Lisfranc injury
An injury to the midfoot involving disruption of the tarsometatarsal (Lisfranc) joint complex. Ranges from subtle ligament sprains to severe fracture-dislocations. Frequently missed at the first medical assessment, with serious long-term consequences if untreated.
📊 Lisfranc injuries occur in around 1 in 55,000 people per year, but are thought to be significantly under-diagnosed - studies suggest up to 20% are missed at initial presentation. Particularly common in American football, rugby, and equestrian injuries.
What is a Lisfranc injury?
The Lisfranc joint - named after the surgeon Jacques Lisfranc who described it - is the junction between the midfoot bones (cuneiforms and cuboid) and the metatarsals. It is a strong, stable joint held together by an arrangement of bones and very robust ligaments, including the Lisfranc ligament itself between the medial cuneiform and the base of the second metatarsal.
A Lisfranc injury is any disruption of this joint complex. It ranges from subtle ligament sprains (where the bones may appear in good position on initial X-rays) to severe fracture-dislocations with multiple displaced bones. Even subtle injuries are clinically very significant - if not treated correctly, the midfoot arch collapses, leading to chronic pain, deformity, and severe midfoot arthritis.
These injuries are infamous for being missed. Up to 20% are not recognised on the initial X-ray, partly because the imaging is often subtle. Patients are sometimes told they have a sprain and sent home, only to return weeks later with persistent symptoms by which time treatment is much harder. A high index of suspicion is essential for anyone with significant midfoot pain after injury.
Common mechanisms
- Direct crush injury - heavy object falling on the midfoot
- Indirect twisting injury - foot is fixed while the body rotates (common in rugby, American football, equestrian sport)
- Fall with the foot pointed down and the body falling forwards
- Low-energy injuries (e.g. stepping off a kerb with the foot twisted) - particularly in older adults
- Motor vehicle collisions with foot trapped on a pedal
Who is at risk? Risk factors include participation in contact sport, equestrian activity (foot caught in stirrup), and high-energy trauma. Subtle low-energy injuries are also seen, particularly in older adults stepping awkwardly.
Symptoms
Symptoms typically begin at the time of injury and can vary depending on the severity:
- Severe pain in the midfoot after injury, often disproportionate to the apparent severity
- Inability to weight-bear, or marked pain with weight-bearing
- Swelling and bruising over the top of the foot - bruising on the sole of the midfoot is highly suggestive of a Lisfranc injury
- Tenderness directly over the Lisfranc joint
- Pain reproduced by twisting or stressing the midfoot
- Sometimes a visible deformity with widening of the forefoot
When to seek help: Attend A&E on the day of injury. Any patient with significant midfoot pain after a twisting injury should have a Lisfranc injury considered until proven otherwise. Persistent midfoot pain a week after a "sprain" warrants further imaging.
How is it diagnosed?
Your foot and ankle specialist will take a detailed history and examine the foot. The following investigations may be arranged to confirm the diagnosis:
- Weight-bearing X-rays - essential. Non-weight-bearing X-rays can completely miss the injury. Look for widening between the first and second metatarsal bases, or step-off in the joint line
- Comparison X-rays of the uninjured foot - useful for subtle cases
- CT scan - the gold standard for defining fracture patterns and subtle bone fragments
- MRI - shows ligament injury where bones look normal, useful for subtle ligamentous Lisfranc injuries
A "fleck sign" on X-ray - a small bone fragment in the space between the first and second metatarsal bases - is pathognomonic of a Lisfranc ligament avulsion. This finding mandates urgent specialist review, even if everything else looks normal.
Treatment pathway
Treatment depends on the severity of the injury, your age, and your activity demands. Many injuries can be managed without surgery; others require surgical fixation.
Non-weight-bearing cast or boot
In a small minority of cases - a truly stable, undisplaced ligamentous injury confirmed on weight-bearing X-rays and MRI - non-surgical treatment in a non-weight-bearing cast for 6 weeks can be considered. Close monitoring with repeat X-rays is essential.
Open reduction and internal fixation (ORIF)
The vast majority of Lisfranc injuries require surgery to restore the precise anatomy of the joint. Screws, plates, or suture buttons are used to hold the joint reduced. Anatomic reduction (within 2mm) gives the best long-term outcomes.
Primary fusion (arthrodesis)
For severe injuries with significant cartilage damage, or for purely ligamentous injuries, primary fusion of the Lisfranc joints may be preferred over fixation. Outcomes are often comparable, with lower rates of needing further surgery.
Non-weight-bearing, then progressive loading
Strict non-weight-bearing for 6-8 weeks. Progressive weight-bearing in a boot from 8-12 weeks. Screws (if used) are often removed at 3-6 months once the ligaments have healed.
Recovery
Recovery is long even with optimal treatment. Most patients are non-weight-bearing for 6-8 weeks. Walking comfortably typically takes 6-9 months. Return to high-impact sport, where possible, is at 9-12 months. Stiffness in the midfoot is common and is the trade-off for joint stability.
- Non-weight-bearing in cast or boot: 0-8 weeks
- Progressive weight-bearing: 8-12 weeks
- Walking in supportive shoes: 3-4 months
- Removal of metalwork (if planned): 3-6 months
- Walking comfortably: 6-9 months
- Return to sport: 9-12 months
What results can I expect?
Outcomes are highly dependent on the quality of reduction. Anatomic reduction (within 2mm) gives a good outcome in 75-80% of patients. Non-anatomic reduction is the strongest predictor of post-traumatic midfoot arthritis, which affects 40-90% of patients depending on the injury severity. Some patients ultimately need midfoot fusion for arthritis.
In numbers
When can I…?
Typical activity timelines for this condition. These are approximate and vary considerably between patients. Always follow the specific guidance given by your surgeon and physiotherapist.
| Activity | Typical timeline | Notes |
|---|---|---|
| Non-weight-bearing | First 6-8 weeks | Strict non-weight-bearing after surgery is essential. Even subtle Lisfranc injuries treated non-operatively need a period non-weight-bearing.[1] |
| Drive | 3-4 months | Only once out of the boot and walking comfortably. Inform your insurer.[2] |
| Sedentary work | 2-4 weeks | Office work is possible early but access and transport are challenging while non-weight-bearing. |
| Return to walking | 3-4 months | Progressive weight-bearing in a boot from 8-12 weeks, out of boot at 12-16 weeks.[1] |
| Hardware removal | 3-6 months (if planned) | Screws (if used) are often removed at 3-6 months once the ligaments have healed.[1] |
| Return to sport | 9-12 months | Full return to impact sport is slow. Some patients never return fully to high-level impact sport.[1] |
Is this normal?
Common concerns from patients with this condition or recovering from treatment, and whether they are expected or worth mentioning to your team.
Related injuries & conditions
Your questions, answered
Plain-English answers to the things people most often ask, grounded in published guidance. Tap a question to open it.
About thisWhat is a Lisfranc injury?
It is an injury to the midfoot, where the long bones of the toes meet the midfoot bones. It ranges from a ligament sprain to a fracture-dislocation, and it is easy to miss.
Bruising on the sole of the foot after a twist or crush is a clue worth mentioning.
Your choiceWhy does getting the diagnosis right matter?
Missed or under-treated Lisfranc injuries can lead to midfoot arthritis and deformity. Weight-bearing X-rays or a CT scan are often used to assess the injury properly.
If a midfoot injury is not settling as a simple sprain should, ask about this.
Your choiceSurgery or not?
Stable, undisplaced injuries may be treated in a cast. Displaced injuries usually need surgery, either fixation with screws and plates or a fusion of the affected joints.
The aim is an accurately aligned, stable midfoot.
Getting backWhat is recovery like?
Expect a period off the foot, often several weeks non-weight-bearing, then a gradual return to loading. Full recovery is commonly six to twelve months.
Returning to load too early risks losing the correction.
Pain & sleepHow do I manage it early on?
Keep the foot elevated, immobilised and rested, and take simple pain relief until you have been assessed.
Avoid weight-bearing on a suspected Lisfranc injury.
UrgentWhat needs prompt assessment?
Marked midfoot swelling, bruising on the sole, or inability to bear weight after a twist or crush injury should be assessed promptly rather than treated as a minor sprain.
Seek urgent help for cold or numb toes.
References & further reading
- 1.British Orthopaedic Foot & Ankle Society: Lisfranc injury patient information
- 2.Royal College of Surgeons of England: Driving after surgery guidance
References are to UK clinical guidance and patient information from recognised organisations. This page is for general information and does not replace personalised advice from your own clinical team.