Understanding Lisfranc Complex Injuries: A Comprehensive Guide
A Lisfranc (midfoot) injury involves damage to the bones or ligaments of the midfoot, which connects the forefoot to the hindfoot. These injuries range from mild sprains to severe fracture dislocations that destabilize the arch. Named after French surgeon Jacques Lisfranc de St. Martin, who first described such injuries in cavalry soldiers, Lisfranc injuries are often serious and can be mistaken for a simple sprain. Without proper diagnosis and treatment, they can lead to chronic pain, arthritis, and permanent deformity.
How Common It Is and Who Gets It? (Epidemiology)
Lisfranc injuries are relatively uncommon but can occur in both athletes and non-athletes. They often result from twisting injuries, sports collisions, or high-energy trauma such as car accidents or falls. Athletes in football, soccer, and basketball are at particular risk due to quick direction changes and high impact. These injuries are most common in younger, active adults.
Why It Happens – Causes (Etiology and Pathophysiology)
A Lisfranc injury occurs when the midfoot experiences excessive force or twisting, causing the ligaments that support the arch to stretch or tear. The injury may also involve bone fractures.
Common causes include:
- A twisting fall or misstep, such as stumbling with the foot flexed downward
- Sports injuries when another player lands on the back of the foot
- Direct trauma, such as a car accident or heavy object dropping on the foot
- High-energy crush injuries involving multiple joints
When these forces disrupt the Lisfranc ligament, which stabilizes the connection between the medial cuneiform and the second metatarsal base, the entire midfoot can become unstable.
How the Body Part Normally Works? (Relevant Anatomy)
The midfoot is formed by several small bones — the cuneiforms, cuboid, and bases of the five metatarsals — that create the foot’s arch. These bones are connected by strong ligaments collectively known as the Lisfranc joint complex, which stabilizes the arch and transfers weight from the calf muscles to the forefoot during walking. Damage to these joints or ligaments disrupts the alignment of the foot and can lead to arch collapse if untreated.
What You Might Feel – Symptoms (Clinical Presentation)
Common symptoms of a Lisfranc injury include:
- Pain and swelling in the middle of the foot
- Bruising on both the top and bottom of the foot (plantar bruising is a hallmark sign)
- Inability to bear weight or severe pain when standing or walking
- Pain that worsens with pushing off the affected foot
Even a mild Lisfranc injury is more serious than a sprain and should not be ignored.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis begins with a physical exam and a review of symptoms.
Typical findings include:
- Tenderness across the midfoot
- Pain during stress testing (twisting or pressing the forefoot)
- Pain with a “piano key” test, in which the toes are gently moved up and down
Imaging tests include:
- Weight-bearing X-rays to detect subtle widening or misalignment between the first and second metatarsals
- CT scans to identify fractures and joint involvement
- MRI to evaluate ligament injuries when X-rays are inconclusive.
Classification
Lisfranc injuries are classified by the direction of displacement and involvement of bone or ligament damage:
- Homolateral: All metatarsals shift in the same direction
- Divergent: Metatarsals shift in opposite directions
Injuries may also be described as ligamentous (soft tissue only), bony (with fractures), or combined. The classification helps guide treatment and predict recovery.
Other Problems That Can Feel Similar (Differential Diagnosis)
Conditions that can mimic Lisfranc injuries include:
- Plantar fasciitis
- Metatarsal stress fracture
- Peripheral neuropathy
- Lumbosacral nerve compression (radiculopathy)
Accurate imaging and examination are essential to distinguish Lisfranc injuries from other midfoot conditions.
Treatment Options
Non-Surgical Care
If the bones are properly aligned and the ligaments are not completely torn, non-surgical treatment may be sufficient.
This includes:
- Immobilization in a non-weight-bearing cast or boot for 6 to 8 weeks
- Gradual transition to partial weight-bearing in a removable boot or orthotic
- Regular X-rays to ensure proper healing
If the bones shift during recovery, surgery may be required.
Surgical Care
Surgery is necessary for displaced fractures or unstable joint alignment. The goal is to realign and stabilize the midfoot for healing.
Surgical options include:
- Open Reduction and Internal Fixation (ORIF): The bones are repositioned and held with screws or plates. Hardware may later be removed after healing.
- Primary Arthrodesis (Fusion): For severe injuries or extensive joint damage, fusion eliminates motion between affected bones, restoring stability and reducing future arthritis risk.
Recovery and What to Expect After Treatment
After surgery, patients typically wear a cast or boot for six to eight weeks without weight-bearing. Physical therapy begins gradually after X-rays confirm healing.
Recovery milestones include:
- Partial weight-bearing after 6–8 weeks
- Return to regular shoes around 3 months
- Full recovery and activity by 6 to 12 months, depending on injury severity
Some lingering stiffness or swelling may persist for several months.
Possible Risks or Side Effects (Complications)
Complications can include:
- Infection or wound healing problems
- Nerve irritation or sensitivity
- Hardware fatigue or breakage (which may require removal)
- Post-traumatic arthritis, even after successful surgery
- Residual stiffness or chronic pain
Long-Term Outlook (Prognosis)
Most patients recover well, particularly when treated early and properly. Stable, non-displaced injuries treated conservatively often heal completely. However, arthritis can develop in the midfoot over time, even after successful surgery. Early intervention provides the best chance of maintaining function and preventing long-term deformity.
Out-of-Pocket Costs
Medicare
CPT Code 28615 – Open Reduction and Internal Fixation (ORIF): $194.89
CPT Code 28730 – Primary Arthrodesis (Fusion): $169.33
Medicare Part B typically covers 80% of the approved cost after the annual deductible. Supplemental insurance plans such as Medigap, AARP, or Blue Cross Blue Shield often cover this remaining 20%, leaving patients with little or no out-of-pocket expenses.
Secondary insurance (TRICARE, employer-based plans, or Veterans Health Administration) may cover any remaining costs once Medicare has processed the claim, typically leaving only a small deductible to be paid by the patient.
Workers’ Compensation
If your Lisfranc injury is work-related, Workers’ Compensation will pay for all surgery, hospital care, and rehabilitation, leaving you with no out-of-pocket costs.
No-Fault Insurance
If the injury resulted from a car accident, No-Fault insurance will generally cover the full cost of surgery and rehabilitation, subject only to minor deductibles or co-payments depending on your policy.
Example
John Adams suffered a Lisfranc fracture and required open reduction and internal fixation (CPT 28615) and primary arthrodesis (CPT 28730). His estimated out-of-pocket cost under Medicare was $194.89. With supplemental insurance through Medigap, the remaining balance was covered, leaving John with no out-of-pocket expenses.
Frequently Asked Questions (FAQ)
Q. What is a Lisfranc injury?
A. A Lisfranc injury involves damage to the midfoot, affecting the joints and ligaments that stabilize the arch of the foot.
Q. How do Lisfranc injuries occur?
A. Lisfranc injuries typically occur from twisting injuries, falls, or direct trauma to the foot, such as a heavy object dropping on it or a motor vehicle accident.
Q. What are the symptoms of a Lisfranc injury?
A. Symptoms include pain in the midfoot, swelling, inability to bear weight, bruising on the bottom of the foot, and sometimes visible deformity.
Q. How is a Lisfranc injury diagnosed?
A. Diagnosis involves a physical examination, X-rays, and possibly advanced imaging like MRI or CT scans to assess the extent of the injury.
Q. Why is it important not to miss a Lisfranc injury?
A. Missing a Lisfranc injury can lead to chronic pain, deformity, and arthritis, significantly affecting foot function.
Q. What nonsurgical treatments are available for Lisfranc injuries?
A. Nonsurgical treatment options may include immobilization with a cast or boot and non-weight-bearing for six to eight weeks if there is no displacement.
Q. When is surgery recommended for Lisfranc injuries?
A. Surgery is recommended when there is displacement or instability in the joints, requiring realignment and stabilization.
Q. What surgical options are available for Lisfranc injuries?
A. Surgical options include open reduction and internal fixation using plates and screws, or primary fusion of the joints if the injury is severe.
Q. What is the recovery process like after surgery for a Lisfranc injury?
A. Recovery typically involves a period of non-weight-bearing, gradual return to weight-bearing activities, and physical therapy to regain strength and function.
Q. What are the long-term outcomes after a Lisfranc injury?
A. Long-term outcomes vary but can include residual pain, stiffness, and the potential development of post-traumatic arthritis.
Q. Can Lisfranc injuries lead to arthritis?
A. Yes, even with proper treatment, Lisfranc injuries can result in post-traumatic arthritis requiring additional interventions.
Q. How can one prevent complications after a Lisfranc injury?
A. Proper diagnosis, timely and appropriate treatment, and adherence to post-treatment rehabilitation protocols are crucial to preventing complications.
Q. How long does recovery take?
A. Full recovery usually takes between six months and one year, depending on the severity and treatment method.
Q. Will I walk normally again?
A. Yes, most patients regain normal walking function, though some may experience mild stiffness.
Q. Can I return to sports?
A. Athletes can return to sports once fully healed, typically after 6–12 months.
Q. Will the hardware need to be removed?
A. Sometimes. Screws or plates may be removed 3–5 months after surgery if they cause discomfort or restrict movement.
Q. Can arthritis develop later?
A. Yes, arthritis can occur even after successful treatment due to cartilage damage during the injury.
Summary and Takeaway
A Lisfranc injury is a serious midfoot condition involving ligament tears or fractures that destabilize the arch. Early diagnosis and treatment are essential to restore function and prevent long-term complications. Stable injuries may heal with casting, while displaced injuries often require surgical fixation or fusion. With appropriate treatment, most patients regain a stable, pain-free foot and return to normal activities.
Clinical Insight & Recent Findings
A recent study in the International Journal of Physiology, Pathophysiology and Pharmacology highlighted the importance of early and precise diagnosis in Lisfranc injuries. While conservative treatment works well for non-displaced cases, surgery is required for unstable or displaced injuries.
The study found that anatomical restoration of the Lisfranc joint—whether achieved by open reduction internal fixation or primary arthrodesis—is the key to long-term recovery and preventing arthritis. (“Recent study on Lisfranc injury management – see PubMed.”)
Who Performs This Treatment? (Specialists and Team Involved)
Lisfranc injuries are treated by orthopedic foot and ankle surgeons or podiatric surgeons. The team also includes anesthesiologists, nurses, and physical therapists who assist with surgery, rehabilitation, and recovery.
When to See a Specialist?
Seek care from a foot and ankle specialist if you have midfoot pain, swelling, or bruising after an injury—especially bruising on the sole of your foot or difficulty bearing weight.
When to Go to the Emergency Room?
Go to the emergency room if you experience severe midfoot pain, swelling, or an inability to stand or walk after trauma. Prompt evaluation reduces the risk of long-term damage.
What Recovery Really Looks Like?
Recovery requires patience. Most patients use crutches or a walker for several weeks, followed by physical therapy to restore mobility and strength. Mild swelling can last for months, but steady improvement is expected with proper care.
What Happens If You Ignore It?
Ignoring a Lisfranc injury can lead to chronic midfoot pain, arch collapse, arthritis, and long-term disability. Untreated injuries often require more complex reconstructive surgery later.
How to Prevent It?
Wear well-fitted, supportive shoes and avoid high-impact twisting movements on uneven surfaces. Athletes should strengthen their foot and ankle muscles and use proper technique during training to reduce risk.
Nutrition and Bone or Joint Health
A diet rich in calcium, vitamin D, and protein supports bone repair and joint health. Omega-3 fatty acids and antioxidants help reduce inflammation during healing.
Activity and Lifestyle Modifications
During recovery, switch to low-impact activities such as cycling or swimming. Gradually resume higher-impact exercise only after full healing is confirmed. Supportive footwear and orthotics help maintain stability and prevent re-injury.
Dr. Mo Athar
