The Midfoot Injury That Gets Missed: Lisfranc Explained
In This Guide
In Short
A Lisfranc injury damages the ligaments and joints in the middle of the foot. It is routinely mistaken for a simple sprain when it is first seen, and a normal-looking X-ray is a large part of why.
- It is routinely mistaken for a sprain. It is often called a “midfoot sprain” at first, and a normal-looking X-ray is a large part of why.
- Bruising in the arch is the giveaway. Bruising on the underside of the midfoot after a twisting injury is a strong sign and should never be brushed off.
- An X-ray taken lying down can look normal. Research on Lisfranc imaging has shown that taking the X-ray while standing on the foot makes subtle injuries much easier to spot, because the looseness in the joint only shows up when the foot takes your weight.
- This is where weight-bearing CT earns its place. Taken while you stand, it picks up subtle Lisfranc injuries more reliably than an ordinary CT, precisely because it looks at the joint while it is taking your weight.
- Missing it matters. If a loose Lisfranc joint is left untreated, the middle of the foot gradually flattens and the joints wear out. Treating it late is considerably harder than treating it early.
- Treatment has moved on. As well as screws and fusion, there is now a flexible form of fixation for injuries where only the ligaments are damaged. Early results are encouraging, though the evidence behind it is still limited.
What the Lisfranc Joint Is
The Lisfranc joint complex is where the long bones of the forefoot meet the smaller bones of the midfoot. It is held together by a set of ligaments, the most important of which runs across the underside of the foot, linking one of the midfoot bones to the base of the long bone behind the second toe.
That long bone sits wedged into a bony notch, like the keystone at the top of an arch. That arrangement is what makes the middle of the foot stiff enough to push off from. It also means that if the keystone and its ligaments are damaged, the whole arch loses its support — and it gives way when you stand on it, which is when it matters.
The joint is named after Jacques Lisfranc de St Martin, a Napoleonic field surgeon.
How It Happens
It happens in two very different ways, which is part of why it gets missed.
- High-energy injuries — road traffic collisions, falls from height, crush injuries. These are usually obvious: the foot is swollen, deformed and clearly badly injured. Nobody misses these.
- Low-energy injuries — and these are the problem. A twist on a planted foot, a stumble off a kerb, a footballer stepping on someone else’s foot, a fall on a foot pointed downwards, a misstep on stairs. The foot swells, the person limps, and the injury looks and feels like a sprain.
Low-energy Lisfranc injuries are common in football, rugby, running and dance, and in ordinary trips and stumbles.
The Signs That Should Prompt a Rethink
If you have any of these after a foot injury, it is worth questioning a diagnosis of “sprain”:
- Bruising on the sole of the foot, in the arch — this is the classic sign (doctors call it plantar ecchymosis) and it is rarely there with a simple sprain
- Pain in the middle of the foot, not the ankle, particularly across the top
- Not being able to put weight on the foot, or pain when pushing off, days after the injury
- Swelling across the top of the midfoot that is not settling as expected
- Pain when the front of the foot is twisted against the heel, or when someone presses across the foot just behind the toes
- A gap or widening between the first and second toes when standing
- Symptoms not improving after two to three weeks, when a sprain should be settling
That last one is the practical one. Ankle sprains follow a predictable improving curve. A midfoot injury that is no better at three weeks is not behaving like a sprain, and that alone warrants reassessment.
Why the X-ray Can Look Normal
This is the heart of the problem. A standard foot X-ray is taken lying down or sitting, with no weight through the foot. A subtle Lisfranc injury may be perfectly reduced in that position — the bones sit where they should, the spaces look normal, the report says no fracture — and only separate when the foot takes body weight.
A review of thirty studies on Lisfranc imaging compared the different scans available:
- Ordinary X-rays show up obvious separation, and standing on the foot for the X-ray makes subtle injuries easier to see
- CT picks up small cracks in the bone, and slight shifts in the joint, better than ordinary X-rays
- MRI is best for showing whether the ligament itself is torn
- Ultrasound can show the ligament on the top of the foot, but it is not reliable for telling whether the joint is loose
The key difference is between a ligament that is torn and a joint that has become loose. MRI answers the first question well. It is less good at the second — and the second is what decides whether you need an operation.
Where Weight-Bearing CT Comes In
This is one of the clearest uses anywhere in the foot for a three-dimensional scan taken while you stand.
A review comparing weight-bearing CT with ordinary CT for Lisfranc injuries found that the weight-bearing scan measures the area more accurately and shows up smaller changes in the joint. It was better at telling healthy joints from injured ones, particularly where the ligament on the top of the foot was damaged, and could pick up small but meaningful differences — such as the width of the gap between the bones behind the first and second toes.
The reason is simply that it looks at the injury while the foot is taking your weight. Both feet can be scanned at the same time, so your uninjured foot gives a direct comparison — which matters enormously when the difference is only a millimetre or two.
If you have been told you have a midfoot sprain, your X-rays were normal, and you are not improving, this is the investigation to ask about.
Treatment
Stable injuries. Where careful assessment shows the joint is genuinely stable — the ligament is sprained but the joint does not separate when you stand on it — no operation is needed: a boot, limited weight through the foot at first, and a gradual return to normal over roughly six to twelve weeks, with a repeat standing scan to confirm nothing has shifted.
That repeat imaging matters. Some injuries that look stable at first turn out not to be, and finding that at four weeks is far better than at four months.
Unstable injuries. If the joint separates when you stand on it, it needs holding in place with an operation. There are three broad approaches, and the evidence genuinely does not yet tell us which is best.
Open Reduction and Internal Fixation (ORIF)
Realigning the joint and holding it with screws or plates. This is the long-established approach.
The screws or plates are often taken out later, which means a second, smaller operation for many people.
Primary Fusion (Arthrodesis)
Permanently joining the affected joints together from the start. Studies comparing this with screws and plates have reached conflicting conclusions.
- Consistently needs less metalwork taken out afterwards
- No difference in further surgery, realignment, infection, overall complications or patient satisfaction
- Disagreement centres on return to activity and function scores, where the evidence is not strong enough to settle it either way
Flexible Fixation
A strong stitch-and-button device that holds the joint but still allows it to move a little, avoiding both rigid screws and fusion.
A 2024 review of 25 studies covering 500 patients whose injuries involved the ligaments only reported better function, more people getting back to activity, and fewer complications and operations to remove metalwork, compared with screws and plates. The authors were clear that this came from low-quality studies, most of which did not compare the two approaches head to head, and that better studies are needed.
A fair summary: if the joint is unstable but only the ligaments are damaged, all three are reasonable choices. Flexible fixation looks promising and avoids a second operation to remove metalwork, but it has not yet been properly compared with the alternatives. Where the surfaces of the joint are badly damaged, fusion is often the more sensible choice from the start.
Recovery
Realistic expectations matter here, because this is a longer recovery than most people anticipate for what was called a sprain.
| Stage | Typical Timing |
|---|---|
| No weight, or limited weight, through the foot | 6–8 weeks |
| In a boot | 8–12 weeks |
| Into a stiff-soled shoe | 3 months |
| Driving | Around 3 months for a right foot |
| Desk work | 2–6 weeks with elevation |
| Manual or standing work | 4–6 months |
| Return to running | 5–8 months |
| Return to pivoting sport | 9–12 months |
| Full benefit | 12 months or more |
A stiff-soled shoe or a carbon insole is often needed for a long period afterwards, and some permanent midfoot stiffness is common.
What Happens If It Is Missed
This is the reason the diagnosis matters so much more than the label suggests.
An unstable Lisfranc injury left untreated does not simply hurt for longer. The arch gradually flattens, the front of the foot drifts outwards and the joints wear out — causing arthritis in the middle of the foot, often in someone in their thirties or forties.
Treating that late is considerably harder than treating it early. Instead of realigning and stabilising a joint that can still be put back into position, it usually means fusing one that has become stiff, worn and misshapen — with a longer recovery and a less predictable result.
If you have a midfoot injury that has not settled, it is worth having properly assessed — even months later, and even if you have been told the X-rays were normal.
Frequently Asked Questions
What is a Lisfranc injury?
An injury to the ligaments and joints in the middle of the foot, where the long bones behind the toes meet the smaller midfoot bones. It ranges from a sprained ligament to bones that have broken and come out of position.
How is it different from a sprained foot?
A simple sprain settles steadily over a few weeks. A Lisfranc injury tends not to, and is often accompanied by bruising in the arch of the foot, pain across the top of the midfoot, and difficulty pushing off.
What does bruising in the arch of my foot mean?
Bruising on the sole of the midfoot after a twisting injury is the classic sign of a Lisfranc injury. It is uncommon in a simple sprain and should always prompt proper assessment.
Why did my X-ray look normal?
Standard X-rays are taken with no weight through the foot, and a subtle Lisfranc injury can look entirely normal that way, only separating when you stand on it. X-rays and CT scans taken while you stand are far better at picking up subtle looseness in the joint.
Do I need an MRI?
MRI is excellent for showing whether the ligament is torn, but less good at showing whether the joint has become loose — and it is the looseness that decides the treatment. A scan taken while you stand usually answers that question better.
Does every Lisfranc injury need surgery?
No. Genuinely stable injuries are treated in a boot, with limited weight through the foot and a repeat scan to confirm nothing shifts. Unstable injuries need an operation to hold the joint in place.
Screws, fusion or flexible fixation — which is best?
The evidence does not yet give a clear answer. Studies comparing screws with fusion disagree with each other, and mainly agree only that fusion is less likely to need metalwork taken out later. Flexible fixation shows promising early results where only the ligaments are damaged, but the evidence behind it is still weak.
How long is the recovery?
Longer than most people expect: typically six to eight weeks protected, three months before comfortable shoe wear, five to eight months before running, and nine to twelve months before pivoting sport.
Can it be treated if it was missed months ago?
Yes, though the options change. Once arthritis has set in and the shape of the foot has altered, treatment usually means fusing the joint rather than simply holding it in place. It is still worth having it assessed — a late diagnosis is far better than none.
Speak to a Specialist
A midfoot injury that is not settling after a few weeks deserves a proper look, particularly if the initial X-rays were reported as normal. That is exactly the situation in which a subtle, unstable Lisfranc injury turns up — and the point at which treatment is still straightforward.
Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital, Stanmore, and Honorary Associate Clinical Professor at UCL. He has a particular interest in sports injuries of the foot and ankle and in weight-bearing CT, which is a useful scan for picking up subtle looseness in the middle of the foot. He sees patients across North and Central London.
Or email secretary@matthewwelck.com. Urgent same-day appointments are offered where possible.
References
- Sripanich Y, Weinberg MW, Krähenbühl N, et al. Imaging in Lisfranc injury: a systematic literature review. Skeletal Radiol. 2020;49(1):31–53. doi:10.1007/s00256-019-03282-1
- Talaski GM, Baumann AN, Walley KC, Anastasio AT, de Cesar Netto C. Weightbearing Computed Tomography vs Conventional Tomography for Examination of Varying Degrees of Lisfranc Injuries: A Systematic Review of the Literature. Foot Ankle Orthop. 2023;8(4):24730114231209767. doi:10.1177/24730114231209767
- O’Connor KP, Olfson ER, Riehl JT. Flexible fixation versus open reduction internal fixation and primary arthrodesis for ligamentous Lisfranc injuries: A systematic review and meta-analysis. Foot (Edinb). 2024;61:102145. doi:10.1016/j.foot.2024.102145
- Peters W, Panchbhavi V. Primary Arthrodesis Versus Open Reduction and Internal Fixation Outcomes for Lisfranc Injuries: An Analysis of Conflicting Meta-analyses Results. Foot Ankle Spec. 2022;15(2):171–178. doi:10.1177/1938640020971417
- Han PF, Zhang ZL, Chen CL, Han YC, Wei XC, Li PC. Comparison of primary arthrodesis versus open reduction with internal fixation for Lisfranc injuries: Systematic review and meta-analysis. J Postgrad Med. 2019;65(2):93–100. doi:10.4103/jpgm.JPGM_414_18
Study data above retrieved via PubMed.
This article is provided for general information and patient education only. It is not a substitute for individual medical assessment, diagnosis or treatment by a qualified healthcare professional.