Lisfranc Injuries: Why This Foot Injury Is Easily Missed and Permanently Disabling

Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

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The Most Commonly Missed Significant Foot Injury

Lisfranc injuries — traumatic disruption of the tarsometatarsal (Lisfranc) joint complex — are among the most commonly missed significant musculoskeletal injuries in emergency settings. Studies suggest 20-40% of Lisfranc injuries are initially missed or misdiagnosed as ankle sprains or midfoot contusions. The consequences of missed Lisfranc injury are severe: progressive midfoot arthritis, arch collapse, and permanent pain and disability that is far more disabling than the same injury properly treated acutely. At Balance Foot & Ankle in Howell and Bloomfield Township, Michigan, we evaluate midfoot injuries with particular attention to Lisfranc pathology.

Mechanism and Anatomy

The Lisfranc joint complex — the articulation between the midfoot (cuneiforms and cuboid) and forefoot (metatarsal bases) — is stabilized by the Lisfranc ligament running from the medial cuneiform to the second metatarsal base. Injury mechanisms include: direct axial load to a plantarflexed foot (stepping into a hole, car pedal injury), twisting fall with the foot fixed, and contact sports tackles. Because the ligament is interosseous (between the bones), even complete ligament rupture may not show dramatic X-ray findings on standard views, making it easily overlooked.

Recognizing Lisfranc Injury

Key clinical clues: midfoot pain and swelling after an injury (not just ankle pain), inability to bear weight on the forefoot, plantar bruising at the arch within the first 24 hours (the pathognomonic sign of Lisfranc injury — this represents blood tracking from the torn ligament), and tenderness directly over the tarsometatarsal joints rather than the ankle ligaments. Weight-bearing X-rays (essential for diagnosis) show: diastasis (gap) between the first and second metatarsal bases, step-off at the tarsometatarsal joints, and avulsion fractures at the base of the second metatarsal or medial cuneiform. CT or MRI adds detail for surgical planning.

Treatment: Why Precision Matters

Stable, purely ligamentous Lisfranc injuries with no displacement may be managed with non-weight-bearing cast immobilization for 6-8 weeks — but close monitoring for displacement is essential. Unstable or displaced injuries require surgical fixation or primary arthrodesis (fusion) of the involved joints. The distinction between stable and unstable, and the choice between fixation and primary fusion, requires subspecialty expertise — general emergency providers frequently underestimate the instability of Lisfranc injuries. Contact Balance Foot & Ankle at (810) 206-1402 urgently if you have sustained a midfoot injury with swelling, plantar bruising, or significant pain — early proper management prevents permanent disability.

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Balance Foot & Ankle — Howell & Bloomfield Township, MI

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When to See a Podiatrist for a Lisfranc Injury

Lisfranc injuries — involving the midfoot joints and ligaments — are commonly missed on initial evaluation and can cause permanent disability if untreated. At Balance Foot & Ankle, Dr. Tom Biernacki uses weight-bearing X-rays and CT imaging to accurately diagnose Lisfranc injuries and determine the best treatment approach.

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Clinical References

1. Myerson MS, Fisher RT, Burgess AR, et al. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle. 1986;6(5):225-242.
2. Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 2002;30(6):871-878.
3. Desmond EA, Chou LB. Current concepts review: Lisfranc injuries. Foot Ankle Int. 2006;27(8):653-660.

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Dr. Tom Biernacki, DPM

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Dr. Tom Biernacki, DPM

Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.