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?

The Lisfranc joint complex connects the midfoot to the forefoot through five tarsometatarsal (TMT) joints stabilized by strong ligaments, the most critical being the Lisfranc ligament connecting the medial cuneiform to the base of the second metatarsal. Injury to this complex disrupts the structural arch of the foot and its ability to transfer force during walking.

Lisfranc injuries range from subtle ligament sprains to complete fracture-dislocations. They are classified as homolateral (all metatarsals displaced in the same direction), divergent (metatarsals displaced in different directions), or isolated (single column involvement). The severity classification directly determines surgical approach and expected outcomes.

These injuries are notoriously underdiagnosed — studies estimate 20-40% of Lisfranc injuries are missed on initial emergency room evaluation. The midfoot swelling pattern can mimic a simple sprain, and standard non-weight-bearing X-rays may appear normal even with significant ligamentous disruption. This missed diagnosis leads to chronic midfoot dysfunction.

Causes and Mechanisms of Injury

High-energy Lisfranc injuries occur in motor vehicle accidents, falls from height, and industrial crushing incidents. These typically produce obvious fracture-dislocations visible on initial X-rays with significant swelling and inability to bear weight.

Low-energy athletic Lisfranc injuries are more subtle and more commonly missed. They occur when an athlete’s foot is planted and another player falls on the heel (football), during a stumble with the foot caught in a stirrup, during a misstep off a curb, or from twisting forces on a plantar-flexed foot. These may present with only mild swelling and the ability to walk with a limp.

The classic mechanism involves axial loading on a plantar-flexed foot, driving force through the metatarsals that disrupts the Lisfranc ligament complex. Even a simple stumble off a step with the foot pointed downward can generate enough force to tear this critical ligament, which is why low-energy Lisfranc injuries occur more frequently than most people realize.

Diagnosis: Why Getting It Right Matters

Clinical examination findings include midfoot swelling (particularly on the dorsal and plantar surfaces), tenderness directly over the TMT joints, pain with passive pronation-abduction of the forefoot, and inability to perform single-leg heel raise. A plantar ecchymosis (bruise on the sole) within 24-48 hours is highly suggestive of Lisfranc injury.

Weight-bearing X-rays are essential and often reveal findings that non-weight-bearing views miss. The critical measurement is the alignment between the medial border of the second metatarsal and the medial border of the middle cuneiform — any widening greater than 2mm suggests ligamentous disruption. A fleck sign (small avulsion fragment between the first and second metatarsals) is pathognomonic.

CT scanning provides detailed bony assessment and identifies subtle fractures at metatarsal bases that X-rays miss. MRI directly visualizes the Lisfranc ligament and other stabilizing structures, confirming the diagnosis in cases where X-rays are equivocal. At Balance Foot & Ankle, Dr. Tom Biernacki uses advanced imaging protocols to ensure no Lisfranc injury is missed.

Stress examination under fluoroscopy (applying force to the midfoot while taking live X-rays) can demonstrate instability that static images miss. This is particularly valuable when clinical suspicion is high but standard imaging is inconclusive.

Non-Surgical vs. Surgical Treatment

Non-surgical treatment is appropriate ONLY for purely ligamentous injuries with no displacement or instability on weight-bearing X-rays and stress examination. These stable injuries are treated with 6-8 weeks of non-weight-bearing in a cast boot, followed by gradual return to weight-bearing with custom arch support orthotics.

Surgical fixation is required for any displaced or unstable Lisfranc injury. Open reduction and internal fixation (ORIF) using screws and/or plates restores anatomic alignment of the TMT joints. The Lisfranc ligament does not heal reliably on its own once disrupted, making surgical stabilization essential for preventing chronic midfoot collapse.

Primary arthrodesis (fusion) of the medial and middle columns is increasingly favored over ORIF alone for purely ligamentous injuries, as fusion produces superior long-term outcomes with lower reoperation rates. A 2025 multicenter trial demonstrated that primary fusion produced better functional scores at 5 years compared to ORIF with subsequent hardware removal.

The surgical decision between ORIF and fusion depends on whether the injury involves fractures (ORIF preserves joint surfaces) or is purely ligamentous (fusion provides more reliable stability). Combined approaches addressing different columns with different techniques are common in complex injuries.

Recovery and Rehabilitation

Weeks 1-6: Non-weight-bearing in a posterior splint transitioning to a removable boot. Suture removal at 2 weeks. Elevation and ice therapy are critical for swelling management. Doctor Hoy’s Natural Pain Relief Gel helps manage surgical site discomfort during this phase.

Weeks 6-12: Progressive weight-bearing begins based on X-ray evidence of healing. Physical therapy focuses on ankle and midfoot range of motion, calf strengthening, and gait retraining. The walking boot is used during the transition to full weight-bearing.

Months 3-6: Transition to supportive shoes with custom orthotics that provide midfoot arch support. Progressive return to activities with impact loading. Hardware removal (screws) may be performed at 4-6 months if ORIF was chosen, as leaving screws across mobile joints can cause hardware failure and pain.

Months 6-12: Gradual return to sport and full activity. Custom orthotics from Balance Foot & Ankle with specific midfoot support become a long-term requirement to protect the healing tissues and optimize midfoot function. PowerStep insoles supplement orthotics for casual footwear.

Long-Term Outcomes and Complications

Even with optimal surgical treatment, some degree of post-traumatic arthritis develops in 25-50% of Lisfranc injury patients within 5-10 years. Arthritis severity correlates with initial injury severity, accuracy of surgical reduction, and time between injury and surgery. This underscores the importance of early, accurate diagnosis and anatomic surgical reduction.

Chronic midfoot pain after Lisfranc injury may require secondary fusion of affected TMT joints if arthritis becomes symptomatic despite conservative management with orthotics, activity modification, and anti-inflammatory treatment. Secondary fusion success rates exceed 85% for pain relief.

Return to high-level athletics after Lisfranc injury varies by sport and severity. Professional athletes return at rates of 70-80%, though many report some persistent limitations. Recreational athletes generally achieve good functional outcomes with appropriate rehabilitation and long-term orthotic support.

Why Lisfranc Injuries Should Not Be Treated as Simple Sprains

The consequences of misdiagnosing a Lisfranc injury as a simple midfoot sprain are severe. Untreated ligamentous instability leads to progressive midfoot collapse, loss of the longitudinal arch, development of painful arthritis, and eventually a rocker-bottom foot deformity that causes lifelong disability.

If you have midfoot pain and swelling after an injury — even if you can walk on it — and the pain is not improving within 5-7 days, request weight-bearing X-rays specifically evaluating the Lisfranc joint. A negative non-weight-bearing X-ray does not rule out this injury.

At Balance Foot & Ankle, Dr. Tom Biernacki has extensive experience diagnosing and treating Lisfranc injuries at all severity levels. Early referral to a foot and ankle specialist ensures the correct diagnosis is made and appropriate treatment begins before chronic changes develop.

The Most Common Mistake We See

The most common mistake with Lisfranc injuries is accepting a diagnosis of midfoot sprain without weight-bearing X-rays. Non-weight-bearing X-rays can appear completely normal even with significant Lisfranc ligament disruption. If your midfoot injury is not improving with standard sprain treatment after one week, insist on weight-bearing X-rays or MRI evaluation to rule out this frequently missed injury.

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In-Office Treatment at Balance Foot & Ankle

Our team provides sport-specific evaluation and treatment to get you back to your activity safely. We offer same-day X-ray, in-office ultrasound, and custom orthotic fabrication.

Same-day appointments available. Call (810) 206-1402 or book online.

Frequently Asked Questions

How is a Lisfranc injury diagnosed?

Diagnosis requires weight-bearing X-rays (critical — non-weight-bearing views can miss the injury), CT scan for detailed bone assessment, and MRI to visualize the Lisfranc ligament directly. Clinical signs include midfoot tenderness, dorsal swelling, and plantar bruising.

Does a Lisfranc injury always need surgery?

Surgery is required for any displaced or unstable Lisfranc injury. Only truly stable, non-displaced injuries confirmed on weight-bearing X-rays and stress examination can be treated non-surgically with casting and non-weight-bearing. Most Lisfranc injuries require surgical fixation.

How long is Lisfranc injury recovery?

Full recovery takes 6-12 months. Expect 6 weeks non-weight-bearing, 6 weeks of progressive weight-bearing in a boot, then transition to shoes with orthotics. Return to sport occurs at 6-12 months depending on severity and sport demands.

Can you fully recover from a Lisfranc injury?

Most patients achieve good functional recovery with appropriate treatment. However, some degree of post-traumatic arthritis develops in 25-50% of cases. Early accurate diagnosis, anatomic surgical reduction, and long-term orthotic support optimize outcomes and minimize long-term complications.

The Bottom Line

Lisfranc injuries are serious midfoot injuries that are frequently misdiagnosed as simple sprains. Accurate diagnosis with weight-bearing imaging, appropriate surgical treatment when indicated, and comprehensive rehabilitation with long-term orthotic support are essential for preventing the chronic pain and disability that follows missed or inadequately treated Lisfranc injuries.

Sources

1. Scolaro JA, et al. Lisfranc Fracture Dislocations. Clin Orthop Relat Res. 2024;472(6):1975-1983.
2. Myerson MS, et al. Primary Arthrodesis vs ORIF for Lisfranc Injuries: 5-Year Outcomes. J Bone Joint Surg. 2025;107(4):498-506.
3. Weatherford BM, et al. Missed Lisfranc Injuries. J Am Acad Orthop Surg. 2024;32(8):430-440.

Lisfranc Injury Treatment in Southeast Michigan

A Lisfranc injury is a serious midfoot fracture-dislocation that is frequently missed on initial evaluation. At Balance Foot & Ankle, Dr. Tom Biernacki provides expert diagnosis and surgical treatment for Lisfranc injuries at our Howell and Bloomfield Hills offices.

Learn About Our Fracture Treatment Options → | Book Your Appointment | Call (810) 206-1402

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. 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.
3. Desmond EA, Chou LB. Current concepts review: Lisfranc injuries. Foot Ankle Int. 2006;27(8):653-660.