Introduction 

You injured your foot and still feel pain, but your X-ray came back normal?

You're not imagining it—pain always means something. In fact, there's a chance you have an injury called a Lisfranc injury that the X-ray didn’t catch. Fortunately, there are other imaging options that can reveal what the X-ray can’t: MRI and CT scan. Here’s what you need to know.

What is a Lisfranc Injury?

When you look at your feet, you may notice that at the junction of each toe, there are bones connected to them, resembling the shape of your fingers—called metatarsals¹. These bones approximately end at the top of the arch of your foot, forming the 'forefoot'. Before them, you'll find the five smaller bones forming your midfoot: the navicular, cuboid, and the three cuneiforms². The last part of your foot is your 'hindfoot', made up of the bone of your heel (calcaneus) and the ankle area with the talus³. 

The junction between your forefoot and midfoot is called the Lisfranc joint. The bones in this area are connected by ligaments. If any ligaments or bones in this area are injured, you're likely experiencing a Lisfranc injury¹.

Why do regular X-rays often miss it?

An X-ray is a 2D black and white picture of your anatomical structures. While big fractures can be seen clearly, sometimes you can miss smaller ones. Here's why:

• Undisplaced fracture: If bones haven't moved much, they might look normal on an X-ray
• If you have a hard time putting weight on your limb and do not stand on it, subtle shifts between bones might not show 
• Overlapping bones: Your midfoot is composed of many bones, sometimes making it hard to spot small separations of the joints 
• Human error: These injuries can be so subtle that sometimes even the most experienced radiologists can miss them

What a CT Scan Can Reveal?

A CT scan (computed tomography) provides a 3D view of your foot's internal structures, making it easier to detect joint separation (luxation) or subtle changes that may not appear on a regular X-ray. It is markedly helpful in evaluating bone injuries.

What CT scans are great for?

1. Tiny fractures that cannot be seen on standard X-rays⁶
2. Misalignment between bones, meaning the bones are no longer in their normal position, which may suggest a Lisfranc injury⁶
3. Comparing both feet side by side, which helps spot small asymmetries that could indicate a problem⁷
4. Measuring the space between bones (like between the medial cuneiform and second metatarsal), which can signal instability if the spacing is abnormal⁷

What an MRI Can Show?

What makes MRI (Magnetic Resonance Imaging) different from other imaging techniques is its ability to show not only bones, but also soft tissues like ligaments, tendons, muscles, and swelling. That’s why it’s especially useful for detecting non-bony Lisfranc injuries.

MRIs are ideal for:

1. Torn or stretched ligaments, especially the Lisfranc ligament—it can detect both elongated and fully ruptured ligaments⁸
2. Soft tissue swelling or internal bone bruising, which may appear as fluid or blood inside the bone after trauma⁹
3. Subtle instability, especially when both CT and X-ray appear normal, but pain or dysfunction remains⁸
4. Planning surgery, as MRI shows the full extent of ligament and joint damage, which helps determine if surgical repair is necessary⁹

CT vs MRI – What’s the Difference?

In short:

• You should get a CT scan if a bone injury is suspected
• You’ll likely need an MRI if your doctor suspects a soft tissue injury or if your pain persists despite a normal X-ray

How Doctors Decide What Imaging to Use

Here’s a simplified protocol doctors generally follow:

1. Start with an X-ray, ideally with the patient putting weight on the foot (if the pain allows it)¹⁰
2. If the X-ray is unclear, if the patient is still in pain, or if the doctor is unsure, they will usually order a CT scan to look for a bone fracture¹¹
3. If no bone injury is found, doctors may ask for an MRI to check for soft tissue damage, especially ligament injuries¹²
4. In general, if the fracture is displaced (meaning the broken bone pieces have moved) or if there is instability (bones moving when they shouldn’t), surgery is often required¹²

Even small Lisfranc injuries require close follow-up, because if left untreated, they can lead to chronic pain, joint degeneration, or long-term mobility issues.¹²

Summary

• Lisfranc fractures are often missed on X-rays, especially if they’re minor or non-displaced¹³
• CT scans are helpful for detecting small fractures or misalignments¹¹
• MRIs are essential to diagnose soft tissue injuries like torn ligaments¹²
• These two techniques are complementary and can speed up diagnosis and treatment¹²

If you’re still feeling pain in the Lisfranc area after a foot injury and a normal X-ray, talk to your doctor about getting a CT scan or an MRI.

You deserve clarity—and the right treatment.