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NFL orthopedic surgeon: Lisfranc foot ailment is 'bizarre injury'

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Tennessee Titans quarterback Jake Locker became the latest victim of a Lisfranc injury last Sunday when he sustained the foot ailment, knocking him out for the rest of the season.

The injury was named after Jacques Lisfranc de St. Martin, a surgeon during the Napoleonic Wars. He discovered a specific type of foot injury was being sustained when some soldiers fell after dismounting horses the wrong way. For football players, the injury has been increasing in recent years for a number of reasons, including type of turf, brand of shoe and size of cleats.

Dr. Robert Anderson, co-chairman of the NFL's Foot and Ankle Committee, talked with NFL Evolution contributing editor Bill Bradley on Wednesday. The team physician of the Carolina Panthers explained the injury, how it occurs and how long a player like Locker faces for rehabilitation. He has been an orthopedic surgeon in Charlotte for the past 24 years.

What exactly is a Lisfranc injury?

A Lisfranic is often mislabeled as a midfoot sprain. So a sprain is basically a ligament injury in any part of the body, but in this situation it's the midfoot. In most cases of athletes, it's not necessarily a bone injury, but a ligament injury. The ligaments of a midfoot joints rupture and the joints become unstable and shift out of place. ... You can have some small bony emulsions or chips injuries occur if the ligaments do pull off. Then these joints become unstable and when they become unstable guys can't push off. So a lot of the complaints guys have when they leave the football field with a Lisfranc-type injury is that, "Hey I don't have any push-off or explosion." They'll have these symptoms and then they'll have a tremendous amount of midfoot pain and swelling. They are injuries that unfortunately take a long time to recover from because when the injury occurs in the midfoot area, basically that's the top of the arch and that's where a lot of the stress goes on a running athlete. In order to push off or power through the foot, you have to have a stable midfoot.

You have a lot of experience with Lisfranc injuries through the NFL Foot and Ankle Committee. Could you provide some background on the committee's research about this injury?

We've been working on this project since about 2005. Back in the 2000s, we saw a tremendous rise in foot and ankle injuries in the NFL and we were trying to figure out why this was happening. This has been an ongoing project of ours, trying to figure out why we have so many Lisfranc, turf toes, high ankle sprains and those kinds of things occurring. What we have basically found out is that it is multi-factorial. It's a combination of the players being faster and stronger, having higher energy injuries and the fact that probably the shoes have changed -- lighter weight and more flexible, bending at the wrong place perhaps -- and then then role of the artificial surface comes into play. What we're finding basically is that when the cleat engages with turf, if it doesn't release at a certain level of torque, then injury can occur. That's why we're seeing so many ankle injuries, ACL injuries. We're aren't blaming this on anybody. We're aren't saying it's all the artificial surface's fault. It's not the shoe maker's fault. It's certainly a combination of multiple factors.

... The owners of the NFL have contributed a tremendous amount of money to investigate these injuries. We've already investigated turf toe and Lisfranc, and now we're investigating the high ankle sprain. We're trying to find the exact mechanism of the injury, what level of torque these injuries occur at and then work with the shoe companies and the turf companies to try to minimize that. It's a real wrestle because the players want performance, so they're looking for more traction. Yet, we're trying to reduce excessive traction to maybe decrease torque and injuries. It's a complicated balance.

How long does rehabilitation take for such an injury?

The question is do they need surgery or not need surgery? We see a lot of stable Lisfranc injuries that don't require surgery. But because the ligaments are still stretched or damaged in some way, it could be 6-8 weeks before a player can come back from even a non-operative Lisfranc sprain. There's some doctors and general managers in the league that basically think that if they get a player with a Lisfranc injury, even it is non-operative, they will go ahead and put him on the (injured reserve list).

There are situations where the Lisfranc needs to be operated on. If the joint is out of place or has a bone injury or has significant instability, then those are reasons for surgery and surgery is basically done to stabilize those joint injuries with a combination of screws or metal plates. That can take 5-6 months to recover from surgery. I tell most of the players, it's not a career-ending injury, but it certainly can be a season-ending injury if they have to have surgery.

It sounds as if the athlete has to be delicate with the foot if he goes the surgical route?

You usually have to stay completely off the foot 6 to 8 weeks after surgery. Then they're in a boot for six weeks. Then they can begin the rehabilitation process, which can take about three months after that. The non-surgical ones, usually they're in a boot for anywhere between 2 to 4 weeks and gradually get back into rehab. But, like I said, it could be 6 to 8 weeks before they're ready to play again.

You had mentioned the shoe or the turf being a possible cause of this injury. Why is that?

We think it's multi-factorial. It could be the shoe, the cleat that's on the shoe, the turf, it could be the position of the player. For instance, we're seeing more Lisfranc injuries in defensive ends because they are basically trying to get around the offensive tackle. Their front of the foot is embedded in the ground, their cleats are engaged and then they twist as they are trying to get around the offensive tackle. That twisting maneuver with the extra load can cause the joints to disrupt. ... It' a bizarre injury. We studied the Lisfranc injury for two years with our research group out of the University of Virginia. It's a very difficult injury to reproduce in the lab. Everything has to be just right for these injuries to occur. But, boy, when they occur, they certainly are frustrating to recover from.

You said you've talked to the shoe companies. How receptive have they been in making changes to help avoid this injury?

We're trying to educate the shoe companies as best we can: where shoes bend, how much they bend, to see whether or not they can put more support in the midfoot region or the forefoot region to minimize some of these injuries. We're hoping that they will be able to design or devise shoes that may be safer. The NFL is certainly not in the business of designing a shoe or to tell the shoe companies what to do. But we try to educate them on what we've learned in the respect to how these injuries occur and what some of the factors may be to where shoes bend and how cleats interact with the surface, whether it's grass or artificial turf.

What's next for the committee?

Whether it's turf toes or high ankle sprains, we're just trying to find ways to protect our players. All of these injuries are going to occur. It's a collision game and these are big strong guys. There's no way to prevent them 100 percent, but if we can minimize or limit some of these foot injuries, we can feel as if we've made an impact. Unfortunately, this another one of those years where we've seen a fair number of Lisfrancs.

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