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Saturday, January 28, 2017

Lisfranc's Injury initially Missed: Email Advice

Hi Dr Blake,

Thank you for the helpful information on your blog, especially the foot strengthening exercises. I have a long and complicated history of foot pain, therefore I wanted to reach out to you personally and ask for some advice.

I am a 52 year-old woman who has struggled with pain in my feet since 2005. I first injured my left foot after I fell on the sidewalk while on vacation. My whole foot hurt and was bruised and swollen, but the x-ray didn’t show any fracture and I was thus told by a specialist it was only a sprain. I rested the foot for about 6 weeks, but the pain didn’t go away (although it didn’t hurt as much as immediately after the injury) and I used pain medication ( painkiller containing  paracetamol and codeine and painkiller containing tramadol) to relieve the pain so that I was able to walk. 

However, my foot didn’t get any better and the pain slowly got worse. After about 1,5 years, I again visited an orthopedic specialist and both CT and MRI scans were taken. These images showed major strains and damage to the Lisfrancs and I was told this was the reason for my pain. I was also told that there wouldn’t be much to do with my injury, and that surgery wouldn’t be advised other than as a last resort. The only treatment I got was that I had orthotics made that actually helped me some with the pain – at least they kept me going until 2014.
 The middle of her foot where the Lisfranc's Joint is shows marked arthritis.

The CT Scan showing Mid-foot arthritis where the bones look irregular

In 2014, the pain was so bad that I had surgery done. Over the years, a large cartilage lump had formed on the top of my foot, and the pain was so bad that walking even short distances was difficult. The surgical procedure involved fusion of the 1st to the 3rd Lisfrancs in order to relieve pain and stabilize the joints. The surgery was successful; I had significantly less pain and could walk normally on the foot although the foot became less flexible and I’ve noticed that my balance is worse than it used to be. Still, it was worth it because my quality of life improved a lot.

All the Hardware to stabilize her foot

Sadly, shortly after the surgery of my left foot I began experiencing pain in my right foot. About one year after the surgery, in 2015, I had an MRI of the right foot. These images showed strain damage to the Lisfrancs similar to my left foot. However, in contrast to my left foot, I hadn’t injured my right foot in any way. The orthopedic surgeon told me that there probably is a heritable component to my injury – that I’m prone to Lisfranc strain because there is something innately “wrong” with the bones in my midfeet. I’m sorry I’m explaining this so vaguely – I don’t know the medical term of my “condition” and I haven’t got any other information than this. My orthopedic surgeon said that he was able to see this partly heritable condition on CT scans.
Dr Blake's comment: Unfortunately we do have weak spots in our bodies, and they tend to involve both sides at different times. Thus, my mom has had 2 knee replacements, with good hips. My father in law has had 2 hip replacements, with good knees. Midfoot arthritis tends to occur on both sides, at variable times, and this is separate from your original injury that forced you to have surgery. 

So, now I’m waiting to have surgery on my right foot too. It will probably be in April 2017. I have some questions I’m hoping you can answer:

1.       What can I do to relieve the pain? Non-weight bearing is not an option because of my profession. My right foot hurts a lot after a normal day, it becomes swollen and sometimes I have trouble sleeping because of the pain.
Dr Blake's comment: You have to use good stable shoes, good orthotic support, and arch taping. You can use a removable boot for short periods of activity (you will know when after you begin to use it).  You should ice for 10 minutes twice daily, and do a full 20 minute contrast bath as close to every evening. Get a bone density evaluation, and make sure you have solid bones to heal. Stay away from NSAIDS if you can, slow down bone healing, except the occasional 2 advils or 1 aleve when you are more riled up. Consider a scooter, where you have no weight on your foot, for shopping, museums, etc. You probably have one for after surgery of the left foot. 
2.       I also often get muscle cramps under and over my foot after a regular day. Is there anything I can do to prevent this?
Dr Blake's comment: Not push through pain, roll the arch over a frozen sports bottle for 5 minutes twice daily to get massage, resting your foot more with boot, scooter, occasionally crutches, mix it up!! Massage the calf to loosen that up. Make sure you are getting correct vitamins like K.
3.       What foot strengthening exercises do you recommend? Are some exercises contra-indicated because of the surgery? Similarly, are some exercises contra-indicated when I’m waiting to have surgery in my right foot? I’ve tried some of the foot balancing exercises, but my right foot becomes quite painful when I do them.
Dr Blake's comment: You have to let pain be your guide unfortunately. So many to the muscles attach into the sore area. Typically you can balance on the left only, but both sides can do active range of motion exercises like moving your foot 3 times a day through the alphabet. Metatarsal doming should be great. Theraband for only the left for right now.
4.       Do you have any advice on foot wear? I’m currently using Hoka shoes without orthotics. What kind of orthotics (if any) is recommended?
Dr Blake's comment: Hokas is a great choice if they are wide enough. You sometimes even to use the New Balance 928 to great the rocker effect and the width (up to 6E in some styles). I hope your left can now take a plastic orthotic with good support, but the right may have to use tape and a soft orthotic device. Try to support the foot tape online and see if it helps before you buy alot. Or experiment with kinesiotape methods. 
5.       I have quite a lot of metal plates and screws in my left foot, and although I have significantly less pain in this foot after the surgery, I still experience some pain and  stiffness  and I wonder if some (or all) of the metal should be removed? If not, what can I do to improve the functioning of my left foot as much as possible?
Dr Blake's comment: Only a surgeon can tell you about the screw and plate removal options, most of my patients leave them in. A good functioning foot needs a very stable foot, which it should be, flexibility across the big toe joint (which you should have), and a powerful achilles tendon. Not knowing anything about you, I would stay start there. Try to develop a plan that gradually and progressively strengthens the achilles/calf of the left foot. I have some videos that I will include, but experiment. 





6.       Finally – is there any possibility to avoid surgery in my right foot? These types of surgery are so comprehensive and there is no “going back”. Would conservative treatment be futile in my case?
Dr Blake's comment: Sure, please right another email and just focus on the right. Do not even mention the left. That will get my brain working better. You can see I even mismatched the photos. Send the right photos again. Only the right. Overall, I hope it was helpful.

I would be really grateful for any answers! Attached are CT and x-ray scans from September 2016, which are the most recent images of my right foot. It is also a x-ray scan of my left foot taken right after the operation in January 2014.

Best regards,

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.