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

What Is a Lisfranc Injury?

A Lisfranc injury involves damage to the Lisfranc joint complex — the group of bones and ligaments that connects the midfoot to the forefoot at the tarsometatarsal (TMT) joints. Named after Jacques Lisfranc de St. Martin, a French surgeon who first described the injury in the early 1800s, Lisfranc injuries range from simple ligament sprains to complex fracture-dislocations that can permanently alter foot function if not properly treated.

The Lisfranc complex is a crucial architectural element of the foot’s arch system. The Lisfranc ligament specifically connects the medial cuneiform bone to the base of the second metatarsal — a critical anchor that holds the entire forefoot in proper alignment relative to the midfoot. When this structure is damaged, the architectural integrity of the midfoot arch is compromised.

Lisfranc injuries are notoriously underdiagnosed. Studies suggest that up to 20% of Lisfranc injuries are initially missed or misdiagnosed as ankle sprains or simple foot sprains. This diagnostic failure has serious consequences — a Lisfranc injury treated as a simple sprain can develop into progressive midfoot arthritis, arch collapse, and chronic disability.

How Lisfranc Injuries Happen

Lisfranc injuries occur through two main mechanisms. High-energy injuries result from significant trauma such as motor vehicle accidents, falls from height, or industrial accidents. These typically cause severe fracture-dislocations with obvious deformity and immediate disability. They are usually recognized promptly because the degree of injury is apparent.

The more commonly missed category is low-energy Lisfranc injuries that occur through indirect force mechanisms. The classic mechanism is axial loading of a plantar-flexed (pointed down) foot — essentially stumbling and having the foot “fold” at the midfoot under body weight. This occurs in athletes (especially football linemen who have their foot stepped on while planted, or soccer and basketball players), in people who miss a step and fall forward, or in equestrian riders whose foot catches in a stirrup.

Simple twisting falls that seem unremarkable can cause significant Lisfranc ligament injuries. The deceptively “minor” mechanism is why these injuries are so often dismissed as sprains by both patients and sometimes medical providers who don’t have experience with foot injuries.

Symptoms: Why Lisfranc Is Mistaken for a Sprain

The symptoms of a Lisfranc injury — midfoot pain, swelling, and difficulty bearing weight — are similar to those of a severe ankle sprain, which is why confusion occurs. Key distinguishing features help identify a Lisfranc injury.

Location of pain and swelling is the most important clue. Ankle sprains cause pain and swelling centered around the ankle and the outer aspect of the foot. Lisfranc injuries cause pain and swelling across the top of the midfoot, at the junction of the arch and the base of the toes. This is the tarsometatarsal joint region, not the ankle.

The “plantar ecchymosis sign” — bruising on the bottom (sole) of the foot, particularly in the arch area — is highly specific for a Lisfranc injury and should immediately raise suspicion even if X-rays appear normal. Ankle sprains do not cause bruising on the bottom of the foot.

Inability to bear weight that seems disproportionate to the apparent injury mechanism suggests a Lisfranc injury. While ankle sprains certainly cause pain with weight-bearing, patients with Lisfranc injuries often find weight-bearing especially agonizing in a way that feels different from a typical sprain.

Pain with specific midfoot manipulation — rotating the forefoot relative to the midfoot or pressing directly on the tarsometatarsal joints — is characteristic of Lisfranc injuries and helps localize the problem during clinical examination.

Why Diagnosis Is Often Missed

Standard non-weight-bearing X-rays can appear completely normal in Lisfranc injuries — especially pure ligamentous injuries without fractures. The key to diagnosis is obtaining weight-bearing X-rays of both feet, which may reveal subtle widening of the space between the first and second metatarsal bases (the “diastasis”) that is only visible when the foot is loaded. A difference of 2mm or more compared to the uninjured foot is diagnostic.

In emergency departments, which see most acute foot injuries, patients in pain are rarely asked to stand on the injured foot for X-rays. This understandable omission leads to diagnostic failure when only non-weight-bearing views are obtained.

MRI provides the most sensitive diagnosis of Lisfranc ligament tears, joint fluid, and bone edema (bruising), especially in the first 48-72 hours when weight-bearing X-rays may not yet show diastasis. CT scan is valuable for evaluating the bony anatomy of complex fracture-dislocations and planning surgical reconstruction.

If you sustained a foot injury and were told it was “just a sprain,” but you continue to have significant midfoot pain, difficulty bearing weight, or pain that is not resolving as expected after 2-3 weeks, seek evaluation by a foot specialist who can reassess with weight-bearing imaging. It is never too late to correctly diagnose a Lisfranc injury, though earlier treatment leads to better outcomes.

Treatment: When Conservative Care Works and When Surgery Is Needed

Treatment of Lisfranc injuries depends critically on the degree of ligament damage and whether there is any instability or displacement at the tarsometatarsal joints.

Truly stable Lisfranc sprains — where the ligaments are partially torn but the joint remains stable with no widening on weight-bearing X-rays — can sometimes be treated conservatively. This involves strict non-weight-bearing for 6-8 weeks in a cast or boot, followed by gradual protected weight-bearing and rehabilitation. However, conservative treatment of Lisfranc injuries requires careful follow-up, as some injuries that appear stable initially develop instability as swelling resolves.

Unstable Lisfranc injuries — with any diastasis on weight-bearing imaging or frank fracture-dislocation — require surgical stabilization. The standard approach involves open reduction and internal fixation (ORIF) using screws, plates, or a combination to hold the tarsometatarsal joints in anatomic position while healing occurs. The hardware is typically removed 3-4 months later once the ligaments have healed.

For severe Lisfranc injuries with significant ligament disruption, primary arthrodesis (fusion) of the tarsometatarsal joints may be recommended rather than fixation and later hardware removal. Multiple randomized controlled trials have shown that primary fusion provides better long-term outcomes than fixation for unstable Lisfranc injuries, because these ligaments often don’t heal to sufficient strength to prevent late instability even after fixation.

Recovery from Lisfranc surgery typically involves 6-8 weeks non-weight-bearing followed by gradual return to activity over 3-6 months. Return to recreational sports takes 6-12 months, and athletes returning to high-level competition may take longer. Proper rehabilitation with physical therapy is essential for regaining strength, balance, and functional movement patterns.

Long-Term Outcomes and the Risk of Midfoot Arthritis

Even with optimal treatment, Lisfranc injuries carry a risk of developing post-traumatic midfoot arthritis. Studies report that up to 50% of patients with significant Lisfranc injuries develop some degree of midfoot arthritis over time, though not all of these patients have significant symptoms. The risk is higher with delayed diagnosis, inadequate initial treatment, and more severe original injuries.

Patients who develop symptomatic midfoot arthritis after Lisfranc injuries may require ongoing management with custom orthotics, activity modification, anti-inflammatory medications, and occasionally corticosteroid injections. For severe, disabling post-traumatic midfoot arthritis that doesn’t respond to conservative treatment, surgical arthrodesis can provide excellent pain relief and functional improvement.

This underscores the importance of prompt, accurate diagnosis and appropriate treatment for Lisfranc injuries. If you have midfoot pain following any foot injury — even one that seemed minor — evaluation at Balance Foot & Ankle can rule out or diagnose a Lisfranc injury and get you on the right treatment path.

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Balance Foot & Ankle — Howell & Bloomfield Township, MI

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Lisfranc Injury Treatment in Michigan

Lisfranc injuries (midfoot fracture-dislocations) are frequently misdiagnosed and require expert care to prevent long-term disability. At Balance Foot & Ankle, Dr. Tom Biernacki provides accurate diagnosis and surgical expertise for these complex injuries — serving Howell and Bloomfield Hills, MI.

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Clinical References

1. Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle. 1986;6(5):225-242.
2. Desmond EA, Chou LB. Current concepts review: Lisfranc injuries. Foot Ankle Int. 2006;27(8):653-660.
3. 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.