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Thursday, August 22, 2013
Le'Veon Bell injury, Lisfranc explanation

By Stephania Bell

Pittsburgh Steelers rookie running back Le'Veon Bell has been unable to stay on the field consistently this preseason. First, it was soreness in his left knee, which caused him to miss the Steelers' preseason opener. Days later, he aggravated the knee in practice. He returned quickly enough to make an appearance in the Steelers' second preseason game, but that outing was cut short due to injury. This time, it was not his knee; Bell sprained his right foot after playing in just one series.

The big question is how long this latest injury, called a midfoot sprain by coach Mike Tomlin (and originally referred to as a Lisfranc sprain in ESPN reports), will keep Bell on the sideline. At this point, there is no timetable being offered by the Steelers, but on the positive side, Bell's injury will not require surgery.

So what is a realistic expectation for fantasy owners? And why does panic ensue when we hear the term "Lisfranc" associated with a foot injury?

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Le'Veon Bell
AP Photo/Keith SrakocicLe'Veon Bell has fallen to 40th among running backs in the ESPN fantasy's RB rankings.

As for what fantasy owners can expect, the only sure thing is that this will be a multiweek injury. Bell has already been ruled out of Pittsburgh's third preseason game, and while the Steelers are not saying when they expect him back -- in their defense, it's too early to make that projection with any degree of certainty -- early reports suggest a recovery time of 6-8 weeks. That time frame is fairly typical for nonsurgical Lisfranc sprains, but it should be noted that, depending on the actual degree of injury, the athlete's ability to heal and whether any setbacks occur along the way, the estimate could fluctuate in either direction.

Ray Fittipaldo of the Pittsburgh Post-Gazette reported Thursday that Bell said he was walking without discomfort and feeling positive about his progress. While that's great news, the big tests will come when he has to push off with running and pivot, twist and cut on that foot. Although the details of the injury aren't available, if it's indeed a Lisfranc sprain, it's difficult to imagine Bell returning to football before late September. It's critical to the long-term foot health of any player who suffers this type of injury that complete healing occurs prior to a return to play, hence the slow progression, even when the player says he feels fine.

This standard slow progression is part of the reason the word "Lisfranc" engenders panic. The standard absence for players who suffer this injury ranges from six weeks for the mildest form to season-ending for the more severe variety. Last season, Jets wide receiver Santonio Holmes, Green Bay Packers running back Cedric Benson and Jacksonville Jaguars running back Maurice Jones-Drew all saw their seasons end due to Lisfranc injuries.

Perhaps more noteworthy is that these injuries were all unique and Holmes was the only player whose season was declared over shortly after the injury. Benson was initially placed on the IR/designated for return list after suffering the injury in Week 5 but did not progress as hoped and ultimately underwent season-ending surgery in late November. Jones-Drew was also hoping to avoid surgery after his Week 7 injury, but his problem persisted and he too underwent surgery in December.

It should be noted that last season Cowboys running back DeMarco Murray suffered a midfoot sprain that cost him six weeks, but he recovered fully and returned during the season.

Maybe now it's a bit clearer as to why the term "Lisfranc" inspires dread. But what is this Lisfranc injury? Lisfranc refers to an area of the foot where the long bones of the forefoot (metatarsals) articulate with the small (tarsal) bones in the middle of the foot. This joint is called the tarsometatarsal joint, or the Lisfranc joint. This joint is in the midfoot region, hence the confusion about the terms, which are often used interchangeably.

Why Lisfranc? Frenchman Jacques Lisfranc, a field surgeon in Napoleon's army, described an amputation technique through this region to address forefoot gangrene following frostbite. There is also a story that soldiers wounded in battle would fall from their horses, but a foot would often remain caught in the stirrup, right at that tarsometatarsal joint. Such an injury often resulted in amputation of part of the foot, from the injured joint forward. Thankfully, with modern medicine, these injuries don't typically require amputation, and surgery can preserve the joint.

Since NFL players aren't riding horses, how does this injury happen? Well, in sports, especially football, one scenario is that the player is running forward with his weight on the ball of his foot and he gets hit or stepped on from behind against his heel. The resultant force through the portion of the foot in between the ball and the heel (midfoot) causes it to buckle, and the midfoot is injured. But it can also result from shearing forces at the foot, the result of a twisting injury when the forefoot remains planted and locked into the ground as the player moves another direction.

Not all Lisfranc injuries are identical. When the midfoot buckles, the ligaments that connect the various bones can become damaged. Ligament injury without any bony impact would be the mildest version of a Lisfranc injury. The more mild sprains can be treated conservatively with rest and rehabilitation. If the damage to the ligaments is more extensive, it can affect the relative position of the bones in the area, and they can shift or dislocate, which is often accompanied by a fracture, resulting in a more serious injury. In the worst-case scenario, an artery passing over that area can also be damaged, affecting blood supply to the foot.

Shifting of the bony alignment typically requires surgery to realign the joint and provide stability, but it's not always easy to detect. Failure to properly correct the injury, however, can result in chronic instability and pain, eventually leading to major arthritis in the area. Even with surgery, it appears that those who have suffered a significant Lisfranc injury may be at increased risk for arthritis down the road, simply because of the trauma to the joint.

The bottom line is that players who suffer these injuries must have their treatment managed carefully, not only with surgery when indicated but in the rehabilitation process as well.