Lisfranc Injuries Explained: Causes, Symptoms & Physiotherapy Treatment

Foot injuries are common, but some are far more serious than they seem at first. A Lisfranc injury is one of them. Many people initially brush off the pain as a simple “midfoot sprain,” only to realise later that the injury is far more complex and requires structured management.

If you’ve had a twisting injury, fall, or impact to the midfoot and you’re struggling to walk normally, this guide will help you understand what a Lisfranc injury is, how it happens, and how physiotherapy supports your recovery.

What Is a Lisfranc Injury?

A Lisfranc injury is damage to the ligaments in the middle of your foot, specifically where the long bones (metatarsals) connect to the small arch bones (cuneiforms). This area is crucial for stability when you walk, run, or push off your toes.

When this ligament is torn or the joints shift out of position, the midfoot becomes unstable which makes every step painful.

Injury severity ranges from:

• Sprain — partial ligament damage

• Diastasis — separation/widening between the metatarsals

• Fracture-dislocation — ligament rupture plus fractures in the metatarsal bases or cuneiforms

  
  

Because this ligament is a keystone for midfoot stability, any injury can significantly affect foot mechanics.

How Do Lisfranc Injuries Happen?

Everyday Low-Energy Causes (Layman’s Terms):

• Twisting your foot when stepping off a curb

• Your foot gets caught and twists while the body keeps moving

• Missing a step on the stairs

• Slipping with the foot plantarflexed (toes pointed down)

• Landing awkwardly on toes or the middle of the foot

  
  

High-Energy Causes (Sporting or Trauma):

• Tackles where the foot is planted

• Motor vehicle accidents

• Falls from height

• Direct impact on the top of the foot

  
  

Even “mild-looking” mechanisms can cause serious internal ligament damage.

Common Signs & Symptoms

What Patients Usually Feel:

• Pain in the middle of the foot or arch

• Difficulty pushing off the foot when walking

• Swelling across the top of the foot

• Pain when standing on toes or doing a calf raise

• Bruising on the bottom of the foot (a red flag for Lisfranc injuries)

• Feeling like the foot is “collapsing” or unstable

  
  

Clinical Signs Physiotherapists Assess:

• Tenderness at the base of the 2nd metatarsal

• Pain with midfoot stress tests (torsional stress, piano key test)

• Pain with passive abduction or pronation of the forefoot

• Inability to perform a single-leg calf raise

• Gait changes: shortened step length, flat-foot walking

• Widening of the forefoot in moderate (severe cases)

  
  

If a Lisfranc injury is missed or managed poorly, it can lead to long-term deformity and arthritis, so early assessment matters.

Physiotherapy Treatment for Lisfranc Injuries

Treatment depends heavily on the severity of the injury. Lisfranc injuries fall into two broad categories:

• Stable (non-displaced) Lisfranc sprains

• Unstable (displaced) Lisfranc injuries, often requiring surgical consultation

1. Initial Management

Imaging

Lisfranc injuries almost always require imaging to confirm the severity:

• X-ray (weight-bearing)

• MRI to assess ligament damage

• CT if fractures are present

  
  

Your physio will recommend referral to a GP or foot & ankle specialist if the injury appears unstable.

Offloading & Protection

Most Lisfranc injuries require:

• CAM boot for 4–6+ weeks

• Non-weight-bearing (crutches) in moderate/serious cases

• Avoiding any pushing-off motions

• Ice and elevation for swelling

  
  

Even mild sprains need protected loading early on to avoid further ligament damage.

2. Mid-Stage Rehabilitation (After Protection Phase)

When cleared to begin loading, physiotherapy focuses on:

Restoring Mobility

• Gentle midfoot mobility

• Ankle and toe range-of-motion exercises

• Careful progression to avoid overstressing healing ligaments

  
  

Strengthening

• Intrinsic foot muscles (short foot exercises, doming)

• Tibialis posterior for arch support

• Peroneals for lateral stability

• Calf strength (progressing from seated to standing)

• Balance training (starting bilateral → single-leg)

  
  

Gait Retraining

Correcting:

• Avoided push-off

• Excess pronation

• Guarded walking patterns

3. Late Rehabilitation & Return to Sport

When pain-free walking and strength return, progression includes:

Functional Strength Work

• Step-ups, sled pushes

• Single-leg calf raises

• Light plyometrics

  
  

Running Progression

• Walk–jog intervals

• Straight-line running

• Later: change-of-direction, acceleration, deceleration

  
  

Sport-Specific Drills

• Cutting, pivoting, jumping

• Contact preparation for field athletes

Return to full sport can take:

• 12–16+ weeks for mild sprains

• 4–6 months or longer for surgical cases

Differential Diagnosis (What Else Could It Be?)

Physios rule out several other conditions that mimic Lisfranc injuries:

1. Midfoot Sprain (Non-Lisfranc)

• Less severe ligament involvement

• No diastasis or instability

  
  

2. Stress Fractures

• 2nd metatarsal base, cuneiform, navicular

• More focal tenderness

  
  

3. Extensor Tendinopathy

• Pain more on the top of the foot

• Worse with resisted toe extension

  
  

4. Tibialis Posterior Tendinopathy

• Pain along inner ankle/arch

• Progressive collapse of arch

  
  

5. Cuboid Syndrome

• Lateral midfoot pain

• Often linked to peroneal dysfunction

  
  

6. Midfoot Osteoarthritis

• Chronic stiffness and swelling

• Not linked to a sudden injury

  
  

7. Plantar Fasciitis

• Pain near heel, not midfoot

• Worse in the morning 

  
  

A Lisfranc injury isn’t something you “walk off.” Because the ligament is a key stabiliser of the midfoot, damage can lead to serious long-term issues if not managed properly.

The good news? With the right diagnosis, structured offloading, and a progressive physiotherapy plan, most people return to full activity safely and confidently.

If you’ve had a twist, fall, or midfoot pain that hasn’t improved, early physiotherapy assessment can save months of complications.