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Health condition · Clinically reviewed

Lisfranc injury, midfoot fracture-dislocation — the most missed foot injury, from ORIF to primary arthrodesis.

Lisfranc injuries range from subtle ligamentous sprain to complete midfoot fracture-dislocation. Frequently missed on early X-ray. Modern stratified care: non-operative for truly non-displaced injuries; ORIF or primary arthrodesis for displaced patterns.

Jump to treatment See red-flag midfoot injury
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

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Every claim is checked against BOFAS, NICE and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects current UK guidance on Lisfranc imaging, ORIF and primary arthrodesis.

Key facts

Lisfranc injury at a glance.

The essentials, in plain English — what a Lisfranc injury is, why it is so often missed, and how modern imaging and surgery are stratified.

  • Definition

    A Lisfranc injury is a fracture-dislocation of the tarsometatarsal (TMT) joint complex — the mechanical keystone of the midfoot.

  • Frequently missed

    Up to 20% of Lisfranc injuries are missed on initial non–weight-bearing X-ray — a low threshold for repeat imaging matters.

  • Modern imaging

    Weight-bearing X-ray plus CT plus MRI is the modern imaging pathway — each answers a different question about the injury.

  • Non-displaced disease

    Truly non-displaced injuries (< 2 mm diastasis) may be treated non-operatively in a non-weight-bearing boot with serial review.

  • ORIF for displaced

    Open reduction and internal fixation is the mainstay for displaced patterns — anatomic reduction is the strongest predictor of outcome.

  • Primary arthrodesis

    Primary arthrodesis is debated as first-line for purely ligamentous Lisfranc injuries — evidence is evolving.

Why this guide matters

Image it, then decide.

Lisfranc injuries are missed when the imaging pathway is skipped — this guide sets out the modern imaging and surgical decisions clearly.

  • Weight-bearing X-rays change diagnoses

    A supine X-ray can look near-normal; standing views reveal diastasis at the first–second metatarsal base that changes the treatment.

  • CT and MRI answer different questions

    CT is unrivalled for bony detail and the fleck sign; MRI is the reference standard for ligamentous injury when X-ray looks clean.

  • ORIF vs primary arthrodesis

    For purely ligamentous Lisfranc injuries, primary arthrodesis is increasingly considered first-line — a real, active debate.

How the diagnosis is made

From painful midfoot to a clear surgical plan.

The steps a UK emergency doctor, GP or foot and ankle surgeon will normally follow, in order — so you know what to expect and why.

  1. 01

    Recognising

    Trauma and weight-bearing history

    Mechanism matters — a twist on a plantarflexed foot, a fall from height or a crush injury should raise Lisfranc as an early differential.

  2. 02

    Recognising

    Plantar bruising sign

    Bruising on the sole of the midfoot is highly specific for a Lisfranc injury — an easy sign to miss if the sole is not examined.

  3. 03

    Recognising

    Weight-bearing AP and oblique X-ray

    Standing X-rays unmask subtle diastasis between the first and second metatarsal bases that a supine film will miss.

  4. 04

    Confirming

    Comparison view of contralateral foot

    Bilateral weight-bearing views allow side-to-side comparison — small asymmetries at the TMT joint become obvious.

  5. 05

    Confirming

    CT for bony detail

    CT resolves bony fragments, subtle fractures and the classic fleck sign of a Lisfranc ligament avulsion.

  6. 06

    Confirming

    MRI for ligament injury

    MRI is the reference standard for the Lisfranc ligament complex — essential when X-ray and CT look normal but suspicion remains.

  7. 07

    Managing

    Foot and ankle surgery consultation

    Any confirmed or strongly suspected Lisfranc injury needs specialist review — the decision between non-op, ORIF and primary arthrodesis is not a primary-care call.

Typical timeline: days to a few weeks from injury to a definitive surgical plan.

Symptoms

What a Lisfranc injury actually feels like.

Midfoot pain and swelling out of proportion to the initial X-ray — plantar bruising and inability to weight-bear are the classic combination.

  • Midfoot pain

    Deep, aching pain across the midfoot after a twist or crush injury — often disproportionate to the initial X-ray findings.

  • Bruising over midfoot

    Visible bruising on the top of the midfoot in the days after injury — a useful early clinical clue.

  • Plantar ecchymosis (specific)

    Bruising on the sole of the foot — highly specific for Lisfranc injury and easily missed unless the sole is examined directly.

  • Swelling of midfoot

    Significant midfoot swelling that persists beyond a typical ankle sprain timeline — a red flag for missed Lisfranc injury.

  • Inability to weight-bear

    Patients often cannot bear weight through the injured foot, or do so with a markedly antalgic gait.

  • Midfoot deformity

    Obvious deformity or widening across the midfoot in high-energy injuries — a surgical presentation.

  • Clicking in TMT joints

    Palpable or audible clicking across the tarsometatarsal joints on stressing the midfoot suggests instability.

  • Red flag

    Acute high-energy midfoot injury with skin compromise, tense swelling or neurovascular concern — treat as a surgical emergency.

Treatment

How Lisfranc injuries are treated in the UK.

A stratified approach — non-operative for truly non-displaced injuries, ORIF or primary arthrodesis for displaced patterns, with delayed fusion for post-traumatic arthritis.

  • Non-weight-bearing boot immobilisation

    For truly non-displaced injuries — a non-weight-bearing boot with serial weight-bearing X-rays to confirm stability over time.

  • Weight-bearing X-ray at 2–4 weeks

    Repeat standing X-rays are essential — a subtle Lisfranc injury can declare itself only once swelling has settled and load is reapplied.

  • ORIF with transarticular screws

    Open reduction and internal fixation with transarticular screws — the traditional workhorse for displaced fracture-dislocation patterns.

  • Suture-button / TightRope fixation

    Flexible fixation across the Lisfranc interval — a joint-preserving alternative to rigid screws in selected ligamentous injuries.

  • Primary arthrodesis of 1st–3rd TMT

    Primary fusion of the medial three tarsometatarsal joints — considered first-line by some surgeons for purely ligamentous Lisfranc injuries.

  • Bridging plate fixation

    Dorsal bridging plates preserve articular cartilage and avoid transarticular screw damage — increasingly used in comminuted patterns.

  • Delayed arthrodesis for post-traumatic midfoot arthritis

    For patients who develop symptomatic midfoot arthritis after ORIF or missed injury — a well-established salvage procedure.

  • Structured rehab and orthoses

    Progressive weight-bearing, midfoot-supportive orthoses and a structured rehab programme after any Lisfranc surgery — recovery is measured in months.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, 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.

Your emergency doctor, GP or foot and ankle team knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • British Orthopaedic Foot and Ankle Society (BOFAS). Lisfranc injury standards and patient information.

  • NICE. Musculoskeletal guidance on midfoot injuries and post-traumatic care.

  • American Orthopaedic Foot & Ankle Society (AOFAS). Clinical guidance on Lisfranc injuries.

  • AO Foundation. Trauma principles for tarsometatarsal fracture-dislocation.

Red flags

When a midfoot injury is a surgical emergency.

Most Lisfranc care is elective — but a handful of scenarios need same-day surgical review or urgent escalation.

  • Open Lisfranc injury

    An open midfoot injury is a surgical emergency — urgent washout, debridement and orthopaedic input required.

  • Compartment syndrome of foot

    Tense swelling, disproportionate pain and pain on passive stretch of the toes — a limb-threatening emergency needing urgent fasciotomy.

  • Missed injury on X-ray

    Persistent midfoot pain and inability to weight-bear after a “normal” initial X-ray — repeat weight-bearing imaging and consider CT or MRI.

  • Post-traumatic midfoot arthritis

    Chronic midfoot pain, stiffness and deformity after a Lisfranc injury — needs foot and ankle review for possible arthrodesis.

  • Post-op infection

    Increasing pain, redness, wound discharge or fever after Lisfranc surgery — same-day surgical team review.

  • Hardware failure

    New midfoot pain, deformity or clicking after ORIF — imaging to exclude screw or plate failure and loss of reduction.

  • Compartment syndrome

    A high-energy midfoot injury with rapidly worsening pain and swelling — do not wait for classic signs before escalating.

  • Chronic Lisfranc instability

    Ongoing midfoot instability months after injury — often reflects an inadequately treated Lisfranc ligament complex.

  • Diabetic Charcot midfoot

    Warm, swollen, deformed midfoot in a person with diabetes — do not assume Lisfranc trauma; consider Charcot neuroarthropathy urgently.

Living with it

A slow recovery, but a well-defined one.

Four things that make the biggest difference after a Lisfranc injury — respecting the timeline, footwear, staged loading and follow-up.

A quiet reminder

Patience beats intensity, every time.

Rushing back to full loading is the single biggest predictor of a poor outcome after a Lisfranc injury — let the timeline do its work.

  1. 01 Rehab

    Respect the timeline

    Recovery from a Lisfranc injury is measured in many months — protected weight-bearing, physio and orthoses over a long arc.

  2. 02 Footwear

    Support the midfoot

    Stiff-soled, supportive footwear and midfoot orthoses reduce load through the healing TMT joints day to day.

  3. 03 Load

    Return to sport carefully

    Return to running or impact sport is staged over months — rushing this is the fastest route to post-traumatic arthritis.

  4. 04 Reviews

    Keep your follow-up dates

    Serial weight-bearing X-rays and clinic reviews are how surgeons catch late diastasis or hardware issues before they become a bigger operation.

Frequently asked

Everything we get asked about Lisfranc injuries.

Quick answers on imaging, ORIF versus primary arthrodesis, recovery and the plantar bruising sign.

  • What actually is a Lisfranc injury?

    A Lisfranc injury is a fracture, dislocation or ligament rupture at the tarsometatarsal (TMT) joint complex — the mechanical keystone of the midfoot. It ranges from a subtle ligamentous sprain through to a complete fracture-dislocation across all five TMT joints.

  • Why is it so often missed?

    Standard non–weight-bearing X-rays in the emergency department can look near-normal even when the Lisfranc ligament is torn. Up to 20% of injuries are missed on initial imaging. Persistent midfoot pain, plantar bruising and inability to weight-bear should trigger weight-bearing X-rays and often CT or MRI.

  • Do all Lisfranc injuries need surgery?

    No. Truly non-displaced injuries (with less than 2 mm of diastasis on weight-bearing views and no instability) can be managed non-operatively in a non-weight-bearing boot with serial imaging. Any displacement or instability needs surgery.

  • What is the difference between ORIF and primary arthrodesis?

    ORIF (open reduction and internal fixation) restores anatomy with screws or plates and preserves the joint. Primary arthrodesis fuses the medial three TMT joints from the outset. Arthrodesis is increasingly considered first-line for purely ligamentous Lisfranc injuries, though this remains debated.

  • How long is recovery?

    Recovery is long. Expect around 6–12 weeks non-weight-bearing after surgery, followed by a graduated return to weight-bearing, physiotherapy and eventually sport over 6–12 months. Post-traumatic arthritis is a real risk even with well-treated injuries.

  • What is the plantar bruising sign?

    Bruising on the sole of the foot after a midfoot injury is highly specific for a Lisfranc injury. It is easy to miss if the sole is not examined directly — always look at the underside of the foot when Lisfranc is on the differential.

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