Lisfranc Ligament Injury: Diagnosis, Weight-Bearing Imaging, and Surgical Management

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

Lisfranc ligament complex injury — disruption of the ligamentous restraints of the tarsometatarsal (TMT) joint complex, named for the French surgeon who described midfoot amputations — ranges from subtle ligamentous sprain (the most commonly missed foot injury in emergency departments) to complete fracture-dislocation of the midfoot, and represents a spectrum where even ‘low-energy’ partial ligament injuries produce significant long-term morbidity if the instability is not recognized and properly treated. The consequence of missed Lisfranc injury is chronic midfoot instability, post-traumatic arthritis, and persistent pain requiring eventual surgical fusion — an outcome largely preventable with timely accurate diagnosis.

Anatomy and Injury Mechanism

Lisfranc ligament anatomy: the Lisfranc ligament proper runs from the medial cuneiform to the base of the second metatarsal — the key stabilizer of the second TMT joint; additional interosseous, dorsal, and plantar ligaments stabilize the entire TMT complex; the second metatarsal base is ‘keystone’ — recessed between the medial and lateral cuneiforms, providing osseous stability. Injury mechanism: indirect (most common in athletes) — axial loading on a plantarflexed foot (stepping in a hole, low-velocity falls); direct — crush injury with high-energy force. The ‘purely ligamentous’ Lisfranc injury without fracture is the most commonly missed — the injury gap closes on non-weight-bearing X-ray. Weight-bearing X-ray diagnosis: weight-bearing AP bilateral comparison views are mandatory — diastasis ≥2mm between the first and second metatarsal bases on the weight-bearing view confirms complete ligament disruption; fleck sign (small avulsion fracture at the second metatarsal base or medial cuneiform attachment of the Lisfranc ligament) is pathognomonic. CT: defines fracture fragment size and position; identifies subtle third/fourth/fifth TMT joint involvement. MRI: most sensitive for purely ligamentous injury without fracture — T2 hyperintensity through the Lisfranc ligament substance confirms tear.

Surgical Treatment

Indications: any diastasis ≥2mm on weight-bearing views; complete ligamentous injury; fracture-dislocation. Anatomic reduction and internal fixation (ORIF): closed or open reduction of the TMT joints; temporary transarticular screw or plate fixation of the second (and third if unstable) TMT joints; the medial column (first and second rays) requires rigid fixation; the lateral column (fourth and fifth) is typically more mobile and may be managed with Kirschner wires. Primary arthrodesis: fusion of the medial column TMT joints (first, second, third) — preferred by some surgeons for purely ligamentous injuries without fracture; avoids hardware removal and provides more durable results in the purely ligamentous pattern; the CORI trial supports primary fusion over ORIF for ligamentous Lisfranc. Hardware removal: transarticular screws require removal at 3–4 months; plates may be retained. Dr. Biernacki at Balance Foot & Ankle evaluates midfoot injuries with weight-bearing X-rays and CT, and performs Lisfranc ORIF and fusion at our Bloomfield Township and Howell offices. Call (810) 206-1402.

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Frequently Asked Questions

When should I see a podiatrist?

See a podiatrist for any foot or ankle pain that persists more than 2 weeks, doesn’t improve with rest, limits your daily activities, or is accompanied by swelling, numbness, or skin changes. People with diabetes or circulation problems should see a podiatrist regularly even without symptoms.

What does a podiatrist treat?

Podiatrists diagnose and treat all conditions of the foot, ankle, and lower leg including plantar fasciitis, bunions, hammertoes, toenail problems, heel pain, nerve pain, diabetic foot care, sports injuries, fractures, and foot deformities — both surgically and non-surgically.

What can I expect at my first podiatry visit?

Your first visit includes a full medical history, physical examination of your feet and gait, and in-office diagnostic imaging if needed (X-rays, ultrasound). We’ll discuss your diagnosis and create a plan tailored to your foot type. Most visits take 30–45 minutes.

Need Treatment at Balance Foot & Ankle?

Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin see patients at our Howell and Bloomfield Township offices.

Book Online or call (810) 206-1402

Most Common Mistake We See

The most common mistake we see is: Waiting too long before seeking care. Fix: any foot pain lasting more than 4 weeks, or any sudden severe symptom, deserves a professional evaluation rather than more rest.

Warning Signs That Need Same-Day Care

Differential Diagnosis: What Else Could It Be?

Not every case of lisfranc (midfoot) injury is straightforward. In our clinic we routinely rule out three look-alike conditions before confirming the diagnosis. If your symptoms don’t match the classic presentation, one of these may explain the pain — which is why physical exam matters more than self-diagnosis.

Condition	How It Differs
Midfoot sprain	No diastasis on X-ray; able to bear weight after initial pain.
Navicular stress fracture	Dorsal midfoot pain with impact loading; stress fx confirmed on MRI.
Cuboid syndrome	Lateral midfoot pain, often following ankle inversion; relieved by cuboid whip.

Red Flags — When to See a Podiatrist Now

In Our Clinic: What We See

In-Office Treatment at Balance Foot & Ankle

If home treatment isn’t providing relief for your foot and ankle conditions, our podiatry team at Balance Foot & Ankle can help with same-day evaluations and advanced in-office care.