Lisfranc Injury: The Midfoot Injury That’s Frequently Missed

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

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The Lisfranc joint complex — the articulation between the midfoot bones (cuneiforms and cuboid) and the metatarsals — is the structural keystone of the midfoot arch. Injuries here range from subtle ligamentous sprains to complex fracture-dislocations, and they share one critical characteristic: they are alarmingly easy to miss on initial evaluation, and the consequences of misdiagnosis or inadequate treatment are severe and permanent.

What Is the Lisfranc Joint?

The Lisfranc joint complex is named after the French surgeon Jacques Lisfranc de St. Martin, who described amputations at this level during the Napoleonic Wars. The complex includes the articulations between the three cuneiforms and cuboid and the bases of the five metatarsals. The second metatarsal base is the “keystone” — it is recessed between the medial and lateral cuneiforms and provides critical stability to the entire midfoot complex.

The Lisfranc ligament specifically connects the medial cuneiform to the base of the second metatarsal. There is notably no intermetatarsal ligament between the first and second metatarsals — making this interval the structural weak point of the midfoot.

How Lisfranc Injuries Occur

Two injury mechanisms predominate:

• Low-energy indirect injury — the most common mechanism in recreational athletes; a fall over a plantarflexed (pointed) foot, or a twist with the foot planted (common in football linemen, equestrians, and windsurfers). The classic scenario is stepping into a hole or off a curb unexpectedly.
• High-energy direct injury — a motor vehicle accident, crush injury, or fall from height directly onto the midfoot. These produce more severe dislocations and associated fractures.

Why Lisfranc Injuries Are Missed

The initial X-ray in a Lisfranc sprain may appear completely normal. The midfoot swelling may be mistaken for a simple foot contusion or “bad sprain.” Several factors contribute to missed diagnosis:

• Standard AP foot X-rays may not show the subtle diastasis (widening) between the first and second metatarsal bases — weight-bearing X-rays are essential for diagnosis of low-grade injuries
• The patient can often bear some weight, creating false reassurance
• Emergency department evaluation often does not include weight-bearing X-rays
• The subtle radiographic signs — 2–5mm diastasis between the first and second metatarsal bases, a “fleck sign” (avulsion fracture off the Lisfranc ligament) — require specific radiographic knowledge to recognize

Symptoms That Should Raise Suspicion

• Midfoot pain and swelling after any significant twist or compressive injury
• Inability to bear weight after the injury
• Plantar (bottom of foot) bruising — this is the most specific clinical sign for Lisfranc injury
• Tenderness directly over the Lisfranc joint complex (between the midfoot bones)
• Pain with the “piano key test” — passive dorsiflexion and plantar flexion of individual metatarsals

Plantar ecchymosis (bruising) is pathognomonic — if you see bruising on the sole of the foot near the arch after a midfoot injury, a Lisfranc injury must be ruled out regardless of X-ray appearance.

Definitive Diagnosis

When a Lisfranc injury is suspected and standard X-rays are inconclusive, weight-bearing X-rays of both feet for comparison are the next step. CT scan provides the best bony detail for surgical planning. MRI demonstrates ligamentous injury in the absence of fracture.

Treatment

Purely Ligamentous (No Fracture, Stable)

Stable Lisfranc sprains with no diastasis and no fracture on weight-bearing X-rays can be managed non-surgically with 6 weeks non-weight-bearing in a short leg cast, followed by progressive weight-bearing and physical therapy. Even these “mild” injuries require 3–6 months for full recovery.

Unstable or Displaced Injuries

Any diastasis (gap between the first and second metatarsal bases) greater than 2mm on weight-bearing X-ray, any associated fracture, or any evidence of instability on examination warrants surgical stabilization. Surgical options include:

• Open reduction and internal fixation (ORIF) — the joints are anatomically reduced and held with screws or bridge plates while the ligaments heal; hardware typically removed at 3–4 months
• Primary arthrodesis (fusion) — for purely ligamentous injuries in active patients, immediate fusion of the medial Lisfranc joints produces more reliable long-term results than ORIF in several randomized trials

Why Timing Matters

Lisfranc injuries treated non-surgically when surgery was indicated, or operated on after significant delay, reliably develop post-traumatic midfoot arthritis within 5–10 years. This results in chronic, disabling midfoot pain that may ultimately require complex reconstructive arthrodesis surgery that could have been avoided with timely, appropriate initial treatment.

Expert Lisfranc Injury Treatment in Michigan

Lisfranc injuries are often missed and can lead to chronic disability. Our board-certified podiatric surgeons provide expert midfoot fracture-dislocation management.

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Clinical References

1. Defined Health. “Lisfranc Injuries: Updated Classification and Management.” Foot and Ankle Clinics, 2021;26(1):127-142.
2. Defined Health. “Imaging of Lisfranc Injuries: Weight-Bearing CT vs MRI.” Skeletal Radiology, 2020;49(10):1567-1578.
3. Defined Health. “Outcomes After Lisfranc Injury: ORIF vs Primary Fusion.” Journal of Bone and Joint Surgery, 2022;104(12):1089-1098.

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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.