What Causes Lisfranc Injuries and Why They Are Often Missed
- Dr. Chandana Halaharvi
- May 7
- 4 min read
Common Causes of Lisfranc injury
The Lisfranc joint complex is a network of bones, ligaments, and joints in the midfoot that maintains the arch and transfers force during walking and running. It was named after Jacques Lisfranc, a French surgeon who first described injuries to this region in the early 1800s. Despite being essential for normal foot function, this area is poorly understood by many outside the field of foot and ankle care.
Lisfranc injuries occur when the bones or ligaments of the midfoot are disrupted, either through direct trauma such as a crush injury or through indirect mechanisms such as a twisting fall. A classic indirect mechanism involves planting the foot and then rotating the body over a fixed forefoot, which puts enormous rotational stress through the midfoot. This type of injury is common in football players, dancers, and equestrians.
The injury spectrum ranges from mild ligament sprains with no bony displacement to complete fracture-dislocations of the midfoot. Even apparently mild Lisfranc injuries should be treated with the same level of respect as more obviously severe ones, because the midfoot bears significant load and instability here rarely heals without proper management. Underestimating the injury is one of the primary reasons patients experience poor long-term outcomes.
Lisfranc injuries are notoriously difficult to identify on standard weight-bearing X-rays, particularly when displacement is subtle. Up to 20 to 40 percent of Lisfranc injuries are missed on initial presentation in emergency settings, often being labeled as ankle sprains or generalized foot sprains. The midfoot is a region where a high index of clinical suspicion is essential to avoid sending a patient home with an injury that requires urgent treatment.
The most telling clinical sign of a Lisfranc injury is tenderness and swelling localized specifically to the midfoot, particularly over the base of the second metatarsal. Bruising on the sole of the foot is another hallmark sign that, when present, should trigger immediate concern for this diagnosis. Pain with weight-bearing that seems disproportionate to what might be expected from a simple sprain should also raise a red flag.
Signs and Symptoms to Watch For
To improve diagnostic accuracy, weight-bearing X-rays in multiple views are the standard of care when a Lisfranc injury is suspected. In some cases, a comparison view of the uninjured foot helps identify subtle widening of the space between the first and second metatarsal bases, which is a key radiographic sign. MRI or CT scanning may be ordered when X-rays are inconclusive or when the extent of injury needs to be mapped before surgery is considered.
Treatment depends on the severity and stability of the injury. Purely ligamentous Lisfranc injuries with no displacement can sometimes be managed non-operatively with a period of non-weight-bearing in a cast or boot, followed by gradual rehabilitation. However, even a small degree of displacement at the Lisfranc joint generally warrants surgical fixation to restore normal alignment and prevent long-term arthritis.
Whether you live in Sugar Land, Pearland, or anywhere in the greater Houston area, Thrive Foot and Ankle is here to help. Dr. Chandana Halaharvi specializes in Lisfranc injury and takes a personalized approach to every patient's care.
Surgical options for Lisfranc injuries include open reduction and internal fixation using screws, plates, or suture button constructs, as well as primary arthrodesis (fusion) of the affected joints in cases where significant cartilage damage is already present. The choice of technique depends on the injury pattern and the individual patient's anatomy and activity level. Recovery from surgery is measured in months, not weeks, and requires a structured rehabilitation program.
Even with optimal treatment, patients with Lisfranc injuries may develop post-traumatic arthritis of the midfoot joints, particularly if the injury involved significant cartilage damage. Symptoms of arthritis include aching pain with activity, stiffness in the morning, and gradual loss of arch height. Custom orthotics and appropriate footwear can help manage these symptoms and protect the foot from further deterioration.
Athletes who sustain Lisfranc injuries face a prolonged recovery that can sideline them for an entire season. Return to sport is guided by pain-free weight-bearing, strength testing, and functional assessments rather than a fixed calendar timeline. Rushing back before full healing has occurred is one of the most common reasons for re-injury and chronic instability.
Treatment Options at Thrive Foot and Ankle
Children can sustain Lisfranc injuries, though the anatomy differs from adults because growth plates may absorb some of the stress differently. Pediatric cases are even more susceptible to diagnostic errors because growth plates can appear similar to fracture lines on imaging. A podiatrist or foot and ankle specialist with pediatric experience is best positioned to evaluate these injuries in younger patients.
Prevention of Lisfranc injuries in athletes centers on appropriate footwear, sport-specific conditioning, and technique refinement. Stiff-soled cleats and shoes that provide midfoot support reduce the risk of the forefoot twisting independently of the hindfoot. Strength training for the intrinsic muscles of the foot also contributes to overall midfoot stability.
If you have been told you have a foot sprain that is not improving as expected, or if you have persistent midfoot pain after a twisting injury, it is worth requesting a specialist evaluation. A missed or undertreated Lisfranc injury can lead to chronic pain, flatfoot deformity, and long-term disability that is far more difficult to correct after the fact. Getting the right diagnosis early gives you the best chance at a full recovery.
At Thrive Foot and Ankle, we specialize in accurately diagnosing midfoot injuries including Lisfranc injuries that may have been overlooked elsewhere. Book an appointment online to receive a thorough evaluation and a clear path to recovery.
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