Painful uncertainty: How Lisfranc injuries have become one of most feared yet least understood maladies in football
The choreography of Taysom Hill's undoing looks no different than the thousands of times he's run this play before. There's 230 pounds of muscly mass, ball in hand, dropping back to pass. There's a decision: to run instead. And then there's acceleration, the quarterback's considerable frame lunging forward. On the first step, his right foot plants. But something—Hill's cleat, Nebraska's turf, the angle, a twitch—goes wrong. It's impossible to pinpoint. What's different is the sound.
To Hill, the sound echoed louder than the roar of the crowd of nearly 90,000 in Lincoln last September. "It was like a rubber band snapped, and I felt this burning sensation in my foot," the BYU quarterback says nearly nine months later. He still plowed 21 yards into the Cornhuskers' end zone, tying the game at 14 in the second quarter, but he went no farther than he had to, falling to his knees just over the goal line. The pain in Hill's right foot had seared more with each step, and he limped to the sideline. By then, his foot felt as if it were on fire.
As Hill described the sensation to BYU's trainers, they began examining him. When they applied pressure to his midfoot, he winced. Equipped only with a C-arm, a mobile imaging device that uses X-ray technology, the medical staff took images that suggested a ligament tear. Without the ability to take weight-bearing images, there was no way to confirm, but the suspected diagnosis they shared with Hill in the second quarter was correct. He'd suffered a Lisfranc injury and would miss the rest of the season.
Lisfranc injuries are named for Jacques Lisfranc de St. Martin, one of Napoleon's surgeons who first described them in 1815. Soldiers sustained the injuries when they fell from their horses and one foot remained stuck in its stirrup, and they often resulted in amputation. Two hundred years later, medical advances have improved that outcome, but Lisfrancs remain among football's most devastating injuries.
The Lisfranc joint complex comprises the bones and ligaments that join the midfoot and the forefoot. The metatarsal and tarsal bones, as well as the joint that connects them, are held in place by ligaments that run across and down the foot. Damage to these ligaments constitutes a Lisfranc injury, and without their support, the bones of the midfoot can dislocate, requiring surgery.
When it comes to walking—and running, cutting, accelerating, you name it—the integrity of the midfoot is essential. If healthy, it transfers force from the calf to the front of the foot and stabilizes stride, which is crucial in football, where documented instances of Lisfranc injuries are on the rise. Such diagnoses were rare in the 1990s, but from 2000–05, the NFL saw an average of 14.2 per season, which increased to 18.9 from 2006–14. (These numbers come from the NFL Injury Surveillance System—ISS for short—and are reported in a soon-to-be-released study by the league's Foot and Ankle Committee. Data at the college level is tougher to quantify; there is no centralized injury database.)
Dr. Robert Anderson, the Carolina Panthers team physician, is football's foremost Lisfranc expert, and he's a co-chair of the Foot and Ankle Committee. Anderson, who has operated on dozens of players with Lisfranc injuries, still terms the injuries "bizarre," based on how much must go right—or wrong—for them to occur.
Initially, most physicians believed Lisfrancs were contact injuries, caused by one player landing on another's heel, or even a tackle gone wrong. More and more, though, the injuries occur without contact, when a player cuts or twists, leaving his forefoot planted while the rest of his foot moves, disrupting the Lisfranc ligaments and joint. "We're finding it particularly in running backs (and) defensive ends as they come around the offensive tackle (and in) defensive backs changing directions," Anderson says. "If their foot is planted in the ground forcibly enough, and then they twist their body around that foot, the joint can actually develop a ligament injury, and they develop a Lisfranc (instability) pattern."
Anderson and the rest of the Foot and Ankle Committee have been studying Lisfrancs in-depth since 2012, and the NFL funds their research with grant money. Dr. Kirk McCullough, a member of the committee, discussed its findings at the American Orthopaedic Foot & Ankle Society conference in 2015. According to his presentation, of the 255 total Lisfranc injuries documented in ISS, 55 (22%) required surgery. Surgery rates nearly doubled from the 2000–05 period to the 2006–14 period, from an average of 2.4 per year to 4.6. (Surgery is necessary when bones shift and involves inserting hardware to stabilize the midfoot. Ligaments heal independently once the bones are aligned.) The study also observed 40 of Anderson's surgical patients at a year or more after the operation. Among the 34 NFL players, 79% had returned to game play by an average of 314 days (about 10 months) post-surgery. All six of the college players observed returned to game play, by an average of 256 days (8.5 months) post-op.
After Hill was diagnosed, the senior quarterback had a decision to make right away. His season would be over after the game, but due to the nature of his injury—the ligaments were completely torn—he wasn't at risk of further damage to his midfoot. So BYU's medical staff decided he could return to the field if he wanted. He'd be limited to taking snaps from the shotgun and passing with little mobility, not to mention at risk of being clobbered by Nebraska's defensive line, but Hill chose to go back in. He played the rest of the second quarter and all of the third.
According to Anderson, who did not treat Hill, about 90% of players he works with say they can't continue to play after the injury. Most face situations similar to that of Ravens cornerback Jimmy Smith, who in 2014 tried to walk off his Lisfranc sprain but says he felt intense pressure and that same stinging, burning sensation. "You look at some of these guys," Anderson explains, "the about 10% that despite a significant Lisfranc injury will still play out the half or whatever—they get the adrenaline flowing, and they just keep going."
That was the case for Hill, who logged 19 throws, a touchdown pass, two sacks and, almost unbelievably, a 35-yard run on his hobbled foot. Chad Lewis, BYU's associate athletic director for development, was on the sideline that day in Lincoln. He played tight end for the Cougars from 1993–96 before a nine-year NFL career and suffered a Lisfranc injury in the NFC Championship in 2005. "Knowing how I felt (after my injury)," Lewis says of Hill, "that was heroic."
As Hill played out the second quarter, various BYU officials paused to share their optimism with Lewis: "He's back! It's all good!" Lewis's response garnered stares. "I was looking at them like, no, his season is over," Lewis recalls. "He's just going to play as long as he can today."
After that, the uncertainty that is a hallmark of Lisfranc injuries set in. Think of it this way: When a player tears a ligament in his knee, his rehab calendar is specific, broken down into weeks with a target return date set soon after surgery. But with Lisfrancs, players are given an initial recovery window of 6–12 months, and their rehab schedules are divided into months-long, inexact chunks.
For Hill, that timetable could have meant a return to full activity by spring football—or just in time for BYU's opener. The gap between those dates seemed a lifetime, but as spring approached, Hill began to understand patience. With past injuries—he's had seasons ended by a knee injury and a broken ankle—he'd felt recovered after four or five months. But at the start of spring ball, he was severely limited, and even in late May, eight months out, he's blunt: "I still don't feel like I have a normal foot."
"You're going to go seven, eight months, and you're still hurting," Lewis says. "You're like, screw it. Nine, 10 months, you're still hurting. (You're thinking), there's no way it can be this long. It is that long."
Hill's early rehab was fairly standard, if such a situation exists for Lisfrancs. After his Sept. 11 surgery by Dr. Timothy Beals, he wasn't able to bear weight on his right foot for two months. Rehab involved activities like using his toes to crunch towels and pick up marbles as well as flexing, spreading and straightening his toes. After that, Hill wore a boot for a month and spent another month putting little stress on the foot and working on much-needed balance. While on crutches and in boots, players often shift their weight to compensate, and afterward, achieving equilibrium can be difficult. "You can tell them to do 50–50 (weight-bearing on each foot), but in their mind … 50–50 might really be 70% on the good leg, 30 on the injured," BYU's rehabilitation coordinator Brett Mortensen says. "We'll put them on the wobble board where they can get that visual feedback."
On Jan. 12, Hill had the hardware in his midfoot removed, but during surgery, his doctor discovered that one of the two screws had broken. Telling the story, Hill points to a jagged mark on top of his wide, size 12 1/2-foot. "This scar used to be tiny," he explains. "They went in the top of my foot, and they carved out two different areas in my bone: next to where the screw came out at so they could get the little drill in there, and … around where the screw was, so they could get it out. Afterwards, my foot was so swollen, so black and blue."
The screw had broken at some point between Hill's three-month X-ray and its removal. Such instances are not uncommon. Denver Broncos linebacker Brandon Marshall, who had Lisfranc surgery in early 2015, waited to have his screws removed until after he played in Super Bowl 50. When doctors operated in February, they elected to leave a piece of broken screw in his foot rather than invasively remove it.
Hill's screw extraction represented a minor setback, but his rehab continued on a loose schedule through spring football. When he couldn't use his foot, he built upper-body strength—Hill has the figure, Mortensen says, of a "college Captain America"—and he gradually moved from running in a pool to running on land. Next came rotational and lateral movement, and Hill was fitted at Bowden Orthotics in Orem, Utah, for custom inserts, a narrower pair for his cleats and another for regular shoes. Once equipped, he began to participate in football-specific workouts at the team's late-spring workouts.
By May, he looks like any other player. Sprinting in a blue BYU tank, his golf-induced farmer's tan is on full display, and if trainers ask him to go 80%, he's at 100. In the weight room, he lifts with linemen, and it's only on certain drills—like single-leg box jumps—that Mortensen and head football trainer Steve Pincock ask him to sit out or modify his motion.
Hill's time in the training room has normalized, too. He spends about as much time with Mortensen as does a player with a tweaked hamstring or tight back. Most of the focus is on activating Hill's leg muscles and stretching his foot, feeling for the pain that remains and working to mitigate it.
The goal, Mortensen says, is for Hill to be 100% by August, and he reminds the quarterback that this is about playing in September—and winning back his starting job from sophomore Tanner Mangum—rather than any one insignificant summertime drill. Now, Hill says, he isn't even sore after some workouts.
While presenting the Foot and Ankle Committee's findings last summer, McCullough revealed that the average Lisfranc patient suffers 1.3 years of discomfort after his initial injury. And though many players report pain lessening with every game after returning, Lewis says his discomfort persists, especially after he skis or plays basketball. The former tight end has become borderline obsessed with the injury, and he talks to as many players who have suffered it as possible. With few exceptions, everyone is in a similar position to his 11 years removed from surgery.
Lewis was 33 when he sustained his injury, already near the end of his career. It was his internal clock, he says, not his foot, that led him to retire at the end of the next season after an eight-game comeback. Anderson says age is not a determinant of a player's ability to return. Still, the older a player is, the less incentive he has to undergo the grueling rehab. Champ Bailey, a future Hall of Fame cornerback, suffered a Lisfranc sprain at age 35 in 2013, and though he never underwent surgery and returned for part of the Broncos' Super Bowl run, his foot pushed him to retire a year later. Santonio Holmes and Cedric Benson both suffered similar fates after their Lisfranc injuries at ages 28 and 29, respectively; Holmes played part of one season after his, and Benson never played again—though both attempted comebacks.
Hill's brother-in-law, former BYU safety Craig Bills, was just 24 when he sustained a Lisfranc injury at his 2015 pro day. About nine months later, he worked out for the Eagles and performed well, earning a spot on Philadelphia's practice squad. The next day, he couldn't walk, and an MRI revealed three stress reactions in his foot. Two months in a boot followed, but only one stress reaction healed. More than a year out from surgery, his future in football is increasingly uncertain.
Still, the majority of Lisfranc comebacks are successful. According to researchers at the Perelman School of Medicine at the University of Pennsylvania, nearly 93% of NFL players who sustained midfoot injuries from 2000–10 returned to play within 15 months of injury and with no statistically significant decrease in performance. In the Foot and Ankle Committee's study, of the 25 of Anderson's players who returned to NFL games, three went on to be Pro Bowlers, and the list of players who have come back from such injuries is a who's who of NFL rosters: Dwight Freeney, Darren McFadden, Ben Roethlisberger, Ryan Clady, Le'Veon Bell, Michael Strahan, Eric Decker, Ryan Kalil.
Instances of Lisfrancs have spiked in recent years in large part due to better awareness and ability to diagnose. Dr. Rebecca Cerrato, a foot and ankle specialist, says that when she began to do research for a paper she co-wrote nine years ago, she was shocked by how inaccurately reported most Lisfranc injuries were. She could also find almost no literature on rehab best practices, which remain vague even as reporting has improved. In 2016, most trainers are better educated and exposed to the injuries, but each Lisfranc injury is so different—a player can tear one ligament or five, and bone displacement varies—that a timeline with the specificity of an ACL post-op is likely unattainable, Cerrato says.
In addition to better awareness leading to more diagnoses, Anderson still believes other factors are at least partially responsible for the recent uptick in Lisfrancs. Shoes, playing surfaces and the increased size and strength of most athletes almost certainly come into play, Anderson says. One of those factors, players' evolution, isn't about to reverse, but playing surfaces and cleats have room for improvement and correction.
"All the players want to be faster, and they think lighter shoes make them (faster)," Anderson says. "You think back to the days of Johnny Unitas, and the shoes those guys wore were like boots. They were like work boots, hiking boots, very stiff, very protective, not much flexibility in the shoe itself. That might've protected those guys in years past from getting these injuries."
The Foot and Ankle Committee has begun a dialogue with shoe companies and has offered to partner with them to engineer the best designs, and among trainers at both the college and NFL levels, lists of shoes to avoid have begun to circulate. (Both Nike and Under Armour, makers of the most popular brands of cleats, did not respond to requests for comment.) Still, most players favor lighter-weight cleats, and many prefer spikes that grip the turf deeper, which could also contribute to injury, according to Cerrato. But with such low odds of a Lisfranc injury occurring and the multiple factors responsible for the damage, it's hardly prudent to make a blanket recommendation that all players bulk up their footwear.
As his rehab has progressed, Hill has become hyperaware of how his foot feels in every shoe he tries. His cleat of choice these days is the Nike Alpha Pro, which provides support for his uncommonly wide forefeet.
But as the fifth-year senior prepares for one last crack at a full season under center, he's not putting all his stock in footwear. Throughout this winter and spring, Hill consulted with five different doctors about his foot. If he couldn't pinpoint what went wrong on that doomed step, he wanted to know every possible cause. Most doctors held stock theories: It was his cleat, it was the playing surface, it was a fluke. One chiropractor, Dr. Craig Buhler, had a different theory, though. Because Hill had been so injured over the course of his career, certain muscles in his body had shut down, leading him to compensate in other areas and send too much force to his foot. Since then, Hill's doctors and trainers have gone through his whole body to determine which muscles fail to properly fire. They found that his hamstrings and quadriceps weren't up to par, and he now spends time in the training room working them and massaging them in an attempt to reactivate them.
Hill will never know the true cause of what went wrong last Sept. 5. There's an element of faith inherent in pushing past this injury, in leading his pack of sprinters without worrying about that pop, in lining up next to a 300-pound offensive tackle in the weight room and matching him squat for squat without fear that his foot might crumble. But just like the hundreds of players who rehabbed from Lisfrancs before him, Hill will sprint and squat and hope that the strange confluence of tissue and turf and traction doesn't ever align again. The odds say it shouldn't. But anyone who's ever spent a year of his life nursing his foot back to function knows the odds don't apply here.