Lisfranc Injury: The Midfoot Injury That’s Often Misdiagnosed

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

Lisfranc injuries — fractures and ligament disruptions at the tarsometatarsal joint complex in the midfoot — are among the most commonly misdiagnosed injuries in orthopedic medicine. They are frequently dismissed as “just a sprain” in urgent care settings, leading to delayed treatment, progressive deformity, and long-term disability. Understanding what a Lisfranc injury is and when to seek specialist evaluation can prevent these outcomes.

What Is the Lisfranc Joint?

The Lisfranc joint complex (tarsometatarsal joint) is the articulation between the midfoot bones (cuneiforms and cuboid) and the bases of the five metatarsals. The Lisfranc ligament — a thick plantar ligament connecting the medial cuneiform to the second metatarsal base — is the primary stabilizer of this joint. Because the second metatarsal is “keyed” into a mortise between the first and third cuneiforms, it resists both medial-lateral and rotational forces on the midfoot.

How Lisfranc Injuries Occur

Two primary mechanisms produce Lisfranc injuries:

• Direct trauma — a heavy object dropping on the midfoot, or crush injuries (common in motor vehicle accidents)
• Indirect mechanism — axial loading on a plantarflexed foot (e.g., falling off a horse with the foot trapped in a stirrup, missing a step on a staircase, sports pivot injuries, and football linemen injuries)

Low-energy Lisfranc injuries in athletes are particularly prone to being underdiagnosed because they may appear subtle on non-weight-bearing X-rays.

Why Lisfranc Injuries Are Often Missed

Studies show that up to 20% of Lisfranc injuries are missed on initial evaluation. On non-weight-bearing X-rays, the joint may appear near-normal even with complete ligamentous disruption. The key diagnostic test is a weight-bearing comparison X-ray of both feet — diastasis (widening) between the first and second metatarsal bases greater than 2mm on the weight-bearing view is diagnostic. MRI further characterizes ligamentous injury and is essential for surgical planning.

Classification

Lisfranc injuries range from purely ligamentous sprains (stable) to fracture-dislocations (unstable). The Myerson classification divides them into: Type A (total incongruity — all tarsometatarsal joints displaced), Type B (partial incongruity), and Type C (divergent patterns). Purely ligamentous injuries may be harder to treat than fracture-dislocations because ligament-only injuries are more prone to missed instability.

Treatment

Non-Surgical (Stable Injuries Only)

Purely ligamentous stable Lisfranc injuries (confirmed by weight-bearing stress films showing <2mm diastasis) can be treated non-surgically with non-weight-bearing cast immobilization for 6–8 weeks, followed by progressive weight-bearing in a walking boot and custom orthotics. Long-term, a carbon fiber plate or custom orthotic provides ongoing midfoot support.

Surgical Treatment

Unstable injuries (fracture-dislocations or widened diastasis on weight-bearing) require surgical stabilization. Options include open reduction and internal fixation (ORIF) with screws or dorsal bridge plating, and primary arthrodesis for severe comminuted injuries or when articular cartilage is damaged. Early anatomic reduction is critical — malreduced Lisfranc injuries lead to chronic midfoot pain, deformity, and post-traumatic arthritis requiring fusion.

Lisfranc Injury — Midfoot Sprain & Fracture Treatment in Michigan

Midfoot pain and swelling after an injury? Lisfranc injuries are often missed and require specialized treatment. Our podiatric surgeons provide expert diagnosis and care.

See Our Sports Medicine & Fracture Care → | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Myerson MS, et al. Classification and treatment of Lisfranc fracture-dislocations. Foot & Ankle International, 1986;7(2):77-80.
2. Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. The American Journal of Sports Medicine, 2002;30(6):871-878.
3. Aronow MS. Treatment of the missed Lisfranc injury. Foot and Ankle Clinics, 2006;11(1):127-142.

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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.