✅ Medically reviewed by Dr. Thomas Biernacki, DPM — Board-Certified Podiatrist · Last updated April 6, 2026

Lisfranc Injury: Why It Gets Missed, How It Is Diagnosed, and Treatment Options

Lisfranc Injuries: Often Missed, Always Important

Lisfranc injuries — disruptions of the tarsometatarsal joint complex at the midfoot — are among the most commonly missed diagnoses in foot and ankle medicine. The injury ranges from a subtle ligament sprain to a devastating fracture-dislocation, but even moderate injuries cause lasting disability when misdiagnosed or undertreated. Understanding the mechanism, clinical presentation, and treatment principles helps patients and clinicians recognize this important injury.

What Is the Lisfranc Complex?

The Lisfranc joint complex refers to the articulation between the five metatarsal bases and the corresponding tarsal bones (cuneiforms and cuboid). The Lisfranc ligament itself connects the medial cuneiform to the second metatarsal base — there is no direct ligament between the first and second metatarsals, making this area the keystone of the complex. Stability of the entire midfoot depends on the integrity of this ligament and the surrounding capsular structures.

How Lisfranc Injuries Occur

High-energy Lisfranc injuries occur in motor vehicle accidents and falls from height, producing gross fracture-dislocation. Low-energy injuries are more subtle and more commonly missed — they occur when the foot is fixed and a rotational force is applied (a football player falling onto a plantarflexed foot), when a heavy object falls on the foot, or during seemingly minor stumbles. Athletes in any sport with rapid direction changes can sustain low-energy Lisfranc injuries that present as “midfoot sprains.”

Why It Gets Missed

Non-weight-bearing X-rays frequently appear normal in ligamentous Lisfranc injuries. The critical step — weight-bearing X-rays of both feet for comparison — is often omitted in emergency settings. The diagnostic finding is a gap of more than 2 mm between the first and second metatarsal bases, or any step-off at the tarsometatarsal joints, on weight-bearing views. Patients with suspected midfoot sprain whose X-rays are normal should receive weight-bearing films; CT scan further evaluates bony injury; MRI assesses ligament integrity and identifies bone marrow edema.

Classification and Stability

Lisfranc injuries are classified as stable (purely ligamentous with minimal displacement on weight-bearing films), partially unstable, or frankly unstable (with displacement or fracture-dislocation). Stability determines treatment — stable injuries can be managed conservatively, while unstable injuries require surgical fixation to prevent progressive displacement and the midfoot arthritis that results from malunited Lisfranc injuries.

Conservative Treatment for Stable Injuries

Truly stable Lisfranc sprains are treated with non-weight-bearing in a cast for 6 weeks, followed by transition to a stiff boot and progressive weight-bearing over the following 4 to 6 weeks. Return to sport takes 3 to 4 months minimum. Even stable injuries are slow to heal and require patience — premature return to activity is a common cause of re-injury and chronic instability.

Surgical Stabilization

Unstable Lisfranc injuries are fixed surgically. Options include open reduction internal fixation (ORIF) with screws or bridge plates across the unstable joints, and primary arthrodesis (fusion) of the medial column for purely ligamentous injuries where ligament healing is unlikely to restore adequate stability. Studies suggest primary fusion of the medial column produces superior long-term outcomes compared to ORIF with hardware removal for purely ligamentous injuries — avoiding the second surgery for hardware removal and producing more consistent stability.

Long-Term Outcomes

Even well-treated Lisfranc injuries carry a risk of post-traumatic midfoot arthritis, particularly when cartilage injury occurred at the time of trauma. Return to pre-injury activity level is common after stable and promptly treated unstable injuries. Delayed diagnosis — the most common preventable adverse outcome — significantly worsens prognosis and may commit the patient to eventual midfoot fusion that could have been avoided with timely stabilization.

Lisfranc Injury Diagnosis and Treatment in Michigan: Avoiding the Misdiagnosis Trap

Michigan patients who have been told their foot X-ray is “normal” after a midfoot injury — but who continue to have significant midfoot pain and swelling — should seek podiatric evaluation for possible Lisfranc injury. Lisfranc injuries are frequently missed on non-weight-bearing X-rays; the ligamentous disruption that defines this injury may only be visible on weight-bearing films that stress the midfoot articulations. At Balance Foot & Ankle, patients with suspected Lisfranc injury receive weight-bearing X-rays (essential), and CT scan or MRI when the diagnosis remains uncertain or surgical planning requires detailed anatomic information. Stable Lisfranc injuries can be managed with cast immobilization and protected weight-bearing; unstable Lisfranc injuries — those with diastasis on weight-bearing imaging — require surgical stabilization, because untreated instability leads to progressive midfoot arthritis, flatfoot collapse, and chronic disability. Michigan patients with persistent midfoot pain after injury should call Balance Foot & Ankle at (810) 206-1402 for evaluation that includes the weight-bearing imaging necessary to exclude this diagnosis.

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Related Treatment Guides

• Lisfranc Injury Treatment
• Stress Fracture Foot & Ankle
• Foot & Ankle Arthritis Treatment

Michigan patients experiencing foot or ankle problems can schedule an appointment at Balance Foot & Ankle — with locations in Howell (4330 E Grand River) and Bloomfield Hills (43494 Woodward Ave #208). Call (810) 206-1402 for same-week availability.

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Related Patient Guides

• Stress Fracture in the Foot: Symptoms & Recovery
• Ankle Pain: Causes by Location & Treatment
• Runner’s Guide to Foot Injury Prevention

Medical References & Sources

• American Podiatric Medical Association — Patient Education
• American Orthopaedic Foot & Ankle Society — Foot Conditions

Clinical References

1. Myerson MS, et al. “Classification and treatment of Lisfranc fracture-dislocations of the tarsometatarsal joint.” Foot & Ankle International. 1986;7(3):178-183.
2. 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.
3. Desmond EA, Chou LB. “Current concepts review: Lisfranc injuries.” Foot & Ankle International. 2006;27(8):653-660.