Question
Hello Dr Katz,
Here's the long story:
In December of 2007, I tripped (over a black cat) while wearing poorly fitting, high-heeled clogs.  I heard and felt a "pop" and was immediately unable to weight-bear.  The ER physician felt I had sustained a Lisfranc injury and referred me to a orthopedic.  
That orthopedic performed an MRI after placing me in a cast.  The MRI showed numerous "hot spots" and a "suspicious for full tear" of the Lisfranc ligament.
Since it was a "partial" tear, I was prescribed a shortleg cast for 6 weeks followed by a camwalker for 8 weeks.  After the camwalker, I was cleared to resume normal activity and at week 12 he cleared me to return to my running marathon training schedule. During this time, I continued to have pain which he assured me was normal due to the severity of a Lisfranc "sprain".  At the end of the 5th month, he performed another weightbearing xray - which showed a 4mm dislocation if the Lisfranc interval.  I was referred to a specialist, a wonderful man who has performed quite a few of these (Dr Robert Mills, Holy Cross Ortho) and had a ORIF requiring two screws with excellent reduction.  6 weeks non weight-bearing followed by 16 weeks in camwalker - he removed the hardware at 20 weeks.  He told me (in a way not to insult or accuse another physician) that I should have been in an orthotic and running should not have been addressed for a year.  Also, the first weight-bearing xray performed in the first office revealed diastasis and the classic "fleck" sign.   

I was doing ok until about 6 weeks ago when I began to experience increasing pain and decreasing tolerance to standing and walking.  I have not run since right before my consult with the surgeon.  I have been VERY active; running 7 marathons and work as a pacemaker/defibrillator company rep (lots of OR time).  During my follow up visit I had a series of xrays done and they reveal arthritis and am now faced with a possible 3rd surgery to perform a fusion.  Complicating this matter is that I also sustained a bunion at the time of the injury.

My doctor has offered to try a brace, but it wont change the arthritis.  If the pain continues to worsen, a fusion will be needed.  I really like my doctor and trust him, but the news on this injury, especially when misdiagnosed and late ORIF is performed looks bleak.  

My question is:
What are my chances of achieving a "minimal pain" state that would allow me to work and walk pain-free?  I have accepted that my marathon and any running days are behind me, but I sure would be happy to be able to walk pain-free.
Because I work in medicine, I completely understand that I need to have realistic expectations without losing hope.

I appreciate any advice you have.  

Answer
Hi Becky,

Based on the injury and all of the treatments, I would say that you will likely develop further arthritis and will likely always have some degree of pain.  In some cases fusions will stop much of the pain.  I would consider some aggressive physical therapy.  Before fusion you might consider a custom ankle-foot orthosis.  There are several types including a Ritchie and Arizona brace.

Sincerely,

Marc Katz, DPM
Tampa, FL
Advanced Podiatry
www.thetampapodiatrist.com
www.tampacryosurgery.com

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