Overview

A Lisfranc joint injury refers to the damage of the bones or ligaments of the midfoot, typically caused by trauma, such as a fall, car accident, or sports injury. This injury can range from a mild strain of a ligament to a complete rupture of a tendon with dislocated bones. The Lisfranc joint complex is a crucial part of the foot, and when injured, it can significantly impact the foot's function, leading to instability, pain, and issues with walking, standing, and sports activities. The long-term outcomes vary widely depending on the severity of the injury, the speed at which diagnosis occurred, the treatment employed, and the individual themselves. For most, the foot heals very well, and they are left with minimal long-term effects, whereas for others, they suffer from chronic pain, such as arthritis, functional limitations, and may even require further procedures to help manage the pain, leading to a lower quality of life. These injuries, while relatively uncommon, can significantly impair function and looking at long-term outcomes and quality of life of previous patients allows for a deeper understanding of how treatment can develop and be more catered to future patients. 

What is the Lisfranc joint?

The Lisfranc joint is a collective of bones and ligaments that connect the midfoot and forefoot. Specifically, the cuneiforms and cuboid of the midfoot meet the metatarsals of the forefoot. The midfoot is made up of five bones that form the arch of your foot. This part of the foot is crucial for everyday tasks, such as standing, and light physical activities. 

What causes Lisfranc injuries?

An injury in this joint is typically caused by the displacement of the bones and ligaments, leading to damage in the bones or ligaments in the midfoot. This injury can be especially difficult to manage as the midfoot is responsible for foot stability, efficient movement, and shock absorption. These injuries can be described as low or high-energy. Low-energy injuries are caused by a relatively low impact, such as a twist or fall. These are commonly associated with sports and can be easily missed or misdiagnosed as a regular ankle sprain. Symptoms in low-energy injuries include midfoot pain, swelling, and bruising.² 

A high-energy injury is much more severe and occurs in high-impact situations such as falls from heights, or car accidents. These are characterised by multiple fractures, and potential damage to ligaments and surrounding soft tissues. Common symptoms involve significant pain and swelling in the midfoot. These injuries are much easier to diagnose, as there are obvious 

deformities associated with them, allowing for a better long-term outlook and fewer complications. Low-energy injuries misdiagnosis happens in close to 20% of cases,³ leading to 

inappropriate treatment and less beneficial long-term outcomes for patients.⁴ The challenges in diagnosis are associated with the subtlety of the injury, inadequate imaging, as standard X-rays can miss initial injuries and insufficient patient care to ensure that all bases have been covered. Misdiagnosis can significantly impact the care of the patients as Lisfranc injuries are understood to worsen over time as the patient continues to walk and athletic activities. In severe cases, this can lead to the arch of the foot collapsing, causing significant functional impairment.⁵

What are the treatment approaches?

Lisfranc injuries can be treated in various ways. Nonsurgical methods can be employed if only a ligament sprain is present. In this case, immobilisation of the foot can be utilised, using a cast to keep the foot stable and prevent weight bearing, which allows the injury to heal. After six weeks, if the pain in the midfoot has disappeared, a return to sports activity is allowed, while using an insole to support the arch.⁶ Surgical options are recommended in cases of instability in the foot, such as fractures, dislocations, or complete ligament tears.⁷ Surgery aims to properly align bones and joints. This includes the use of bolts to increase stability in the Lisfranc complex, and this is known as open reduction and internal fixation (ORIF),⁸ or can include the use of fusion of the affected joints to create the desired stability, known as joint fusion. Joint fusion is preferred in cases with severe injuries where reconstruction is difficult.⁹ The choice of surgery is not only dependent on the severity of the injury but can also be influenced by the patient. In the case of a young athlete, surgery may be preferred as it will allow a better return to action. This was shown in the case of NBA athlete Chet Holmgren, player for the Oklahoma City Thunder. He ruptured a tendon in the Lisfranc joint and required two separate procedures. The first was an ORIF surgery where bolts were used to increase stability in the foot and promote healing. The second procedure was a surgery to remove the ‘hardware’ in the foot. After the first procedure, Holmgren used a walking boot and a scooter to prevent weight being placed on the injured foot. After the second procedure. Holmgren was able to rehab and take steps toward an NBA return. 

In the initial phase of recovery after surgery, the objective is to protect the injury site and prevent stress on the joint; this can again include a cast to prevent weight bearing and promote healing.¹⁰ Early rehabilitation aims to restore basic movement through a gradual progression of weight bearing guided by the physician and X-rays. As healing progresses, more demanding activities can be added to the routine, such as walking. Full rehabilitation is a lengthy process and is not completely linear; regular follow-up appointments can help patients, as physicians can monitor healing and address any complications the patient may have. Patients can aid their own progress in various ways, such as wearing shoes that support the arch and provide cushioning. Patients can also avoid smoking, as it can delay healing.

Long-Term Outcomes

In mild cases, patients may regain normal foot function after 6 -12 months, while those with more severe injuries may continue to experience limitations. Of the 22 NBA, WNBA, NCAA Men's and Women's basketball players with Lisfranc injuries, 17 of them were able to return to the court. The players who retired possibly faced challenges when returning and were unable to return to pre-injury performance levels.¹¹ In the case of non-athletes, generally, patients are able to restore foot function, specifically the ability to walk, stand, and undergo light physical activities, such as jogging. After injury, the biggest concern is post-traumatic arthritis. Unfortunately, this can occur even with correct treatment of the injury, but it is more likely to develop if the joint is not properly aligned or if the injury was particularly severe. The arthritis can be treated through physical therapy and orthotics. In severe cases, joint fusion may be required to reduce pain and improve function.¹² In cases where arthritis does not present, residual pain and swelling may still be present for years after the injury. After the initial Lisfranc injury, the joint may be weaker and have impaired function, increasing the chance of a re-injury, especially in athletes.¹³ The long-term mental impact of the injury must also be considered. Patients may be confronted with anxiety and a loss of confidence in their mobility. Chronic pain or inability to return to previous levels may cause distress. Patients and their physicians can discuss methods for alleviating these feelings through recommendations of counselling. Overall, many patients can enjoy a functional level of mobility after the injury and can return to normal life. Some patients may face more challenges that require ongoing management. In the case of Chet Homgren, he was able to return and be an integral part of the 2025 NBA Champions, the Oklahoma City Thunder. Overall when looking at a Lisfranc injury and the quality of life of the patient after the injury, the most important factors are the original diagnosis; ensuring that its early and that the injury is not misdiagnosed, the treatment method chosen; ensuring that whether surgery or a less invasive method is used, that it is the correct method for the patient and their body, and finally, the patient themselves; ensuring that they adhere to the guidelines, listening to their body and being patient with themselves will allow them and their physician to create the best treatment plan and help them recover effectively.