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

The Most Commonly Missed Foot Injury

The Lisfranc injury — a sprain, fracture, or dislocation involving the tarsometatarsal (Lisfranc) joint complex at the base of the metatarsals where the midfoot meets the forefoot — is one of the most frequently missed diagnoses in foot and ankle medicine. Studies suggest that 20–40% of Lisfranc injuries are not identified at initial presentation in emergency departments. This delay in diagnosis matters enormously: Lisfranc injuries left untreated or inadequately treated progress to painful post-traumatic arthritis that may ultimately require surgical fusion.

At Balance Foot & Ankle in Howell and Bloomfield Township, Michigan, Dr. Tom Biernacki DPM and Dr. Carl Jay DPM are highly attuned to this injury pattern and the imaging nuances required for its diagnosis. If you have sustained a midfoot injury during sport or from direct trauma and your pain seems out of proportion to what an “ankle sprain” should feel like, a specific evaluation for Lisfranc involvement is warranted.

Anatomy of the Lisfranc Joint Complex

The Lisfranc joint complex refers to the articulations between the three cuneiform bones and the cuboid of the midfoot and the bases of the five metatarsals. This joint complex is stabilized by multiple ligaments — the most critical being the Lisfranc ligament itself, which runs from the medial cuneiform to the base of the second metatarsal. This ligament is the primary restraint preventing diastasis (separation) between the first and second metatarsal bases, which is the hallmark of a significant Lisfranc injury.

The second metatarsal base is recessed relative to the first and third — it is “keyed” into a slot formed by the three cuneiforms, providing inherent bony stability. This architectural arrangement makes the Lisfranc joint normally quite stable, but when sufficient force is applied — particularly axial loading on a plantarflexed foot — the ligamentous and bony constraints can be overwhelmed.

How Lisfranc Injuries Happen

Two main injury mechanisms account for most Lisfranc injuries. Direct trauma — a vehicle rolling over the foot, a heavy object falling on the midfoot — can produce high-energy Lisfranc fracture-dislocations that are rarely missed. More commonly, and more often missed, is the indirect mechanism: axial loading through a plantarflexed foot, as occurs when a horse steps on a rider’s foot caught in a stirrup (the classic historical mechanism that gave this injury its name, after French surgeon Jacques Lisfranc), when a football lineman’s foot is stepped on while the knee is on the ground, or — very commonly in the modern setting — when someone simply trips and catches the forefoot while the rearfoot plants.

Lisfranc injuries are increasingly recognized in lower-energy mechanisms including athletic pivoting on a fixed forefoot, missing a step while walking, and motor vehicle accidents where the foot is braced against the floorboard. These low-energy sprains may have only subtle findings on initial examination and imaging, making the diagnosis even more challenging.

Warning Signs and Physical Examination Findings

Midfoot pain and swelling after the typical injury mechanisms described above should trigger specific Lisfranc evaluation. A particularly suggestive finding is plantar ecchymosis — bruising on the sole of the midfoot — which indicates significant deep ligamentous disruption and is highly specific for Lisfranc injury, though not always present. Tenderness to palpation directly over the Lisfranc joint complex (the dorsal midfoot, between the first and second metatarsal bases) is a key finding.

Pain with the “piano key” test — passive dorsal and plantar manipulation of individual metatarsal bases — and pain with midfoot stress tests helps identify which specific joints are involved. The inability to perform a single-leg heel rise is a functional test that is positive in significant Lisfranc injuries. Comparing the injured foot to the contralateral foot for symmetry of bony landmarks is important — even subtle widening between the first and second metatarsal bases is abnormal.

Imaging: Why Standard X-Rays Can Miss This Injury

Non-weight-bearing X-rays of the injured foot are often ordered in the emergency department but can appear completely normal in ligamentous Lisfranc injuries without fractures, because the joint separates only under load. Weight-bearing X-rays — taken with the patient bearing full body weight on the affected foot — are essential and dramatically increase diagnostic sensitivity. Even small amounts of diastasis (>2mm gap between the first and second metatarsal bases, or between the medial cuneiform and second metatarsal base) is diagnostic of a significant Lisfranc injury.

CT scan is valuable for identifying associated fractures and for surgical planning. MRI provides the most detailed assessment of ligamentous integrity, identifying partial tears and bone marrow edema that confirm the diagnosis even when X-rays appear normal. For any patient with midfoot pain after appropriate trauma mechanism, persistent pain beyond 1–2 weeks, or clinical examination findings suggesting Lisfranc involvement, weight-bearing X-rays and consideration of advanced imaging are essential steps.

Treatment: Why Timing Matters

Stable Lisfranc injuries — pure ligamentous sprains without diastasis on weight-bearing X-rays — can be managed conservatively with 6–8 weeks of non-weight-bearing in a cast, followed by gradual rehabilitation. These injuries still require significant rest and monitoring to ensure no late instability develops. Unstable injuries — those with any diastasis, fracture-dislocation, or instability on examination — require surgical stabilization with screws, plates, or flexible fixation devices to restore and maintain anatomic alignment while ligaments heal. Allowing an unstable Lisfranc injury to heal in a malreduced position predictably results in progressive post-traumatic arthritis, deformity, and chronic pain. Early, anatomic fixation remains the best strategy for preventing long-term disability.

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Balance Foot & Ankle — Howell & Bloomfield Township, MI

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When to See a Podiatrist for Midfoot Injuries

Lisfranc injuries are among the most commonly missed foot injuries, often dismissed as simple sprains. Missed diagnosis leads to chronic pain and arthritis. Dr. Tom Biernacki at Balance Foot & Ankle has the expertise to identify subtle Lisfranc injuries and provide appropriate treatment.

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Clinical References

1. Myerson MS, et al. “Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment.” Foot and Ankle. 1986;6(5):225-242.
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. Siddiqui NA, et al. “Lisfranc fracture-dislocation: a review.” Journal of Foot and Ankle Surgery. 2018;57(4):818-823.

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.