Skip to main content

Health condition

Lisfranc injuries, the midfoot injury that's easy to miss.

From a subtle ligament sprain to a full fracture-dislocation - a high index of suspicion, the right imaging and specialist input make all the difference.

Jump to treatment
A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Editorial team

    Written by our editorial team from the UK sources listed on each page.

  • 02

    Sourced from guidance

    Checked against BOAST, BOFAS and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK guidance on weight-bearing imaging, CT diagnosis and specialist fixation pathways.

Key facts

Lisfranc injuries at a glance.

The essentials, in plain English - what it is, how it happens, and how it's diagnosed and treated in the UK today.

  • What it is

    Disruption of the tarsometatarsal joint complex - the midfoot - ranging from a simple ligament sprain to a full fracture-dislocation.

  • Mechanism

    Axial load on a plantarflexed foot - falls from height, road traffic collisions, equestrian or American football injuries - or a direct crush.

  • Classic sign

    Bruising across the plantar arch (plantar ecchymosis) is the tell-tale clue clinicians look for on the sole of the foot.

  • Often missed

    A significant proportion of Lisfranc injuries are missed on first presentation - a high index of suspicion is essential.

  • Imaging pathway

    Weight-bearing X-ray first if tolerated; CT is the specialist-commissioned gold standard for subtle injury.

  • Treatment split

    Stable sprains go into a cast or boot; unstable or displaced injuries need surgical fixation by a foot and ankle specialist.

Why this guide matters

A suspicious mind catches what an X-ray can miss.

Lisfranc injuries are uncommon but consequential - missed early, they cost function and joints later. The three points below shape everything else on this page.

  • Suspicion beats a normal X-ray

    A non-weight-bearing film can look reassuring while the joint is unstable - weight-bearing views or CT settle the question.

  • Plantar bruising is a specific clue

    Bruising on the sole, not just the top, of the foot should always prompt a proper look at the midfoot.

  • Stability decides the pathway

    A stable sprain heals in a cast; an unstable or displaced injury needs surgical fixation - getting this distinction right matters.

How the diagnosis is made

From a suspicious mechanism to a confirmed diagnosis.

The steps a UK emergency department or orthopaedic team will normally follow, aligned with BOAST and BOFAS - so you know what to expect and why.

  1. 01

    Assessing

    History and mechanism

    Axial load on a plantarflexed foot, a crush injury, or a fall - the mechanism is the first clue to a Lisfranc injury.

  2. 02

    Assessing

    Examination for plantar bruising

    Bruising on the sole of the foot, midfoot swelling and pain on abduction or pronation stress point strongly towards this diagnosis.

  3. 03

    Assessing

    Neurovascular and compartment check

    The dorsalis pedis pulse is at risk - every examination checks perfusion and screens for compartment syndrome.

  4. 04

    Confirming

    Weight-bearing X-ray

    If the patient can tolerate it, a weight-bearing film looks for widening of the 1st-2nd metatarsal space and the "fleck sign".

  5. 05

    Confirming

    CT scan - the gold standard

    Specialist-commissioned CT (see our CT scan guide) is the gold standard for subtle injuries that plain film can miss.

  6. 06

    Referring

    MRI for ligamentous injury

    When there is no fracture but instability is suspected, MRI assesses the Lisfranc ligament itself.

  7. 07

    Referring

    MDT foot and ankle referral

    A specialist-commissioned multidisciplinary foot and ankle orthopaedic team, aligned with BOFAS standards, takes it from here.

Typical timeline: emergency assessment to a confirmed diagnosis, usually within the same visit.

Symptoms

What a Lisfranc injury actually looks like.

The classic mix of midfoot pain, plantar bruising and instability. And the features that mean it's time to escalate urgently.

  • Midfoot pain and swelling

    Pain centred over the midfoot, often worse with any attempt to bear weight.

  • Inability to weight-bear

    Many patients simply cannot put weight through the foot after the injury.

  • Plantar arch bruising - the classic sign

    Ecchymosis on the sole of the foot is a specific and often under-recognised marker of this injury.

  • Pain on abduction or pronation stress

    A specific stress test that reproduces midfoot pain and helps confirm instability.

  • Midfoot instability on examination

    A specialist may detect abnormal movement between the midfoot bones on manual stress testing.

  • Neurovascular compromise

    The dorsalis pedis artery runs close to the injury - reduced pulses need urgent specialist review.

  • Polytrauma with foot pain

    In a polytrauma patient, foot pain deserves the same suspicion as any other limb injury - it is easy to overlook.

  • Red flag - compartment syndrome

    Severe, disproportionate pain and tense swelling in the acute setting needs emergency assessment.

Treatment

How Lisfranc injuries are treated in the UK.

Cast or boot for a stable sprain, surgical fixation for an unstable or displaced injury - and a staged path back to weight-bearing either way.

  • Non-weight-bearing cast or boot

    For a stable sprain with no diastasis - six weeks of protected immobilisation under specialist follow-up.

  • Surgical fixation (ORIF)

    Screws and plates for unstable or displaced injuries - specialist-commissioned foot and ankle orthopaedic care.

  • Primary arthrodesis

    Fusion of the affected joints at the time of surgery for severe fracture-dislocations - reserved for the more destructive injury patterns.

  • Compartment syndrome monitoring

    Close observation in the acute setting - an emergency if pain, swelling or neurovascular signs escalate.

  • Staged weight-bearing

    A carefully sequenced return to loading the foot, guided by healing on imaging and by the surgical team.

  • Physiotherapy

    Structured rehabilitation to restore strength, balance and gait once the joint is stable enough to move.

  • Foot orthotics

    Supportive insoles and footwear adjustments to offload the midfoot during and after recovery.

  • Delayed arthrodesis

    For post-traumatic arthritis or chronic instability following a missed or delayed diagnosis - specialist-commissioned.

What this guide is based on

The sources behind every claim on this page.

UK national trauma standards and specialist society guidance, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

A doctor who has examined your foot and seen your imaging can tell you which parts apply to you. If in doubt, get seen - urgently if there is any doubt about circulation.

  • BOAST. British Orthopaedic Association Standards for Trauma - Diagnosis and management of Lisfranc injuries.

  • BOFAS. British Orthopaedic Foot and Ankle Society guidance on midfoot trauma.

  • Royal College of Surgeons. Standards for the management of open lower limb fractures.

  • NICE. Fractures (non-complex): assessment and management (NG38) - relevant imaging and referral principles.

Red flags

When a Lisfranc injury needs urgent attention.

Most Lisfranc injuries are managed on a planned pathway. These are the situations that aren't - and where emergency or urgent specialist review is needed.

  • Compartment syndrome

    Pain out of proportion to the injury, tense swelling and a tight foot - an emergency needing immediate assessment.

  • Absent or reduced pulses

    Loss of the dorsalis pedis pulse suggests vascular compromise and needs an emergency specialist opinion.

  • Open fracture-dislocation

    A break in the skin over a fracture-dislocation is a surgical emergency requiring urgent debridement and fixation.

  • Missed diagnosis on first presentation

    A normal-looking non-weight-bearing X-ray does not exclude this injury - persistent midfoot pain needs re-assessment.

  • Foot pain in polytrauma

    A distracting major injury elsewhere can mask a Lisfranc injury - examine the foot specifically, every time.

  • Progressive plantar bruising

    Worsening ecchymosis on the sole after injury is a strong prompt to image the midfoot properly.

  • Displaced fracture with skin tenting

    Skin under tension over a displaced fragment risks pressure necrosis and needs prompt reduction.

  • Chronic instability after inadequate care

    Ongoing midfoot pain and a feeling of give-way after treatment points to under-treated instability.

  • Delayed presentation beyond six weeks

    Late diagnosis narrows the treatment options and raises the risk of post-traumatic arthritis - refer promptly.

Living with it

A recoverable injury, with a clear staged plan.

Four things that make the biggest difference to recovery - protecting the joint, moving early under guidance, supportive footwear and watching for late arthritis.

A quiet reminder

Patience with the plan protects the joint.

Rushing weight-bearing before the joint or fixation is ready is one of the most common causes of a poor long-term outcome.

  1. 01 Protect

    Stick to the weight-bearing plan

    The staged return to loading exists for a reason - skipping ahead risks the fixation or the healing ligament.

  2. 02 Move

    Start rehabilitation early

    Physiotherapy-led strengthening and balance work, begun as soon as it is safe, shortens the road back.

  3. 03 Support

    Get the footwear right

    Supportive footwear and, often, custom orthotics reduce midfoot strain long after the initial injury has healed.

  4. 04 Escalate

    Watch for arthritis symptoms

    New stiffness or aching months or years later can mean post-traumatic arthritis - ask about arthrodesis if it happens.

Frequently asked

Everything we get asked about Lisfranc injuries.

Quick answers on diagnosis, plantar bruising, surgery and what happens if treatment is delayed.

  • What is a Lisfranc injury?

    It is disruption of the tarsometatarsal joint complex - the midfoot - ranging from a sprain of the Lisfranc ligament through to a full fracture-dislocation. It usually follows an axial load on a plantarflexed foot, such as a fall, a road traffic collision or a sporting injury.

  • Why is it so often missed?

    The injury can look deceptively minor on a standard non-weight-bearing X-ray, and the midfoot is easy to overlook in a patient with other, more obvious injuries. A high index of suspicion, plantar bruising on examination, and weight-bearing imaging or CT when in doubt all help catch it early.

  • What is the plantar bruising sign?

    Bruising that appears on the sole of the foot, across the plantar arch, rather than just the top of the foot. It is a classic and fairly specific marker of a Lisfranc injury and should prompt further imaging even when X-rays look reassuring.

  • Do all Lisfranc injuries need surgery?

    No. A stable sprain with no widening of the joints (no diastasis) can often be managed with six weeks in a non-weight-bearing cast or boot. Unstable or displaced injuries need surgical fixation, usually with screws and plates, sometimes with fusion for the most severe patterns.

  • What imaging is used to diagnose it?

    A weight-bearing X-ray is the first-line test if the patient can tolerate standing on the foot, looking for widening between the first and second metatarsals and the "fleck sign". CT is the specialist-commissioned gold standard for subtle injuries, and MRI is used when ligament injury is suspected without a fracture.

  • What happens if treatment is delayed?

    A missed or delayed diagnosis increases the risk of chronic midfoot instability and post-traumatic osteoarthritis. Long-term management of these complications can include delayed arthrodesis - fusing the affected joints - under specialist-commissioned orthopaedic care.

Related content

Keep reading.