Introduction

A Lisfranc injury is a disruption to one or more Lisfranc joints, more commonly known as tarsometatarsal joints. This joint connects the midfoot to the forefoot and plays a crucial role in everyday movement, maintaining stability.¹ The word Lisfranc is named after a French surgeon, Jacques Lisfranc de St. Martin, who was the first physician to describe injuries to this ligament.² Injuries can include dislocations, fractures, and sprains, and they can greatly vary in severity.³ Lisfranc injuries are rare, with one in every 55,000 incidences reported in 2006; however, it is important that this injury is not missed and is treated appropriately, as it can cause long-term damage. However, to do so requires diagnostics, which have been recognised as quite challenging for Lisfranc injuries.^4,5 The purpose of this article is to explore why there are diagnostic challenges and how to improve detection.

Anatomy and mechanism of injury

In simple words, the Lisfranc joints connect foot bones called tarsals to longer foot bones called metatarsals. There are 5 metatarsals, and each of them connects to a different tarsal. These joints are joined together tightly by ligaments, which restrict their movement.⁶ As there are many different bones involved, this complexity can raise diagnostic challenges. High-energy trauma is defined as injuries caused by forces such as falls or motor accidents, whereas low-energy trauma is when injuries are caused by mechanical force, which, on a usual basis, would not cause injury, for example, a little trip.^7,8 Generally, Lisfranc injuries can be caused by both high- and low-energy trauma. In Lisfranc injuries resulting from high-energy trauma, misdiagnosis can occur due to polytrauma within the patient, causing distracting injuries. On the contrary, low-energy trauma Lisfranc injuries can also cause diagnostic issues, as there are fewer obvious clinical signs which can be flagged to healthcare professionals.⁹ Unlike simple ankle sprains or heel fractures, Lisfranc injuries involve complex joint structure and hidden ligament damage, making them particularly easy to overlook during initial assessment.

Types of lisfranc injuries and their presentation

Types of Lisfranc injuries include sprains or ruptures (injury to the ligament), fractures (broken bones), or dislocations (bones out of place). These injuries can merge, further adding to the complexity and severity of the condition. There are several symptoms which are recognised to be associated with Lisfranc injuries, but these symptoms are generally quite vague and can match other conditions. Despite their vagueness, common symptoms include:

• Persistent pain in the centre of the foot, causing struggle to walk or stand up / difficulty bearing weight
• Swelling of the foot
• Bruising
• Numbness and tingling sensation
• Broadening of the midfoot¹⁰

One important thing to understand about Lisfranc injuries is that some are easy to spot, while others are much more subtle. The obvious ones usually show clear signs on an X-ray, like bones out of place or fractures. Subtle injuries can look like a basic sprain at first, which makes them easy to miss. That’s a big problem because if they’re not diagnosed and treated early, they can lead to serious issues down the line—like the arch of your foot collapsing, painful arthritis, or ongoing, chronic pain. Catching it early really makes all the difference.

Diagnostic imaging challenges

Limitations of plain radiographs

Radiography is a pivotal imaging technique used in healthcare which utilises ionising radiation such as X-rays and gamma rays. They are fantastic for capturing internal structures of the body or certain objects. So, in the case of Lisfranc injuries, they are great to see any potential fractures.¹¹ A plain radiograph refers to the sole use of the fundamental X-ray. While it is still great to produce images, there are some notable limitations with the plain radiograph, such as its difficulty capturing soft tissue damage, limited detail for complex fractures, and, of course, its exposure to ionising radiation.¹²

Advanced imaging techniques

A computed tomography (CT) scan is a more advanced form of an X-ray, as it involves a series of them to produce a more detailed image of bones and even soft tissues. It is used frequently to detect injuries. CT scans are great for determining the location, extent, and severity of fractures, which X-rays can struggle with.¹³ Another imaging technique is the MRI scan, which has no potential adverse health risks like CT scans or X-rays, as it does not utilise ionising radiation; instead, it uses magnets. The MRI provides high-resolution views of soft tissues such as ligaments, tendons, muscles, and cartilage, which makes it a valuable tool for identifying ligament tears associated with Lisfranc injury, compared to the CT scan, which is more advantageous for fractures.¹⁴

Clinical examination and missed diagnoses

The symptoms overlap with lots of other injuries. For example, symptoms such as midfoot swelling and tenderness are often mistaken for a simple sprain or other soft tissue injury. Clinical examination needs to be thorough and effective to avoid this, and different tests can help differentiate between a Lisfranc injury and something else. Certain tests can include the midfoot stress test, which involves squeezing the foot to help diagnose stress fractures. In terms of imaging techniques for diagnosis, a fundamental tool is the X-ray, but these may be inconclusive; therefore, CT scans or MRI are used for better detection of both bone and soft tissue.¹⁵

Consequences of missed or late diagnosis

A study found that 10 out of 17 patients had their injuries missed at the initial presentation, and this can have consequences, including chronic pain, difficulty bearing weight, and general discomfort. It can also lead to more serious complications such as flatfoot deformity and arthritic changes. Missing injuries at the initial presentation consequently lead to a delayed diagnosis, which often requires secondary surgical intervention. This is less favourable, as it is more invasive and uncomfortable for the patient. Furthermore, these delays often result in prolonged recovery and increased long-term disability, as shown by poorer outcomes in conservatively treated patients.¹⁶

Missing or delayed diagnosis also has emotional consequences. The continuous pain and discomfort can turn a physical challenge into a mental one. This further heightens the difficulty of carrying out day-to-day activities and can make it harder for individuals to seek help.

Strategies for improving diagnosis

There are several ways in which the accuracy of diagnosis can be improved. One of them is for clinicians to seek diagnostic feedback, as most inaccurate diagnoses are not looked into or questioned as to why they were incorrect. By learning from real-world cases, future diagnoses can improve.

As well as that, studying in short, frequent sessions can help the brain to build better and more useful mental models of how the injury presents, to recognise patterns faster and avoid common mistakes in the future. This can be done by using digital resources or the healthcare team testing themselves regularly.

One last strategy that can largely improve diagnosis is building a strong multidisciplinary team and making diagnosis more of a team effort. Different disciplines of healthcare can each contribute towards diagnostics, for example, having orthopaedic or foot/ankle specialists. New AI tools are being created to help spot subtle signs on X-rays that doctors might miss, which could lead to catching these injuries earlier.¹⁷

Summary

In summary, Lisfranc injuries are quite a rare type of injury, and their rarity contributes to diagnostic challenges. Common symptoms of a Lisfranc injury include pain, swelling, and bruising, but these symptoms overlap with so many other conditions, which can lead to misdiagnosis. Accurate diagnosis is vital, as it means individuals can receive appropriate treatment promptly. In the case of misdiagnosis, this can lead to persistent issues and may even develop into more serious conditions.

One big factor for accurate diagnosis is for a condition to be well studied so that clinicians can spot the flags of this injury, which, in this case, it is not. Therefore, a key step to improving diagnosis is to study the condition further, and when there is a misdiagnosis, the reasons for this mistake need to be studied to avoid issues in the future. Also, building a diagnostic team with diverse expertise can greatly improve diagnosis, as different knowledge will help make the most educated decision.