Revista de Medicina Desportiva (English) March 2018 | Page 26

• type 2 – diastasis between 1 and 5
mm exists between the first and
second metatarsals without longi-
tudinal arch in the lateral X-ray
• type 3 – presents diastasis and
longitudinal arch collapse.
In the acute phase, the patient
presents weight-bearing midfoot
pain and edema, with partial or total
gait limitation. Structural damage is
strongly suspected with the pres-
ence of ecchymosis in the plantar
region. The “piano key test” may pre-
sent a positive sign, consisting of a
dorsal prominence of the metatarsal
bases, which is reduced with exer-
tion of plantar pressure. 10-12
In an imaging perspective, regard-
ing the anteroposterior X-ray, the
medial side of the second metatarsal
should be aligned with the medial
side of the intermediate cuneiform,
as well as in the oblique X-ray, the
medial side of the cuboid should
intersect the medial side of the
fourth metatarsus. In the weight
bearing lateral X-ray, an alignment
must exist between the dorsal
region of the first metatarsus and
the medial cuneiform. Contralateral
comparison of the foot should be
obtained in order to improve diag-
nostic acuity. In addition, the pres-
ence of diastasis in the basal region
should raise suspicion of possible
injury whenever the value is greater
than or equal to 2mm. Stress radiog-
raphy has a controversial role in the
literature. 10,13 Computed tomography
may also play a relevant role, espe-
cially in more complex bone lesions
typical of high-energy trauma. 13-15
Magnetic resonance imaging plays a
preponderant role in ligament inju-
ries, in both the characterization and
in the identification of the injury. 10,13 Conservative treatment consists
of a suropodalic cast with immobi-
lization or with orthosis during six
weeks without load, being that from
this point on, and depending on the
patient’s pain symptoms, gradual
progression of physical activity may
be allowed, accompanied by physi-
cal therapy, or if painful symptoms
persist, an additional period of
fo ur weeks with a new orthosis. 9,16
Conservative treatment in the sports
population remains controversial
and is reserved for stable and non-
dislocated injuries. Regarding this
injury, few studies exist in the sports
population. Several authors, how-
ever, indicate this method as suc-
cessfully compatible, although more
recently it has been associated with
a higher risk of failure. 9,16-18
Surgical treatment in the sports
population is presented with good
results in the literature with high
rates of return to sport activity.
Some controversy exists as to the
type of fixation used (screws, plate
and screws or elastic suture-button
fixation). Biomechanically, there
doesn’t seem to apparently be a dif-
ference between fixation only with
screws (Figure 4) or with plate and
screws. However, fixation with an
elastic suture-button method yields
conflicting results in the literature.
A pertinent and sustained concern
in the literature is related to the
joint damage caused by transarticu-
lar screws and the evolution of the
degenerative changes, as well as the
capacity to achieve an anatomical
reduction in both techniques, with
the utilization of plaque and screws
being sometimes described as a bet-
ter reduction method. 10,19,20
Primary arthrodesis is described
in the literature in several circumstances, including the sports
population, offering contrast-
ing results. One of the underlying
problems regarding this issue is
that in the sports population most
of the injuries are of a ligamentous
nature and on several occasions
the results described in the litera-
ture refer to populations with bony
lesions resulting from high energy
trauma (contrary to most common
sports accidents). The opinion of the
authors regarding primary arthro-
desis in purely ligamentous lesions
in the athletic population is that
it should not be performed. This
opinion is supported by the scientific
literature. 10,21
Post-operative rehabilitation
presents highly variable values ​​
in the literature (between 3 and 8
weeks) with no load, as well as a
highly discrepant time in return to
sport activity (3 to 7 months). The
literature does not present uniform
guidelines regarding the extraction
of the implanted material, being this
a controversial issue. However, it is
usually performed at approximately
six months after surgery, depend-
ing on the need to remove the
implanted material. 10,21-23
In conclusion, it should be noted
that the Lisfranc lesion terminol-
ogy comprises a diverse spectrum
of lesions, which in itself reveals
the complexity of the subject. These
injuries can bring about instabil-
ity and deformity, which will cause
joint degeneration with devastating
consequences for the athlete. It is of
special importance to note that the
role of the clinician is highly rel-
evant in the identification of typical
ligament subtle lesions in the ath-
letic population, since these are pre-
cisely those that are more difficult to
Figure 2 – Exemplification of the classic
model of the mechanism of injury. Figure 3 – Radiograph of a foot with a
Lisfranc lesion. Fugura 4 – Radiograph of a foot after
surgical treatment.
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