Up to one-third of Lisfranc injuries, which are defined as any bony or ligamentous injury to the tarsometatarsal joints of the foot, arise from a sports-related impact.1–3 These unique injuries arise due to excessive twisting or axial force to the plantar flexed foot and are often undiagnosed, with more than 20% being missed on initial radiographs.4 When left untreated, these injuries increase the risk of degenerative arthrosis of the tarsometatarsal joints and, in some variants, the naviculocuneiform joint, leading to significant impairment.1 Failure to diagnose leads to not only arthritis but also commonly deformity with abduction and collapse of the medial longitudinal arch, increasing the morbidity to the patient.
High incidence rates have been found in athletic populations,1 particularly football and rugby players. Additionally, several recent high-profile Lisfranc injuries among professional football and rugby players have led to increased scrutiny regarding the impact of these injuries on athletes' careers.5,6 In the general population, even after successful treatment, patients have low functional outcome scores and high rates of posttreatment arthritis, with significant limitations in physical activity.1 Because the professional athlete is exposed to far greater daily stresses, clinical outcomes are potentially worse.
The evidence-based literature lacks a qualitative and quantitative posttreatment assessment of high-level athletes with these types of injuries. Several clinical trials indicate relatively high return-to-play rates (range, 93%–94%) for collision athletes,7–9 suggesting that Lisfranc injuries may not have a severe impact on athletes' careers; however, these studies were not designed to compare postinjury performance, differences between ligamentous and bony injuries, and the effects of surgical care. The purpose of this study was to assess the impact of a Lisfranc injury on the ability of a professional football or rugby athlete to return to play and perform at high levels following both nonoperative and operative treatment.
Materials and Methods
Using a well-established, multistep protocol involving review of archives of the public record,10–14 the authors identified professional American football and international rugby athletes who sustained a “Lisfranc injury” from 2000 to 2015. Players were first identified via either the Pro Sports Transactions database or the News-Bank database using the search terms “Lisfranc” and “Lisfranc injury.” Once players were identified, injury details were confirmed with a second source derived from player profiles, newspaper archives, press releases, or team injury reports. Injuries were included only if they could be confirmed as either ligamentous or bony injuries. Players with associated or additional lower extremity injuries requiring concomitant procedures were excluded as well.
Statistical metrics such as return to play, recovery time, games played, proportion of games started, minutes per game, and game performance were collected for the season before injury and 3 seasons after injury. Athletes excluded from performance analysis included those who did not return (n=6), were offensive linemen in the National Football League (NFL) (n=6), or did not play a full season before sustaining the injury (n=4). Offensive linemen were not included in performance analysis because of a lack of performance metrics for this specific position. Player performance measurements varied by sport and position. For NFL players, previously published and validated performance score formulas12 consisted of weighted averages of touchdowns, yards, sacks, and interceptions, varying by player position. For rugby players, points and tries per game were used as assessments of performance. For each player, postinjury and preinjury participation and performance were compared to evaluate the impact of injury. Thus, each player served as his own control.
Statistical analysis was performed using SPSS version 24 software (IBM Corp, Armonk, New York). An independent samples t test was used to compare age, height, weight, body mass index, and years of experience among players who did and did not return. A 2-tailed paired t test with Levene's test of equality was used to evaluate changes in participation and performance following injury. P≤.05 was deemed statistically significant.
A total of 47 professional athletes (NFL=35, rugby=12) met the inclusion criteria for this study, having 23 ligamentous injuries and 24 fractures. Most players (75%) were treated operatively. In the NFL, 29 (83%) players successfully returned to play, taking on average 10.0±2.9 months to do so. All 12 (100%) rugby players returned to play, taking on average 7.7±5.0 months to do so (Table 1). Players in the NFL who returned started a higher proportion of games 1 season before injury compared with players who did not return (84% vs 47%, respectively, P=.03).
Player Demographics Across Sports
There was no significant difference in return-to-play rate (P=.83) and career length following injury (P=.32) between ligamentous and bony injuries (Table 2). Among NFL players, bony injuries required longer recovery times compared with ligamentous injuries (11.1 vs 8.7 months, P=.02). However, bony injuries were treated operatively more often than ligamentous injuries (89% vs 56%, P=.05), and players who received operative treatment took significantly longer to return to play than players who underwent nonoperative treatment (10.4 vs 6.4 months, P=.001). There was no statistical difference in return-to-play rates between the football and rugby athletes (83% vs 100%, P=.13).
Comparison of Bony and Ligamentous Injuries in the National Football League Athletes
Compared with preinjury participation, NFL players started fewer games 2 and 3 seasons following injury (P=.002 and .035, respectively). Furthermore, players showed a significant decline in performance level 1 season after injury (21%, P=.05), which returned to preinjury levels 2 and 3 seasons after injury (P=.09 and .10, respectively). Among NFL players, there was no difference in performance change between bony and ligamentous injuries (P=.84) as well as between operatively and nonoperatively treated injuries (P=.89) up to 3 seasons after surgery. However, among NFL athletes, offensive players showed a significantly greater decline in performance compared with defensive players 1 season after injury (P=.02) (Figure). There were no significant differences in return-to-play rate or recovery time between these 2 groups (P=.96 and .74, respectively). For professional rugby players, compared with pre-injury levels, there were no significant differences in points or tries per game (P=.73 and .82, respectively) or minutes played per game after injury (P=.97).
National Football League player postinjury performance by position. *Statistically significant (P=.02).
In the general population, Lisfranc injuries have led to significant declines in function and physical activity, with high rates of comorbidity such as arthrosis of the naviculocuneiform joint.1 Because the lower extremities of professional athletes are exposed to much greater stresses than those of the general population, this is a potentially career-threatening injury.
In the current study, 41 (87%) of 47 collision athletes were able to return to professional play following Lisfranc injury. This return-to-play rate is similar to that of other studies of professional rugby and football athletes sustaining Lisfranc injuries (range, 92%–94%).7,9 The relatively high return-to-play rates of the current study, along with others,7,9 suggest a favorable prognosis for professional athletes following Lisfranc injuries; however, further analysis of player participation and performance after returning shows that NFL players start fewer games 2 and 3 seasons following injury (P=.002 and .035, respectively), as measured by proportion of total games played, and have a 21% decline in performance 1 season after returning from injury (P=.05). This is in concordance with the results of McHale et al,9 who reported a statistically nonsignificant decline in performance among NFL players sustaining Lisfranc injuries. These results collectively indicate that although players may eventually return to play at high rates, their early performance suffers. Importantly, player performance returned to preinjury levels 2 and 3 seasons after injury, which may suggest that players are returning to play without adequate recovery time.
The data from this study also show that offensive football players had a significantly greater decline in performance compared with defensive players (P=.02). The most likely explanation for this finding is the relative absolute value of performance score for offensive vs defensive players. Because the offensive players in the current study had significantly higher values at baseline (based on the higher number of opportunities to accumulate relevant statistics), there is a higher likelihood that small differences in score would be seen. For defensive players, although a difference in on-field performance may exist after return to play, the relatively lower baseline score may not allow for detection from a statistical basis.
Although comparisons between rugby and American football athletes are limited because of disparate league structures, body mechanics, and playing styles, the data from this study do highlight some important differences. For example, although most of the Lisfranc injuries in the NFL were treated operatively (75%), only 25% of rugby players received operative management, even with similar proportions of bony injuries across both sports (54% vs 42%, respectively). This may represent differences in orthopedic practice patterns internationally or indicate that football players are predisposed to more severe injuries requiring more invasive treatment. Further investigation is needed to corroborate these preliminary results.
Although Lisfranc injuries are known to cause impairment in the general population, the comparison of outcomes following ligamentous and bony injuries varies in the available literature. For example, Kuo et al15 reported a trend toward poorer outcomes in purely ligamentous injuries, whereas other studies have shown worse outcomes following bony injuries.16 Mai et al12 reported that, among common professional football injuries, ligamentous injuries tend to have a greater impact on an athlete's career compared with traumatic bony fractures. In contrast, the data from the current study indicate that athletes with ligamentous and bony Lisfranc injuries have similar outcomes regarding return-to-play rate and postinjury performance. This may suggest that the foot, more specifically the Lisfranc joint, responds differently from other areas of the body.12 The stress-bearing location of the Lisfranc joint at the articulation of the midfoot and the forefoot, along with its unique anatomy of both bony and ligamentous processes, may contribute to the fact that both types of injuries lead to significant disability.
This study had several limitations. First, the use of public sources introduces several confounders, such as playing style, team preferences, and selection bias for high-profile players. Second, radiographic evidence confirming the grade of Lisfranc injury, as well as specific surgical details and methods (eg, screw placement), was not available. These factors could play a role in player recovery and performance after injury and were not accounted for with this methodology.
Professional athletes in the NFL have an 83% return-to-play rate following Lisfranc injury and should expect a significant decline in league participation and performance after treatment, regardless of ligamentous or bony injury types. Additionally, offensive football players may have a more difficult time returning to preoperative performance levels compared with defensive players. Finally, professional rugby players have a high rate of return with little effect on participation and performance after injury.
- Lewis JS Jr, Anderson RB. Lisfranc injuries in the athlete. Foot Ankle Int. 2016; 37(12):1374–1380. doi:10.1177/1071100716675293 [CrossRef]
- Vuori JP, Aro HT. Lisfranc joint injuries: trauma mechanisms and associated injuries. J Trauma. 1993; 35(1):40–45. doi:10.1097/00005373-199307000-00007 [CrossRef]
- Benirschke SK, Meinberg E, Anderson SA, Jones CB, Cole PA. Fractures and dislocations of the midfoot: Lisfranc and Chopart injuries. J Bone Joint Surg Am. 2012; 94(14):1325–1337. doi:10.2106/JBJS.L00413 [CrossRef]
- Haapamaki VV, Kiuru MJ, Koskinen SK. Ankle and foot injuries: analysis of MDCT findings. AJR Am J Roentgenol. 2004; 183(3):615–622. doi:10.2214/ajr.183.3.1830615 [CrossRef]
- Blitz NM. NFL's Lisfranc's foot fracture epidemic: what's causing it?Huffington Post. October12, 2012. http://www.huffingtonpost.com/neal-m-blitz/nfls-lisfrancs-foot-fract_b_1961141.html. Accessed July 1, 2017.
- The Center for Podiatric Care and Sports Medicine. The scourge of the NFL: examining Lisfranc injuries, causes, and treatment. http://healingfeet.com/sports/scourge-nfl-examining-lisfranc-injuries-causes-treatment. Published June 10, 2014. Accessed July 1, 2017.
- Deol RS, Roche A, Calder JD. Return to training and playing after acute Lisfranc injuries in elite professional soccer and rugby players. Am J Sports Med. 2016; 44(1):166–170. doi:10.1177/0363546515616814 [CrossRef]
- Osbahr DC, O'Loughlin PF, Drakos MC, Barnes RP, Kennedy JG, Warren RF. Midfoot sprains in the National Football League. Am J Orthop (Belle Mead NJ). 2014; 43(12):557–561.
- McHale KJ, Rozell JC, Milby AH, Carey JL, Sennett BJ. Outcomes of Lisfranc injuries in the National Football League. Am J Sports Med. 2016; 44(7):1810–1817. doi:10.1177/0363546516645082 [CrossRef]
- Hsu WK, McCarthy KJ, Savage JW, et al. The Professional Athlete Spine Initiative: outcomes after lumbar disc herniation in 342 elite professional athletes. Spine J. 2011; 11(3):180–186. doi:10.1016/j.spinee.2010.12.009 [CrossRef]
- Kester BS, Behery OA, Minhas SV, Hsu WK. Athletic performance and career longevity following anterior cruciate ligament reconstruction in the National Basketball Association. Knee Surg Sports Traumatol Arthrosc. 2017; 25(10):3031–3037. doi:10.1007/s00167-016-4060-y [CrossRef]
- Mai HT, Alvarez AP, Freshman RD, et al. The NFL Orthopaedic Surgery Outcomes Database (NO-SOD): the effect of common orthopaedic procedures on football careers. Am J Sports Med. 2016; 44(9):2255–2262. doi:10.1177/0363546516651426 [CrossRef]
- Minhas SV, Kester BS, Hsu WK. Outcomes after lumbar disc herniation in the National Basketball Association. Sports Health. 2016; 8(1):43–49. doi:10.1177/1941738115608361 [CrossRef]
- Minhas SV, Kester BS, Larkin KE, Hsu WK. The effect of an orthopaedic surgical procedure in the National Basketball Association. Am J Sports Med. 2016; 44(4):1056–1061. doi:10.1177/0363546515623028 [CrossRef]
- Kuo RS, Tejwani NC, DiGiovanni CW, et al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000; 82(11):1609–1618. doi:10.2106/00004623-200011000-00015 [CrossRef]
- Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006; 88(3):514–520.
Player Demographics Across Sports
|Characteristic||Total (N=47)||National Football League (n=35)||Rugby (n=12)|
|Age, mean±SD, y||26.5±3.5||27.4±3.0||24.0±3.7|
|Body mass index, mean±SD, kg/m2||30.9±4.1||31.5±4.2||29.2±3.2|
|League experience, mean±SD, y||4.2±2.9||4.5±2.9||3.1±2.6|
|Type of injury, No.|
| Ligamentous||23 (49%)||16 (46%)||7 (58%)|
| Bony||24 (51%)||19 (54%)||5 (42%)|
| Operative||35 (75%)||26 (74%)||3 (25%)|
| Nonoperative||12 (25%)||9 (26%)||9 (75%)|
|Time to return, average±SD, mo||9.4±3.7||10.0±2.9||7.7±5.0|
Comparison of Bony and Ligamentous Injuries in the National Football League Athletes
|Characteristic||Bony Injury (n=19)||Ligamentous Injury (n=16)||P|
|Time to return, mo||11.1||8.7||.02|
|Career after, y||2.1||3.3||.32|