Lisfranc Injury: Why It's Often Missed & What

Lisfranc Injury: Podiatrist’s Complete Guide to Diagnosis, Grading & Treatment

A Lisfranc injury can appear deceptively minor on initial X-ray — a small fleck of bone, a 1-2 mm joint space widening — yet cause years of chronic midfoot pain and arch collapse if not treated correctly from the start. This is the injury that ended professional athletes’ careers before imaging and surgical techniques improved enough to repair the damage reliably. In our clinic, we approach any midfoot injury with significant swelling and difficulty weight-bearing as a potential Lisfranc injury until proven otherwise.

What Is a Lisfranc Injury?

The Lisfranc joint complex encompasses the five tarsometatarsal (TMT) joints that form the articulation between the cuneiform bones and the bases of the five metatarsals. The Lisfranc ligament itself connects the medial cuneiform to the base of the second metatarsal and is the primary stabilizing structure of the entire complex. Lisfranc injuries disrupt this stability through three mechanisms: purely ligamentous (sprain to complete tear), bony (fracture at the joint complex without ligament tear), or combined (fracture-dislocation). The Myerson classification describes three types based on the pattern of displacement: Type A (total incongruity), Type B (partial incongruity), and Type C (divergent).

Lisfranc injuries occur in two broad contexts: high-energy trauma (motor vehicle accidents, falls from height) and low-energy mechanisms (plantar flexion loading with axial load — the classic “cleat stuck in turf” or “stepping off a curb wrong” mechanism in athletes). Low-energy Lisfranc injuries are more commonly missed because the deformity is subtle on standard X-rays.

Lisfranc Injury Symptoms

Characteristic clinical findings include:

• Midfoot pain and swelling — swelling centered over the dorsal midfoot rather than the ankle is the key distinguishing feature from an ankle sprain
• Plantar ecchymosis — bruising on the sole of the foot in the arch region is highly specific for Lisfranc injury (though not always present)
• Inability to single-leg heel raise — a positive single-leg heel raise test (inability to rise onto the ball of the affected foot) is sensitive for unstable Lisfranc injuries
• Tenderness at the Lisfranc joint line — focal tenderness directly over the 1st-2nd TMT joint
• Piano key sign — pain reproduced with dorsoplantar stress on individual metatarsal bases

How We Diagnose Lisfranc Injuries

Standard non-weight-bearing X-rays miss up to 20% of Lisfranc injuries. We obtain weight-bearing X-rays of both feet for comparison — a medial clear space (between the medial cuneiform and 2nd metatarsal base) greater than 2 mm compared to the contralateral side, or any TMT malalignment, is diagnostic. CT scan provides the most detailed bony anatomy for surgical planning, identifying subtle fracture lines and joint incongruity. MRI is the gold standard for pure ligamentous Lisfranc injuries — it directly visualizes the Lisfranc ligament, plantar TMT ligaments, and associated bone marrow edema.

Lisfranc Injury Treatment

Purely ligamentous Lisfranc sprains with demonstrated stability on stress X-rays are treated non-operatively: non-weight-bearing in a short-leg cast for 6 weeks, followed by protected weight-bearing and graduated return to activity over 3-4 months total.

Unstable Lisfranc injuries — demonstrated by any displacement on weight-bearing X-rays, or instability on stress testing under fluoroscopy — require surgical fixation. Surgical options include open reduction and internal fixation (ORIF) with plates and screws, and primary arthrodesis of the medial column (1st-3rd TMT joints). Evidence increasingly favors primary arthrodesis for ligamentous injuries and medial column involvement — randomized controlled trials show better long-term outcomes and fewer reoperations compared to ORIF with screw removal. Hardware is typically removed at 3-4 months after ORIF.

The Most Common Mistake We See

The most common failure is treating an unstable Lisfranc injury as a “bad sprain” and allowing weight-bearing in a boot. The unstable TMT joints settle into malalignment under load, resulting in midfoot arthritis, arch collapse, and chronic pain that is dramatically more difficult to treat than the original injury. When in doubt, non-weight-bearing until stability is confirmed with weight-bearing X-rays is the correct default.

Frequently Asked Questions

How long does a Lisfranc injury take to heal?
Stable sprains: 3-4 months to return to full activity. Surgical ORIF: 4-6 months. Primary arthrodesis: 6-9 months. Residual midfoot stiffness and aching with prolonged activity can persist for 1-2 years, particularly after more severe injuries.

Will I need surgery for a Lisfranc injury?
Only if the injury is unstable — demonstrated by displacement on weight-bearing X-rays or stress testing. Many mild Lisfranc sprains are stable and heal with non-operative management. The key is confirming stability with appropriate imaging before committing to a treatment approach.

Can Lisfranc injuries cause long-term problems?
Inadequately treated unstable Lisfranc injuries reliably produce post-traumatic midfoot arthritis within 3-5 years. Proper stabilization — whether non-operative for stable injuries or surgical for unstable ones — dramatically reduces this risk.

The Bottom Line

Lisfranc injuries are high-stakes diagnoses where missing instability leads to long-term midfoot arthritis and arch collapse. Any midfoot injury with significant swelling, plantar bruising, or difficulty weight-bearing needs weight-bearing X-rays as a minimum. When instability is confirmed, surgical treatment with ORIF or primary arthrodesis produces good long-term outcomes that non-operative treatment of unstable injuries simply cannot match.

Why Lisfranc Injuries Are So Often Missed

This is the single most important thing to understand about this injury, and it is the reason a seemingly minor midfoot sprain can end in a fused joint years later.

A substantial share of Lisfranc injuries — commonly cited as up to a fifth to a third of cases — are missed at the first presentation. Not through carelessness, but because of one specific technical problem: a standard X-ray taken lying down can look completely normal.

The Lisfranc ligament runs on the underside of the foot, from the medial cuneiform to the base of the second metatarsal. When it tears, the joint only separates once the foot is loaded. Take the X-ray with the patient on the table and the bones sit back in position. Take it standing, and the gap appears.

So if you were told your midfoot X-ray was fine but you still cannot put weight through the middle of your foot two weeks later, that combination deserves a second look rather than more rest.

What imaging actually needs to be done

• Weight-bearing X-rays, not lying-down films. This alone resolves most missed diagnoses.
• Comparison views of the opposite foot, taken the same way. Normal midfoot spacing varies between people; the reliable comparison is you against yourself.
• The fleck sign — a small flake of avulsed bone in the space between the first and second metatarsal bases. It is easy to overlook and it is close to diagnostic.
• Separation of more than about 2 mm between the medial cuneiform and the second metatarsal base, compared with the other foot, indicates an unstable injury.
• CT when the X-rays are equivocal or there are small fractures — it shows the joint surfaces far better.
• MRI when the injury is purely ligamentous and the bones look intact. This is the group most often reassured and sent home.

How It Happens — Including the Unremarkable Ways

The dramatic mechanisms are well known: a football lineman whose foot is planted and plantarflexed when someone lands on the heel, a rider whose foot stays in the stirrup during a fall, a motor vehicle collision.

But a meaningful number arrive from something entirely mundane — stepping awkwardly off a curb, missing the bottom stair, a foot rolling under the body during a twist. Patients frequently apologise for wasting our time because the story sounds too trivial for a serious injury. The mechanism does not have to be impressive. The exam and the weight-bearing film decide it, not the story.

Suggestive findings include bruising on the sole of the midfoot — plantar ecchymosis is a well-recognised red flag — inability to bear weight, pain on twisting the forefoot against the hindfoot, and swelling concentrated over the middle of the foot rather than the ankle.

Stable Versus Unstable — the Decision That Sets Everything

Once diagnosed, one question determines the whole treatment path: does the joint stay in position under load?

Stable, non-displaced injuries can be treated without surgery — a period of non-weight-bearing in a cast or boot, typically six to eight weeks, with repeat weight-bearing films along the way to confirm nothing has shifted. That follow-up imaging is not a formality; a small number of injuries that look stable initially displace once the patient starts loading the foot.

Unstable injuries need surgery. Leaving a displaced Lisfranc joint to heal out of position reliably produces midfoot arthritis, and the operation to fix that later is considerably bigger than the one that would have prevented it.

Two surgical approaches are used. Open reduction and internal fixation realigns the joints and holds them with screws or plates while the ligaments heal. Primary arthrodesis — fusing the affected joints at the outset — has increasingly been favoured for purely ligamentous injuries, because torn ligament heals less predictably than bone and the fusion avoids a second operation for arthritis down the line. Which is appropriate depends on whether the injury is bony or ligamentous, how many joints are involved, and your activity demands.

Recovery and Return to Sport

This is a slow injury, and knowing that in advance is worth a great deal.

• Weeks 0–6/8: non-weight-bearing in a cast or boot. Strict, and not negotiable — the midfoot takes enormous load with every step.
• Weeks 6–12: graduated weight-bearing in the boot as imaging confirms position is held.
• Months 3–4: out of the boot into a supportive shoe, usually with an orthotic to offload the midfoot. Physical therapy begins properly.
• Months 4–6: most daily activity restored. Swelling that comes and goes at the end of the day is normal and can persist well past this point.
• Months 6–12: return to running and cutting sports. High-level athletes are frequently at the longer end, and nine to twelve months is not unusual after a surgically treated unstable injury.

Hardware is sometimes removed once healing is complete, particularly screws crossing joints that need to move again. That is a smaller, separate procedure, planned rather than unexpected.

What Happens If It Is Missed

An untreated unstable Lisfranc injury does not simply stay sore. The midfoot settles into a slightly collapsed, malaligned position, the arch flattens, and the joint surfaces wear abnormally. The result is post-traumatic midfoot arthritis — persistent aching across the middle of the foot, difficulty with push-off, and a bony prominence on top of the arch that catches in shoes.

By that stage, the reconstruction required is a midfoot fusion, and the outcome, while usually good, is not as good as it would have been from timely fixation. That is the whole argument for taking a midfoot injury that is still painful at two weeks seriously.

If you cannot bear weight through the middle of your foot, have bruising on the sole, or were told an X-ray was normal but the foot has not improved, ask specifically for weight-bearing views with comparison of the other foot. Balance Foot & Ankle sees patients in Howell (4330 E Grand River Ave, Howell, MI 48843) and Bloomfield (43494 Woodward Ave #208, Bloomfield Township, MI 48302). Call (810) 206-1402.

Sources

• Weatherford BM et al. Lisfranc joint injuries. J Am Acad Orthop Surg. 2022.
• Henning JA et al. Primary arthrodesis vs ORIF for Lisfranc injuries. J Bone Joint Surg Am. 2020.
• Myerson MS. The diagnosis and treatment of injury to the tarsometatarsal joint complex. JBJS. 2018.

More questions patients ask

How is a Lisfranc injury diagnosed?

Lisfranc injuries are frequently missed — studies show up to 20% are diagnosed late. Key findings: bruising on the bottom of the midfoot (pathognomonic — almost always indicates Lisfranc injury), inability to bear weight, midfoot pain and swelling. Weight-bearing X-rays show widening between the 1st and 2nd metatarsal bases (>2mm is diagnostic) and possibly fracture fragments (fleck sign). CT scan provides better fracture detail. MRI assesses ligament integrity in subtle cases with normal X-rays.

Do all Lisfranc injuries require surgery?

No — purely ligamentous Lisfranc sprains with stable alignment on weight-bearing X-rays can be treated conservatively: 6-8 weeks non-weight-bearing in a cast, then progressive weight-bearing over 4-6 weeks. However, any displacement (>2mm on weight-bearing X-rays) requires surgical fixation (either temporary screw fixation with delayed removal, or primary fusion for severe cases). Inadequately treated Lisfranc injuries develop post-traumatic midfoot arthritis that is extremely debilitating and difficult to treat.

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