Ligamentous injuries to the midfoot during athletic endeavors are becoming more common and more troublesome as they can take significant time before the athlete is able to return to play. Late changes in alignment or post-traumatic arthritis are complications of inadequate treatment.
The mechanism of injury is either direct impact to the dorsal midfoot or a twisting injury to the hindfoot with a plantar-flexed, fixed forefoot. Examination reveals ecchymosis and pain in the midfoot. Rarely is there enough instability to allow detection on physical examination. Provocative tests such as external rotation stress of the midfoot or physical activity (single leg hop or walking on tip toes) can recreate symptoms if the patient’s pain allows for it. Weight-bearing anteroposterior and lateral radiographic examination of both feet focusing on the midfoot is essential, allowing comparison between the injured and uninjured extremity.
Diastasis between the proximal first and second metatarsal is a classic radiographic finding, but proximal extension between the cuneiforms can also be present. A more severe injury shows loss of the longitudinal arch or subluxation of the midfoot that is identified on a lateral radiograph. A tear or an avulsion of Lisfranc ligament along with other midfoot ligaments is the underlying pathology. Advanced imaging modalities including computed tomography and magnetic resonance imaging are useful in these more subtle injuries or when more specific anatomical detail is required. Non-displaced injuries are typically treated conservatively with a period of non–weight bearing followed by a gradual return-to-play protocol. Injuries with diastasis or loss of arch height, in addition to cases subluxation or dislocation of joints or displaced fractures require surgical intervention to restore normal anatomical relationships–the most significant factor suggestive of a good result. Arthrodesis of the affected joints is advocated for severe intra-articular injury and has been proposed for purely ligamentous injuries, although this is controversial in an athlete as a primary repair technique.