Orthopaedics and Rehab

What is a Lisfranc injury and how come it sidelines athletes for so long?

Orthopaedics and Rehab

Lisfranc injuries often occur in high-impact sports such as basketball, football, or soccer when athletes are pushing off on their toes and putting pressure on their midfoot.

In the world of high-impact sports, two injuries have become inexorably linked with the dreaded term “season-ending surgery:”

  • Anterior cruciate ligament (ACL) tears, which affect the stability of the knee joint, usually requiring reconstructive surgery and about six months of rehab
  • Achilles tendon ruptures or tears, which involve the largest tendon in the body that connects the heel bone to the calf muscle at the back of the ankle, often requiring surgery and about a year to rehab and recover

Recently, a less-well-known foot injury has joined the debilitating duo:

Lisfranc injuries have sidelined several pro athletes for the 2022-2023 season, including Dallas Cowboys cornerback Jourdan Lewis and Carolina Panthers rookie quarterback Matt Corral in the NFL, and Oklahoma City Thunder center Chet Holmgren, who was the No. 2 overall pick in the 2022 NBA draft.

Named for the surgeon in Napoleon’s army who discovered the condition among many of its cavalry soldiers, Lisfranc injuries are usually caused by a severe twisting of the foot that creates a fracture, dislocation, or ligament strain/tear in the midfoot – the area where the bridges of your toes connect to the rest of your foot.

Lisfranc injuries are rare, affecting about 1 in 55,000 people in the U.S. every year, but too often they are misdiagnosed or dismissed as a simple sprain. Left untreated or treated improperly, they can lead to chronic foot pain, altered gait, osteoarthritis, and long-term disability. For elite athletes, Lisfranc injuries can be career-threatening.

UT Southwestern’s Orthopaedic Surgery and Sports Medicine service treats multiple Lisfranc injuries per month. Our foot and ankle specialists are experts in diagnosing and managing this complex condition in athletes and nonathletes alike. Although Lisfranc injuries are significant and painful, with proper care and physical therapy our team can help get you back on your feet and playing the sport you love.

What causes a Lisfranc injury?

The foot has a lot of moving parts, and many of them come together in the Lisfranc joint complex, where bones, tendons, and ligaments provide much-needed arch support, flexibility, and stability.

In sports like football and basketball, Lisfranc injuries usually occur when a player’s foot is flexed forward, gets stuck or stepped on, and twists in an unnatural position.

X-ray of a Lisfranc injury showing instability in the midfoot (UT Southwestern)
A weight-bearing X-ray shows a Lisfranc injury that causes instability in the midfoot. A devastating injury for an elite athlete, Lisfranc fractures or ligament tears usually require surgery and extensive rehab.

Offensive lineman, for example, are at risk for Lisfranc injuries because their feet are planted and their heels are off the ground while they block, making them susceptible to strains or tears as defensive players exert force on them. Similarly, if a running back gets a cleat stuck in the ground, the twisting motion can cause a Lisfranc dislocation or tear. In basketball and soccer, when the front portion of a player’s foot is extended and another player steps on the heel, a twist to escape could lead to Lisfranc ligament damage.

Of course, Lisfranc injuries don’t only affect athletes. They can be caused by a high-energy trauma, such as a car accident or a heavy object falling on the foot, or even a missed step on the stairs. Jacques Lisfranc de St. Martin first identified the condition when cavalrymen in Napoleon’s army would get thrown from their horses but one of their feet would get caught and twisted in the stirrups.

Today, military personnel continue to face the prospect of Lisfranc injuries (albeit not from falling off horseback), as do runners, windsurfers, and mountain bikers who ride over rugged terrain with their feet strapped to the pedals.

Lisfranc vs. a sprain

Lisfranc foot injury bruising on the sole of the foot, which is a classic sign of instability in the midfoot.
Bruising on the sole of the foot is a classic sign of a Lisfranc injury.

Many patients will try to “tough it out” when they sprain their foot, but if it’s a Lisfranc injury the pain will likely persist and so will other symptoms, such as:

  • Swelling on top of the foot, which will be sore to the touch
  • Bruising on the top and bottom of the foot
  • Inability to put weight on the foot
  • Pain trying to push off

At UT Southwestern, we always take weight-bearing X-rays for patients with foot injuries because they are more effective at detecting a fracture or a collapse of the midfoot. Weight-bearing X-rays can also show if there is a widening of the joint between the first and second metatarsals (big toe and second toe), a clear indication of ligament damage.

If the X-ray is normal or inconclusive but our foot and ankle specialists still suspect a Lisfranc injury, we may recommend an MRI, which allows us to look more closely at soft tissue around the bones and assess tendon or ligament damage.

How are Lisfranc injuries treated?

Dr. Dane Wukich
Dane Wukich, M.D., is Chair of the Department of Orthopaedic Surgery at UT Southwestern.

Lisfranc injuries vary in severity, from strains, which can be treated by immobilizing the foot and keeping weight off it, to tears, fractures, or dislocations that require surgery to insert a screw or plate and restore stability to the foot.

For a mild strain, the patient will likely be asked to wear a boot for 6-8 weeks and use crutches to keep weight off the injured foot – allowing the ligaments time to heal. After eight weeks, we’ll X-ray the foot again and if the bones have not shifted, the patient will move to physical therapy and moderate weight-bearing exercises.

If there is any instability in the midfoot area – even 1-2 millimeters ­– the injury will likely require surgery to realign the bones. We make an incision in the top of the foot and place screws or plates to hold the joint complex in proper anatomical position so the bone and ligaments can heal.

The initial recovery after Lisfranc surgery includes six weeks of no weight-bearing, followed by three months of protected weight-bearing. The foot will be in a cast or a boot, and patients can use a scooter or crutches to keep weight off it.

In most cases, the hardware will be removed 4-6 months after surgery. Physical therapy and rehab, which will begin at the six-week mark, will help strengthen the muscles and restore movement. But patience and perseverance are required with this injury because it will likely be at least six months before an athlete can regain the ability to push off and run.

Bouncing back from Lisfranc injuries

Depending on the severity of the injury, full recovery from a Lisfranc tear or fracture could take up to a year – and it’s certainly not guaranteed. Philadelphia Eagles running back Duce Staley retired a few years after sustaining a Lisfranc injury.

One millimeter of displacement in the midfoot has the potential to alter or end the careers of athletes who rely on the ability to push off, change direction quickly, and run away from defenders. Even after successful surgery and rehab, some patients face chronic pain, arthritis, and loss of their arch.

That’s why it’s crucial if you are concerned about a potential Lisfranc injury, see a foot and ankle specialist who is trained to diagnose and treat the complex condition properly. To talk with one of our experts, call 214-645-8300 or schedule an appointment online.