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

A Lisfranc injury — disruption of the ligamentous and osseous complex at the tarsometatarsal (TMT) joint — is one of the most commonly missed serious foot injuries in emergency medicine. Often dismissed as a midfoot sprain or attributed to a minor twist, an unstable Lisfranc injury that is treated as a sprain results in progressive midfoot collapse, post-traumatic arthritis, and chronic disability. The correct diagnosis requires a high index of suspicion, weight-bearing X-rays, and CT imaging — and management ranges from a few weeks in a boot for subtle ligamentous sprains to surgical fixation for displaced fracture-dislocations. At Balance Foot & Ankle in Howell and Bloomfield Hills, MI, Dr. Tom Biernacki, DPM evaluates and manages the full spectrum of Lisfranc injuries for Michigan patients.

What Is the Lisfranc Joint Complex?

The Lisfranc joint complex — named after French surgeon Jacques Lisfranc de Saint-Martin — comprises the articulations between the five metatarsal bases and the three cuneiforms and the cuboid (the tarsometatarsal joints). The complex is stabilized by the Lisfranc ligament: a strong interosseous ligament connecting the medial cuneiform to the base of the 2nd metatarsal. The 2nd metatarsal base is recessed between the medial and lateral cuneiforms in a “keystone” configuration that provides bony stability; the Lisfranc ligament provides the primary ligamentous constraint. When this ligament tears — with or without associated fractures — the metatarsals can shift laterally and dorsally relative to the tarsus, disrupting midfoot architecture and load transmission.

Mechanisms of Lisfranc Injury

Lisfranc injuries occur through two primary mechanisms. High-energy direct injuries — motor vehicle accidents, falls from height, industrial crush injuries — produce complete dislocation with associated metatarsal fractures (the Quenu and Kuss homolateral or divergent patterns). Low-energy indirect injuries — stepping off a curb awkwardly, stumbling on stairs, or athletic planting-and-twisting mechanisms — produce subtle ligamentous Lisfranc injuries that are the most frequently missed presentation in emergency departments. Equestrian riders are classically described at risk — the foot caught in the stirrup during a fall creates the hyperplantarflexion force that tears the Lisfranc ligament. In current practice, sports-related low-energy Lisfranc injuries in football linemen, soccer players, and gymnasts are the most common presentations at podiatric practices.

Symptoms — Why Lisfranc Injuries Are Missed

Lisfranc injuries are missed because many patients can bear weight initially — particularly with partial ligamentous tears — leading both patients and clinicians to assume a minor sprain. The characteristic clinical findings that should raise suspicion for Lisfranc injury are: midfoot pain and swelling rather than ankle pain (the mechanism is midfoot, not lateral ankle); plantar ecchymosis (bruising on the bottom of the foot at the midfoot) — when present, this is nearly pathognomonic for Lisfranc injury and should trigger immediate imaging; inability to perform a single-leg heel raise due to pain at the midfoot; and point tenderness at the base of the 2nd metatarsal and medial cuneiform. The “piano-key test” — applying downward pressure on each metatarsal head in turn and observing for pain at the TMT joint — is a useful bedside assessment. Any midfoot injury with plantar ecchymosis should be treated as a Lisfranc injury until proven otherwise.

Diagnosis — Weight-Bearing X-Rays Are Mandatory

The critical diagnostic error for Lisfranc injuries is obtaining non-weight-bearing X-rays and interpreting them as normal. Subtle Lisfranc diastasis — widening between the 1st and 2nd metatarsal bases — may only be visible on weight-bearing AP and oblique foot X-rays, where the patient’s full body weight opens the partially torn ligament. The diagnostic thresholds for Lisfranc diastasis on X-ray are: greater than 2mm widening between the 1st and 2nd metatarsal bases on the AP view; misalignment of the medial border of the 2nd metatarsal with the medial border of the intermediate cuneiform; and the “fleck sign” — a small avulsion fracture at the base of the 2nd metatarsal or medial cuneiform indicating ligament avulsion. CT scanning is superior to X-ray for quantifying displacement and characterizing associated fractures; MRI is the most sensitive modality for pure ligamentous Lisfranc injuries without fracture.

Conservative Treatment — Only for Stable, Non-Displaced Injuries

Conservative management is appropriate only for stable Lisfranc injuries — pure ligamentous sprains without diastasis (widening) on weight-bearing X-ray. These represent a small subset of all Lisfranc injuries. Treatment involves non-weight-bearing in a short-leg cast or CAM walker for 6 weeks, followed by gradual weight-bearing progression and physical therapy. Weight-bearing X-rays must be repeated at 6 weeks to confirm maintained alignment — if diastasis develops during the healing phase, surgical conversion is required. Return to sport typically occurs at 3–4 months for stable injuries. Even with stable, non-displaced injuries, some patients develop chronic midfoot pain requiring late reconstruction if ligamentous healing is incomplete.

Surgical Treatment — The Standard for Displaced Injuries

Unstable Lisfranc injuries — any with measurable diastasis on weight-bearing X-ray or CT, any with associated displaced fractures — require surgical stabilization. The two primary surgical approaches are open reduction and internal fixation (ORIF) with screws and/or plates, and primary arthrodesis (fusion) of the medial column TMT joints. ORIF aims to restore anatomic alignment while preserving joint motion; the hardware is typically removed at 3–4 months. Primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) is increasingly preferred for ligamentous Lisfranc injuries because it has lower rates of post-traumatic arthritis and revision surgery than ORIF, while functional outcomes are equivalent — midfoot motion at these joints is minimal and patients do not experience meaningful stiffness from fusion. The 4th and 5th TMT joints are not fused due to their contribution to lateral forefoot flexibility. Surgical recovery involves 6 weeks non-weight-bearing, followed by progressive loading in a boot, with return to sport at 4–6 months.

Red Flags — Seek Immediate Evaluation

Seek same-day or emergency evaluation for a midfoot injury if: you have any bruising on the bottom of the foot at the midfoot (plantar ecchymosis — highly specific for Lisfranc injury); you cannot bear weight at all after a twisting or crush mechanism; there is visible deformity or step-off at the midfoot dorsum; you had a “heard a pop” at the midfoot during the injury; you are a diabetic patient and have any midfoot pain after injury (Charcot neuroarthropathy can mimic Lisfranc and is a surgical emergency). Do not assume a midfoot injury is “just a sprain” and wait several days — displaced Lisfranc injuries require surgery, and delay in fixation worsens outcomes as swelling complicates surgical repair.

Lisfranc Injury Treatment at Balance Foot & Ankle — Michigan

Dr. Tom Biernacki, DPM provides urgent Lisfranc evaluation including in-office weight-bearing digital X-ray, CT coordination for complex fracture assessment, and both conservative and surgical management. Second-opinion consultations for Lisfranc injuries managed elsewhere are available and welcome. Appointments at our Howell office (4330 E Grand River Ave, Howell MI 48843) and Bloomfield Hills office (43494 Woodward Ave #208, Bloomfield Hills MI 48302). Call (810) 206-1402 or

book online for same-day urgent evaluation.

Lisfranc Injury Treatment in Michigan

Lisfranc injuries (midfoot fracture-dislocations) are frequently missed and can lead to chronic pain and disability if improperly treated. Our podiatric surgeons specialize in diagnosing and treating these complex midfoot injuries.

Learn About Our Fracture & Surgical Treatments → | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Myerson MS, 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.” 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.