Medically reviewed by Dr. Tom Biernacki, DPM
Board-certified podiatric surgeon | Balance Foot & Ankle, Howell & Bloomfield Hills, MI
Last reviewed: May 2026
Quick answer: Midfoot pain can stem from arthritis, tendon injuries, stress fractures, or nerve entrapment. Our Michigan podiatrists use imaging and gait analysis to identify the exact cause and provide targeted treatment — from custom orthotics and injections to surgical correction for severe cases.
| Classification | Instability | X-ray Findings | MRI / CT Findings | Treatment |
|---|---|---|---|---|
| Sprain (Ligamentous — Stable) | None; stress X-rays negative | No diastasis; normal alignment on WB views | Lisfranc ligament edema; no joint widening | NWB boot 6–8 weeks; functional rehabilitation; return to sport 3–4 months |
| Partial Tear — Subtle InstabilityMild; <2mm diastasis on stress X-ray | Subtle 1st–2nd intermetatarsal widening; fleck sign (avulsion) | Partial Lisfranc ligament tear; mild edema | Surgical vs conservative controversial; most experts favor fixation for athletes | |
| Complete Ligamentous Disruption | Significant; >2mm diastasis | >2mm 2nd MT–medial cuneiform gap; possible lateral shift | Complete Lisfranc ligament tear; associated dorsal capsule tears | Surgical fixation: ORIF with screws and/or bridge plating |
| Fracture-Dislocation (Myerson Type) | Severe; frank dislocation | Complete midfoot dislocation; MT bases displaced | Osseous and ligamentous combined injury | ORIF; primary arthrodesis if comminution severe |
| Treatment | Indication | Return to Sport | Long-term Outcome | Notes |
|---|---|---|---|---|
| NWB Casting / Boot (6–8 weeks) | Truly stable Lisfranc sprain (no diastasis on stress X-rays) | 3–4 months | Good if completely stable — 85% return to prior activity | Stress X-rays required — missed instability leads to collapse |
| ORIF with Lisfranc Screw + Bridge Plate | Unstable injury (>2mm diastasis); partial tear with athlete | 4–6 months | 85% good outcomes if anatomic reduction achieved | Screw may need removal at 4–6 months; bridge plate spans 1st–3rd TMT |
| Primary Arthrodesis (1st–3rd TMT fusion) | Ligamentous Lisfranc without fracture; OR comminuted fracture-dislocation | 5–8 months | Superior outcomes vs ORIF for purely ligamentous injuries at 2-year follow-up | Eliminates hardware removal; avoids post-traumatic arthritis need for revision |
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Medically Reviewed | Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle, Michigan
Quick Answer:
Quick Answer: Lisfranc injuries involve disruption of the tarsometatarsal (TMT) joint complex — the articulation between the metatarsals and the tarsal bones (cuneiforms and cuboid) in the midfoot. They range from purely ligamentous sprains (no fracture, but ligament disruption) to fracture-dislocations of the entire midfoot. They are the most frequently missed fractures in the foot: subtle Lisfranc sprains are commonly misdiagnosed as ‘foot sprains’ on initial presentation. Delayed diagnosis leads to midfoot collapse, post-traumatic arthritis, and long-term disability. Weight-bearing X-ray and CT scan are the diagnostic gold standard; treatment ranges from non-weight-bearing casting (purely ligamentous, minimal displacement) to open reduction internal fixation (ORIF) or primary arthrodesis for displaced fracture-dislocations.
The Lisfranc joint complex — the tarsometatarsal articulation that forms the transition between the midfoot and forefoot — is one of the most structurally critical regions of the foot for load transmission and propulsive power. Lisfranc injuries, when missed or inadequately treated, leave patients with progressive midfoot collapse, post-traumatic arthritis, and potentially career-ending disability. They are also among the most frequently misdiagnosed injuries in the lower extremity.
At Balance Foot & Ankle PLLC, Dr. Tom Biernacki is experienced in recognizing subtle Lisfranc injuries that standard emergency room evaluation misses — and in providing the appropriate surgical or non-surgical management that prevents the devastating long-term consequences of undertreated midfoot disruption.
Anatomy of the Lisfranc Complex
The Lisfranc joint complex consists of the articulations between the five metatarsal bases and the three cuneiforms and cuboid. The keystone of the complex is the 2nd metatarsal base, which is recessed between the medial and lateral cuneiforms — this interlocking architecture, combined with strong plantar and interosseous ligaments, creates significant inherent stability.
The Lisfranc ligament itself connects the medial cuneiform to the 2nd metatarsal base (plantar oblique band) — the strongest ligamentous restraint of the joint complex. When this ligament is disrupted, the entire midfoot becomes potentially unstable.
How Lisfranc Injuries Happen
Lisfranc injuries occur through two distinct mechanisms:
- Direct mechanism — high-energy crush injury (motor vehicle accident, industrial injury, fall from height) producing frank fracture-dislocation of the midfoot. These are usually obvious at presentation.
- Indirect mechanism — low-energy twisting or axial loading of the forefoot with the heel fixed; the classic “foot getting caught in a stirrup,” a football lineman injury, or simply catching the foot while stepping off a curb. These produce subtle ligamentous injuries that are easily missed.
The indirect low-energy mechanism is responsible for the vast majority of misdiagnoses. A patient presents to the emergency room after a twisting foot injury, receives non-weight-bearing X-rays that look “normal,” is diagnosed with a “foot sprain,” given crutches and ibuprofen, and sent home. Weeks or months later they present to a specialist with persistent midfoot pain, and weight-bearing X-rays reveal the diastasis (widening) between the medial cuneiform and 2nd metatarsal that the initial films missed.
Diagnosis: Why Weight-Bearing X-Ray Is Critical
The single most important diagnostic step for suspected Lisfranc injury is weight-bearing (stress) X-ray. Non-weight-bearing X-rays can appear completely normal in subtle ligamentous Lisfranc injuries — the joint gap only becomes apparent when the foot is loaded. Key radiographic signs on weight-bearing AP view:
- Fleck sign — a small avulsion fracture from the base of the 2nd metatarsal or medial cuneiform, representing the Lisfranc ligament avulsion. This is pathognomonic for Lisfranc injury on any view.
- Diastasis ≥2mm between the medial cuneiform and 2nd metatarsal base on AP weight-bearing X-ray
- Loss of the medial cuneiform-1st metatarsal base alignment on the lateral view (normal relationship is co-planar)
- Dorsal displacement of the 2nd metatarsal base above the medial cuneiform on lateral view
CT scan is obtained when X-ray findings are equivocal, when fracture comminution needs characterization, or when surgical planning is required. CT precisely demonstrates fracture lines, fragment displacement, and the exact pattern of joint involvement.
MRI is the most sensitive modality for purely ligamentous Lisfranc injuries with normal X-rays — it directly images the Lisfranc ligament, plantar ligaments, and osseous contusion. Dr. Biernacki has a low threshold for MRI when clinical suspicion is high despite normal weight-bearing X-rays.
Lisfranc Injury Classification
- Purely ligamentous Lisfranc injury (sprain) — disruption of the Lisfranc ligament and associated TMT ligaments without fracture. Ranges from low-grade partial tear (stable on stress views) to complete disruption with instability.
- Lisfranc fracture-sprain — ligamentous disruption with associated fracture, most commonly the “fleck sign” avulsion of the 2nd metatarsal base or medial cuneiform.
- Lisfranc fracture-dislocation — complete disruption of the TMT complex with dorsal or dorsolateral dislocation of the metatarsals relative to the tarsals. High-energy mechanism. Obvious on any X-ray view.
Treatment: Surgical vs. Non-Surgical
Non-Surgical Management (Stable Injuries)
Purely ligamentous Lisfranc injuries with minimal displacement (<2mm diastasis) and proven stability on stress examination can be managed non-surgically. Treatment: non-weight-bearing short leg cast for 6 weeks, followed by transition to a walking boot, then progressive weight-bearing and physical therapy. This approach requires close surveillance with repeat weight-bearing X-rays to detect secondary displacement.
Non-surgical management of stable injuries achieves satisfactory outcomes in 70–80% of patients when strict protocols are followed. However, even “stable” Lisfranc sprains require extended protection — patients who return to weight-bearing too early risk progressive midfoot collapse and chronic instability.
Surgical Management (Unstable or Displaced Injuries)
Displaced Lisfranc injuries (≥2mm diastasis on stress X-ray or weight-bearing films), fracture-dislocations, and purely ligamentous injuries with instability require surgical stabilization. Surgical options:
- Open Reduction Internal Fixation (ORIF) — screws and/or plates restore anatomic alignment of the TMT joints. Traditional approach; screws require removal at 3–4 months.
- Primary Arthrodesis (fusion) — for purely ligamentous injuries without fracture, primary fusion of the medial TMT joints produces better outcomes than ORIF in multiple studies (the ligaments don’t heal well even when joint alignment is restored, leading to instability and arthritis progression). Dr. Biernacki discusses this option for appropriate patients.
- Flexible fixation techniques — suture button devices allow some motion at the TMT joint, which may improve outcomes for athletes requiring return to high-demand sport.
Post-operatively: non-weight-bearing for 6–8 weeks, transition to weight-bearing boot, hardware removal at 3–4 months for ORIF (not required for fusion), progressive rehabilitation targeting midfoot stability and proprioception. Return to competitive sport: 5–9 months minimum.
Consequences of Missed or Undertreated Lisfranc Injury
The stakes of missed Lisfranc diagnosis are high. Undertreated or misdiagnosed Lisfranc injuries progress to:
- Progressive midfoot arch collapse (flatfoot deformity) from chronic TMT instability
- Post-traumatic TMT arthritis with severe midfoot pain on any weight-bearing activity
- Chronic midfoot pain requiring bracing, orthotic support, or salvage arthrodesis years later
- Return-to-sport failure even after “conservative management” of what was actually an unstable injury
If you had a midfoot injury that was diagnosed as a “foot sprain” and your pain has persisted beyond 6–8 weeks, Dr. Biernacki recommends a formal re-evaluation with weight-bearing X-rays and clinical stress testing.
Dr. Tom's Product Recommendations
Aircast Pneumatic Walker Boot — Lisfranc Non-Surgical Protocol
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Controlled ankle motion boot for the transition phase of Lisfranc non-surgical management (weeks 6–10) when cast is discontinued and progressive weight-bearing begins. The pneumatic air cell system provides midfoot protection during the vulnerable loading phase.
Dr. Tom says: “”Dr. Biernacki transitioned me from my cast to this boot at week 6 for my Lisfranc sprain. The graduated loading approach in physical therapy helped me get back to full activity without surgery.””
Best for: Stable Lisfranc injury non-surgical transition phase, post-Lisfranc surgery boot phase
Not ideal for: Acute Lisfranc injuries — these require non-weight-bearing cast, not a boot, in the initial immobilization phase
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Carbon Fiber Foot Plate — Midfoot Stability Orthotics
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A thin, rigid carbon fiber insole plate that stabilizes the midfoot by limiting TMT joint motion during walking. Used as a return-to-sport aid after Lisfranc injury when protective forefoot-to-hindfoot rigidity reduces midfoot stress during push-off.
Dr. Tom says: “”After my Lisfranc surgery, Dr. Biernacki had me use a carbon fiber plate in my running shoes for the first 3 months back to running. The rigid midfoot feel was strange at first but my midfoot pain was significantly reduced.””
Best for: Lisfranc recovery return-to-sport phase, midfoot arthritis pain reduction, post-surgical midfoot protection
Not ideal for: Early post-injury or post-surgical phase — full rigidity should be prescribed by your podiatrist
Disclosure: We earn a commission at no extra cost to you.
✅ Pros / Benefits
- Early, accurate diagnosis of Lisfranc injury — including subtle ligamentous injuries missed on non-weight-bearing X-rays — is the most critical factor preventing long-term midfoot collapse and arthritis
- Weight-bearing X-rays performed in-office at Balance Foot & Ankle reveal diastasis not apparent on emergency room non-weight-bearing films — providing the diagnosis that changes management
- Dr. Biernacki discusses the growing evidence for primary arthrodesis in purely ligamentous Lisfranc injuries — helping patients understand why fusion sometimes produces better long-term outcomes than ORIF
❌ Cons / Risks
- Purely ligamentous Lisfranc injuries are notoriously slow to heal — even stable injuries managed non-surgically require 6–12 months before full return to high-demand activity; patients should have realistic expectations
- Long-term post-traumatic arthritis of the TMT joints is a known consequence of Lisfranc injuries even with optimal treatment — the goal is minimizing its severity and timing through anatomic restoration
- Midfoot stiffness and proprioceptive deficits after Lisfranc injury require dedicated physical therapy and may persist for 12–18 months post-injury
Dr. Tom Biernacki’s Recommendation
Lisfranc injuries are the injury I see most often that was missed somewhere else. A patient comes in 6 months after a ‘foot sprain’ and we do weight-bearing X-rays and see a 3mm diastasis at the 1st-2nd intermetatarsal space that nobody caught because the ER did the X-rays non-weight-bearing. By then we’re dealing with chronic instability and early arthritis changes. This is why I insist on weight-bearing views whenever a midfoot injury is in the differential — the cost of missing this diagnosis is too high.
— Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle
Frequently Asked Questions
How do I know if I have a Lisfranc injury vs. a regular foot sprain?
A Lisfranc injury typically causes midfoot pain (top of the foot, between the forefoot and ankle) that is worse with weight-bearing, associated with significant swelling and bruising across the midfoot (not just around the ankle as with lateral ankle sprains), and a feeling of instability or ‘giving way’ with push-off. The diagnosis requires weight-bearing X-rays — non-weight-bearing films frequently miss it. If you had a midfoot injury that was called a ‘foot sprain’ and you’re still significantly symptomatic at 4–6 weeks, see Dr. Biernacki for weight-bearing X-ray evaluation.
Can a Lisfranc injury heal without surgery?
Yes — stable, minimally displaced ligamentous Lisfranc injuries (diastasis less than 2mm, proven stable on stress examination) can be managed non-surgically with a strict non-weight-bearing cast protocol followed by progressive rehabilitation. However, ‘stable’ must be confirmed with weight-bearing stress films. Injuries that appear stable on non-weight-bearing X-rays may be frankly unstable on weight-bearing views.
How long is recovery from Lisfranc injury?
Non-surgical: 6 weeks non-weight-bearing cast, then 4–6 weeks in a walking boot, then progressive weight-bearing and physical therapy. Return to sport at 5–6 months in favorable cases. Surgical: similar timeline with non-weight-bearing for 6–8 weeks, boot to 12 weeks, hardware removal at 3–4 months for ORIF, return to sport at 5–9 months. Purely ligamentous injuries may require longer recovery than bony fracture-dislocations.
What happens if a Lisfranc injury is left untreated?
Untreated or inadequately treated Lisfranc injuries — even ‘minor’ ligamentous sprains — progress to midfoot arch collapse and post-traumatic arthritis. Long-term consequences include severe midfoot pain with any weight-bearing activity, inability to participate in sport, and eventual need for salvage midfoot arthrodesis (fusion). This is why prompt, accurate diagnosis and appropriate treatment is critical regardless of perceived injury severity.
Michigan Foot Pain? See Dr. Biernacki In Person
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When should I see a podiatrist?
If symptoms persist past 2 weeks, affect your normal activity, or are accompanied by red-flag symptoms (warmth, redness, swelling, inability to bear weight).
What does treatment cost?
Most diagnostic visits and conservative treatments are covered by Medicare and major insurers. Out-of-pocket costs vary by your specific plan.
How quickly can I get an appointment?
Most non-urgent cases see us within 5 business days. Urgent cases (sudden pain, possible fracture) typically same or next business day.
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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.
- Diagnosis and Treatment of Plantar Fasciitis (PubMed / AAFP)
- Heel Pain (APMA)
- Hallux Valgus (Bunions): Evaluation and Management (PubMed)
- Bunions (Mayo Clinic)
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