Original Research

Midfoot Sprains in the National Football League

Am J Orthop. 2014 December;43(12):557-561

Midfoot sprains in the National Football League (NFL) are uncommon. There are few studies on midfoot sprains in professional athletes, as most studies focus on severe traumatic injuries resulting in Lisfranc fracture-dislocations.

We conducted a study to evaluate midfoot sprains in NFL players to allow for better identification and management of these injuries. All midfoot sprains from a single NFL team database were reviewed over a 15-year period, and 32 NFL team physicians completed a questionnaire detailing their management approach. A comparative analysis was performed analyzing several variables, including diagnosis, treatment methods, and time lost from participation.

Fifteen NFL players sustained midfoot sprains. Most injuries occurred during games as opposed to practice, and the injury typically resulted from direct impact rather than torsion. Twelve players had nonoperative treatment, and 3 had operative treatment. Nonoperative management resulted in a mean of 11.7 days of time lost from participation. However, there was a significant (P = .047) difference in mean (SD) time lost between the grade 1 sprain group, 3.1 (1.9) days, and the grade 2 sprain group, 36 (26.1) days. Of the 3 operative grade 3 patients, 1 returned in 73 days, and 2 were injured late in the season and returned the next season.

Eleven (92%) of the 12 players who had nonoperative treatment had a successful return to play, and 10 (83%) of the 12 played more games and seasons after their midfoot injury. Depending on the diastasis category, NFL team physicians vary treatment: no diastasis (84% cam walker), latent diastasis (47% surgery, 34% cam walker), and frank diastasis (94% surgery).

In the NFL, midfoot sprains can be a source of significant disability. Successful return to play can be achieved with nonoperative management for grade 1 injuries within 1 week and grade 2 injuries within 5 weeks. However, severe injuries with frank diastasis that require operative management will necessitate a more significant delay in return to play. Either way, most NFL athletes will have a successful NFL career after their midfoot sprain injury.

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References

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Midfoot (Lisfranc) joint injuries are uncommon in the general population, with a reported incidence ranging from 1 per 50,000 to 1 per 60,000 per year.^1,2 The majority of these midfoot injuries result from high-velocity direct trauma involving severe disruption of the tarsometatarsal joint.^1-6 Most of the literature on Lisfranc injuries are based on cohorts that include trauma patients. On the other hand, low-velocity indirect injuries of the tarsometatarsal joint have also been associated with midfoot or Lisfranc sprains.⁷ These injuries are even less extensively studied in athletes, who may sustain them from torsion or the shoe–surface interface.⁸

Foot and ankle injuries are among the most common injuries in athletes and represent 16% to 22% of all sports injuries.⁹ Although midfoot sprains are not common in the general population, sporting activities appear to result in a higher rate of midfoot injury, especially in elite athletes. In fact, midfoot sprains comprise the second most common athlete injury to the foot, after metatarsophalangeal joint injuries.¹⁰ Football players are especially prone to midfoot sprains; incidence is 4% per year, with offensive linemen sustaining 29.2% of midfoot sprains.¹⁰ The most common mechanism of injury is an axial longitudinal force while the foot is plantarflexed and slightly rotated.^11,12

There is a paucity of literature detailing the impact of midfoot injuries on football players.^8,10,13 A study of 23 collegiate football players found that they may have initially underwent a long period of acute disability but had very minor long-term complaints resulting in residual functional disability.¹⁰ However, there are no case series detailing the impact of midfoot sprains on professional football players for whom delayed return to sport can potentially have a devastating impact on a career in terms of both acute- and long-term disability.

We conducted a study to further define the mechanism of injury, diagnosis, treatment, and outcomes among National Football League (NFL) players with midfoot sprains. In addition, we aimed to provide a qualitative analysis of diagnostic and treatment algorithms being used by NFL team physicians in their management of midfoot sprains in these high-level contact athletes.

Materials and Methods

We evaluated midfoot sprains in NFL players in 2 specific phases. In phase 1, we retrospectively reviewed prospectively collected data involving midfoot sprains in professional players from a single NFL team over a 15-year period. In phase 2, we collated diagnostic and treatment algorithms for midfoot sprains among all 32 NFL team physicians by means of a structured questionnaire. Institutional review board approval was obtained for this study at the investigators’ institution.

In phase 1, a NFL team injury database was reviewed for midfoot sprains that had been prospectively entered by a team-certified athletic trainer after consultation with the head orthopedic team physician. All injury and diagnostic modalities and treatments were then analyzed. These included player position, foot and ankle protective gear (none, tape, brace, or unknown), playing surface (grass, AstroTurf, FieldTurf, or unknown), field condition (normal, wet, hard, or unknown), onset of injury (acute, chronic, or unknown), place of injury (game or practice), time of injury in game or practice (first quarter, second quarter, third quarter, fourth quarter, or unknown), type of play (collision, tackled, tackling, blocked, blocking, running/cutting, kicking, or unknown), and mechanism of injury (direct, torsion, shearing, or unknown).

Once the diagnosis was confirmed by physical examination and radiographic findings, midfoot sprain treatment was initiated based on the following algorithm protocols. Nondisplaced sprains were treated with a period of immobilization in a cam walker with progression to weight-bearing as tolerated (grade 1). Once asymptomatic, rehabilitation was initiated, including range of motion, strengthening, and proprioception, and gradual return to play as tolerated. Injuries with subtle diastasis (2-5 mm) were typically treated with nonoperative management in the same manner as the nondisplaced sprain protocol (grade 2); however, signs of gross instability indicated the potential requirement for surgical management. Some of these injuries underwent stress-testing to determine if there was gross instability. If the injury had subtle diastasis with instability or frank (>5 mm) displacement (grade 3), then surgical management was performed with closed versus open reduction and internal fixation (ORIF). The postoperative course included no weight-bearing for 4 to 6 weeks followed by partial weight-bearing for an additional 4 to 6 weeks. After approximately 8 to 12 postoperative weeks, screw removal was performed followed by progression to full weight-bearing and a comprehensive rehabilitation program, including range of motion, strengthening, proprioception, and gradual return to play. Return to play was allowed when the athlete was asymptomatic and had normal range of motion and strength. Time lost from participation was then recorded based on the dates of injury and return to play.