Lisfranc Injury — Tarsometatarsal Ligament & Midfoot Fracture Michigan

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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Why Lisfranc Injuries Are the Most Frequently Missed Fracture

The Lisfranc injury — disruption of the tarsometatarsal (TMT) joint complex at the midfoot — is the most frequently missed significant foot injury in emergency medicine. The reasons: the midfoot X-ray findings can be subtle (1–2mm widening between the medial cuneiform and second metatarsal base); the mechanism is often low-energy and appears benign (stepping off a curb, missing a step); and the pain and swelling pattern initially mimics a simple midfoot sprain. The consequence of missing a Lisfranc injury is severe: untreated Lisfranc disruption leads to progressive midfoot collapse, post-traumatic arthritis, and a chronically painful flatfoot deformity that ultimately requires surgical fusion — a far more complex procedure than the primary fixation would have been. At Balance Foot & Ankle in Howell and Bloomfield Hills, Michigan, Dr. Tom Biernacki, DPM evaluates midfoot injuries with the precision to identify Lisfranc disruptions at presentation. Call (810) 206-1402.

The Lisfranc Complex — Anatomy and Injury Mechanism

The Lisfranc joint complex is the articulation between the three cuneiforms, the cuboid, and the bases of the five metatarsals — the tarsometatarsal (TMT) joints that form the transverse arch of the midfoot. Stability is provided by the Lisfranc ligament (interosseous ligament from the medial cuneiform to the second metatarsal base — the most critical stabilizer) and the dorsal and plantar TMT ligaments. Two injury mechanisms: high-energy (motor vehicle accidents, falls from height — obvious clinical presentation, multiple TMT fracture-dislocations visible on X-ray); and low-energy (missing a step, athletic twist, horse riding foot caught in stirrup — subtle presentation with minimal radiographic displacement). Low-energy Lisfranc injuries are the diagnostic challenge — the injury is ligamentous rather than bony, and non-weight-bearing X-rays may appear near-normal.

Diagnosis — Weight-Bearing X-Ray and CT

The diagnostic key for Lisfranc injuries: weight-bearing X-rays (or stress X-rays under fluoroscopy) are mandatory for any midfoot injury with plantar ecchymosis (bruising in the arch — highly sensitive sign for Lisfranc disruption) or tenderness at the TMT joints. On weight-bearing AP X-ray: the medial border of the second metatarsal base should align precisely with the medial border of the middle cuneiform — any step-off or gap indicates Lisfranc disruption. On weight-bearing AP and oblique: the medial border of the fourth metatarsal should align with the medial border of the cuboid. Greater than 2mm widening between the first and second metatarsal bases indicates Lisfranc ligament disruption — surgical indication. CT is ordered when X-rays are inconclusive — CT reveals small avulsion fractures at the second metatarsal base (fleck sign) that confirm ligamentous injury and identifies articular involvement guiding surgical planning.

Surgical Versus Conservative Management

Stable Lisfranc injuries (ligamentous sprain with <2mm displacement on stress X-ray, intact articular surfaces) are managed conservatively: non-weight-bearing cast 6–8 weeks, progressive weight-bearing in a walking boot 8–12 weeks, with repeat weight-bearing X-rays at 6 weeks to confirm maintenance of alignment. Conservative management failure rate: approximately 40% develop progressive displacement and require late surgery — emphasizing the importance of serial X-ray monitoring. Unstable Lisfranc injuries (>2mm displacement, fleck sign, any dislocation) require surgical fixation: open reduction with screws fixing the medial and middle columns, and Kirschner wires for the lateral column; or primary arthrodesis of the medial TMT joints (superior outcomes at 2 and 5 years compared to ORIF in ligamentous-dominant injuries). Recovery: non-weight-bearing 6–8 weeks, walking boot 3 months, return to sport 6–12 months.

Lisfranc Injury Evaluation in Howell & Bloomfield Hills Michigan

Any patient with midfoot pain after a twisting injury, plantar ecchymosis, or inability to bear weight on the forefoot requires Lisfranc evaluation — same-day if possible. Dr. Tom Biernacki, DPM performs weight-bearing X-rays with Lisfranc alignment assessment, CT coordination for equivocal cases, and appropriate surgical referral for unstable injuries at Balance Foot & Ankle. Serving Howell, Brighton, Dearborn, Bloomfield Hills, Troy, and all Southeast Michigan. Book your evaluation or call (810) 206-1402.

Lisfranc Injury Specialist in Michigan

Lisfranc injuries are frequently misdiagnosed as simple sprains but can lead to chronic pain and arthritis if not properly treated. Our surgeons have extensive experience diagnosing and treating these complex midfoot injuries.

Explore Our Foot & Ankle Surgery Services → | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Myerson MS, et al. Lisfranc injuries: evaluation and management. J Am Acad Orthop Surg. 2010;18(1):44-51.
2. Desmond EA, Chou LB. Current concepts review: Lisfranc injuries. Foot Ankle Int. 2006;27(8):653-660.
3. 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.

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Dr. Tom Biernacki, DPM

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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.