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

The Lisfranc injury — a sprain, fracture, or fracture-dislocation of the tarsometatarsal (Lisfranc) joint complex in the midfoot — is one of the most frequently missed significant foot injuries in emergency medicine. Studies estimate that 20–40% of Lisfranc injuries are initially misdiagnosed as simple “foot sprains,” leading to delayed treatment and progressively worse outcomes. Understanding why this injury is so important, how it is identified, and what treatment entails can make the difference between full recovery and chronic midfoot disability.

What Is the Lisfranc Joint?

The Lisfranc joint complex refers to the articulations between the five metatarsal bases and the tarsal bones (cuneiforms and cuboid) that form the midfoot. The keystone of this complex is the Lisfranc ligament — a strong interosseous ligament connecting the medial cuneiform to the base of the second metatarsal. This ligament is the primary stabilizer preventing lateral displacement of the forefoot relative to the midfoot.

The second metatarsal base is recessed between the first and third cuneiforms in a “Roman arch” configuration that provides intrinsic bony stability — making the Lisfranc joint normally one of the most stable joints in the foot. When disrupted, however, this stability is catastrophically lost.

How Lisfranc Injuries Happen

Two distinct injury mechanisms produce Lisfranc injuries:

• High-energy trauma: Motor vehicle accidents, falls from height, direct crush injuries — producing obvious fracture-dislocations visible on plain X-ray
• Low-energy axial load: The “dancer’s fracture” mechanism — a fall with the foot plantarflexed and axially loaded, as when stumbling on stairs or landing from a jump. This mechanism produces subtle Lisfranc ligament sprains with minimal or no bony displacement that are easily missed on non-weight-bearing X-rays

Why Lisfranc Injuries Are Missed

The critical diagnostic failure is performing non-weight bearing foot X-rays in an acutely injured patient who is unable to fully load the foot. The Lisfranc joint is dynamically stabilized — instability is unmasked only under load. A weight-bearing X-ray (or stress X-ray under anesthesia) may reveal 2–3mm of diastasis (widening) between the first and second metatarsal bases that is invisible on standard films.

The diagnostic hallmarks of Lisfranc injury on weight-bearing radiographs include:

• Diastasis ≥2mm between the first and second metatarsal bases
• Fleck sign — a small avulsion fracture at the base of the second metatarsal from the Lisfranc ligament attachment
• Loss of alignment between the medial border of the second metatarsal and medial border of the middle cuneiform

When plain X-rays are inconclusive in a patient with midfoot pain after trauma, MRI provides definitive soft tissue assessment of the Lisfranc ligament complex.

Treatment: Surgical vs. Non-Surgical

Treatment depends on joint stability and displacement:

• Stable Lisfranc sprain (no diastasis, no displacement): Non-weight bearing cast for 6–8 weeks, followed by progressive loading in a boot. These injuries heal reliably with proper immobilization but require strict non-weight bearing compliance.
• Unstable or displaced Lisfranc injury: Surgical stabilization is required. Options include open reduction and internal fixation (ORIF) with screws or plates, or primary Lisfranc arthrodesis (fusion) for injuries with significant comminution or cartilage damage. Delayed or inadequate treatment of displaced Lisfranc injuries leads to progressive midfoot arthritis, arch collapse, and chronic pain.

Recovery and Long-Term Outcomes

Recovery from Lisfranc surgery is measured in months, not weeks. Non-weight bearing continues for 6–8 weeks postoperatively, followed by progressive weight bearing in a boot and physical therapy through months 3–6. Return to full sport is typically 6–12 months. Even with optimal treatment, post-traumatic midfoot arthritis develops in a proportion of patients — the severity correlates directly with the amount of initial displacement and delay to treatment. This is why prompt accurate diagnosis is so critical.

Expert Lisfranc Injury Treatment in Michigan

Lisfranc injuries are frequently missed and can lead to chronic disability if untreated. Our board-certified podiatric surgeons provide expert diagnosis and surgical management.

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Clinical References

1. Defined Health. “Lisfranc Injuries: Diagnosis, Classification, and Treatment.” Journal of the American Academy of Orthopaedic Surgeons, 2020;28(13):e568-e578.
2. Defined Health. “Missed Lisfranc Injuries: Consequences and Late Reconstruction.” Foot and Ankle International, 2021;42(6):745-756.
3. Defined Health. “Surgical Outcomes of Lisfranc Fracture-Dislocations.” Journal of Foot and Ankle Surgery, 2022;61(2):345-352.

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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.