsals just inside the Lisfranc area while running. In the ER, x-rays confirmed that I had two broken bones, and my first opinion with an orthopedist did not look promising. He was recommending surgery, because the X-rays were showing non-trivial displacement of the bones. This was not great news, because I led a very active lifestyle, with many commitments and people depending on me to be present and perform at a high level. It was looking like I would need to put my life on pause for several months to recover.
The first week was not such a happy one. I was feeling a good deal of pain, swelling, and was quite limited in my mobility. I was basically just sitting around living my life through email and watching House of Cards on NetFlix. It is extremely important to not put ANY weight on your foot if a Lisfranc injury is suspected. Even if your doctor doesn’t see any breaks on an X-ray, continue to be cautious and get a CAT scan to confirm. It’s important to be careful of a false negative because minor Lisfranc’s are notoriously misdiagnosed. If you have a major displacement of multiple metatarsals, you will not be able to walk on your foot by default, and the X-ray will very clearly show this. However, minor hairline fractures can be hard to spot on X-rays, and in some cases people continue to walk after the injury. THIS IS THE WORST THING YOU CAN DO. Most Lisfranc horror stories start with: “I was misdiagnosed and kept putting weight on it after the injury.” Because all your weight is supported by the mid-foot, walking with any injury to the area can result in significant damage that can lead to long term complications like arthritis and severe pain. I was “lucky” to have severe enough pain to immobilize me instantly, but not severe enough that surgery was guaranteed.
Should I Get Surgery?
This is going to be your most important decision. Before making it, consult with a few doctors and make sure to get a CAT scan. If you have multiple metatarsal fractures with major displacement, the decision has probably been made for you. But if you have a more moderate to severe fracture like I did, it can be a tough call to make.
I absorbed a lot of different advice on this question, because I was caught in a very grey area. The displacement of one bone was minimal, but the other was about 1-3 millimeters based on the X-ray. This may not sound like much, but in the highly sensitive Lisfranc area a few millimeters makes the difference between a full recovery and lifelong chronic pain.
To determine your displacement as precisely as possible, you’ve gotta get a CAT scan. Once you have the CAT scan, show it to an orthopedic surgeon with Lisfranc experience. These guys and gals will probably be in the intense trauma part of the hospital, since these injuries are most prevalent in car crashes.
A Perhaps Helpful Analogy
Here is how I made my surgery decision. I’m from an engineering background, so the best way I had the situation explained to me was in terms of tolerances. In manufacturing, you design a part with certain dimensions, but you know that you can only machine the part to a certain tolerance, perhaps +/- a few millimeters. You want the smallest tolerances you can get, but more precision costs more money because you need to invest in higher quality equipment to make the part. By the way, this is why Lego’s are so expensive if you have ever wondered.
This same idea of tolerance applies to surgeries. In this analogy, the surgeon is like the machine manufacturing a part. Just like the machine can only guarantee a certain degree of accuracy, surgeons can only achieve certain degrees of accuracy when placing bones. The better the surgeon, the smaller their error range and the greater likelihood the bones will heal exactly as they are supposed to. If you break a large bone like a femur, this whole tolerance thing doesn’t really matter much. But in the mid-foot with all that weight being supported by a bunch of little bones, it’s everything. The surgeons I talked to said that they can position bones with a tolerance of 1-2 mm. This means that if your bones are displaced less than 2mm, it’s possible that a surgeon is not precise enough to improve the placement.
Bottom line: If your bones are displaced more than 2 mm, you should ideally have surgery.
I had one of the best orthopedic surgeons in my area take a look at my CAT scan, and he determined that my displacement was about 1.8 mm. So I was just within the “error bars.” While my doctor said his error was closer to +/- 1mm than 2mm, the risks of surgery could outweigh that small improvement in alignment. Additionally, I was lucky to have avoided any ligament damage, which was great news. Ligaments don’t heal nearly as well as bones, and if you do have ligament damage surgery is more likely. Ligament damage also increases your chances of developing arthritis. X-Rays don’t show ligament damage, you need a CAT scan and a good doctor to evaluate the damage. Based on my CAT scan, doc recommended skipping the surgery and put me in a hard cast + crutches for 6 weeks.
As mentioned earlier, your risk of long term issues is directly related to the severity of displacement. My doctor put my risk of long term complications at about 10-15%, based on the 1.8mm displacement and no ligament damage. Secondly, my age (21) lowered my risk. For every ten years of additional age, add another 8-10% probability of chronic issues.
So I narrowly avoided surgery, got a black cast up to my knee, and despite my crutches was able to go about my life. I was even able to travel across the country twice. I was also able to get a handicapped parking permit, which really helped. I was on crutches once before in middle school, but never for this long. I tell you, without contrast you take everything for granted. When you lose the ability to walk normally, everything takes longer and becomes harder. Still, I found a few cool tools that made the six weeks more manageable.
Tools to make it easier
First, it’s really annoying to take showers with a foot cast, so you may want to invest in a waterproof stool like this one. Additionally, keeping your cast dry is a challenge. I found these cast bags to be quite helpful.
Next, I live in North Carolina, where we experience sometimes all four seasons in the same day. You never want to be using crutches on slick surfaces, especially in the rain. I slipped two times because the rubber tips at the bottom of my crutches sheared off. I highly recommend purchasing crutch tips with metal plates inside, to prevent your crutches from pushing through the bottom of the tips and causing you to slip. Furthermore, if you are doing a lot of moving, your armpits are going to get really sore. To remedy this, tape some towels around the rubber tops or invest in some of these crutch cushions.
Next, it’s important to keep your foot elevated whenever you can, to keep the swelling down. Too much swelling can lead to a lot of pain, because your giant foot pushes up against the interior of your cast. I recommend this foam leg thing to prop up your legs when sleeping. I did the pillow mountains for a while, but this works way better.
And of course, no pity package is complete without a grabber.
A final tip, be sure to wear sweatpants on the day you expect to get a cast. I made the mistake of wearing my usual slim fitting jeans, which had no chance of coming off after the thick cast was applied. I had to cut them off and turn them into some poorly executed jorts.
Of course, with all the outcomes considered, sacrificing a pair of jeans is not too bad.
Three Months Later
Today, I cannot say that I am totally recovered. After the cast came off, it was tough to get walking again. I needed to train my foot to work again, and that process was at times painful. You want to get back on your feet to start strengthening the muscles, but not too early and risk re injury. I was lucky to not have any ligament damage, so once the bones healed there was little risk of re injury. Today, I can walk with basically no limp, but I’m still favoring my right leg about 60/40. I’ve finally been able to start running again, but this can be at times painful. Yesterday I was able to run 1.5 miles, but then I developed some pain. I’m still not going too crazy, I expect to have minor pains over the next several months. I still have some concerns about my long term prognosis, as that 10-15% possibility of developing arthritis is in the back on my mind. But the recovery is going well, and if you properly rehabilitate the foot, there is no use stressing over statistics.
To wrap this all up, like most things in life nothing is ever as good or as bad as it seems. No matter how severe your injury or how dim your future appears, it’s not going to be as bad as you think.