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Tuesday, September 5, 2017

Lis Franc Injury: Email Advice

Dear Dr. Blake, 

I (myself) have what I think is an interesting Lis franc injury and if you have a moment I would greatly appreciate your opinion. 

Athletic history, 10 years of ultra-endurance running (trail 100 miles) and Ironman triathlons. 

MOI: Outstretched leg on the boat dock with the boat moving towards the dock. Arch placed on edge of dock, the force of boat bent foot at arch (plantar surface towards the heel). immediate “pop” swelling over medial cuneiform, tender to palpation.  

Date of injury ~June 1st. Initial X-ray negative, circumferential swelling/bruising (medial and plantar, mainly) and the majority of pain subsided by day 3-4. Walked but with slight limb but continued to improve slowly over next 4-weeks but still had difficulty running (pain around 1st/2nd metatarsals and medial arch with push-off. No pain with stairs. At 4-weeks had MRI 

MRI: tiny non-displaced fx at the medial aspect of navicular, small cortical avulsion fx from the second metatarsal base. interosseous Lis franc “compatible with high-grade disruption, A torn stump of fibers remain attached to the medial second metatarsal base and distal lateral aspect of the medial cuneiform. It is difficult to appreciate intact interosseous Lis Franc ligament fibers at this time. Complete disruption of the dorsal Lis Franc ligament. The plantar ligament is at least partially detached from the second metatarsal base, in the setting of the tiny cortical avulsion fx.”

presentation at 4-weeks - near normal ambulation, minimal pain (except attempting to run) and very little instability
Due to lack of instability Ortho Rx: non-weight bearing in boot x 4 weeks, ambulating in boot x 2 weeks, then 2weeks in stiff soled shoes, then follow up. 

Currently, I’m in my 1st week of walking in stiff shoes. Very little pain around Lis franc/dorsal part of the foot, other than the feel of stretching. Occasional pain in 3rd/4th phalanges. Occasional pain around the anterior portion of ankle/malleolus, (navicular/cuboid area). There is a firm “nodule” about the mid portion of the foot in-between the plantar fascia and medial portion of the arch. A majority of the pain (nearly constant) is in the area of the medial side of foot near the top of the arch. Occasionally it occurs distally, and other times it's more proximal (in/around the fleshy area between the medial malleolus and calcaneus). Pain is reproducible by full dorsiflexion and eversion. Pain is felt along the medial arch and pulls (causes pain on top of medial cuneiform. Little to no instability, but will occasionally “lock-up” and feel a "knuckle crack" (no pain). 

when performing single leg toe raises slight pain from arch/nodule area and “stretching” around medial cuneiform. I can run, but the pain from arch and ankle area increase post-run. My follow-up is next week and although considering the severity of the MRI, I feel my presentation is not remarkable. With the ultimate goal of returning to running,  I’m curious on your thoughts if surgery sounds like it might still be necessary? Or other options you might suggest at this point. 

I appreciate any advice you might have!

Thank you, 

Dr. Blake's comment: Thank you so very much for emailing this problem. Typically, we will have a surgeon have the first crack at deciding if the foot should be repaired. With your wonderful athletic life, if the wrong decision is made, the arch could collapse the next time or even the thousandth time you put a tremendous load on it. So, 2-3 independent surgical opinions to protect you from yourself and your goals are in order. This is different from a fracture we can follow pain wise as we rehabilitate someone. And, you have to treat the worse case scenario possibility. If you do have it repaired, even though there is a time for rehabilitation, there should be no reason you can not get back into full activity. 
     Please have a stress test x-ray put on the Lisfranc's to check its integrity. This is particularly important if they decide to let you go back to athletics. Athletics should be with KT arch taping to stabilise the joint, along with the highest arched orthotic that can be made to stabilise without throwing you to the outside. I hope this helps somewhat. 

https://youtu.be/HT-ug-RhAmg

Here is the section from my book on Lisfranc's Joint Injuries which emphasizes the conservative.

2. Lisfranc’s Sprain

    Across the instep, where the metatarsals meet the arch, is a series of joints called the Lisfrancs joint. It involves all the metatarsals, with the most severe injury under the first and second metatarsal bases. Here lies the Lisfranc Ligament, and when torn, can cause the entire arch to collapse.
     A complete tear of the Lisfranc’s ligament, a diagnosis made by MRI, is a surgical injury. It is one of the most serious sprains in the whole body and must be over treated. This is not the topic of our discussion here. For the many Lisfranc injuries, not involving a complete tear of the ligament, conservative treatment works well. Remember a sprain occurs with some twisting motion or sudden acute jarring force. Without a history of this, most likely pain in this area is some other diagnosis as we will discuss later.

The Lisfranc Ligament runs between the base of the 2nd metatarsal and the first cuneiform.

    The top 10 conservative treatments for Lisfranc’s sprain/injuries (without complete rupture of the Lisfranc Ligament):
  1. Arch supports (typically custom) with as high of a medial arch as possible/comfortable.
  2. MRI for ligament testing. Also, make sure patient can do a one sided toe raise. This can be impossible with a complete ligament tear.
  3.  Kinesio taping in a circumferential wrap around the entire foot for 2 months longer than you think you need to.
  4. Avoid activities that lift the heel off the ground initially.
  5. Ice Pack 2 times daily for 20 minutes to reduce the inflammation.
  6. Create a pain-free environment with crutches, removable boots, other assistive aids.
  7. Pain over 5 in the area of the Lisfranc’s Joint should be over protected until you are certain it is not a ligament rupture.
  8. Begin metatarsal doming, 2 positional inversion/eversion therabands, and Single Leg Balancing. Go to YouTube and type drblakeshealingsole foot strengthening exercise playlist. Remember no exercise should hurt.
  9. There is really no stretching for this injury that helps directly. However, massaging the arch to move the swelling that collects there can be very helpful.
  10.     Stretching the Achilles tendon indirectly takes the tension off the arch. When done, do both gastrocnemius and soleus stretches but only with the heel firmly on the ground. Go to YouTube and type drblakeshealingsole Achilles stretches.
Lisfrancs and Sesamoid Injury: Email Advice

Hi Dr. Blake,
First, let me say what an incredible resource your blog has been for me - and how grateful I am that you take the time to advise and treat patients simply because you believe everyone has the right to heal. So thank you.  As for me, I've seen far too many doctors - who all have very different opinions (and seemingly different levels of commitment to my healing). I'm desperately seeking a treatment plan - and some patience with the many questions that I have.
Now here's my story… I'm 30 years old and live in New York City. Back in late MARCH, I tripped up (yes UP) the stairs -- and injured my toe/foot. I seemed to only have pain in my big toe (top of my foot) - in the phalange and metatarsal. The first podiatrist I saw didn't catch anything in the x-ray and believed it was a stress fracture. After 3 weeks of it not seeming to get any better, he still gave me his blessing to go on my 2 week Europe trip. I should have listened to instinct...but alas. I went, wrapped my foot, threw it in a hiking boot, grabbed a cane, and went on my way. The trip was great - but by the last day, I couldn't stand. And my foot was purple.
Came home beginning of May - switched doctors. Got an MRI (and another x ray) - and it was confirmed that I have a fractured tibial sesamoid, as well as a Lis franc ligament sprain. The doctor seemed to pay little regard to the Lis franc injury - saying that a sprain isn't serious.
Dr. Blake' s comment: A Lisfranc injury is one of the most severe foot injuries I treat, with one of the highest percentages for sprains needing surgery.  
Now here's where things get even more complicated. I was heading to Los Angeles for a gig a few days later. The doctor advised me to non-weight bear for 3 weeks (in a removable walking boot), use a dancers pad, then see another doctor (doctor #3).  I continued to have swelling - but iced and did contrast baths daily. Saw an ortho in Los Angeles - who perhaps due to my desire to be as conservative as possible - decided to keep me non-weight bearing for 8 weeks. The last thing I wanted was to look back and wish I would have committed to more time. He also thought that the bone might be dying, and thought that when I'm back in NYC I should have a CT scan (or bone scan?)
So now...I'm back in NYC. Saw a new Ortho (doc #4). He said that I should start putting weight on it and to stay in the boot until my next appointment -- in 4 weeks. And he said no CT scan.  Unfortunately, I had no advice on how to wean off the crutches - it was implied that it would easy to just start walking. Not really the case for me. So...I started weight bearing while still using the crutches for a few days, then went down to one crutch, and now to a cane. I seem to be doing pretty well -- except that I keep getting a shooting pain in my ankle every time I step a certain way (which isn't that often - but when it happens it HURTS). Been happening now for the last 4 days. The sesamoid, however, seems to be ok. Still a little swollen - but doesn't seem to have very much pain at the fracture site.
Also, my whole body seems pretty out of whack (my hips have a very strange turn out right now).
Dr. Blake's comment: Typically this out of whack feeling is part of any cast regimen.  It is helped greatly by using an EvenUp on the side without the cast and never going to one crutch.  It should be 2 crutches or no crutches since one crutch and sometimes canes throw your back and pelvis into strange tilts.

So now that you know my story, I have so many questions...

1. My big toe still feels so strange. Like it weighs 5 pounds. Which is how it felt when I first injured it (why I assumed I broke my toe). I can barely bend it down - and can't bend it up at all. Is this normal? The pain/stiffness/heaviness goes from the joint of my big toe down to the middle of my foot. Often times I have strange twitching there as well...
Dr. Blake's comment: For what I know, this is all normal for your injury and being in a cast and non-weight bearing for a while. You are gradually progressing from the Immobilization Phase of Rehab to the Re-Strengthening Phase. During this phase, you need a lot of physical therapy guidance to work on the remaining swelling and increase the range of motion, strength, flexibility, and balance. There is a lot of hard work ahead.  

2. At this point, should I be forcing my toe to bend? Or is it all still healing that it should still be immobilized most of the time?
Dr. Blake's comment: For these injuries, you never push the toe bending part of rehab. You let that come naturally. It is always fun to measure the range of motion at each stage if you have a therapist you will be working with. Typically you come out of the cast with almost no motion in the joint. Definitely, you can start doing some of the self-mobilization movements. Go to YouTube and type drblakeshealingsole Self Mobilization Hallux Limitus. You can gain 20-30 degrees as you begin to walk normally, and another 20 degrees as you begin to run.  Keep the joint pain free when you are working on it, you never know if more healing is still going on it there.

3. What about ankle exercises? Could that also interfere with the healing of the sesamoid/toe? Any physical therapy for the rest of my body? Or should I still wait?
Dr. Blake's comment: Core and other lower extremity strengthening that does not hurt the injury can normally be started right after the injury.  There is a benefit to riding a stationary bike with one foot even when there is no tension on the foot in the boot. There are so many core, hip, knee, and ankle movements that you should be doing right now, and that is why a PT or Personal Trainer can help. The stronger the core, the more normal you are lifted off the foot, and the faster the rehabilitation goes.
4. This Lis franc sprain - is this really something that should be so swept under the rug? I finally researched it and it sounds like it could be a big deal. How do I find out if the sprain has healed?
Dr. Blake's comment: Lisfranc Injuries are big deals. You need to wait 3 months for your first MRI  to get a repeat MRI to document healing.  I treat all Lisfranc Sprains very seriously with a 2-year commitment to orthotic devices, arch taping, and a gradual progressive re-strengthening program on all the important intrinsic and extrinsic muscles/tendons that support the arch. Go to YouTube and type drblakeshealingsole foot and ankle strengthening playlist.

    The middle of my foot definitely hurts right now - but I assume a lot of it has to do with the fact that I'm putting weight on it for the first time in 8 weeks. I also have a bony bump in the middle of my foot - under the big toe. The doctor assumed it was from the boot. Does that sound right to you - or could it have something to do with this Lis franc thing?
Dr. Blake's comment: Lisfranc's Injuries hurt in the middle of the foot. If you are weight bearing, get an orthotic ASAP to stabilize that area and learn to tape your arch (Chapter 4).  I am not sure what the bony bump is. You could send me a photo of you pointing it out, and another of the same spot on MRI.  

5. Does walking in the walking boot for 4 weeks after being non-weight bearing for 8 (and in a hiking boot for 4 weeks before that) seem like the right treatment course?
Dr. Blake's comment: Yes, but 16 weeks of immobilization means 32 weeks minimum more to get your foot healthy again. Go slow, go gentle, but persist. You are still in the hands of the docs for direction, but PTs and Personal Trainers and Athletic Trainers should have the most prominent role in your recovery now.  

6. My left foot has also been hurting quite a bit - since it's been doing most of the work the last couple of months. Is there an insert/insole you can recommend helping this? Mostly the middle of my foot. What about Superfeet?
Dr. Blake's comment: When you get custom made functional foot orthotics from a sports podiatrist, they are always made in pairs. Consider seeing Dr. Karen Langone, Dr. Robert Conenello, and Dr. David Davidson in New York. You can also see the AAPSM website for all the New York members. I am typically safe recommending from that list.  

7. I've been using the bone stimulator twice a day on my sesamoid - which is why I haven't been taping. Should I be taping and just removing it daily?
Dr. Blake's comment: The bone stimulator has a 3-inch penetration. You can aim the beam from the top of your foot where you do not have tape, and it will still work. That way you can tape also. This is at least my understanding of the Exogen bone stimulator but check with the local rep.
8. I'm not 100% sold on this ortho I'm seeing in NYC. He's just so rushed - in and out in 5 minutes. Do you know a doc (ortho or DPM) here that you would recommend? I had been recommended someone at the hospital for special surgery - but unfortunately, they don't take my insurance (GHI/Emblem)
Dr. Blake's comment: See my recommendations above. Even if they are a distance, it is worth it. They can refer you to a local PT to do the lion's share of the work.  

9. Would it be possible for me to send you my MRI from the beginning of May? I would love to know your thoughts.
Dr. Blake's comment: Yes, Dr. Rich Blake, 900 Hyde Street, San Francisco,
         CA, 94109.  

    Thank you so much for taking the time. As I mentioned, I generally need to be on my feet all day (although this last one in LA was thankfully pretty low key). I'm so anxious for my foot to feel normal again, but I'm also committed to recovery and can be as patient as I need to be. However, I just need to feel like I'm doing what's "right". And with so many different doctors over the last few months (all with very different opinions) - I'm left fairly confused and rather discouraged.
Any thoughts/advice would be so greatly appreciated.

MANY THANKS,
Jill (name changed)

Sorry, one last question!!  I've been using 1/4" adhesive felt applied directly to my foot for the dancer's pad. Is this correct for use in a boot?
Dr. Blake's comment: See if you can place as an insert in the boot. Somewhere in my blog “drblakeshealingsole” I have an example of this. Get working on your orthotics ASAP and then just place that in the boot. I sure hope this helps you.

Thanks!!!


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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.