Lisfranc injuries/ common football player injuries

Le'Veon Bell injury, Lisfranc explanation

August, 22, 2013

AUG 22

4:19

PM ET

By Stephania Bell | ESPN.com

• T

Pittsburgh Steelers rookie running back Le'Veon Bell has been unable to stay on the field consistently this preseason. First, it was soreness in his left knee, which caused him to miss the Steelers' preseason opener. Days later, he aggravated the knee in practice. He returned quickly enough to make an appearance in the Steelers' second preseason game, but that outing was cut short due to injury. This time, it was not his knee; Bell sprained his right foot after playing in just one series.

The big question is how long this latest injury, called a midfoot sprain by coach Mike Tomlin (and originally referred to as a Lisfranc sprain in ESPN reports), will keep Bell on the sideline. At this point, there is no timetable being offered by the Steelers, but on the positive side, Bell's injury will not require surgery.

So what is a realistic expectation for fantasy owners? And why does panic ensue when we hear the term "Lisfranc" associated with a foot injury?

[+]Enlarge
AP Photo/Keith SrakocicLe'Veon Bell has fallen to 40th among running backs in the ESPN fantasy's RB rankings.

As for what fantasy owners can expect, the only sure thing is that this will be a multiweek injury. Bell has already been ruled out of Pittsburgh's third preseason game, and while the Steelers are not saying when they expect him back -- in their defense, it's too early to make that projection with any degree of certainty -- early reports suggest a recovery time of 6-8 weeks. That time frame is fairly typical for nonsurgical Lisfranc sprains, but it should be noted that, depending on the actual degree of injury, the athlete's ability to heal and whether any setbacks occur along the way, the estimate could fluctuate in either direction.

Ray Fittipaldo of the Pittsburgh Post-Gazette reported Thursday that Bell said he was walking without discomfort and feeling positive about his progress. While that's great news, the big tests will come when he has to push off with running and pivot, twist and cut on that foot. Although the details of the injury aren't available, if it's indeed a Lisfranc sprain, it's difficult to imagine Bell returning to football before late September. It's critical to the long-term foot health of any player who suffers this type of injury that complete healing occurs prior to a return to play, hence the slow progression, even when the player says he feels fine.

This standard slow progression is part of the reason the word "Lisfranc" engenders panic. The standard absence for players who suffer this injury ranges from six weeks for the mildest form to season-ending for the more severe variety. Last season, Jets wide receiver Santonio Holmes,Green Bay Packers running back Cedric Benson and Jacksonville Jaguars running back Maurice Jones-Drew all saw their seasons end due to Lisfranc injuries.

Perhaps more noteworthy is that these injuries were all unique and Holmes was the only player whose season was declared over shortly after the injury. Benson was initially placed on the IR/designated for return list after suffering the injury in Week 5 but did not progress as hoped and ultimately underwent season-ending surgery in late November. Jones-Drew was also hoping to avoid surgery after his Week 7 injury, but his problem persisted and he too underwent surgery in December.

It should be noted that last season Cowboys running back DeMarco Murray suffered a midfoot sprain that cost him six weeks, but he recovered fully and returned during the season.

Maybe now it's a bit clearer as to why the term "Lisfranc" inspires dread. But what is this Lisfranc injury? Lisfranc refers to an area of the foot where the long bones of the forefoot (metatarsals) articulate with the small (tarsal) bones in the middle of the foot. This joint is called the tarsometatarsal joint, or the Lisfranc joint. This joint is in the midfoot region, hence the confusion about the terms, which are often used interchangeably.

Why Lisfranc? Frenchman Jacques Lisfranc, a field surgeon in Napoleon's army, described an amputation technique through this region to address forefoot gangrene following frostbite. There is also a story that soldiers wounded in battle would fall from their horses, but a foot would often remain caught in the stirrup, right at that tarsometatarsal joint. Such an injury often resulted in amputation of part of the foot, from the injured joint forward. Thankfully, with modern medicine, these injuries don't typically require amputation, and surgery can preserve the joint.

Since NFL players aren't riding horses, how does this injury happen? Well, in sports, especially football, one scenario is that the player is running forward with his weight on the ball of his foot and he gets hit or stepped on from behind against his heel. The resultant force through the portion of the foot in between the ball and the heel (midfoot) causes it to buckle, and the midfoot is injured. But it can also result from shearing forces at the foot, the result of a twisting injury when the forefoot remains planted and locked into the ground as the player moves another direction.

Not all Lisfranc injuries are identical. When the midfoot buckles, the ligaments that connect the various bones can become damaged. Ligament injury without any bony impact would be the mildest version of a Lisfranc injury. The more mild sprains can be treated conservatively with rest and rehabilitation. If the damage to the ligaments is more extensive, it can affect the relative position of the bones in the area, and they can shift or dislocate, which is often accompanied by a fracture, resulting in a more serious injury. In the worst-case scenario, an artery passing over that area can also be damaged, affecting blood supply to the foot.

Shifting of the bony alignment typically requires surgery to realign the joint and provide stability, but it's not always easy to detect. Failure to properly correct the injury, however, can result in chronic instability and pain, eventually leading to major arthritis in the area. Even with surgery, it appears that those who have suffered a significant Lisfranc injury may be at increased risk for arthritis down the road, simply because of the trauma to the joint.

The bottom line is that players who suffer these injuries must have their treatment managed carefully, not only with surgery when indicated but in the rehabilitation process as well.

Lisfranc (Midfoot) Injury

Lisfranc (Midfoot) Injury

Lisfranc (midfoot) injuries result if bones in the midfoot are broken or ligaments that support the midfoot are torn. The severity of the injury can vary from simple to complex, involving many joints and bones in the midfoot.

A Lisfranc injury is often mistaken for a simple sprain, especially if the injury is a result of a straightforward twist and fall. However, injury to the Lisfranc joint is not a simple sprain that should be simply "walked off." It is a severe injury that may take many months to heal and may require surgery to treat.

Anatomy

The midfoot is the middle region of the foot, where a cluster of small bones forms an arch on the top of the foot. From this cluster, five long bones (metatarsals) extend to the toes. The bones are held in place by connective tissues (ligaments) that stretch both across and down the foot. However, there is no connective tissue holding the first metatarsal to the second metatarsal. A twisting fall can break or shift (dislocate) these bones out of place.

The Lisfranc joint complex includes the bones and ligaments that connect the midfoot and forefoot. Lisfranc injuries include ligament strains and tears, as well as fractures and dislocations of bone (far right).

The midfoot is critical in stabilizing the arch and in walking (gait). During walking, the midfoot transfers the forces generated by the calf muscles to the front of the foot.

The midfoot joint complex is also called the Lisfranc joint. It is named after French surgeon Jacques Lisfranc de St. Martin, who served in the Napoleonic army in the 1800s.

The Lisfranc joint complex has a specialized bony and ligamentous structure, providing stability to this joint.

Top of page

Description

The midfoot will be affected if the bones are broken (fractured) or the ligaments are torn (ruptured). Injuries can vary, from a simple injury that affects only a single joint to a complex injury that disrupts multiple different joints and includes multiple fractures.

(Left) This is a subtle injury to the midfoot with widening between the first and second metatarsals (circle), compared with the normal foot on the left. (Center) This x-ray shows a fracture of the second metatarsal (arrow) and a fracture of the cuboid (circle). (Right) This shows a very severe injury of the foot from a high-energy event. It has resulted in a complete dislocation of the entire midfoot (box). Because no bones have been broken, a fusion may be recommended, given the high risk for future arthritis.

Lisfranc injuries tend to damage the cartilage of the midfoot joints. Cartilage covers the ends of bones in the joints, allowing the joints to move smoothly. If severe midfoot injuries are not treated with surgery, then damage to the cartilage and increased stress at the midfoot joints will result in both flatfoot and arthritis, which require complex surgery to correct. Even with successful surgery for the Lisfranc injury, arthritis can still develop in later life.

Cause

These injuries can happen with a simple twist and fall. This is a low-energy injury. It is commonly seen in football and soccer players. It is often seen when someone stumbles over the top of a foot flexed downwards.

More severe injuries occur from direct trauma, such as a fall from a height. These high-energy injuries can result in multiple fractures and dislocations of the joints.

Symptoms

The most common symptoms of Lisfranc injury include:

• The top of foot may be swollen and painful.
• There may be bruising on both the top and bottom of the foot. Bruising on the bottom of the foot is highly suggestive of a Lisfranc injury.
• Pain that worsens with standing or walking. The pain can be so severe that crutches may be required.

If standard treatment for a sprain (rest, ice, elevation) does not relieve pain and swelling, you should seek care from a Podiatrist at Advanced foot & Ankle Center!.

Doctor Examination

Medical History and Physical Examination

After talking with you about your symptoms and discussing your concerns, your podiatrist will examine your foot and ankle. Although some of the physical tests the podiatrist will perform may be painful, none of them will make the injury worse.

The discoloration on the bottom of the foot is very suggestive of a Lisfranc injury.

Specific things Dr. Raymond A. DiPretoro, Jr. will look for include:

• Bruising along the bottom of your foot. This suggests a complete tear of the midfoot ligaments or a midfoot fracture.
• Tenderness to pressure (palpation) along the midfoot.
• Pain with a stress examination of the midfoot. Dr. DiPretoro may grasp your heel and twist the front of your foot to determine whether there is pain at the midfoot. This should not cause pain in your uninjured foot.
• Pain with a "piano key" test. Dr. DiPretoro may grasp your toes and move them up and down to determine whether this causes pain. This puts stress across the midfoot and will produce pain if there is an injury.
• Single limb heel rise. Dr. DiPretoro may ask you to stand on one foot and come up on "tip toes." This places significant stress across the midfoot and is useful if the injury is subtle. This test should not cause pain in your uninjured foot.

Imaging Tests

Other tests that the doctor may order to help confirm your diagnosis include:

X-rays. Broken bones (fractures) and the position of the bones can be seen in an x-ray picture. An x-ray also can show the alignment of the Lisfranc joint. Any change in the normal joint may suggest injury to the ligaments.
If the injury happened after a simple twist and fall (a low-energy injury), the doctor may ask that an x-ray be taken with the patient standing. In this case, the doctor is looking for a ligament injury, especially if the bones are not expected to be broken. Injuries will not be made worse from a standing (weightbearing) x-ray, nor will an injury that might be treated without surgery progress to need surgery if this test is done. The doctor sometimes may take x-rays of your uninjured foot, either for comparison or to determine the stability of the joint.

(Left) In this non-weightbearing x-ray, the Lisfranc injury does not show any abnormal widening (arrow). (Right) The tear of the Lisfranc ligament is more evident in this weightbearing stress x-ray, showing a widening of the joint.

Magnetic resonance imaging (MRI) scan. These studies can create better images of soft tissues like the tendons. This test is not required to diagnose a Lisfranc injury. It may be ordered in cases where the diagnosis may be in doubt.
Computerized tomography scan (CT ) scan. These scans are more detailed than x-rays and can create cross-section images of the foot. This test is not required to diagnose a Lisfranc injury. Because a CT scan will help evaluate the exact extent of the injury and the number of joints that have been injured, a surgeon may order this test to help plan surgery.

Treatment

Treatment for a Lisfranc injury depends on how severe the injury is.

Nonsurgical Treatment

If there are no fractures or dislocations in the joint and the ligaments are not completely torn, nonsurgical treatment may be all that is necessary for healing. A nonsurgical treatment plan includes wearing a non-weightbearing cast for 6 weeks. You must be very strict about not putting weight on your injured foot during this period. This then progresses to weightbearing in a removable cast boot or an orthotic.

Your doctor will want to follow up with you regularly and take additional x-rays to make sure your foot is healing well. In the course of follow up, if there is any evidence that the bones in the injured joint have moved, then surgery will be needed to put the bones back in place.

Surgical Treatment

Surgery is recommended for all injuries with a fracture in the joints of the midfoot or with abnormal positioning (subluxation) of the joints. The goal of surgical treatment is to realign the joints and return the broken (fractured) bone fragments to a normal position.

Internal fixation. In this procedure, the bones are positioned correctly (reduced) and held in place with plates or screws. Because the plates or screws will be placed across joints that normally have some motion, some or all of this hardware may be removed at a later date. This can vary from 3 to 5 months after surgery, and is at the surgeon's discretion.
Occasionally, the hardware may break before it is removed. This is not unusual when screws or plates span bones that have some movement. Metal can fatigue and fail under these conditions, just as a paperclip will fail if bent repeatedly. Most often surgery is successful even if some of the hardware fails.

Various methods of internal fixation can be used to fix Lisfranc injuries. (Left) Multiple screws can be used. (Center) A combination of plates and screws are sometimes required when fractures are present in addition to a torn ligament. (Right) Plates that span the joints are also an excellent method of fixation.

Fusion. If the injury is severe and has damage that cannot be repaired, fusion may be recommended as the initial surgical procedure. A fusion is essentially a "welding" process. The basic idea is to fuse together the damaged bones so that they heal into a single, solid piece.
Lisfranc injuries that may require fusion include joints that cannot be repaired with screws or plates or when the ligaments are severely ruptured. The hardware will not need to be removed because the joints are fused and will not move after they heal.
Rehabilitation. After either surgery (reduction or fusion), a period of nonweightbearing for 6 to 8 weeks is recommended in a cast or cast boot. Weightbearing is started while the patient is in the boot if the x-rays look appropriate after 6 to 8 weeks. The amount of weight a patient can put on their foot, as well as the distance the patient is allowed to walk, is at the surgeon's discretion. Impact activities, such as running and jumping, should be avoided until the hardware has been removed.

Recovery

Some athletes never return to their pre-injury levels of sport after these injuries. Despite excellent surgical reduction and fixation, arthritis may occur from the damage to the cartilage. This may result in chronic pain and may require fusion in the future.

Seahawks left tackle, Russell Okung has Turf Toe!

Source: Russell Okung has turf toe

Posted by Mike Wilkening on September 16, 2013, 12:20 AM EDT

AP

Seahawks left tackle Russell Okungsustained a turf toe injury in Sunday night’s game vs. San Francisco, a league source told PFT.

Okung departed the game in the first half. He has been replaced by Paul McQuistan.

The 24-year-old Okung was the Seahawks’ No. 1 pick in 2010. He has been the club’s starting left tackle throughout his NFL career.

The Seahawks host the winless Jaguars next Sunday.

Turf Toe: Symptoms, Causes, and Treatments

Turf Toe: Symptoms, Causes, and Treatments

Turf toe is not a term you want to use when talking to a head football coach about his star running back or the ballerina before her diva debut. “Turf toe” is the common term used to describe a sprain of the ligaments around the big toe joint. Although it’s commonly associated with football players who play on artificial turf, it affects athletes in other sports including soccer, basketball, wrestling, gymnastics, and dance.  It’s a condition that’s caused by jamming the big toe or repeatedly pushing off the big toe forcefully as in running and jumping. 

Here is information about turf toe -- what causes it, how to prevent it, and how it's treated -- to help you stay in the game.

What Causes Turf Toe?

Turf toe is a sprain to the ligaments around the big toe joint, which works primarily as a hinge to permit up and down motion. Just behind the big toe joint in the ball of your foot are two pea-shaped bones embedded in the tendon that moves your big toe. Called sesamoids, these bones work like a pulley for the tendon and provide leverage when you walk or run. They also absorb the weight that presses on the ball of the foot.

When you are walking or running, you start each subsequent step by raising your heel and letting your body weight come forward onto the ball of your foot. At a certain point you propel yourself forward by "pushing off" of your big toe and allowing your weight to shift to the other foot. If the toe for some reason stays flat on the ground and doesn't lift to push off, you run the risk of suddenly injuring the area around the joint. Or if you are tackled or fall forward and the toe stays flat, the effect is the same as if you were sitting and bending your big toe back by hand beyond its normal limit, causing hyperextension of the toe. That hyperextension, repeated over time or with enough sudden force, can  -- cause a sprain in the ligaments that surround the joint.

Typically with turf toe, the injury is sudden. It is most commonly seen in athletes playing on artificial surfaces, which are harder than grass surfaces and to which cleats are more likely to stick. It can also happen on a grass surface, especially if the shoe being worn doesn't provide adequate support for the foot. Often the injury occurs in athletes wearing flexible soccer-style shoes that let the foot bend too far forward.

What Are the Symptoms of Turf Toe?

The most common symptoms of turf toe include pain, swelling, and limited joint movement at the base of one big toe. The symptoms develop slowly and gradually get worse over time if it’s caused by repetitive injury. If it’s caused by a sudden forceful motion, the injury can be painful immediately and worsen within 24 hours. Sometimes when the injury occurs, a "pop" can be felt. Usually the entire joint is involved, and toe movement is limited.

Sever's Disease (Heel Pain) Exercises and Treatment

What is Sever’s Disease?
Sever's Disease Exercises & Treatment


Sever’s disease is a painful condition of the heel in growing children. The condition occurs as a result of traction on the growth plate at the back of the heel bone where the heel cord (Achilles’ tendon) attaches.

Exercises

Etretching Exercises

The child should stretch his/her heels to provide flexibility. Have your child: Sit in a chair with feet flat on the ground Bend over and grasp his or her toes Pull toes upward until he/she feels a stretch. The child should also stretch out the Achilles’ tendon. Have your child: Stand on the lowest step of the stairs in the house, with only the front part of the feet actually touching the stair. Rise up on tiptoe and then lower himself or herself until the heels are below the level of the step. Use the banister for balance.

Treatment

Treatment Ice the heel for 15-20 minutes after each practice or game. Insert heel pads in the child’s shoes, and do not let him or her walk around in bare feet. Anti-inflammatory medication (Advil or Aleve) can be used as needed. The pain generally subsides in a few weeks to months, but can last as long as a year. Restriction of activity may be necessary to control symptoms. The exercises above can help the child’s feet stay limber and protect the heels.

Heel Pain and Sever's Disease in Adolescents!

Heel Pain and Sever's Disease

The calcaneal apophysis is a growth center where the Achilles tendon and the plantar fascia attach to the heel. It first appears in children aged 7 to 8 years. By ages 12 to 14 years the growth center matures and fuses to the heel bone.

Injuries can occur from excessive tension on the Achilles tendon and the plantar fascia, or from direct impact on the heel. Excessive stress on this growth center can cause irritation of the heel, also called Sever’s disease.

Symptoms

Athletes with Sever’s disease are typically aged 9 to 13 years and participate in running or jumping sports such as soccer, football, basketball, baseball, and gymnastics. The typical complaint is heel pain that develops slowly and occurs with activity. The pain is usually described like a bruise. There is rarely swelling or visible bruising. The pain is usually worse with running in cleats or shoes that have limited heel lift, cushion, and arch support. The pain usually goes away with rest and rarely occurs with low-impact sports such as bicycling, skating, or swimming.

Physical exam

A physical exam of the heel will show tenderness over the back of the heel but not in the Achilles tendon or plantar fascia. There may be tightness in the calf muscle, which contributes to tension on the heel. The tendons in the heel get stretched more in patients with flat feet. There is greater impact force on the heels of athletes with a high-arched, rigid foot.

Tests

The doctor may order an x-ray because x-rays can confirm how mature the growth center is and if there are other sources of heel pain, such as a stress fracture or bone cyst. However, x-rays are not necessary to diagnose Sever’s disease, and it is not possible to make the diagnosis based on the x-ray alone.

Other conditions that cause heel pain

Heel pain can also be caused by a stress fracture in the heel, bursitis, tendonitis, bone cysts, and rheumatologic disorders. If the athlete is not active in impact sports or is not between age 9 and 13 years, other conditions should be considered.

Treatment

The following are different treatment options:

• Rest and modify activity. Limit running and high-impact activity to rest the heel and lessen the pain. Choose one running or jumping sport to play at a time. Substitute low-impact cross-training activities to maintain cardiovascular fitness. This can include biking, swimming, using a stair-climber or elliptical machine, rowing, or inline skating.
• Reduce inflammation. Ice for at least 20 minutes after activity or when pain increases. Nonsteroidal anti-inflammatory drugs (NSAIDs) may also help.
• Stretch the calf. Increase calf flexibility by doing calf stretches for 30 to 45 seconds several times per day.

We Remember 9/11.....

Just wanted to remember this day by honoring all of those brave people who lost their lives on this horrific day!  We will never forget and will keep you close to our hearts!

We will never forget,

Advanced Foot & Ankle Center

9/11 Memorial Website September 11, 2001, a day we will never forget home | 9/11 Websites | Other Websites | Photos 1 | Photos 2 | Quotes 1 | Quotes 2
We recommend this businesses in New York Area. Visit them to help the local economy.   Article Hell Directory - An article directory with many great articles. Education News & Articles - Site offered edcuational articles and latest news. Hot Traveler Reviews - Offers travel tips, news and articles.	We shall never forget We shall keep this day, We shall keep the events and the tears In our minds, our memory and our hearts and take them with us as we carry on.
	I want to extend appreciation to the people who helped organize events for the September 11, 2001 day. A special thank you to all the people who helped donate and helped contribute to the funds. I want to urge that in your September 11 reflections, you will remember the love, the strength, the hope that carried us through and also brings us together today.
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