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

Lisfranc injuries are among the most frequently missed and most consequential foot injuries in athletes. Named for French military surgeon Jacques Lisfranc de St. Martin (who described the tarsometatarsal joint complex in the early 19th century), these injuries range from subtle ligamentous sprains to complete fracture-dislocations — and the difference in treatment and outcome between adequately and inadequately treated Lisfranc injuries is profound.

What Is the Lisfranc Joint Complex?

The Lisfranc joint complex refers to the tarsometatarsal (TMT) joints — the articulations between the bases of the five metatarsals and the three cuneiforms and cuboid. The keystone of this complex is the second metatarsal base, which recesses into a mortise between the medial and lateral cuneiforms. The Lisfranc ligament connects the second metatarsal base to the medial cuneiform — there is no direct ligamentous connection between the first and second metatarsal bases, creating a biomechanical vulnerability.

Mechanisms of Injury

Two main mechanisms:

• High-energy direct crush: Motor vehicle accidents, heavy object falls on the foot — typically produces overt fracture-dislocation visible on X-ray
• Low-energy indirect mechanisms: Athletic pivoting on a planted forefoot, landing awkwardly from a jump, or axial loading on a plantarflexed foot — the mechanism of most sports-related Lisfranc injuries. These “low-energy” injuries produce subtle ligamentous disruption that may be missed on non-weight-bearing X-rays

Sports with high Lisfranc incidence: American football (linemen stepping on a plantarflexed foot), equestrian sports (foot caught in stirrup), gymnastics, and any sport involving cutting and pivoting.

Why Lisfranc Injuries Are Commonly Missed

The classic error: a football player “twists his foot,” is seen in the training room or emergency department, X-rays show “no fracture,” and he is told he has a midfoot sprain and sent back to activity. Three months later he still can’t push off — and now has midfoot instability and early midfoot arthritis.

Non-weight-bearing X-rays frequently miss Lisfranc injuries. The diagnostic key is bilateral weight-bearing foot X-rays with comparison views. On weight-bearing, an unstable Lisfranc injury will show widening between the first and second metatarsal bases (>2 mm is diagnostic) or subtle lateral displacement of the Lisfranc column. The “fleck sign” — a small avulsion fracture at the base of the second metatarsal — is pathognomonic when present.

CT scan characterizes fracture pattern for surgical planning. MRI identifies purely ligamentous injuries with no bony involvement.

Classification: Stable vs. Unstable

Stable injuries: Ligament sprain with intact ligamentous complex on stress examination — no diastasis with weight-bearing. Treated conservatively with non-weight-bearing for 6 weeks followed by progressive loading. Return to sport at 3–4 months.

Unstable injuries: Ligamentous disruption with diastasis on weight-bearing or stress views, or any osseous Lisfranc fracture-dislocation. Require surgical stabilization — open reduction and internal fixation (ORIF) or primary arthrodesis of the involved TMT joints.

Surgical Options

ORIF: Reduces and stabilizes the Lisfranc complex with screws and/or plates. Historically the standard for purely ligamentous unstable injuries; hardware is removed at 3–4 months to restore motion. Outcomes are good for purely ligamentous injuries in young athletes.

Primary arthrodesis: Fuses the medial (1st, 2nd, 3rd TMT) column. Recent randomized evidence (Ly and Coetzee, JBJS 2006) suggests primary arthrodesis produces better functional outcomes than ORIF for purely ligamentous Lisfranc injuries — avoiding the second surgery for hardware removal and providing a more durable repair of ligamentous tissue that heals poorly.

Return to Sport Timeline

Stable injuries: 3–4 months. ORIF with hardware removal: 5–7 months. Primary arthrodesis: 6–9 months. NFL players with Lisfranc ORIF typically return to play by mid-season or early the following season. High-level soccer and basketball athletes return at similar timelines. Missing the diagnosis and returning to sport too early — the most common error — converts a treatable injury into a career-altering one.

Lisfranc Injury in Athletes — Recovery & Return to Sport

Lisfranc midfoot injuries range from sprains to fracture-dislocations and are commonly missed in athletes. Our podiatric surgeons diagnose these injuries accurately with weight-bearing imaging and provide the right treatment — from immobilization to surgical fixation — for safe return to sport.

View Our Sports Injury Treatments | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. American Journal of Sports Medicine. 2002;30(6):871-878.
2. Desmond EA, Chou LB. Current concepts review: Lisfranc injuries. Foot & Ankle International. 2006;27(8):653-660.
3. Lattermann C, et al. Lisfranc fracture-dislocation: a review of a commonly missed injury. Emergency Medicine Journal. 2007;24(10):677-679.

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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.