- A Lisfranc injury is damage to the midfoot — the area where the long metatarsal bones meet the smaller bones of the arch.
- It ranges from a mild sprain to a complete fracture-dislocation, and the severity isn't always obvious on standard X-rays.
- It's commonly misdiagnosed as a simple sprain.
- Mild sprains heal with bracing and time. Unstable or displaced injuries need surgical fixation.
- Recovery is long: 3–6 months for non-surgical, 6–12 months for surgical cases.
What are a Lisfranc injury?
The Lisfranc joint complex is a row of joints in the middle of the foot that connects the long bones (metatarsals) to the smaller bones (cuneiforms and cuboid). A strong ligament — the Lisfranc ligament — holds the second metatarsal in place and is the keystone of the entire midfoot. When that ligament is torn or the joint is disrupted, the midfoot loses its stability and the arch can collapse.
Lisfranc injuries happen three main ways: high-energy trauma (car accidents, falls), athletic injuries (twisting on a planted foot in football, soccer, ballet), and low-energy injuries (stepping off a curb wrong). The high-energy injuries are usually obvious. The low-energy and athletic injuries are the ones that get missed — patients are told they have a midfoot sprain, given a boot, and discharged. Months later, the arch is collapsing.
At NES, we evaluate every midfoot pain or swelling that doesn't resolve normally for a Lisfranc injury specifically. Standard X-rays miss subtle Lisfranc injuries — we use weight-bearing comparison views or CT/MRI when suspicion is high. Surgery is required for any unstable injury; the consequences of missing one are progressive midfoot arthritis and a permanently painful foot.
See it in motion
Animations licensed from ViewMedica · Swarm Interactive
What it feels like
Symptoms depend on severity but commonly include:
- Pain in the middle of the foot, on the top of the arch
- Significant swelling and bruising on the top of the foot
- Bruising on the BOTTOM of the arch — a classic and easy-to-miss Lisfranc sign
- Inability to bear weight on the foot, or pain with each step
- Widening of the foot when comparing to the uninjured side
- Pain that's not resolving as fast as a typical ankle sprain should
Why it develops
Lisfranc injuries have three typical mechanisms:
- High-energy trauma — motor vehicle crash, fall from height, crush injury
- Twisting injury on a planted foot — football, soccer, basketball, ballet
- Low-energy missteps — stepping off a curb, slipping on a stair
- Foot wedged under a brake pedal during a car accident (classic mechanism)
How we diagnose a Lisfranc injury
Lisfranc injuries demand careful imaging. Standard non-weight-bearing X-rays frequently miss them. Weight-bearing X-rays — and direct comparison to the uninjured foot — reveal subtle widening that confirms instability. CT scan is the gold standard for fracture detail; MRI is helpful for ligamentous-only injuries.
Non-surgical care
Truly stable, non-displaced Lisfranc sprains can be treated non-surgically with strict protocol:
- Strict non-weight-bearing in a cast or boot for 6–8 weeks
- Transition to a walking boot for another 4–6 weeks
- Repeat weight-bearing X-rays at each stage to ensure no late instability
- Custom orthotics with a rigid midfoot support after the boot comes off
- Physical therapy for range of motion and strength
- Return to full activity at 4–6 months, with a gradual return-to-sport progression
Surgical care
Any unstable or displaced Lisfranc injury requires surgery. The two main approaches are open reduction with internal fixation (ORIF) and primary fusion.
- Open reduction and internal fixation (ORIF) with screws or plates — preserves joint motion
- Primary arthrodesis (fusion) — eliminates the joint entirely; lower reoperation rates in selected patients
- Tightrope or suture-button fixation for ligamentous-only injuries
- Hardware removal at 3–6 months for screw fixation cases (controversial — some surgeons leave them in)
Surgical recovery is long: non-weight-bearing in a cast for 6–8 weeks, weight-bearing in a boot for another 6 weeks, transition to shoes and physical therapy at 3 months. Return to running and full sport is typically 6–12 months.
When to see a specialist
- Midfoot pain after any injury — even one that seemed minor
- Bruising on the bottom of the arch (this is a near-pathognomonic sign for Lisfranc)
- A foot injury that's not improving on the expected ankle-sprain timeline
- Inability to bear weight in the middle of the foot
- A previously diagnosed "midfoot sprain" that's still painful weeks later
Lisfranc injuries are treated by Dr. Yama Dehqanzada, Dr. Mia Horvath, and Dr. Thomas Melillo. Dr. Ron Bowman (MD orthopedics) co-manages high-energy fracture cases. Same-day imaging and casting are available at our Cedar Mill and Hoyt offices.