Lisfranc Injury Years Later: Post-Traumatic Arthritis

A Lisfranc injury can leave a lasting mark on your foot and your daily life, even a decade or more after treatment. Post-traumatic arthritis is the most common long-term complication, though how much it bothers you varies widely from person to person. Some people walk away with near-normal function; others deal with chronic midfoot pain, a stiffer gait, and limits on what their foot can handle. The story of what happens years later depends on several factors, from how severe the original injury was to what type of surgery you had and whether the initial alignment was restored properly.

Post-Traumatic Arthritis Is the Headline Problem

If there is one issue that defines life after a Lisfranc injury, it is arthritis in the midfoot. The tarsometatarsal joints absorb enormous forces during walking, running, and pushing off, and once they have been disrupted, the cartilage tends to wear down over time. A study that followed 32 patients for an average of 14 years found that post-traumatic arthritis was the most common complication, but it also found something reassuring: not all patients who develop arthritic changes on X-rays actually have symptoms.¹ In other words, an X-ray that looks rough does not always mean a foot that feels rough.

That said, the quality of the initial surgical repair matters enormously. Research in a military population reinforced that anatomic reduction at the time of surgery is the single most important predictor of long-term outcome, and that when post-traumatic arthritis does develop significantly, it tends to bring poor functional results in highly active people.² If the bones were not put back in their correct position initially, or if they shifted after surgery, the odds of meaningful arthritis climb.

How commonly does arthritis show up? A systematic review of non-operatively managed injuries found rates of secondary osteoarthritis ranging from about 5% to 38%, depending on the study and the severity of the original injury.³ That is a wide range, but it reflects the reality that Lisfranc injuries exist on a spectrum from subtle sprains to severe fracture-dislocations, and your long-term arthritis risk tracks closely with where your injury fell on that spectrum.

How Your Gait Changes Over Time

Even when pain is manageable, the biomechanics of your foot often shift in ways you may not consciously notice. Gait analysis studies consistently show that people treated for Lisfranc injuries walk more slowly than uninjured individuals and have reduced range of motion in the midfoot during the push-off phase of walking.⁴ That push-off phase is when the midfoot bears peak stress, and the stiffness left behind by the injury or surgery limits how efficiently the foot can transfer energy.

The effects do not stop at the midfoot. Research looking at joints above the injury site found that ankle power generation was reduced on the injured side, and the knee joint on that side absorbed less force too, suggesting that the entire leg adjusts its movement pattern to compensate for a stiff or painful midfoot.⁵ If you have ever felt like your injured foot “just doesn’t push off the same” or that your opposite hip or knee takes extra strain, this compensatory pattern is likely why.

Plantar pressure testing tells a similar story. Compared to healthy feet, the injured side typically shows reduced peak pressure under the midfoot and under the second metatarsal head during walking.⁶ One study found that these pressure changes are present on both the injured and the uninjured foot, which suggests the body is reorganizing how it distributes load across both legs rather than just protecting the hurt side.⁷

What the Functional Scores Actually Show

Patient-reported outcome scores give a useful snapshot of where people end up years down the road. At a mean follow-up of about six years after open reduction and internal fixation, one cohort had an average physical function score near the population norm and a foot-and-ankle function score around 77 out of 100.⁸ Those numbers paint a picture of satisfactory but not perfect recovery, and there is significant spread between individuals. A separate case series found substantial variability in outcomes, with mental health scores tending to hold steady while physical function scores varied widely between patients.⁹

The takeaway is that most people reach a functional level where they can handle daily life, but a meaningful minority continue to deal with pain and limitations that affect how they exercise, work, and move. The variation is partly explained by injury severity, surgical quality, and individual healing, but some of it remains frustratingly unpredictable.

The Hardware Question

If you had open reduction and internal fixation with screws or plates, the question of whether that hardware should come out is one you will probably face. There are three broad approaches: routine removal for everyone, removal only when the hardware causes symptoms, and leaving it in permanently. A multicenter study comparing all three found no significant difference in midfoot functional scores at final follow-up, with median scores in the low-to-mid 90s across all three groups.¹⁰ The conclusion was that routine removal is not necessary and that selective removal based on individual symptoms minimizes complications.

A separate study, however, found that patients who did have hardware removed showed a modest but statistically significant improvement in physical function and pain interference scores compared to those who kept their hardware in.¹¹ The disagreement between studies probably reflects the fact that hardware bothers some people more than others. If your screws are causing localized tenderness or limiting midfoot motion, removal is likely worth it. If the hardware is not bothering you, the evidence suggests you can safely leave it alone.

When the First Surgery Fails

A question that looms for people still in pain years later is whether a salvage fusion surgery will be needed. The largest ORIF-specific study to date found that conversion to arthrodesis was uncommon: about 2.7% of patients at five years and 2.8% at ten years.¹² That is reassuring, because it means the vast majority of initial fixation surgeries hold up over the long term without requiring fusion.

When salvage arthrodesis is needed, however, the outcomes are generally worse than when fusion is done as the primary procedure. A study comparing primary and secondary arthrodesis found that patients who needed a salvage fusion were significantly more likely to have a poor or severe outcome, with substantially higher pain and lower physical function at final follow-up. The injury pattern also mattered: divergent injuries (where the metatarsals splay in opposite directions) had nearly seven times the odds of needing a secondary fusion compared to injuries where the bones displaced in the same direction.¹³

Fixation Versus Fusion as the Initial Surgery

The debate over whether to fix the bones in place with screws (ORIF) or fuse the joints from the start (primary arthrodesis) is one of the more contentious topics in foot surgery, and it directly affects your long-term outlook. A meta-analysis found that ORIF led to much higher rates of hardware removal, but the two approaches showed no significant difference in patient-reported outcomes or rates of other revision surgery.¹⁴

A more recent systematic review and meta-analysis did find a statistically significant advantage for primary arthrodesis on patient-reported outcome scores, but the authors cautioned that the difference may not be clinically meaningful and that a definitive answer requires a large, high-quality randomized trial.¹⁵ In practice, the choice often depends on the injury pattern. Purely ligamentous injuries with no bone fractures may benefit more from primary fusion because ligament-only injuries are prone to losing their alignment over time. Injuries with large bony fragments that can be precisely reduced may do just as well with fixation that preserves midfoot motion.

Mild Injuries Treated Without Surgery

Not every Lisfranc injury goes to the operating room. Stable, non-displaced injuries are often treated with casting or a walking boot and physical therapy. The long-term picture for these milder injuries is generally encouraging, but not risk-free. A prospective study of stable Lisfranc injuries found that median functional scores continued to improve beyond the one-year mark, reaching the maximum possible score by final follow-up, with median pain levels at zero.¹⁶

A larger retrospective series of 55 patients told a more nuanced story. About two-thirds scored well on pain and function measures, but roughly 7% ended up with poor scores below 60 out of 100.¹⁷ And a systematic review of non-operative outcomes raised a warning flag: one included study found late displacement in over half of patients initially managed without surgery, and surgical intervention rates across studies were as high as 56%.¹⁸ The lesson is that truly stable injuries do well without surgery, but injuries that initially appear stable sometimes shift over time, and close follow-up with repeat imaging is essential.

Returning to Sport and High-Level Activity

For athletes, the question is not just whether they can walk comfortably but whether they can compete at their previous level. The answer is mixed. A study of NFL players found that over 90% returned to play at a median of about 11 months, and the decrease in performance afterward did not reach statistical significance compared to matched controls.¹⁹ That sounds encouraging, but a separate analysis of NFL athletes found a different picture: while 83% returned to play, they started significantly fewer games in the second and third seasons after surgery, and offensive players experienced a roughly 21% decline in statistical performance one season after returning.²⁰

At the recreational level, a case series of athletes treated surgically found that 80% returned to sport at an average of about 29 weeks, rating themselves at roughly 87% of their pre-injury level. However, two-thirds still had occasional pain during activity, with average pain hovering around 2 out of 10.²¹ So while most athletes can get back on the field, a low-grade discomfort during high-impact activities seems to be a common feature of life after a Lisfranc injury, even when functional recovery goes well.

The Occupational Toll

High physical demands do not just apply to athletes. Military service members, construction workers, and others whose jobs involve prolonged standing, running, or carrying heavy loads face real career consequences. A study of military service members found that at an average follow-up of three and a half years after surgical treatment, 20% had been medically separated from service because of limitations from their injury.²² Another study focused on workplace outcomes found that 13 patients had a poor outcome severe enough that they had to change jobs or were unable to find work solely because of their Lisfranc injury.²³

These numbers underscore something that does not always come through in clinical outcome scores: even when a foot scores “satisfactory” on a functional scale, it may not be satisfactory for the specific demands of your life. Preoperative counseling about the realistic possibility of long-term limitations is something the research explicitly recommends.

What Happens When the Injury Was Missed

Lisfranc injuries are famously easy to miss on initial evaluation, especially when they are purely ligamentous and do not show obvious fractures on standard X-rays. A delayed or missed diagnosis generally leads to worse long-term outcomes, including chronic pain, midfoot arthritis, and significant functional disability.²⁴ If the bones are allowed to sit out of alignment for weeks or months before anyone recognizes what happened, the window for a clean surgical reduction narrows, and the odds of needing a salvage fusion go up.

Weight-bearing CT scans have become an increasingly valuable tool for detecting chronic instability or subtle displacement that standard X-rays miss. Research has shown that injured Lisfranc ligament complexes produce measurable increases in the space between the first and second metatarsal bases and between the second metatarsal and the medial cuneiform compared to the uninjured side.²⁵ If you are years out from an injury that was never properly diagnosed and you still have midfoot pain, a weight-bearing CT can help determine whether subtle joint widening or instability is the culprit.

Managing Chronic Symptoms Without More Surgery

For people dealing with ongoing discomfort years after a Lisfranc injury who are not candidates for or do not want additional surgery, conservative management options do exist. Orthopaedic shoes and custom foot orthoses can meaningfully improve gait stability. A study of patients with chronic foot and ankle injuries found that orthopaedic shoes improved local dynamic stability across all three movement axes and reduced pain scores by about 29%.²⁶

Carbon-fiber footplates and stiff-soled shoes reduce the demand on the midfoot during push-off by transferring force more directly through the sole. Custom molded orthoses with arch support can redistribute plantar pressures away from painful areas. Physical therapy focusing on proprioceptive retraining, intrinsic foot muscle strengthening, and gait pattern correction also plays a role. A case report on conservative management of a subtle Lisfranc injury highlighted the importance of restoring a normal gait pattern to prevent chronic overstress of injured tissues, along with appropriate orthotic prescription and proprioceptive retraining.²⁷

Ligamentous Versus Bony Injuries and What It Means Long-Term

The type of tissue damaged in the original injury influences the trajectory years later. Purely ligamentous Lisfranc injuries, where the bones themselves are intact but the connecting ligaments are torn, tend to be trickier. Ligaments heal with scar tissue that is less mechanically robust than the original structure, making the joint more prone to gradual displacement over time. A study tracking both ligamentous and bony injuries found loss of reduction in both groups and varying degrees of arthritis in both, with each group requiring one secondary fusion.²⁸ While the numbers were small and the rates similar, the clinical community generally views purely ligamentous injuries as carrying a higher risk of chronic instability.

This distinction matters practically because it affects the surgical decision. When there is a bony component, fracture healing can restore structural stability in a way that ligament healing often cannot. That is one reason some surgeons lean toward primary fusion for purely ligamentous injuries, particularly when the patient has high physical demands. If you are years out and struggling with a ligamentous Lisfranc injury that was initially fixed with screws, the instability pattern may look different on weight-bearing imaging than it did on the non-weight-bearing films taken in the operating room, and that difference can guide decisions about whether a salvage fusion would help.

Midfoot Arthritis Beyond Trauma

It is worth noting that midfoot arthritis is not exclusively a post-traumatic phenomenon. Primary osteoarthritis, inflammatory arthritis, and neuropathic joint disease can all affect the tarsometatarsal joints independently of any injury.²⁹ If you had a Lisfranc injury years ago and now have worsening midfoot pain, it is easy to assume the old injury is the sole cause. But particularly if the pain pattern has changed or spread to joints that were not involved in the original injury, it is worth considering whether something else is contributing. Inflammatory conditions like rheumatoid arthritis or gout can layer on top of post-traumatic damage, and addressing them requires a different treatment approach. A thorough workup that includes bloodwork and updated imaging can tease apart how much of the current problem traces to the old Lisfranc injury and how much is new territory.