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 disruption of the tarsometatarsal (TMT) joint complex at the midfoot — the region where the metatarsal bones meet the tarsal bones. The Lisfranc ligament, named after French surgeon Jacques Lisfranc de St. Martin, is the primary stabilizer connecting the second metatarsal base to the medial cuneiform. Injuries range from isolated ligamentous sprains to complete fracture-dislocations in which the entire midfoot is disrupted.

Lisfranc injuries are frequently missed on initial evaluation and misdiagnosed as midfoot sprains, leading to delayed treatment and significant long-term disability. Awareness of this injury pattern is critical for athletes, primary care providers, and urgent care clinicians.

How Lisfranc Injuries Occur

High-energy mechanisms — motor vehicle accidents, falls from height, and athletic collisions — produce complete fracture-dislocations. Low-energy mechanisms produce the more subtle but still serious ligamentous injuries: an athlete plants a foot and is struck, twisting the midfoot; a dancer falls from pointe; a football player is tackled with the foot planted. These low-energy injuries are the ones most commonly missed.

Symptoms and Why They Are Misleading

Lisfranc injuries cause midfoot pain, swelling, and bruising. The pathognomonic finding is plantar ecchymosis — bruising on the bottom of the foot at the arch — which indicates ligamentous disruption and should immediately raise suspicion for a Lisfranc injury in any patient with midfoot trauma. However, early X-rays may appear normal in purely ligamentous injuries, leading to missed diagnoses when weight-bearing films or advanced imaging are not obtained.

Diagnosis

Accurate diagnosis requires weight-bearing X-rays of both feet for comparison. Key radiographic findings include widening of the space between the first and second metatarsal bases, avulsion fractures at the base of the second metatarsal, and lateral displacement of the metatarsals relative to the tarsals. When X-rays are equivocal, CT scan provides detailed bony anatomy, and MRI evaluates ligamentous integrity and identifies bone marrow edema indicating injury.

Treatment: When Is Surgery Needed?

Non-Operative Treatment

Purely ligamentous Lisfranc injuries with no displacement on weight-bearing X-rays — a true sprain — may be treated non-operatively with six to eight weeks of non-weight-bearing in a cast, followed by progressive return to weight-bearing with orthotic support. However, these patients must be monitored closely because any subsequent displacement requires surgical intervention.

Surgical Fixation: ORIF

Displaced Lisfranc injuries — those with any measurable widening or fracture displacement — require open reduction and internal fixation (ORIF). The surgeon reduces the dislocated joints anatomically under fluoroscopic guidance and secures them with screws placed across the tarsometatarsal joints. Accurate anatomic reduction is critical — even small amounts of residual displacement lead to post-traumatic arthritis.

The hardware is typically removed at three to four months once healing is confirmed, as retained screws across mobile joints are prone to fatigue fracture.

Primary Arthrodesis

For purely ligamentous injuries with no bony Lisfranc fragment, some surgeons prefer primary fusion of the medial TMT joints over ORIF, arguing that ligamentous injuries will not heal with sufficient stability to prevent late arthritis regardless of fixation. Primary arthrodesis produces more reliable long-term outcomes in purely ligamentous cases and avoids the need for hardware removal.

Recovery After Lisfranc Surgery

Non-weight-bearing in a cast for six to eight weeks is standard after fixation or fusion. Progressive weight-bearing in a boot follows at eight to twelve weeks. Return to athletic activity takes six to twelve months depending on the severity of injury and type of fixation. Post-traumatic midfoot arthritis can develop even after anatomic fixation and may eventually require additional surgery. Early, accurate treatment provides the best chance of a good long-term outcome.

If You Sustained a Midfoot Injury

Any midfoot injury that causes significant swelling, bruising on the bottom of the foot, or inability to bear weight should be evaluated urgently by a foot and ankle specialist. Do not assume a midfoot injury is a simple sprain without appropriate weight-bearing imaging and specialist evaluation. Contact Balance Foot & Ankle for urgent evaluation of suspected Lisfranc injuries.

Lisfranc Injury Treatment in Michigan

Lisfranc injuries — midfoot sprains, fractures, and dislocations — are frequently misdiagnosed as simple sprains. Dr. Tom Biernacki provides expert diagnosis and both surgical and conservative management of Lisfranc injuries at Balance Foot & Ankle.

Learn About Our Foot Surgery Options | 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.” 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.

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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.