When it comes to being infamous, Lisfranc injuries are up there with ACL tears and concussions, and Pittsburgh Steelers running back Le'Veon Bell recently became the latest to receive the diagnosis. NFL Network's Ian Rapoport broke the news early Wednesday afternoon.
Rapoport later added that the Steelers do not believe surgery is necessary and expect the injury to sideline Bell for about six weeks.
While a six-week recovery timeframe is certainly possible, players and medical personnel fear Lisfranc injuries for a few reasons: They can linger, they can be unpredictable and they are frequently marked by complicated, frustrating recoveries.
To better understand why that is, it helps to examine the injury itself.
Located roughly halfway between the tips of the toes and the back of the heel, the Lisfranc joint is actually a large joint complex that links the metatarsals—the long bones that make up the bases of the toes—to the bones that make up the heel.
Just like any other joint, the Lisfranc complex coordinates and stabilizes motion between bones. It does so with the help of multiple ligaments—bands of tough tissue that connect one bone to another.
Specifically, the Lisfranc joint transfers force generated above the ankle through the foot and into the toes, allowing them to point and push off the ground among other motions. As such, a stable Lisfranc complex is crucial for walking, running, jumping and cutting.
Athletic Lisfranc joint injuries usually occur via one of a few injury mechanisms, all of which involve the application of upward, downward or twisting forces to the midfoot.
For example, equestrian athletes classically suffer the injury when their foot stays trapped in a stirrup after they fall from a horse. The sudden jerking, twisting motion of the front and midfoot places tremendous stress on the complex, overexerting the ligaments and causing one or more tears. Falling from a height can also cause the injury when the feet impact the ground.
In football, one athlete stepping on the foot of another has the potential to produce a Lisfranc injury, as does forcefully twisting the ankle of a pointed foot. Stepping on the heel of a foot that is lying topside down also threatens the integrity of the joint.
Along with ligament injury, particularly strong blows to the foot can also produce bone fractures at or near the complex, complicating the injury. Cartilage damage within the joint can also occur, and one or more metatarsals can dislocate from the complex altogether.
Regrettably, rehabbing a Lisfranc injury is no easy task. The injury also comes in many different shapes and forms.
Since injured ligaments are weaker ligaments, the arch of the foot is less stable following a Lisfranc injury such as Bell's. Bearing weight is not only painful but also detrimental to recovery, as it places significant stresses on healing ligaments. Uninjured ligaments must also pick up the slack, placing them at an increased risk of sustaining injuries in their own right.
Should a fracture of one or more metatarsals occur, doctors may decide surgery is necessary to fully stabilize the broken bones. Such an operation uses metal screws and plates to fix the broken bones into their normal anatomical position, and recovery time often exceeds five or six months. It can even approach an entire year.
Unfortunately, the initial realignment of the foot is only the beginning.
Even in the best-case scenario, midfoot osteoarthritis can develop following Lisfranc injuries—especially after those requiring surgery. The dreaded complication is chronic, progressive and can produce significant stiffness and chronic pain, drastically reducing the foot's functionality. Without optimal foot strength and flexibility, making a career as a running back in the NFL can become quite difficult—if not impossible.
Luckily, it appears Bell will avoid surgery—for now.
Though exact medical details are unavailable to the public, the announcement that Bell may not need surgery implies his bones are only minimally displaced—perhaps a millimeter or so. It also suggests that any fractured bones that may exist remain in their proper anatomical alignment.
Nevertheless, as mentioned, early projections still have Bell missing at least six weeks—a testament to the complexity of his looming rehab and of the Lisfranc complex itself.
Bell will likely need to remain entirely non-weight-bearing on his injured side for several weeks in order to allow the injured ligaments to heal.
If he were to bear too much weight too soon, he could exacerbate the injury by causing further ligament tears and possibly bone displacement. Doing so could add weeks or months to his rehab time, and it could also necessitate surgery.
After clearing his non-weight-bearing status, Bell will start slowly adding more and more weight onto his foot—as well as increase the amount of time he spends on his feet—until he can support the entirety of his body weight without pain. All the while, he will also work on strength, range-of-motion and flexibility training to regain any lost function.
With any luck, Bell will eventually return to his pre-injury state. That said, a six-week timetable, while possible, sounds extremely optimistic to say the least, and the extent of a Lisfranc injury sometimes isn't even clear for up to a week or two after the injury takes place.
What's more, many Lisfranc injury rehab protocols call for six weeks of a non-weight-bearing status alone, and even "minor" injuries can cost entire seasons.
Perhaps those are the reasons underlying Pittsburgh, according to NFL.com's Dan Hanzus, seeking a second opinion on the injury.
After all, when it comes to a running back many touted as a long-term answer to Pittsburgh's backfield problems, it definitely makes sense to exercise more caution rather than less.
Dr. Dave is a resident physician at the University of Washington with plans to pursue fellowship training in Primary Care (non-operative) Sports Medicine. Medical information discussed above is based on his own knowledge.