Editorial commentary: Anatomical insights, diagnostic challenges and evolving treatment strategies for midfoot sporting injuries in elite athletes

Abstract

The ability to return to sports (RTS) is of utmost importance for professional elite athletes [1-3, 11-16, 21, 24, 25]. Delayed treatment can lead to prolonged downtime, which also can seriously affect the performance, function, future activity level and livelihood of these professional elite athletes [1-3, 11-16, 21, 24, 25]. This is particularly prevalent in high-level competitive sports, where sports-related injuries of the foot can make a significant difference between achieving optimal performance versus facing premature retirement. With this in mind, some of the most challenging and career-altering foot injuries in athletes include Lisfranc injuries, Jones fractures and navicular stress fractures. Although these injuries are distinctively different from both anatomical and biomechanical perspectives, they share several commonalities such as frequent misdiagnosis, delayed treatment, prolonged recovery time with high risk of complications such as non-union, malunion, midfoot deformities, chronic pain and finally post-traumatic osteoarthritis [6-10, 14, 19-21, 23, 24].

Therefore, it is an excellent moment to find a specially themed issue on sports-related injuries in professional elite athletes dedicated to the midfoot comprising of Lisfranc injuries, Jones fractures and navicular stress fractures. This issue highlights the anatomical intricacies, diagnostic challenges and the evolving treatment strategies in managing these clinically relevant injuries in the athletic population.

A comprehensive understanding of the midfoot anatomy is essential to early diagnosis and initiation of accurate management plan. In the Lisfranc joint, for instance, subtle, isolated ligamentous Lisfranc injuries are increasingly reported in athletes, yet they are commonly overlooked at the initial presentation due to the subtlety of the imaging findings. Liu et al. illustrated the complex, but unique architecture of the tarsometatarsal joints in their review on Lisfranc joint anatomy including the base of fifth metatarsal and the navicular bone in this themed issue [17, 18]. They have also addressed the age-old question related to the very existence of the Lisfranc joint itself [18]. Moreover, their study examined the anatomy of the intercuneiform joints, which is crucial for understanding the variants of ligamentous Lisfranc injuries, often with proximal extension, particularly reported in competitive athletes [18, 21].

Following that, the distinctive features of the base of the fifth metatarsal bone and the navicular bone with its respective vascular supplies were reviewed to highlight the anatomical basis for risk of avascular necrosis, prolonged healing time, leading to extended delay in RTS [10, 14, 17, 19, 23]. These structures are exceptionally vulnerable due to the watershed areas and tenuous nature of their blood supply, underscoring the importance of timely recognition, early intervention and appropriate management strategies.

Lisfranc injuries, Jones fractures and navicular stress fractures are collectively associated with substantial morbidity and thereby a threat to athletic careers [4-8, 12, 14-21]. However, there remains a lack of a standardised approach to the management of these injuries. In response, the International Foot and Ankle Sports Consensus (IFASC) committee formed by expert members from 25 countries across 6 continents convened to establish evidence-based management guidelines for the treatment of sporting injuries of the foot and ankle in elite athletes, especially in terms of Lisfranc injuries, Jones fractures and navicular stress fractures.

In terms of the Lisfranc injuries, Semelsberger and Boggiano et al. provided consensus statements and systematic review on the diagnosis and assessment of these injuries, while discussing the role of non-operative management for Lisfranc injuries in athletes [22]. To establish the diagnosis of subtle injuries of the Lisfranc joint is challenging, as obvious clinical instability on the initial examination or overt joint diastasis on index imaging may not always be evident [1, 8, 12, 14, 21, 24]. As a result, the IFASC committee strongly recommends weight-bearing radiographs of both feet, as well as interval clinical examinations with weight-bearing radiographs if there is any suspicion of instability—even minor—that might not be detected on initial presentation [22]. This is especially relevant, if non-surgical management is discussed. This recommendation emphasises the importance to confirm the stability of the Lisfranc joint before deciding on the most appropriate treatment.

Moving towards the treatment of unstable Lisfranc injuries, the consensus statements on surgical treatment options were reviewed by Balboni et al., who provided key recommendations for the management of both ligamentous Lisfranc injuries and Lisfranc fracture-dislocations [4]. Open reduction and internal fixation (ORIF) is preferred over arthrodesis for elite athletes with ligamentous Lisfranc injuries. Although no specific fixation techniques could be recommended by the consensus report, the systematic review revealed better clinical outcomes with flexible constructs (e.g., suture button fixation) compared with rigid constructs (e.g., ORIF with plates and screws). Nonetheless, the authors stated that studies utilising flexible constructs for ligamentous Lisfranc injuries had shorter average follow-up periods when compared with those who have undergone surgery using rigid constructs. In cases of Lisfranc fracture-dislocations, ORIF remains the treatment of choice over arthrodesis in athletes with a caveat that the cartilaginous articular surfaces are intact or damaged by less than 50%.

In cases of significant articular surfaces damage, arthrodesis is, however, recommended. Additionally, the type of sports was also highlighted by the consensus report as a major consideration, because athletes involved in sports requiring greater foot flexibility may benefit from fixation rather than arthrodesis [4]. Notably, a central take-home-message from the consensus is that open direct visualisation of the joint reduction with intraoperative fluoroscopic assessment is vital to achieve anatomical reduction although percutaneous fixation may in some cases be a viable option [4]. These are important findings with meaningful clinical relevance and real-world applicability.

It has been shown that Lisfranc injuries have the highest operative rate and are associated with the highest season-ending injury rate in an epidemiological study of 3607 foot injuries in American collegiate athletes [6]. As a result, Webber et al. focused their systematic review on the ability to RTS after Lisfranc injuries [25]. They found that at least 74% of athletes were able to return to their preinjury level of sporting activities [24, 25]. However, other smaller studies have reported higher rates of return to preinjury level of sports, with some studies reporting return rates as high as 100% [25]. According to the consensus report, athletes typically remain non-weight-bearing for at least 4–6 weeks following surgery, transitioning into a walking boot at 6–8 weeks with RTS expected at 4–6 months. The authors also showed that although patients with ligamentous Lisfranc injuries were allowed earlier weight-bearing than those with bony Lisfranc injuries, the average time to RTS is generally longer for those with ligamentous injuries. These findings and consensus statements can be useful to guide postoperative rehabilitation milestones in terms of weight-bearing status and RTS timelines.

Jones fractures present a particularly challenging dilemma in the athletic population because they can manifest either as acute traumatic fractures or stress fractures due to repetitive microtrauma from overuse. Balboni et al. conducted a comprehensive review comparing non-operative versus operative treatment options for Jones fractures in athletes while establishing expert consensus statements related to the establishment of the diagnosis, treatment strategies, weight-bearing regimes and the ability to RTS [5]. Interestingly, non-operative treatment for both acute traumatic (16.1%) and stress Jones (8.2%) fractures was shown to have higher failure rate compared with operative treatment (4.1% for acute traumatic fracture, 6.3% for stress fracture). Operative treatment resulted in shorter average time to RTS regardless of acute or stress fractures consistent with the consensus recommendations of the IFASC committee [5]. In harmony with this finding, the authors concluded that operative treatment would be preferred for stress Jones fractures, while acute Jones fractures might be treated non-operatively.

Navicular stress fractures, although relatively uncommon in the general population, are much more prevalent among athletes. These fractures are known for their prolonged recovery time and high risk of non-union. In a study of 899 professional rugby players, those with navicular stress fractures took the longest time to RTS at an average of 188 days, despite only accounting for 1% of all foot injuries [20]. Therefore, the evidence-based management guidelines and the consensus statements reported by Webber et al. are clinically highly relevant because of the paucity of literature in terms of surgical options for these hard-to-treat stress fractures [26]. Their work fills a critical gap in the existing literature on navicular stress fractures. Following that, Hong and Calder reported an original series of elite athletes with chronic navicular stress fracture non-union, who had undergone treatment using vascularises pedicle bone grafting [15]. This treatment successfully yielded stable bony union and ability to RTS without any significant complications. An intriguing aspect of this study is that more than three-quarters of the athletes had experienced previously failed surgical interventions further emphasising the complexity of this injury.

Midfoot sports-related injuries including Lisfranc injuries, Jones fractures and navicular stress fractures, represent significant challenges for elite athletes in terms of accurate diagnosis, effective treatment, and the ability to RTS. Advancement in understanding the midfoot anatomy, identifying diagnostic pitfalls, and refining treatment strategies along with consensus guidelines can offer a comprehensive and tailored approach to the management of these complex injuries. Only through time and continued research such as those presented in this themed issue that a more up-to-date and personalised approach to treating these complex injuries can lead to improved clinical outcomes and thereby improve career longevity for professional elite athletes.

Looking forward, the future lies in improving diagnostic tools for early diagnosis, ensuring accurate treatment protocols, and implementing evidence-based rehabilitation strategies to support long-term recovery and optimal performance for midfoot sports-related injuries.

The authors declare no conflicts of interest.

The authors have nothing to report.