Diagnosing foot injury difficult

Conway McLEAN, DPM

Ladies and gentlemen, I would like to present, for your reading entertainment, another medical mystery. Granted, this may not be an everyday sort of problem, but, because of the difficulty in getting an accurate diagnosis, and the frustration experienced by many who have suffered from this injury, I felt it worth presenting to you for your enlightenment.

This is the story of Brook. Actually, to be more precise, this is the story of Brook’s foot. And her foot pain! Brook was a healthy, active 25 year-old, enjoying the many outdoor activities in the area, with mountain biking being one of her favorite. Not that she was terribly experienced, or very good, but she enjoyed it, and it gave her an excellent workout. She did worry about injury, but knew better than to push her limits. She was not very competitive, and was perfectly happy to just “plug along”.

Brook had fallen, not frequently and not badly, but it was somewhat inevitable. She had always been able to get up, and get back on, but the last one had been a bit more traumatic. Her foot had been caught on the pedal because of her “clipless” shoes (which obviously is a misnomer: your foot is clipped to the pedal with this type of shoe-pedal combination. Who came up with this nomenclature?)

She felt her foot get twisted by the fall, but, once again, was able to get up and get going. The pain she felt in her foot, basically in the middle of the arch, was significant, but she was able to finish her ride so how bad could it be?

That was her thinking for the next week, during which she continued to experience a dull, aching pain in her foot when she stood or walked. Brook noticed some swelling, and a little bruising in her arch, but she didn’t make much of it.

The pain was another matter: it did not resolve with time, as she had hoped. If anything, the foot became more swollen, and the ache did not resolve with rest. Standing was becoming difficult.

Her roommate was a nursing student, and recommended the old standard of RICE, the acronym for the use of rest-ice-compression and elevation. This did make it feel better, but she still had a sizable amount of pain.

This is where our story takes a detour from the optimal course of action. The school health service was consulted, and a trip to the urgent care center in town was encouraged. She obediently made the journey, and an x-ray was taken, as well as a cursory exam performed.

Their diagnosis was a foot sprain, and the recommendation was an anti-inflammatory medication, and the use of crutches. Although this latter instrument of torture did indeed relieve her pain, her arms suffered terribly. Still, it all seemed worthwhile if it would allow the injury to heal, so that she might get back to her routine.

After a week and a half of crutch use and ibuprofen, she decided it was time to ditch the crutches and get back to some semblance of a normal life. Much to her chagrin, within a minute of bearing weight on the affected limb, her pain returned. Her frustration knew no bounds. What did she have to do to get some lasting relief?

Naturally, her parents chimed in with a proposal: see the family doctor. His exam revealed nothing particularly exciting, nor did his evaluation of the previously exposed x-rays. His treatment plan consisted of physical therapy, and, to her dismay, more crutch use. At this point, she was willing to try most anything, but the exercises the physical therapist showed her were quite painful, and seemed to provide no benefit, to her way of thinking. She was not convinced, and had just one burning question: what was actually wrong with her foot?

So? What was? What had been damaged, and how was it going to get better? The foot and ankle specialist she then consulted performed a considerably more thorough exam, and ordered some specialized x-ray views. His diagnosis was startling, and quite disconcerting. She had a Lis-franc’s injury! Sounds kind of poetic, doesn’t it? Actually, it is a fairly serious condition in which the first metatarsal bone becomes slightly (or sometimes obviously) separated from the adjacent bones.

The joint between the metatarsal bones and those of the middle of the foot is called the Lis-francs joint, after a French physician who studied the anatomy, and the injury, back in the early 1800’s. A critically important ligament, it connects the second metatarsal bone to one of the bones of the middle part of the foot, and functions to keep everything aligned and in place.

When this ligament is torn or damaged, the stressful forces exerted upon these structures will cause instability, and therefore pain. How much pain is a critical question, and often a function of how much instability is produced. A Lis-franc’s dislocation is often accompanied by a fracture in which a small piece of bone is pulled of the base of the second metatarsal. Brook’s foot specialist identified this small fragment, often a key finding, it helps in making the diagnosis. This is a simple one when there is a large and obvious gap between the first and second bones. Sometimes the forces on the area are so high, multiple fractures occur.

Brook was put into a removable cast boot, and dispensed a knee scooter, which, to her mind, was one of the greatest inventions of the 21st century. Although it took a considerable amount of time to heal, she felt better knowing a specific diagnosis had been made. As she had been warned, the use of a specialized foot support (aka foot orthotics), placed inside her shoes, allowed her to walk and stand comfortably. Sports, and some forms of exercise (like jogging and mountain biking) would have to wait awhile.

Immobilization is the key when a Lisfrancs injury is not too severe, while surgery is generally required when multiple dislocations are seen. Often, with this degree of damage, traumatic arthritis results, and chronic pain can be experienced. When the dislocation is subtle, arriving at a correct diagnosis is difficult, and often missed. Sufferers have gone years without knowing what is wrong with their foot.

There are times for a generalist, a doctor who treats most anything, but one of the most important skills of a family physician is knowing when to refer a patient, and who to refer them to. Insurance plans can be extremely complicated, with many nuances and subtleties, but a referral is not required for a majority of them.

Sometimes going directly to the type of physician most able to treat your problem is time saving, and also pain saving. Just ask Brook, she’ll tell you: the first step to relief may be finding out what the problem is.

Editor’s note: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.