A Lisfranc injury (often misspelled as “Liz Frank”) is damage to the ligaments, bones, or both in the middle of the foot, where the long bones leading to the toes connect to the small bones forming the arch. It ranges from a mild ligament sprain to a complete dislocation of the midfoot, and between 20% and 40% of these injuries are initially misdiagnosed as simple sprains. That missed diagnosis matters because untreated Lisfranc injuries can lead to chronic pain, a collapsed arch, and arthritis that may require surgery years later.
The Anatomy Behind the Name
The Lisfranc joint isn’t a single joint. It’s a complex system where the bases of the five long foot bones (metatarsals) meet a row of small, irregularly shaped bones (three cuneiforms and the cuboid) in the midfoot. These bones are arranged in a staggered, arch-like pattern, with the base of the second metatarsal recessed into the row like a keystone in a Roman arch. That recessed position gives the midfoot its structural rigidity.
Holding this architecture together is a web of ligaments on the top, bottom, and between the bones. The most important one, called the Lisfranc ligament, connects the inner cuneiform to the base of the second metatarsal. It’s the largest ligament in this area, roughly 4.5 times bigger than the ligaments on top of the joint and twice as large as those on the bottom. One notable gap in the design: there is no ligament directly connecting the first and second metatarsal bases, which makes the space between them a natural weak point.
Because the ligaments on top are the smallest and weakest, dislocations in this area almost always shift upward (dorsally), pushing the metatarsal bases toward the top of the foot.
How Lisfranc Injuries Happen
There are two broad categories: high-energy and low-energy. High-energy injuries come from car crashes, falls from height, or heavy objects landing on the foot. These crush-type injuries tend to cause fractures alongside ligament tears and carry a higher risk of serious complications like open wounds or damage to blood flow in the foot.
Low-energy injuries are far more common in everyday life and sports. The typical scenario involves an axial force, meaning pressure straight down through the foot, while the foot is pointed downward and slightly rotated. Think of a football player whose foot is planted and bent under them when another player falls across it, or someone catching their foot in a hole while twisting. That pointed-down position weakens the ligaments on top of the foot, leaving the joint vulnerable to rotational forces. This mechanism is common in football, soccer, basketball, and running sports.
Signs You Might Have One
The hallmark symptoms are swelling and pain across the top of the midfoot, especially when pushing off while walking or standing on your toes. The pain is typically worse with weight-bearing, which distinguishes it from many simple sprains that hurt regardless of position.
One of the most telling signs is bruising on the sole of the foot. This plantar bruising is unusual in ordinary ankle or foot sprains and strongly suggests bleeding from damaged structures deep in the midfoot. Not everyone develops it, but when it’s present, it should raise a red flag. You may also notice that the midfoot feels unstable, as if the arch is flattening, or that the space between your big toe and second toe looks wider than normal.
Why These Injuries Get Missed
Somewhere between 20% and 40% of Lisfranc injuries are overlooked or written off as foot sprains during the first medical visit. This happens for a few reasons. On standard X-rays taken while you’re sitting or lying down, the bones may look perfectly aligned because there’s no load on them. It’s only when you stand on the injured foot that the damaged ligaments fail to hold the bones in place, and the telltale gap between the first and second metatarsal bases appears.
Weight-bearing X-rays are the key diagnostic tool. On these standing films, doctors measure the gap between the inner cuneiform and the second metatarsal base, and also look at whether the second metatarsal has shifted relative to the middle cuneiform. In injured patients, these measurements are significantly larger than in healthy feet, with an average difference of roughly 3 mm for the gap and 2 mm for the shift. A small bone fragment visible between the first and second metatarsal bases, known as the “fleck sign,” is another strong indicator. It represents a chip pulled off by the Lisfranc ligament as it tears, and its presence confirms instability. CT scans and MRIs are sometimes used for subtle injuries that don’t show clearly on X-rays.
Non-Surgical Treatment
If the bones remain well-aligned on weight-bearing X-rays, meaning the ligament is sprained but not completely torn, the injury can often be treated without surgery. This typically involves a period in a non-weight-bearing cast or boot, followed by a gradual return to walking. Athletes with these milder (Grade I) injuries have returned to sport in 11 to 18 weeks with excellent outcomes using this conservative approach.
The catch is that “well-aligned” needs to be confirmed under load. If initial X-rays look fine but symptoms persist, repeat weight-bearing films or advanced imaging should follow. A ligament that appears intact without body weight on it may be completely incompetent once you stand.
When Surgery Is Needed
Any displacement of the bones on weight-bearing X-rays, or a complete ligament tear confirmed on MRI, typically requires surgical repair. Two main approaches exist: fixation with screws or plates to hold the bones in place while ligaments heal, and fusion (arthrodesis), where the damaged joint surfaces are permanently joined together.
A meta-analysis comparing these two approaches found no significant difference in complication rates or the quality of bone alignment achieved. However, fusion produced better functional scores, higher return-to-activity rates, less postoperative pain, and a lower chance of needing a second surgery to remove hardware. For injuries involving primarily ligament damage (rather than fractures through the joint surface), fusion has become increasingly favored because ligaments in this area heal poorly even when held in position by screws.
Athletes with moderate injuries treated surgically have returned to play in 12 to 20 weeks. Severe dislocations or injuries involving multiple columns of the midfoot are typically season-ending and carry a significantly longer recovery.
What Recovery Looks Like
After surgery, the typical protocol starts with about 8 weeks of no weight on the foot at all, using crutches full-time. Around the 8-week mark, you transition into a walking boot while still relying on crutches, and full unsupported walking usually begins around 14 weeks after surgery.
Physical therapy often starts around 15 weeks post-surgery. Early goals include regaining range of motion and calf strength. A milestone like performing a single-leg heel raise without pain can take about 3 weeks of therapy to achieve. From there, progression moves through straight-line jogging, then lateral drills and cutting movements, then sport-specific conditioning. In one documented case of a high school football player, this progression took roughly 10 weeks of therapy before he could join team conditioning, and he was cleared for full practice about 8 months after surgery.
Long-Term Outlook
The most common long-term complication is arthritis in the midfoot. In one study following patients for an average of 6 years after surgical repair, about 10.5% developed post-traumatic arthritis with visible joint changes on X-rays. Other potential issues include chronic pain and gradual flattening of the arch.
The single biggest predictor of a poor long-term outcome is whether the bones were restored to their exact anatomic position. A large retrospective study found that non-anatomic reduction, meaning the bones healed even slightly out of place, was a significant risk factor for developing osteoarthritis. This is why accurate diagnosis and proper initial treatment matter so much, and why a missed or undertreated Lisfranc injury carries consequences that may not surface for years.