Return to play without surgery seen in grade 2 Lisfranc injuries

Terry Stanton

A study presented at the American Orthopaedic Foot & Ankle Society Specialty Day found that professional football players who sustain minor midfoot sprains and are managed conservatively may return to play within 3 weeks. Results also showed that players with severe injuries involving frank diastasis underwent surgery more than 90 percent of the time.

One team: 15 years
The review of the single NFL team found just 15 midfoot injuries in the team database over a 15-year period. Of these, seven were grade 1 sprains (nondisplaced); five were grade 2 injuries (2 mm–5 mm diastasis); and three were grade 3 injuries (subtle diastasis with instability or > 5 mm displacement).

Management guidelines were based on severity of injury:

• Grade 1—Immobilization in a controlled ankle motion (CAM) walker boot with progression to weight-bearing as tolerated. Once the injury was asymptomatic, rehabilitation was begun and included range of motion, strengthening, and proprioception, with gradual return to play as tolerated.
• Grade 2—Generally managed conservatively as with grade 1 sprains; signs of gross instability potentially indicated surgical management. Some injured players underwent stress testing to assess for gross instability .
• Grade 3—Surgical management. Postoperatively, no weight-bearing was permitted for 6 weeks, followed by 6 weeks of partial weight-bearing. After approximately 12 weeks, screws were removed, with progression to full weight-bearing and rehabilitation begun. Return to play was allowed when the athlete was asymptomatic with a normal range of motion and strength.

Time lost from participation was based on the dates of injury and return to play.

Although players with grade 1 injuries returned to play in an average of just 3.1 days, those with grade 2 injuries were out for an average of 36 days (P = 0.047). Overall, nonoperative treatment of either grade 1 or 2 midfoot sprains resulted in 11.7 days out of play.

Among the players who received open reduction and internal fixation (ORIF), one returned to play in 73 days (same season) while the other two patients, who incurred their injuries toward the end of the season, returned to play the following season with no persistent problems. Within the same season, no recurrent injuries were reported after successful return to play.

Across the league
In the second phase of the study, surveys were completed by team physicians representing all 32 NFL teams. When evaluating the severity of midfoot sprains, most (63 percent) of respondents used stress view radiographs.

Treatment decisions were based on severity of injury, including the extent of diastasis. For example, grade 1 sprains were primarily treated with immobilization (27 team physicians used a CAM walker, two used casting, two used only ankle taping or an elastic-cloth bandage). Initial weight-bearing protocols varied among team physicians, but most (78 percent) choose to protect the player, including 17 non–weight-bearing, eight partial weight-bearing, and seven weight-bearing as tolerated. Players generally progressed to full weight-bearing by 3 weeks.

For midfoot sprains with subtle diastasis, various treatments were used. Slightly more than half of team physicians (53 percent) chose nonoperative management, although nearly all (97 percent) maintained initial non–weight-bearing restrictions.

Grade 3 sprains were primarily treated with surgical management; just two physicians recommended initial nonoperative management with a CAM walker. ORIF using screws was the preferred surgical treatment.

Regardless of treatment, all physicians implemented initial non–weight-bearing restrictions. Most (59 percent) of the team physicians do not allow a return to play until the hardware is removed; however, 38 percent allow full participation with contact, and 3 percent allow partial participation with no contact.

“Anecdotally, the NFL team physicians surveyed in our study have suggested that midfoot sprains with no or subtle displacement may be treated with nonoperative measures while yielding satisfactory clinical outcomes,” said Dr. Osbahr. “Our subset of athletes from one team corroborates these findings even though the series is small.” He said the survey also suggests that there is a considerable variation in regard to the “optimal” management plan among the physicians treating these elite athletes.

Dr. Osbahr said that although the study demonstrates that most athletes with midfoot strains can return to play at an elite level, it did not assess pre-injury and post-injury performance levels. And he noted that this short-term follow-up study cannot project the long-term consequences of these injuries.

“Future studies should further characterize nonsurgical and surgical treatment as well as the role of diagnostic stress radiography in the management of midfoot sprains with subtle diastasis, because long-term implications are largely unknown” the authors concluded. “Nonetheless, the current study demonstrates successful short-term outcomes for midfoot injuries with subtle diastasis can be achieved, even in elite athletes.”

This project was a companion to a study Dr. Osbahr and associates conducted on syndesmotic ankle sprains in the NFL; it was also presented at Specialty Day (see “NFL Study Sheds Light on Syndesmotic Sprains”)

Coauthors with Dr. Osbahr (no conflicts reported) were Mark C. Drakos, MD (no conflicts); Padhraig F. O’Loughlin, MD (no data); Ronnie P. Barnes, MA, ATC (no conflicts); John G. Kennedy, MD (no conflicts); and Russell F. Warren, MD (Biomet, Smith & Nephew, Cayenne, Orthonet, ReGen Biologics, Wolters Kluwer Health/Lippincott Williams & Wilkins).

Terry Stanton is senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Bottom Line

• Most team physicians treat midfoot (Lisfranc) strain with no diastasis using immobilization, generally with a CAM walker.
• Although a small cohort of athletes with midfoot sprains involving subtle diastasis may successfully return to play with non-operative treatment, team physicians are still varied in their recommendation for operative or non-operative management of these injuries.
• Most athletes with midfoot sprain—even those treated surgically—may return to play at an elite level when defining short-term outcomes.
• Long-term outcomes for midfoot sprains in athletes are not known.