{"id":28657,"date":"2026-08-25T12:00:37","date_gmt":"2026-08-25T10:00:37","guid":{"rendered":"https:\/\/www.physiotutors.com\/?post_type=research&p=28657"},"modified":"2026-08-24T22:05:56","modified_gmt":"2026-08-24T20:05:56","slug":"lisfranc-injury-diagnosis","status":"publish","type":"research","link":"https:\/\/www.physiotutors.com\/research\/lisfranc-injury-diagnosis\/","title":{"rendered":"Lisfranc Injury Diagnosis and Management: Key Considerations for Physiotherapists"},"featured_media":28670,"template":"","meta":{"_acf_changed":false,"_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":""},"featured-tag":[],"tracking_tag":[2198,2200],"class_list":["post-28657","research","type-research","status-publish","has-post-thumbnail","hentry","tracking_tag-ankle-foot","tracking_tag-diagnosis-imaging"],"acf":{"free_access":"unfree","app_link":"https:\/\/app.physiotutors.com\/research-reviews\/lisfranc-injury-diagnosis","sections":[{"acf_fc_layout":"page-header-small","background":{"background_image":28669,"background_image_alt_text":""},"heading":"Lisfranc Injury Diagnosis and Management: Key Considerations for Physiotherapists","subheading":"Hammad et al. (2026)","benefits":[{"benefit":"This narrative review provides an overview of the clinical assessment, imaging, management, and rehabilitation of Lisfranc injuries"},{"benefit":"Lisfranc injuries are frequently missed or misdiagnosed, potentially resulting in delayed treatment, persistent pain, functional deficits, and poorer outcomes."},{"benefit":"Early recognition and appropriate imaging are essential, particularly when a rotational injury occurs on a plantarflexed foot, as maintaining anatomic alignment is strongly associated with better outcomes"}]},{"acf_fc_layout":"content","background_color":"none","content_alignment":"left","content_editor":"

Introduction<\/h2>\r\nAnkle sprains are among the most common conditions encountered in physiotherapy practice. Due to the anatomy of the ankle complex, the lateral ankle ligaments are particularly vulnerable to injury, with inversion on a plantarflexed foot being the most common mechanism. However, this mechanism can also place substantial stress on the midfoot, particularly the dorsomedial tarsometatarsal region, potentially involving the Lisfranc ligamentous complex, a key stabilizer of the midfoot.<\/span>\r\n\r\nLisfranc injuries require specific management, often including a period of non-weight-bearing, yet they are frequently missed or misdiagnosed. Although traditionally considered rare, recent evidence suggests that their incidence may be higher than previously thought, particularly in athletic populations.<\/span>\r\n\r\nThis review aims to provide physiotherapists with practical clinical knowledge to recognize, assess, and appropriately refer patients with suspected <\/span>Lisfranc injury<\/span>.<\/span>\r\n\r\n \r\n

Methods<\/h2>\r\nThis study is a retrospective narrative review. Medical databases were systematically searched following the PRISMA guidelines and search strategy. Comparative and observational studies were included without age restrictions, while case reports, animal studies, and expert opinions were excluded. A total of 48 studies were included in the final review.<\/span>\r\n\r\n[caption id=\"attachment_28658\" align=\"alignnone\" width=\"968\"]\"Lisfranc From: Hammad et al., Translational Sports Medicine (2026)[\/caption]\r\n\r\n \r\n

Results<\/h2>\r\nAnatomy<\/b>\r\n\r\nThe Lisfranc joint complex comprises the articulations between the three cuneiforms and cuboid and the bases of the five metatarsals. The alignment of these bones provides structural stability to the medial and lateral foot arches and is reinforced by the Lisfranc ligament complex, which consists of the dorsal (DLL), interosseous (ILL), and plantar (PLL) ligaments.<\/span>\r\n\r\nThe dorsal and plantar ligaments originate from the cuneiforms and attach primarily to the bases of the metatarsals, while the interosseous Lisfranc ligament originates from the medial aspect of the medial cuneiform and inserts onto the base of the second metatarsal. A plantar extension also contributes to the attachment toward the third metatarsal.<\/span>\r\n\r\nThe Lisfranc complex is particularly important for midfoot stability because there is no direct interosseous ligament between the first and second metatarsals. Consequently, the DLL, ILL, and PLL provide much of the ligamentous stability of the tarsometatarsal region.<\/span>\r\n\r\n[caption id=\"attachment_28659\" align=\"alignnone\" width=\"1234\"]\"Lisfranc From Chen et al., Foot & Ankle Specialist (2020)[\/caption]\r\n\r\n \r\n\r\n[caption id=\"attachment_28661\" align=\"alignnone\" width=\"734\"]\"Antero-superior From: 3D4Medical. (2026). [Computer software]. Elsevier.[\/caption] \r\n\r\n[caption id=\"attachment_28662\" align=\"alignnone\" width=\"920\"]\"Antero-inferior From: 3D4Medical. (2026). [Computer software]. Elsevier.[\/caption] \r\n\r\n[caption id=\"attachment_28663\" align=\"alignnone\" width=\"914\"]\"Plantar From: 3D4Medical. (2026). [Computer software]. Elsevier.[\/caption] \r\n\r\nIncidence, etiology and biomechanics<\/b>\r\n\r\nRecently published data suggest that nearly 30% of <\/span>Lisfranc injury diagnoses <\/span>are initially missed, particularly following low-energy mechanisms or in polytrauma patients. In collegiate football players, Lisfranc injuries may account for up to 20% of foot injuries.<\/span>\r\n\r\nThe typical mechanism involves rotational stress applied to a plantarflexed foot, which can result in disruption of the dorsal ligaments and\/or fracture at the metatarsal base. Other common mechanisms include forefoot twisting, crush injuries, and high-energy trauma.<\/span>\r\n\r\nBiomechanical studies suggest that the interosseous Lisfranc ligament (ILL) is the stiffest component of the Lisfranc ligament complex. Disruption of this ligament can therefore substantially compromise midfoot stability and may require surgical fixation when adequate stability cannot be maintained conservatively.<\/span>\r\n\r\nDiagnosis, imaging and physical examination<\/b>\r\n\r\nFollowing trauma, patients typically present with midfoot pain, swelling, and difficulty with weight-bearing. Plantar ecchymosis is particularly suggestive of a <\/span>Lisfranc injury diagnosis<\/span>.<\/span>\r\n\r\nClinical examination should include the piano-key test, first metatarsal\u2013cuneiform mobilization, abduction stress testing, and assessment of the medial arch. Arch collapse or asymmetry compared with the unaffected side may further increase suspicion. Furthermore, this Physiotutors clinical examination may help guide your Lisfranc injury assessment. <\/span>https:\/\/www.youtube.com\/watch?v=0ugLq8Ns5VU<\/span>\u00a0<\/span>\r\n\r\nPlain radiographs are the initial imaging modality, but non-weight-bearing X-rays may miss Lisfranc injuries. Weight-bearing radiographs are therefore preferred when tolerated, as they may reveal C1\u2013M2 diastasis, avulsion fractures, or malalignment of the second metatarsal relative to the middle cuneiform.<\/span>\r\n\r\nWhen radiographs are inconclusive despite high clinical suspicion, CT is indicated to better characterize fractures and bony displacement. However, conventional non-weight-bearing CT may underestimate dynamic instability. Weight-bearing CT (WBCT) is an emerging modality that may improve detection of subtle Lisfranc instability.<\/span>\r\n\r\nMRI is particularly useful for assessing ligamentous and soft-tissue injury, with reported sensitivity and specificity ranging from approximately 94\u201397% and 75\u201388%, respectively.<\/span>\r\n\r\nFinally, although ultrasound is becoming increasingly accessible in physiotherapy, its role in the establishment of <\/span>Lisfranc injury diagnosis <\/span>remains limited. Operator dependency and limited visualization of deeper ligamentous structures make it insufficient as a standalone diagnostic tool.<\/span>\r\n\r\nClassification<\/b>\u00a0<\/span>\r\n\r\nFour classification systems have been proposed for Lisfranc injuries and are detailed in Table 1. These systems help clinicians characterize injury severity and guide treatment decisions, particularly regarding surgical management. Although newer classification methods may improve the precision of clinical and surgical decision-making, further validation and development of emerging weight-bearing CT (WBCT)-based systems are needed.<\/span>\r\n\r\n[caption id=\"attachment_28664\" align=\"alignnone\" width=\"1186\"]\"Lisfranc From: Hammad et al., Translational Sports Medicine (2026)[\/caption]\r\n\r\n \r\n\r\nManagement options\u00a0<\/b>\r\n\r\nManagement largely depends on injury stability and displacement. Stable injuries with \u22642 mm diastasis between the second metatarsal and medial cuneiform may be managed conservatively, typically with relative rest and non-weight-bearing immobilization for 4\u20136 weeks, followed by gradual reloading.<\/span>\r\n\r\nFor >2 mm displacement at the C1\u2013M2 articulation, surgical fixation is generally considered. Similarly, \u226515\u00b0 of sagittal talometatarsal angulation may indicate instability and support surgical management. Surgery may also be considered when symptoms persist, or joint malalignment remains.<\/span>\r\n\r\nHowever, these thresholds are largely clinically driven, and further research is needed to establish standardized criteria for treatment selection.<\/span>\r\n\r\nSurgical management<\/b>\r\n\r\nCommon surgical approaches include open reduction and internal fixation (ORIF), arthrodesis, bridge plating, flexible fixation, and percutaneous techniques. Regardless of the technique used, the primary goal is to restore and maintain anatomic alignment, which is strongly associated with better clinical outcomes.<\/span>\r\n\r\nRehabilitation<\/b>\r\n\r\nFollowing Lisfranc surgery, patients typically remain non-weight-bearing for 6\u20138 weeks, followed by a gradual progression to weight-bearing. Transition to normal footwear is generally expected around 12 weeks, when physiotherapy can focus on gait retraining, edema management, and restoring joint mobility.<\/span>\r\n\r\nA phase-based rehabilitation protocol has been proposed and is detailed in the table below.<\/span>\r\n\r\n[caption id=\"attachment_28665\" align=\"alignnone\" width=\"1200\"]\"Lisfranc From: Hammad et al., Translational Sports Medicine (2026)[\/caption]\r\n\r\n \r\n\r\nNotably, normalization of strength, balance, and hop symmetry threshold are prerequisites for phase IV, where more athlete-focused programs can restart. Interestingly, the rehabilitation program should focus on restoring normal forefoot rocker and push-off mechanics that are commonly impaired after Lisfranc injury. Rocker mechanism refers to the rolling over the metatarsophalangeal joint to allow force transmission during late stance.\u00a0<\/span>\r\n\r\nReturns to ambulation and sport<\/b>\r\n\r\nAnatomic alignment is a key predictor of recovery. Weight-bearing is typically resumed after 6\u20138 weeks of immobilization, with most patients returning to normal footwear around 3 months. Full recovery may take up to 6 months, depending on injury severity.<\/span>\r\n\r\nRehabilitation should address the impaired foot rocker mechanism, with progressive loading targeting foot intrinsic muscles, tibialis posterior, plantarflexor strength, and forefoot function.<\/span>\r\n\r\nBefore return to sport, consider:<\/span>\r\n\r\nPain-free sport-specific drills<\/span>\r\n