Learning about the scary, life-altering potential of a Lisfranc fracture
This article is first in a series of seven that chronicles my experience following Lisfranc injury.
Part 1: Learning about the scary life-altering potential of a Lisfranc fracture
Part 2: Setting goals for Lisfranc recovery gives optimism, determination and purpose
Part 3: Surgery day and learning about the Arthrex InternalBrace
Part 4: Lisfranc recovery is slower and tougher than imagined
Part 5: Relearning to walk and ride a bike after Lisfranc surgery
Part 6: The 215-mile Lisfranc recovery test
Part 7: Looking back a year later. What’s fixed and what isn’t.
Part 8: Did the iWalk crutch speed my recovery?
If you’ve never heard of a Lisfranc fracture you’re not alone. I didn’t know what to make of it when I was informed it’s what was wrong with my right foot. After all, it was nine days after the injury, and I’d just limped into the doctor’s office under my own power. As far as I could tell I was on the mend.
“You have a fairly serious injury,” the podiatrist said. “You don’t have to have surgery, but if you’re active at all, you should.”
He picked up a skeleton model of a foot and showed me where the Lisfranc ligament is supposed to be: in the middle of the foot, right above the arch. Mine was most likely completely torn, but it’s possible it was a partial tear. Not the worst he’d seen. Not the mildest, either. Surgery would involve putting a single screw through the middle of my foot to do the work of the missing ligament until enough scar tissue formed in its place. He’d leave the screw for four or five months and remove it via a second surgery.
A post-injury, pre-surgery trip to Bend, Ore. and implementing the rest, ice, compression, elevation (RICE) method in the truck.
In his way, he gently urged me to enlist for surgery as soon as possible, but all I heard was that I didn’t have to. My intuition was to avoid surgery at all costs. In my mind surgeries lead to more surgeries, and I didn’t want to start down that slippery slope. I stood up and limped out of his office, determined to heal on my own.
That night I dug into the world-wide web and started learning about this relatively rare and fairly serious injury. The more I read, the more frightened I became.
According to a July 1998 article in American Family Physician, Lisfranc fractures account for fewer than 1 percent of all fractures and are frequently misdiagnosed. It’s named for a French military surgeon, Jacques Lisfranc, who identified the joint after a soldier fell off his horse with his foot stuck in a stirrup.
I read with mounting consternation how serious the injury can be. It almost always ends the careers of professional athletes. It can cause debilitating osteoarthritis years after its been fixed. Recovery involves anywhere from six to 12 weeks of zero weight-bearing activity on the affected foot, and another one to four months walking in an orthopedic walking boot.
Even then, patients wore carbon footbeds and reported pain and complications for years. This wasn’t insignificant stuff at all. I got scared. I pondered the array of strenuous activities that make me happy: skiing, mountain biking, whitewater kayaking, rock climbing, hiking, backpacking, HIT classes. I thought about less intense activities that might also be impacted: walking downtown for dinner, walking the dog, jumping across the street with my nephews, wearing flip-flops. This thing had the potential to change my life.
Traditional crutches worked for a few days, but once I got my hands on the iWalk hands-free crutch (read my review here) there was no turning back.
It took a day of reading and fingernail chewing, but I called and scheduled the surgery. I’d go under the knife that Thursday, two days later.
But that’s where life threw me a curve ball.
Lisfranc surgery alternatives
Some friends work in medicine, and when they heard about my pending surgery referred me to another foot specialist for a second opinion. An orthopedic surgeon, she agreed with the original diagnosis, but suggested a different surgery. Having recently completed a foot and ankle fellowship, she’d learned a relatively new method of repairing the Lisfranc fracture. Instead of inserting a screw, she’d drill a hole through the joint and thread it with collagen-coated FiberTape. The tape, called the Arthrex Internal Brace) would become a permanent part of the joint.
This made a lot more sense to me. The tape would stay in the joint to help my permanently-weakened ligament do its extremely important job.
(Because the surgical method is relatively new, I write an entire post about it, so follow this link for more about the Arthrex Internal Brace.)
Facing the challenge of Lisfranc head-on
There are some excellent resources on the internet about Lisfranc injuries. They range from scholarly peer-reviewed articles to horrifying chatroom anecdotes about ongoing pain and debilitation, and everything in between.
My outcome is still far from certain, but I’m writing this recovery journal because I want to focus on a positive path toward full recovery and leave a trail of breadcrumbs about how I did it. Aside from authoritative papers and websites written with an academic tone, I've found such resources to be the most interesting, helpful and encouraging.
I also want to keep track of what’s working for me and what isn't. Being sidelined from almost all activity is life-altering. I’m simultaneously wrestling with depression, muscle atrophy, being dependent on others, and being slow at everything I do. There are methods to cope with such issues, but I need to write down what's working and what's not in order to approach it from a somewhat scientific perspective.
This journal is about the planning, the challenges and the overcoming.
How’d I get a Lisfranc injury?
The initial unweighted x-ray of my foot. There's disagreement as to whether any breaks are visible, but the most serious injury, the Lisfranc fracture, is not.
I knew as soon as it happened. I heard three or four distinct cracks from my right foot when I landed. I rolled onto my back and breathed deep. It hurt. I needed time to collect myself. Moving wasn’t going to be easy.
It was close to midnight on June 2 and the end of a long day. I’d gotten up early and rounded up coolers and tables for our neighborhood block party, then got on my mountain bike and rode to Table Rock where there’s a collection of Boise, Idaho’s most technical mountain bike trails. The night before, I’d succeed at riding almost all of the area's toughest rock obstacles--features I'd been riding around for years--but I went over the handlebars on a relatively easy rock drop that I’d ridden a dozen or more times. I wanted redemption. I wanted to go back and ride the drop clean, which I did.
The weighted x-ray. The blue arrow indicates the Lisfranc joint and shows greater separation while weighted.
That afternoon, my wife and I joined the neighborhood block party, where kids played on a blow-up waterslide, rode scooters and skateboards in the freshly-paved (and closed) street and jumped on a trampoline while adults barbecued and socialized. I had my eye on the trampoline all day, but there were always four or five kids on it. I’d have to wait before throwing my 180 pounds around on the thing.
By the time all the kids went to bed, it was dark, and the party was winding down. A small group of neighbors sat in a front yard talking about politics, and I slipped away to finally have a session on the trampoline. Thirty seconds is all it took. I jumped a few times and did a front flip, failing to land as clean as I wanted. So I did it again. The second time, I started with a back flip, then used the rebound to tuck into a front flip, what the gymnasts call a punch front. I over-rotated on the front flip, and all of my weight came down on the ball of my right foot while my torso continued to spin forward—in effect hyperextending my foot. The pain was fairly sharp. Combined with the audible cracks, I knew it was broken.
Even then, I decided to sleep on it, but I woke with extreme swelling and discomfort. My wife drove me to the emergency room where I became a statistic. I am now among the 20 percent of people who are not at first diagnosed with a Lisfranc fracture. The physician assistant on duty examined the x-ray and immediately suspected a fracture of the middle cuneiform. The x-ray tech hadn’t taken weighted films, so the Lisfranc injury didn’t show. The PA referred me to the orthopedic specialists, but called later that day to relay that the imaging lab didn’t see anything wrong. I’d been given an all-clear from radiology. He encouraged me to visit an orthopedic specialist anyway. (As an important side note, the PA was correct. In addition to the Lisfranc fracture I had fractures of the middle cuneiform and first metatarsal.)
When I finally had my appointment nine days later, I was confident I didn’t have a severe problem. I’d started walking on the foot already and sometimes even left my crutches at home.
It was the bruising on the bottom of my foot that gave it away, but weighted x-rays confirmed it further. My 30 seconds on the trampoline would become a season of recovery.
Click here to join or review the Lisfranc Fracture Club on Facebook. It’s reported to be a supportive community.
Disclaimer: I am not a medical or mental health professional. I'm not even current on my CPR or first aid certifications. Do not substitute any information found here for a visit with a knowledgeable doctor, preferably one who specializes in foot and ankle problems.