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Making the Cut: A Foot Injury Connects 2 Bronco Receivers

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They play the same position. They have both had the same injury. They share the same agent in Todd France, and have history with a mutual coach. While the first one is a given and the second, coincidence; the latter two have combined to make Eric Decker and Brandon Stokely familiar teammates.

 Decker was diagnosed with a Lisfranc injury--a tear of the ligament that holds his first two toes in place. This is a critical injury for a player that needs to cut and plant his feet running pass routes. Brandon Stokley suffered a similar injury while playing for the Baltimore Ravens in 2002.

The rookie found his mentor in a roundabout way. Stokley reached out to Decker soon after the University of Minnesota wideout injured his left foot in a game against Ohio State in October. Stokely came to know about Decker through Jedd Fisch, the former Gophers offensive coordinator who’s since taken a position with the Seattle Seahawks. Fisch, once the receivers’ coach for the Broncos, asked Stokley to say a few encouraging words to Decker after he got hurt. Stokley took it a step further by forging a friendship.

When he hurt his foot during that game, Eric didn’t realize how bad his injury was. It took him more than a week to figure out what really happened. Unfortunately it turned out to be a Lisfranc sprain, which promptly ended his college career and required him to have surgery.

The Injury

 Lisfranc injuries occur at the midfoot, where a cluster of small bones forms an arch on top of the foot between the ankle and the toes. From this cluster, five long bones (metatarsals) extend to the toes. The second metatarsal also extends down into the row of small bones and acts as a stabilizing force. The bones are held in place by connective tissues (ligaments) that stretch both across and down the foot. However, there is no connective tissue holding the first metatarsal to the second metatarsal. A twisting fall can break or shift (dislocate) these bones out of place.

To put it more plainly, the Lisfranc joint is located at the intersection where the big toe and the second biggest toe attach to the base of the foot.

There are different types of Lisfranc injuries and they can be described in various ways. One way is to differentiate them based on whether the injury is purely due to ligament rupture, or whether a small fleck of bone is pulled off (avulsed) from the ligament’s attachment to the bones of the foot. Also in the most severe high energy injuries, there may be a dislocation of the joints of the midfoot and/or multiple fractures present. A Lisfranc injury can also be classified based on which direction the involved bones move (are displaced) during the injury once the involved ligaments are torn.

Have you ever dropped a heavy box on the top of your foot? Or accidentally stepped in a small hole and fallen, twisting your foot? These two common accidents can result in a Lisfranc fracture-dislocation of the midfoot. Another mechanism by which a Lisfranc injury occurs is when an athlete, typically an offensive lineman in football, sustains a direct blow compression injury through their foot. The lineman is blocking an opposing defender while moving forward such that only their forefoot is on the ground while their heel is raised in the air. If another player falls on the blocker’s heel, a significantly large axial force occurs through the lineman’s Lisfranc joint. Furthermore, if any twisting motion also occurs, the injury can be more severe.

That's not how Decker sustained his injury though. It occurred while running a route that required him to cut quickly toward the sideline.

 "It was a freak accident. We had a corner and a post route and Adam (Weber) threw the ball to the sideline. I thought I had more room than I did. I looked down and saw I was hugging the sidelines and tried to quickly plant my left foot. I think I put a little too much pressure on the wrong place. It felt like my cleat collapsed, so I looked down at my cleat to see if it broke. I put some more pressure on my foot and right from there I knew something was wrong. We taped up the arch on my foot, I thought maybe something just fell out of place a little bit and it was nothing serious. I took my first step and I knew it was worse than I thought."

Lisfranc fracture-dislocations are often mistaken for sprains. The top of the foot may be swollen and painful. There may be some bruising. If the injury is severe, you may not be able to put any weight on the foot. These injuries are often difficult to see on X-rays.

When gone unrecognized, Lisfranc injuries can have serious complications such as joint degeneration and compartment syndrome (a build-up of pressure within muscles that can damage nerve cells and blood vessels). If the standard treatment for a sprain (rest, ice and elevation) doesn't reduce the pain and swelling within a day or two, a referral to an orthopedic specialist should be given.

The orthopedist will examine the foot for signs of injury. He may hold your heel steady and move your foot around in a circle. This motion produces minimal pain with a sprain, but severe pain with a Lisfranc injury. If your initial X-ray did not show an injury, the orthopedist may request several other views, including comparison views of the uninjured foot and stress or weightbearing X-rays. In some cases, a CT scan or MRI may be necessary to confirm the diagnosis.

The Treatment

With the advances in medical technology, this type of injury has gone from jeopardizing an athletes career to a situation that can be fixed.

 "I had mine in the dark ages; they weren’t doing many then," said Stokley, who’s entering his 12th season. "To come back from that was the toughest by far."

Treatment for a Lisfranc injury depends on the severity of the injury. A short-leg walking cast, a removable short-leg orthotic or a non­weight-bearing cast is used to stabilize the joint. This is continued for four to six weeks or until symptoms have resolved. The potential for disability following a Lisfranc joint injury justifies the use of a non­weight-bearing cast. The orthopedist will also recommend foot exercises to build strength and help restore full range of motion.

Often, an operation is needed to stabilize the bones and hold them in place until healing is complete. Pins, wires or screws may be used. Afterwards, a cast is worn and limited weightbearing on the foot for six to eight weeks is required. A walking brace may be prescribed when the hardware is removed. An arch support and a rigid soled shoe may also be needed until all symptoms have disappeared. In some cases, if arthritis develops in these joints, the bones may have to be fused together.

After open reduction and internal fixation, most orthopedists suggest that the foot be immobilized in a cast for eight to 12 weeks with minimal (toe-touch) weight-bearing. Noncasted, full weight-bearing usually is not allowed until the screw or pin is removed at eight to 12 weeks. For three months after cast removal, the patient should wear a protective shoe with a well-molded orthotic.

Lisfranc sprains involve an arduous rehabilitation. The recovery time is very difficult to project, but 6 to 13 months is about the average. It all depends on the severity of the injury. With the advances in sports medicine and orthopedic technology, an athletes recovery time can be lessened. However, if a return to activities is done too quickly, re-injury may occur. This can result in damaged blood vessels, the development of painful arthritis (which is most common) and an even longer healing time.

Stable Lisfranc injuries that do not require surgery may cause an athlete to miss 2 months or more of their season. However, most athletes are able to successfully return at some point. Those injuries that are unstable, and require surgical repair, are serious injuries that almost always cause the injured athlete to miss the remainder of their season. It is also not uncommon for a high level athlete to not be able to return to the same level of athletic performance even in following seasons. Two well-known examples are Eric Rhett and Duce Staley both of whom had surgery for a serious Lisfranc injury and never successfully returned to their pre-injury form.

Decker's Repair

*** Note: This picture is different from Eric Deckers. It is intended as a reference only. ***

"For about a week-week and a half I was trying to decide what the actual injury was and how severe it was. The next step was to find a doctor to do it. There were about four or five guys that we sent all of my X-rays, CAT Scans, and MRI’s out to, to get kind of a consensus of what needed to be done, surgery wise."  

 He decided on Dr. Robert Anderson out of Charlotte, North Carolina, highly regarded in the NFL as one of the best foot and ankle specialists. On November 4th, 2009, a plate three inches long and two inches wide was placed alongside the first metatarsal bone with a single screw going through the plate and first and second metatarsal bones in his mid-foot to hold them in place.   

Dr. Anderson recommended that the plate and screw be
taken out so that Eric could have better flexibility and mobility through the mid-foot. So the Dr. went in and removed the hardware on March 15th.

  "I had my second surgery to get my hardware removed. I started jogging about three weeks ago, progressing very well... My hope is by June I'll be running. If nothing else, making cuts, probably not a lot of contact stuff. Definitely by July, I'll be ready to go. Full go, no restrictions."

Following the procedure in November, Decker was told he'll need eight months of rehabilitation before he's at full speed again. That will be just in time for Training Camp.  

"I’m doing a lot of controlled motions and movements with my physical therapist. I’m not running or jogging or doing any of that work with the other guys outside, but I’m definitely working my way towards that and I feel very comfortable and very confident where I’m at so far."

This injury is not uncommon

Brady Quinn is acquainted with it. He suffered a severe LisFranc sprain in his left foot in Week 15 last season but didn't need to be surgically repaired. Quinn has regained his health and will vie for the starting QB spot in Training Camp.

The Broncos aren't the only football team that have had to deal with this injury. The Miami Dolphins are well versed in Lisfranc injuries too. RB Ronnie Brown is recovering from a Lisfranc fracture from last season. He is a little further in his recovery from surgery than Decker. He participated in OTA's last week and admitted having soreness.

RG Donald Thomas made his NFL debut on September 7, 2008 against the New York Jets and injured his left foot in the 2nd quarter. He played through the injury and finished the game, but the injury later proved to be a Lisfranc fracture and he was placed on season-ending injured reserve two days later.

WR Ted Ginn Jr. suffered a torn Lisfranc ligament in his foot during the BCS Championship game, and made a full recovery in time to participate in the team's training camp in 2007.

I'm gonna see my friend, I'm gonna see my friend make it go away. I'm sick of everything, I'm gonna see my friend and make it go away.

--Eddie Vedder

 On draft day, Stokely had contact with Decker

"He sent me a text today and he's one of the first people I responded to. I've got a lot of respect for Brandon, he's a great guy. He reached out to me in November when I had my surgery. He went through a Lisfranc as well and he told me, "It was going to be fine. It was going to be a process, as far as getting back. That I was going to be healthy, that I would make a full recovery. Try and take the lessons learned from what I've gone through and to try and become a better man.' I'm just trying to become a better man and learn from a guy like him because he's been in the league for a long time, he's been with great organizations and obviously he's a tremendous person."

Decker credits Stokley immensely for preventing a bleak outlook on what could have been a career ending injury even before it started. Brandon told Decker not to rush back. The return to full recovery took Stokely nearly a year of his career before the pain eased in his right foot. He thinks he attempted a come back too soon, trying to impress the Colts after signing as a Free Agent in 2003. The best advice he could give Decker was to not be anxious to return, let it fully heal.

"To get a phone call from him saying, ‘Hey, I’ve been through this injury, I’m thinking about you,’ it helped me prepare," Decker said. "He let me know about the ups and downs, the mindset he took into it."

Now that Decker is a Bronco, he can get inspiration and veteran tutelage a few lockers down.

"I get to come in and learn from him, he knows how to be successful," Decker said.

Brandon's full recovery took nearly a year of his career before the pain eased in his right foot. He thinks he attempted a come back too soon. He was trying to impress the Colts after signing as a Free Agent in 2003. The best advice he could give Decker was to not be anxious to return, let it fully heal.

Decker has been taking mental reps along with fellow rookie receiver DeMaryius Thomas at OTA's. Thomas has his own recovery going, after breaking his left foot doing drills just before the NFL combine. While route running is still a little ways away, Eric will be ready for Training Camp.

"Right on schedule, maybe a little ahead," Decker said. "I feel very good about my progression. I haven’t had any setbacks—no pain, no swelling. Just positive signs."

 Positive signs indeed. Learning from an NFL receivers coach and then making friends and gaining a mentor with a successful teammate, I'd say the setbacks for Decker are fading into an Orange sunset.

Go Broncos!