A Lisfranc injury is a midfoot injury involving the tarsometatarsal joints, where the long bones of the foot (the metatarsals) connect to the midfoot bones (the cuneiforms and cuboid). In a Lisfranc injury, one or more metatarsals can shift (sublux or dislocate) relative to the tarsal bones, often alongside damage to the Lisfranc ligament, a key stabiliser between the medial cuneiform and the base of the second metatarsal.
Lisfranc injuries range from mild ligament sprains through to severe fracture-dislocations. They are important to recognise early because even small amounts of joint malalignment can change how load moves through the midfoot, increasing the risk of long-term pain and post-traumatic arthritis. For many people, physiotherapy for Lisfranc injury is essential, whether the injury is managed in a boot or cast, or after surgery, to restore movement, rebuild strength, and return safely to walking, running, work, and sport.
In day-to-day language, people may describe this as a “midfoot sprain”, “midfoot fracture”, “tarsometatarsal fracture”, or “Lisfranc fracture”. If you have significant midfoot swelling, bruising on the sole, or difficulty weight bearing after a twist or direct impact, it is worth being assessed promptly as these injuries can be missed early on.
Key Facts
- Lisfranc injuries are relatively uncommon but clinically significant. Large epidemiology research reports an incidence of about 1 case per 55,000 person-years (roughly 0.2% of all fractures). 🔗
- An estimated 20 to 40% of Lisfranc injuries are initially missed, which is why early assessment, weight-bearing imaging when appropriate, and timely referral are important. 🔗
- Plantar bruising (the plantar ecchymosis sign) is a recognised clinical warning sign of significant Lisfranc injury and should prompt careful evaluation, even if early X-rays look normal. 🔗
- Stable, minimally displaced Lisfranc injuries (often defined as less than 2 mm displacement) can have good outcomes with non-operative management in appropriately selected cases. 🔗
Risk Factors
- High-energy trauma such as motor vehicle accidents, falls from height, or crush injuries.
- Sports involving fixed foot positions (bindings) and rotational falls.
- Field sports with tackling, pivoting, and contact while the foot is planted.
- Reduced ankle mobility or calf tightness that increases midfoot loading during gait.
- Previous foot or ankle injury that changes load distribution through the midfoot.
Symptoms
- Midfoot pain, often described as deep aching across the top of the foot or through the arch.
- Swelling over the midfoot, sometimes spreading into the forefoot.
- Difficulty weight bearing, including limping or inability to walk normally.
- Pain when walking downstairs, pushing off, or trying to stand on tip-toes.
- Bruising on the top of the foot and, importantly, bruising on the sole (plantar bruising).
- A feeling that the foot is unstable, “shifts”, or collapses through the midfoot when trying to walk.
Aggravating Factors
- Standing, walking, or any attempt to push off through the forefoot (toe-off).
- Walking downstairs or downhill, where the midfoot is loaded while the ankle bends.
- Trying to run, jump, cut, or pivot (even if the injury started as a simple twist).
- Tight footwear that compresses a swollen midfoot, or unsupported shoes that allow midfoot collapse.
Causes
Lisfranc injuries occur when the tarsometatarsal joints are forced beyond their normal range and the stabilising ligaments are strained or torn, sometimes with associated fractures. The most common injury zone involves the second tarsometatarsal joint and the Lisfranc ligament complex, which acts like a strap tying the midfoot together.
Direct trauma is a common cause, such as a heavy object falling onto the top of the foot, the foot being run over, or a high-force crush injury (for example motor vehicle accidents or workplace injuries). Indirect trauma can also cause Lisfranc injuries, typically when the foot is pointed down (plantarflexed) and a twisting force is applied. This can happen when a foot gets stuck and the body rotates, when a rider falls while the foot remains in a stirrup, or during a sports tackle when the foot is planted.
Sports with bindings over the forefoot (for example snowboarding, wakeboarding, and kitesurfing) can increase risk if a fall twists the foot while it is fixed in place. Ballet dancers may also be at risk during spins and turns performed on a pointed foot. In some cases there may be significant soft tissue swelling and, rarely, blood vessel or nerve compromise, which increases the urgency of medical review.
How Is It Diagnosed?
Diagnosis is based on a combination of injury history, symptoms, and imaging. A physiotherapist will usually start with a careful subjective assessment of the mechanism (direct crush vs twist on a pointed foot), followed by examination of swelling, bruising patterns, tenderness, and the ability to weight bear. Specific findings that raise suspicion include midfoot swelling, pain with forefoot twisting or midfoot stress, and bruising on the sole (plantar bruising), which can be a red flag for deeper ligament injury.
Because Lisfranc injuries can be subtle early on, and because missing them can lead to long-term problems, a physiotherapist will commonly recommend medical imaging and urgent referral when red flags are present. You may be advised to avoid weight bearing until you have been reviewed by a GP, emergency department, or orthopaedic specialist.
Investigations & Imaging
- Weight-bearing X-ray (both feet for comparison when possible)
- Assesses alignment at the tarsometatarsal joints and looks for widening (diastasis) or subtle displacement that may not appear on non-weight-bearing images.
- CT scan
- Provides detailed bony assessment, identifying small fractures and joint surface involvement that can be missed on plain X-ray.
- MRI
- Best for assessing ligament injury and associated soft tissue damage, particularly when X-rays are normal but clinical suspicion remains high.
Grading / Classification
- Hardcastle Type A
- Total incongruity: all metatarsals displace in the same direction as a unit.
- Hardcastle Type B
- Partial incongruity: one or more metatarsals displace, but not all of them.
- Hardcastle Type C
- Divergent pattern: metatarsals displace in different directions, often reflecting higher instability.
Physiotherapy Management
Physiotherapy for Lisfranc injury is designed around protecting the healing midfoot, restoring mobility and strength safely, and progressively rebuilding walking and running tolerance. Your physiotherapist will align rehab with your orthopaedic plan. This matters because Lisfranc injuries can behave very differently depending on whether the joint is stable (managed in a boot or cast) or unstable (managed surgically).
Across both pathways, the priorities are: controlling pain and swelling, maintaining ankle and toe mobility without stressing the midfoot, rebuilding calf and foot strength, restoring balance and confidence in weight bearing, and retraining gait so you do not overload the midfoot during recovery.
Exercise
Physiotherapy exercises begin with movements that protect the midfoot while keeping the rest of the limb strong. Early exercises often include gentle toe range of motion, ankle pumps, and isometric calf and lower-limb strengthening to limit deconditioning while you are in a boot or non-weight bearing. Your physiotherapist may add hip and knee strengthening because better control at the hip and knee can reduce abnormal foot loading when you return to walking.
As weight bearing is cleared, exercises progress to controlled foot and ankle strengthening, such as seated heel raises, then standing heel raises, and later single-leg calf work. Balance training is introduced early in weight bearing because midfoot injuries commonly reduce confidence and proprioception. In later rehab, you may work on controlled midfoot loading drills, step-ups, and sport-specific progressions, with clear criteria for increasing load based on pain, swelling response, and gait quality.
If your rehab is post-operative, your physiotherapist will also address scar and soft tissue mobility (once appropriate), and carefully restore ankle and forefoot mobility while respecting the surgeon’s restrictions on midfoot motion.
Activity Modification
Activity modification is not just “rest”. It is a structured plan to protect the injured tarsometatarsal joints while keeping you active in safe ways. Your physiotherapist will help you understand which activities stress the midfoot most, particularly walking long distances, pushing off, stairs, and uneven ground. Early on, you may need crutches, a scooter, or strict non-weight bearing as directed.
When weight bearing is allowed, physiotherapy focuses on graded exposure: short, flat walks first, then gradually longer distances, then inclines, then faster walking, then running drills when appropriate. For athletes, a staged plan may include bike or pool conditioning first, then a return-to-run program that avoids sharp cuts and pivots until the midfoot is strong and symptoms remain stable.
Footwear changes are usually part of activity modification. Supportive, stiff-soled shoes can reduce midfoot bend and help you tolerate walking earlier in the return phase.
Manual Therapy
Manual therapy in Lisfranc injury rehab is used thoughtfully. The goal is to restore mobility in surrounding joints without overstressing the injured tarsometatarsal region. Early manual therapy commonly targets the ankle, subtalar joint, and toes to prevent stiffness that develops when you have been immobilised. Your physiotherapist may use soft tissue techniques to manage calf tightness and swelling, and later use joint mobilisation techniques to help normalise ankle movement that affects push-off.
If you have surgery, manual therapy may include scar management and soft tissue work around the incision sites once healing allows. Midfoot-specific techniques are typically introduced only when cleared and only if stiffness is a limiting factor, because aggressive midfoot mobilisation too early can aggravate symptoms or risk joint irritation.
Postural Retraining
“Posture” for Lisfranc rehab is really about whole-limb alignment during walking and running. Many people unconsciously avoid midfoot loading by turning the foot out, limping, or shortening stride length. Over time this can overload the ankle, knee, hip, or the other foot. Physiotherapy focuses on gait retraining so weight shifts smoothly through the heel, midfoot, then forefoot without a sudden collapse or a painful push-off.
Your physiotherapist may work on pelvic and hip control drills, step mechanics, and cadence changes for runners. The aim is to reduce twisting forces through the midfoot and improve shock absorption through the whole limb.
Bracing & Taping
Bracing and taping can be helpful in Lisfranc injury rehab, especially during the transition back to weight bearing. A boot provides rigid protection early. Later, taping can reduce midfoot motion and provide confidence when returning to walking. Some people benefit from a carbon fibre insert or stiff insole to limit midfoot bending in regular shoes during the return-to-activity phase.
Your physiotherapist may also use taping to reduce swelling and improve comfort, and to guide load through the foot during gait retraining. Importantly, taping is a support, not a substitute for progressive strengthening and graded loading.
Heat & Ice
Ice can assist with pain and swelling in the early stage and after activity increases. Your physiotherapist may recommend short ice applications after walking progressions to help manage flare-ups. Heat is used less commonly early on, but may be used later for calf and ankle stiffness once swelling has settled.
Tens
TENS can be used as part of pain management for Lisfranc injuries, particularly when you are transitioning from immobilisation to weight bearing and discomfort limits movement. It is generally used as an adjunct to rehabilitation, not a primary treatment.
Education
Education is a major part of Lisfranc injury rehab. Your physiotherapist will explain what activities load the midfoot, what swelling patterns are acceptable during progression, and how to pace increases so you do not provoke a significant flare. You will also be educated on footwear choices, how to use crutches or a boot safely, and how to recognise red flags such as increasing pain, progressive deformity, numbness, or new colour change in the foot.
For athletes, education includes realistic timelines, return-to-run criteria, and how to modify training to protect the midfoot while maintaining overall conditioning.
Other
Other physiotherapy management may include a return-to-work plan (particularly for standing jobs), safe conditioning options such as cycling or deep-water running, and coordination with your GP and orthopaedic team. If you have ongoing midfoot sensitivity, your physiotherapist may also guide graded exposure to weight bearing, sensory desensitisation strategies, and progressive walking tolerance targets.
Other Treatments
Other treatments can include immobilisation in a cast or boot, pain relief medications as advised by your doctor, and orthotics or shoe modifications during the return-to-walking phase. Non-surgical management is generally reserved for injuries confirmed to be stable, with no concerning separation of the joints on weight-bearing imaging.
Some people benefit from a stiff-soled shoe, carbon insert, or custom insole during later rehab to reduce midfoot bending as activity increases. These supports are usually paired with physiotherapy so that strength, balance, and movement quality keep improving rather than relying solely on external support.
Surgery
Surgery is commonly recommended for unstable Lisfranc injuries, displaced fracture-dislocations, or injuries that show diastasis or malalignment on imaging. The most common operation is open reduction and internal fixation (ORIF), where the surgeon realigns the joints and stabilises them with screws and/or plates. In some cases, particularly when joint surfaces are severely damaged or instability is high, a surgeon may recommend primary fusion (arthrodesis) of the involved joints.
After surgery, a period of immobilisation and restricted weight bearing is typical. Once cleared, post-operative physiotherapy becomes vital to restore ankle and foot movement, rebuild strength, retrain gait, and prepare for return to work and sport. A thorough Lisfranc injury rehab program also aims to reduce the risk of long-term stiffness and secondary arthritis.
Prognosis & Return to Activity
Recovery depends on injury severity, whether surgery was required, and how quickly the injury was diagnosed and protected. Stable injuries managed non-operatively may progress faster once weight bearing is safe, while displaced injuries and surgical cases generally require a longer rehabilitation period.
In most cases, a phased physiotherapy program is needed to rebuild walking tolerance, restore strength, and normalise gait. For sport, return is guided by criteria rather than a single date: minimal swelling after activity, good single-leg strength and balance, and the ability to walk briskly and perform functional drills without pain spikes. Many athletes require months, not weeks, to return to full competition after a Lisfranc injury, particularly in sports involving sprinting, cutting, or jumping.
Complications
- Post-traumatic midfoot arthritis causing ongoing pain and stiffness.
- Persistent swelling and reduced tolerance to standing and walking.
- Chronic midfoot instability or collapse if the injury heals with malalignment.
- Secondary issues such as ankle or knee pain due to altered gait patterns.
Preventing Recurrence
- Build lower-limb strength and control, especially calf, hip, and balance work, to reduce twisting forces through the midfoot during sport and uneven ground walking.
- Use sport-specific footwear and check binding setup (for example snow sports) to reduce rotational stress through the forefoot during falls.
- Progress running and field training gradually after any midfoot sprain, and avoid early return to cutting and pivoting until your physiotherapist has cleared strength and balance benchmarks.
- Address ankle mobility restrictions early. Limited ankle dorsiflexion can increase compensatory midfoot bending and load at the tarsometatarsal joints.
When to See a Physio
- If you cannot weight bear after a twist, fall, or direct impact to the midfoot.
- If you notice bruising on the sole of the foot (plantar bruising) or rapid midfoot swelling.
- If pain persists beyond a few days despite rest, especially if stairs and push-off are difficult.
- If you have already been told it is a “sprain” but you are not improving as expected, as Lisfranc injuries can be missed early.