Lisfranc Ligament Injury: Diagnosis, the Missed Injury Problem, and Surgical Timing

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

The Lisfranc ligament — the primary ligamentous stabilizer of the first and second tarsometatarsal articulation — is injured far more frequently than emergency department statistics suggest. Up to 20% of Lisfranc injuries are missed on initial presentation, misdiagnosed as midfoot sprains and treated with conservative management that allows progressive midfoot collapse, post-traumatic arthrosis, and chronic disability. Accurate diagnosis requires specific radiographic technique and a high index of clinical suspicion.

Anatomy and Injury Mechanism

The Lisfranc ligament complex — the plantar Lisfranc ligament (the strongest component, running obliquely from the medial cuneiform to the base of the second metatarsal), the dorsal Lisfranc ligament, and the interosseous Lisfranc ligament — provides rotational stability between the medial and lateral columns of the midfoot. There is no direct ligament between the first and second metatarsal bases — the Lisfranc ligament is the only structure preventing splaying at this level. Injury mechanisms: low-energy indirect (axial loading on a plantarflexed foot — the classic equestrian and ballet dancer mechanism) and high-energy direct (crush injury, dashboard impact). Low-energy Lisfranc injuries with subtle diastasis are the most commonly missed.

Diagnosis and Surgical Timing

Weight-bearing radiographs are mandatory — non-weight-bearing X-rays miss up to 50% of Lisfranc diastasis by allowing the torn ligament’s gap to close passively. The key finding: diastasis between the medial aspect of the second metatarsal base and the lateral aspect of the medial cuneiform >2mm on weight-bearing AP view indicates Lisfranc disruption. CT scanning defines the fracture pattern in bony Lisfranc injuries. MRI identifies purely ligamentous injuries without bony avulsion. Surgical timing is critical: primary ligament repair or ORIF (for bony injuries) or primary arthrodesis (for purely ligamentous injuries with instability) performed within 2–3 weeks of injury produces superior outcomes compared to delayed surgery after midfoot collapse has occurred. Patients presenting more than 6 weeks post-injury typically require salvage arthrodesis. Dr. Biernacki at Balance Foot & Ankle evaluates midfoot injuries with weight-bearing X-rays at the initial visit. Call (810) 206-1402 for prompt midfoot injury evaluation at our Bloomfield Hills or Howell office.

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When to See a Podiatrist

Many foot conditions can be managed conservatively at home, but some require professional evaluation. See a podiatrist promptly if you experience:

• Pain that persists for more than 2 weeks despite rest
• Swelling, redness, or warmth that isn’t improving
• Numbness, tingling, or burning in the feet
• A wound or sore that is not healing within 2 weeks
• Any foot concern if you have diabetes or poor circulation
• Nail changes that suggest fungal infection or other problems

At Balance Foot & Ankle, our three board-certified podiatrists — Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin — provide comprehensive foot and ankle care at our Howell and Bloomfield Township offices. Most insurance plans are accepted.

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Board-certified podiatrists Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin see patients daily at our Howell and Bloomfield Township, MI offices.

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Don’t Miss a Lisfranc Injury: Diagnosis & Surgical Timing

Lisfranc midfoot injuries are missed in up to 20% of cases, leading to chronic pain and disability. Our podiatric surgeons use weight-bearing imaging and clinical expertise to diagnose these injuries early and time surgery optimally for the best outcomes.

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Clinical References

1. 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.
2. Desmond EA, Chou LB. Current concepts review: Lisfranc injuries. Foot Ankle Int. 2006;27(8):653-660.
3. Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. J Bone Joint Surg Am. 2006;88(3):514-520.