LisFranc Injury

Basic Anatomy

A "LisFranc" injury is an injury to the joint between the long bones in the foot (metatarsals) and the bones they connect to (tarsal bones). This injury can affect the ligaments (soft tissue that connects bone to bone) of these bones and/or include fractures of the bones themselves. The injury can hurt the whole foot or be limited to part of the foot.

Since there is very little skin over the bones of the foot, nerves and arteries that lie directly on top of the bones can be injured as well. This injury can cause the foot to swell a great deal. The bones can push on the skin causing damage or blistering of the skin.

The bones and ligaments are important for keeping the shape of your foot. When you step down, your bones and ligaments resist that force and keep the bones in their proper places, maintaining the arch of your foot. When your ligaments or bones are injured, your foot can collapse, which causes pain while walking.

Figure 1: This is a model showing the top of the foot. The black box is where the 1st and 2nd metatarsals (rays) meet the bones of the midfoot. The blue box represents the LisFranc ligament. It can be injured in a LisFranc injury, which means that the bones can move away from each other. This makes the foot unstable.

X-ray of the top of a foot — Figure 2: An x-ray of the top of a foot. There is no injury in this x-ray and the bones are lined up as they should be. The white box shows where the 1st and 2nd rays connect to the midfoot bones.

X-ray of a LisFranc injury — Figure 3: An x-ray of a LisFranc injury. It can be difficult to see, even to someone trained to look for it. The space between the 1st and 2nd rays is larger. They have moved away from each other. In the zoomed-in picture, the arrow points to the widening. The blue lines on the borders of the bones would normally line up. There is also a small white fleck (white arrow). This is a piece of bone that is attached to the LisFranc ligament that has "pulled off" the bottom of the 2nd ray.

The image on the left shows a LisFranc injury; the picture on the right shows a LisFranc dislocation — Figure 4: The image on the left shows a LisFranc injury. The blue arrow is pointing to a break in the bone at the bottom of the 2nd ray. The picture on the right shows a LisFranc dislocation, in which the bones are no longer lined up to the mid-foot bone.

Mechanism and Epidemiology

LisFranc injuries are rare and account for less than 1 percent of all fractures. They happen after trauma to a foot from a fall, motor vehicle accident, a crush injury, or even an athletic injury. This can happen when you have placed your weight on your foot, with your toes pointed down and you twist your foot. Since this injury can happen with injuries to the ligaments only or the bones and ligaments, it can happen in many different ways. A crush injury that causes a LisFranc injury can look very different from an athletic injury.

Initial Treatment

These injuries will make the middle of your foot hurt when you try to walk or stand. Your foot can swell up. The pain may be so bad you can’t walk. A doctor will examine your foot to make sure your skin is okay and that the bones are not pushing on it. X-rays of your foot will be taken, and x-rays of your other, uninjured foot may also be taken for comparison. A CT scan may also be done, because it can be hard to see the details of your injury using just x-rays. This is especially true if just the ligaments are injured.

If your bones are pushing against the skin or are far away from where they should be, your doctor may attempt a reduction (pushing the bones back into place). This can be done in the emergency room or the operating room. If the bones came through the skin or they can’t be put back into place, you will usually have to go to the operating room.

A splint or a boot may be used to protect your foot and to help with your pain by stabilizing your injury. Generally, your doctor won’t want you putting any weight onto your foot, and you should elevate your foot to help reduce swelling. As long as your skin is okay and your bones are in a good position, you can usually go home from the emergency room and be seen by an orthopaedic surgeon in a clinic on another day.

This patient had a crush injury to his foot, part 1

This patient had a crush injury to his foot, part 2 — Figures 5-6: This patient had a crush injury to his foot. He had a LisFranc injury with a break to the 2nd-4th rays. On the x-ray of the side of the foot the blue lines should line up. When the bones don’t line up it can put pressure on the blood vessels of the foot. This causes lots of swelling which can be seen in the picture of his foot. The large blue arrow shows the soft tissue swelling over top of the bone. Because of the swelling in the foot, pins had to be used to temporarily hold the bones in place. Once the bones are lined up better, the swelling can go down. Surgery may be done later to replace the pins with plates or screws.

General Treatment

LisFranc injuries often require surgery. There are times when the bones are lined up in a way that allows them to heal without surgery. In that setting, they generally require a cast or splint and no weight bearing for several weeks to months.

Surgery can be done several ways. Screws, plates and screws or even pins can be used to hold your bones together. Your surgeon will make the decision how best to fix your specific injury. The bones can be fixed in a way that allows the ligament or bones to heal. This may keep the joints between the bones as they were. Your surgeon may also decide to fuse the bones together by removing the cartilage between the bones. A discussion about the risks and benefits of both of these options should be had with your surgeon. In surgery, pins may be placed through the skin to hold the bones in place. These may be taken out in clinic a few weeks later. This can be slightly painful, but in general is very quick and many patients tolerate the pain well.

If the bones are fixed and not fused together, the plates, screws or pins may need to be taken out later. This usually means another surgery that requires anesthesia.

Screws alone, plates and screws, or pins can be used to fix LisFranc injuries — Figure 7: Screws alone, plates and screws, or pins (as seen in Figure 6) can be used to fix LisFranc injuries.

Postoperative Care

After surgery, it is important to elevate your foot to reduce swelling. The skin on the top of your foot is thin, and swelling causes tension on the wound. Usually, you will be in a splint, cast or a boot for several weeks to months. This protects the bones and ligaments while they are healing. You will also probably not be able to put weight on your foot for 2-3 months while it is healing. This will require using crutches, a walker, a knee scooter, or even a wheelchair to get around safely. The most important thing is to follow the instructions of your surgeon. Falls, putting weight on your foot too early, or too much swelling can cause problems that may affect how you heal.

After a period of not putting weight on your foot, you may start physical therapy. The therapist may work on motion of your ankle, and once approved by your surgeon they may work with you on putting some weight on your foot. It is generally several months before you can put your full weight on your foot. While this may be frustratingly slow, it is important for proper healing of your bones and ligaments. It is important to follow the instructions of your surgeon.

Long Term

LisFranc injuries can have long term effects on your foot. Some people are able to get back to the activity level they had before the injury. However, it is common to have some persistent pain, stiffness, and weakness. This can happen even after a surgery and healing period that goes perfectly. Your foot takes all the weight of your body with each step. There is a lot of stress across these small bones and ligaments, and after a LisFranc injury they may not be as good as they were before your injury. This may mean that you have to modify your activities. It may also mean using special shoes or braces. Sometimes people require more surgery in the future.

Physical Therapy Videos - Foot & Ankle

More Information

American Academy of Orthopaedic Surgeons

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Christopher Domes, MD
Edited by the OTA Patient Education Committee and David Sanders, MD (section lead)
All x-rays and pictures taken from the personal collection of Dr. Domes