Lisfranc Ligament Injury: Classification, Imaging, and Surgical Treatment

The Lisfranc ligament complex is the primary stabilizer of the tarsometatarsal (TMT) joint complex — the articulation between the midfoot tarsal bones (medial, intermediate, and lateral cuneiforms plus the cuboid) and the five metatarsal bases. Injury to the Lisfranc ligament ranges from subtle midfoot sprain to frank TMT dislocation, and the diagnosis is frequently missed on initial evaluation because non-displaced or minimally displaced injuries can appear nearly normal on non-weightbearing X-rays. The key diagnostic test is standing (weightbearing) anteroposterior and oblique X-rays, which unmask diastasis between the first and second metatarsal bases that is pathognomonic for complete Lisfranc ligament disruption. Missed Lisfranc injuries progress to post-traumatic midfoot arthritis, flatfoot deformity, and permanent disability — the threshold for surgical stabilization is low because conservative management of unstable injuries has poor outcomes.

Lisfranc Injury Classification and Imaging Criteria

Category	Myerson Classification / Features	X-ray Findings	Treatment
Type A — Total incongruity	All 5 TMT joints displaced in same direction (homolateral); all stabilizing ligaments disrupted; most unstable pattern	All metatarsal bases shifted laterally or dorsolaterally en masse; diastasis 1-5 metatarsals; no isolated column involvement	ORIF with screws or bridge plating; primary arthrodesis for severely comminuted or ligamentous-only injury
Type B1 — Partial medial incongruity	Medial column only displaced; first metatarsal displaced medially; lateral 4 metatarsals normal	First metatarsal base medially shifted; gap at first TMT joint; second metatarsal base normal alignment	ORIF medial column; screw from medial cuneiform to 2nd metatarsal base (Lisfranc screw)
Type B2 — Partial lateral incongruity	One or more lateral metatarsals displaced laterally; medial column intact	2nd-5th metatarsal base diastasis; medial cuneiform to 2nd metatarsal gap; dorsal subluxation	ORIF lateral column; bridge plating 4th-5th if comminuted
Type C1 — Divergent partial	First metatarsal displaced medially AND lateral metatarsals displaced laterally; partial disruption of both columns	Divergent pattern: 1st metatarsal base gaps medially, 2nd-5th shift laterally; wide diastasis at 1st-2nd intermetatarsal space	ORIF both columns; Lisfranc screw mandatory for medial column stability
Type C2 — Divergent total	All TMT joints completely disrupted with divergent displacement; highest energy; most unstable	Complete disruption all columns; >2mm diastasis 1st-2nd metatarsal space; dorsal displacement; associated fractures	Primary arthrodesis preferred for pure ligamentous total disruption; ORIF if adequate bone stock
Subtle/occult (sprain)	Partial ligament injury; TMT joints reduced on static imaging; diastasis only apparent on stress or weightbearing views; often misdiagnosed as “midfoot sprain”	Non-weightbearing X-ray: normal or borderline. Standing AP: 1-2mm diastasis between 1st and 2nd metatarsal bases. Fleck sign: avulsion fracture at base of 2nd metatarsal (pathognomonic). MRI confirms partial vs. complete ligament tear	NWB cast 6 weeks if MRI confirms partial tear and TMT joints stable under stress; ORIF if any instability on exam or stress imaging

Lisfranc Injury: Diagnosis Workup, Surgical Indications, and Outcomes

Step	Details
Mechanism and history	Direct: crush injury to midfoot (motor vehicle, heavy object). Indirect: axial load on plantarflexed foot (fall from height, horse-riding stirrup catch, football lineman pile-on, gymnast landing). Low-energy: simple twist or misstep (most common in athletes; these are the subtle injuries most frequently missed). Presentation: immediate midfoot swelling, inability to bear weight, ecchymosis plantar arch (Lisfranc sign — 39% sensitive but highly specific when present)
Imaging protocol	Step 1: standing (weightbearing) AP, lateral, oblique foot X-rays — mandatory; non-weightbearing views routinely miss unstable injuries. Normal alignment: medial border of 2nd metatarsal base aligns with medial border of intermediate cuneiform; medial border of 4th metatarsal base aligns with medial border of cuboid. Diastasis >2mm between 1st-2nd metatarsal bases = positive. Step 2: if X-rays equivocal → CT scan for fracture characterization and pre-op planning. Step 3: MRI for subtle/partial injuries — T2 hyperintensity of Lisfranc ligament confirms tear; assess degree of dorsal ligament involvement
Surgical indications	Any diastasis >2mm on weightbearing X-ray; any TMT joint incongruity; instability on stress examination under anesthesia; complete Lisfranc ligament disruption on MRI with clinical instability; all Myerson Type A, B, C. Relative: subtle injury with partial MRI tear but clinical instability (failed conservative + weight-bearing diastasis). Note: primary arthrodesis vs ORIF is surgeon-dependent — multiple studies show no difference in outcomes for pure ligamentous injuries; primary arthrodesis may reduce reoperation rate
ORIF technique	Lisfranc screw (trans-articular or extra-articular): 3.5mm-4.0mm cortical screw from medial cuneiform to 2nd metatarsal base — provides direct stabilization of the Lisfranc joint. Additional screws or bridge plates for lateral column. Timing: immediate if open injury or vascular compromise; delay 5-10 days if significant swelling (wrinkle sign before incision). Hardware removal at 4-6 months for screw fixation; bridge plates: assess healing before removal decision
Outcomes and complications	ORIF stable injuries: 80-85% return to pre-injury activity; midfoot arthritis develops in 40-50% at 5 years even with anatomic reduction. Primary arthrodesis: similar functional outcomes, lower reoperation rate. Missed/delayed diagnosis: near-universal post-traumatic arthritis, flatfoot deformity, chronic midfoot pain — prognosis significantly worse than timely ORIF. Return to sports: 4-6 months minimum; high-level athletes 6-9 months. Athletes with subtle Lisfranc injuries treated operatively return to sport at higher rates than non-operatively treated

At Balance Foot & Ankle in Howell and Bloomfield Township, any midfoot injury with inability to bear weight is evaluated with standing weightbearing X-rays — the key diagnostic step that identifies Lisfranc diastasis missed on non-weightbearing films — and MRI is obtained for occult injuries when the fleck sign, plantar ecchymosis, or clinical instability suggests Lisfranc involvement despite normal static imaging. Call (810) 206-1402.

More questions patients ask

How common is a Lisfranc ligament injury?

Lisfranc injuries account for 1 in 55,000 Emergency Department visits, but their incidence is likely underestimated — many are misdiagnosed as midfoot sprains. They occur from both high-energy trauma (motor vehicle accidents, falls from height) and low-energy mechanisms (athletic pivoting, missing a step). Low-energy Lisfranc injuries are the most commonly missed, with delays in diagnosis of weeks to months reported in the literature.

What happens if a Lisfranc injury is not treated?

Untreated Lisfranc instability leads to post-traumatic midfoot arthritis, progressive flatfoot deformity (midfoot collapse), and chronic pain. The timing of treatment dramatically affects outcome — surgical stabilization within 6 weeks produces far better results than delayed surgery. Patients treated conservatively for injuries later found to have midfoot instability often require more extensive salvage procedures.

What imaging is needed for a Lisfranc injury?

Weight-bearing X-rays of both feet are the first essential study — comparing the injured and uninjured feet for 1st–2nd intermetatarsal space widening (>2mm is diagnostic). Non-weight-bearing films often appear normal even with complete instability. CT scan provides the best bony injury detail. MRI evaluates the specific ligaments injured. A high index of suspicion with appropriate imaging prevents the diagnostic delays that worsen outcomes.

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