Mid Foot Injuries in Athletes: Lisfranc Injuries Skip to main content

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Mid Foot Injuries in Athletes: Lisfranc Injuries

Mid Foot Injuries in Athletes: Lisfranc Injuries - El Paso Chiropractor

Athletes are subjected to experience a variety of injuries or conditions due to their exposure of rigorous activities. While they may be highly trained to warm up and exercise accordingly before engaging in their specific physical activity or sport, an accident during practice or training can often be unpredictable and inevitable. From landing incorrectly after a jump to simple degeneration, athletes who frequently utilize their feet in numerous exerting ways are more prone to suffer foot injuries than the general population.
Foot injuries occur frequently among athletes and they manifest in various forms. From stress fractures of the metatarsals and tarsal bones to chronic soft tissue injuries, such as plantar fasciitis and midfoot sprains to the joints between the tarsals and metatarsals. Although generally considered to occur infrequently, injuries to the midfoot, specifically the Lisfranc joint or the tarsometatarsal joint during Lisfranc injuries, these afflictions require special attention as they can be considerably devastating to most athletes.
Lisfranc injuries are high speed injuries which can result in serious deformity of the midfoot joints, commonly due to dislocations and/or fractures. Automobile or motorcycle accidents, violent falls onto the foot or a severe, crushing injury to the foot, are several of the most common circumstances which can lead to Lisfranc injuries. In sport settings, this form of foot injury is less severe, often resulting from a crushing and/or twisting means to the planted weight-bearing foot. But, when it does occur, Lisfranc injuries can cause overwhelming consequences for the athlete.
Approximately 16 percent of all sports injuries involve the foot. Although foot complications in athletes are reasonably common, Lisfranc injuries are quite rare. Researchers found that Lisfranc injuries account for up to 4 percent of all college level football injuries. Severe forms of the complication can unfortunately not only be season-ending but career-ending as well for the athlete.
Per researchers, this type of foot injury is more frequent in sports such as football, with an increased percentage of Lisfranc injuries occurring in offensive linemen, followed by rugby, as these types of sports usually involve high levels of contact through the foot. The injury has also been reported to occur in baseball, gymnastics, horse riding, windsurfing, rodeo riding and skydiving.

Anatomy of the Lisfranc Joint

The skeletal structure of the foot is intricately supported by ligaments as well as the intrinsic and extrinsic muscles which extend through the plantar arch and dorsum of the foot. The Lisfranc complex is a term utilized to describe the articulation between the midfoot and forefoot. It includes the joints surrounding the proximal row of cuneiforms and cuboid along with the distal row of metatarsal heads. Injury to this area of articulations can develop in various ways.
The natural concave structure of the foot shapes into a solid formation together with ligaments and other tissues of the midfoot, composing a very strong and stable structure to prevent the arch of the foot from collapsing.
Lisfranc Joint Anatomy Diagram - El Paso Chiropractor
The Lisfranc joint is comprised of three main sections: first, the medial column, the joint found between the first metatarsal and the medial cuneiform which allows for 3.5 mm of dorsal plantar movement; second, the middle column, consisting of the second metatarsal and its articulation with the medial and middle cuneiform as well as the lateral cuneiform. This joint is believed to have greater structural stability and it forms the keystone of the Lisfranc joint. The third metatarsal and the lateral cuneiform also comprise the middle column, which allow for less than 1 mm of movement; and last, the lateral column, the joint between the cuboid and the fourth and fifth metatarsals, the most mobile articulation, allowing for up to 13 mm of movement.
Lisfranc Ligament Anatomy Diagram - El Paso Chiropractor
Each column is separated by three different synovial capsules, constituting for three synovial systems. These structures are stabilized by the metatarsal interosseous ligaments, however, the base of the first and second metatarsals do not contain any intervening interosseous ligaments, but rather, the second metatarsal is connected to the medial cuneiform through the plantar oblique ligament, best referred to as the Lisfranc ligament. This allows each structure to function independently from the other, an essential function towards the normal locomotion of the foot. Despite this, the dorsal surface of this joint is considerably unstable, often causing the metatarsals to dislocate as a result when increased pressure is distributed to the foot.
Longitudinal and Transverse Arches of the Foot Diagram - El Paso Chiropractor

Mechanism of Injury

The area of the midfoot is also supported by overlapping tendons. Each tendon belongs to the tibialis anterior and attached to the dorsum of the first metatarsal base and medial cuneiform, the peroneus longus which attaches to the plantar and lateral section of the first metatarsal, and the tibialis posterior tendon, attaching to the navicular to indirectly control the position of the arch. Moreover, the plantar fascia and the intrinsic muscles of the foot add additional support to the arch of the foot.
Lisfranc injuries affecting the middle of the foot can be categorized from low energy to high energy. Low energy injuries can be identified as ligamentous in nature where minor dislocations and bone fractures occur. High energy injuries typically occur after automobile accidents where midfoot dislocations and fractures occur.
Low energy Lisfranc injuries of the midfoot commonly occur in athletes. For instance: a forced hyper-plantar-flexion of the midfoot where the foot remains in a fixed motion can cause injury to the foot. In horse riders and windsurfers, this circumstance occurs frequently because their foot is usually fixed by a strap. In the case a rider or surfer falls backwards during an accident, the load of the body pushes the foot into a position of intense plantarflexion while the foot is still tied to the strap; also, a direct impact to the heel while the foot remains locked in plantarflexion can also cause a Lisfranc injury. This scenario results when weight falls onto the back of the heel during the pushing off process of movement, forcing the structures of the foot to compress. This can be seen in football where a player is about to push off and another player falls on that foot while it’s in a position of plantarflexion. It may also result in skydivers who land when their foot is in this same position; then, a crushing injury to the foot while it is in a pronated, weight-bearing position, can cause this type of foot complication. Because of the structure of the foot, these types of injuries are usually less common, however, a strong compressing force through the midfoot may stretch and damage the plantar ligaments of the Lisfranc joint.
In comparison with the strength of the plantar ligaments, dislocations in the direction of the dorsal ligaments are much more common than plantar dislocations, generally due to the differing forces being placed on the foot in normal injury mechanisms.
Lisfranc Injury Mechanism of Injury - El Paso Chiropractor

Symptoms of Lisfranc Injuries

A majority of sports injuries are often undiagnosed and Lisfranc injuries can also be subtle and therefore difficult to detect. Many times, when an athlete has also suffered ankle injuries or foot fractures, healthcare professionals can overlook Lisfranc injuries. Also, if athletes are not able to properly describe the mechanism of their injury to a medical specialist, it can be challenging for doctors to correctly diagnose injuries to the midfoot.
After several days or weeks when the original injury occurred, the foot will be painful in the area of the midfoot along the dorsal complex of the Lisfranc joint and in the plantar arch. The intrinsic foot muscles will also display palpable spams.
Athletes with Lisfranc injuries will often have a hard time walking, specially during the push-off stage of gait, along with palpation pain over the first tarsometatarsal joint and between the first and second metatarsals and their subsequent joints with the tarsals. There may also be considerable swelling over the midfoot, to the point where the observable veins are concealed. Furthermore, ecchymosis or bruising may occur in the plantar arch of the foot.
Upon clinical assessment, the affected athlete will experience pain along the first tarsometatarsal joint through supination/pronation of the midfoot and through dorsiflexion/abduction of the forefoot. The healthcare professional may also squeeze the metatarsal heads together, to determine if the individual feels symptoms of pain. The medical specialist may also perform the piano key test, where they will grasp each individual toe and move them in a plantar and dorsal position, to determine the presence of Lisfranc injuries.



In a patient’s X-rays, healthcare professionals commonly look for fractures at the base or neck of the metatarsals, they examine whether a small avulsion is present along the medial base of the first or second metatarsal, they view the orientation of the metatarsals to make sure they correspond to the tarsal bones, perform an evaluation through the presence of displacement between the first and second metatarsal heads, more than 2 mm of this seen in an X-ray is a diagnosis for a Lisfranc injury, and finally, upon examination on a patient’s X-rays, healthcare professionals will check whether the medial cortex of the fourth metatarsal lines up with the medial border of the lateral cuneiform where there is no interruption of the dorsal cortical line of the first metatarsal to the medial cuneiform.
Current studies found that some X-rays missed barely over 30 percent of subtle Lisfranc joint separations, suggesting that various views of imaging testing may be more sensitive than others. Therefore, CT scans are generally preferred to assess the presence of Lisfranc injuries.

CT Scans and MRI

CT scans can also be extremely helpful to evaluate alterations of the joint spaces in the foot as well as assessing any relating fractures. A CT scan can benefit an X-ray diagnosis and can be utilized together with the X-ray to determine whether surgery may be required. Although not frequently used, MRI can also be utilized to evaluate any soft tissue injuries in relation to Lisfranc injuries, such as major tendon disruptions like the peroneus longus tendon.


Lisfranc injuries are majorly classified in systems relating to the severe high energy form of the complications. However, a different classification system developed by a group of researchers was created for the athletic population with Lisfranc injuries. Each degree of injury in the athlete can be categorized as follows: ability to weight-bear; local point tenderness over the Lisfranc ligament; and a radiographic appearance of the Lisfranc joint.
The three stages of a Lisfranc injury are as follows:

Stage 1

With stage 1 Lisfranc injuries, the athlete is able to weight-bear, but, they cannot return to play. They may also experience tenderness over their first tarsometatarsal joint. Radiologically, results will show no diastasis greater than 2 mm between the first and second metatarsal joint with no collapse of the arch as measured by the cuneiform, fifth metatarsal vertical distance.

Stage 2

With stage 2 Lisfranc injuries, athletes are able to partially weight-bear and they cannot return to play. Moderate tenderness may be experienced over the medial aspect of the first tarsometatarsal joint. Radiologically, evaluation results will indicate diastasis between 2 to 5 mm between the first and second metatarsal joint with no collapse of the arch as measured by the cuneiform, fifth metatarsal vertical distance.

Stage 3

With stage 3 Lisfranc injuries, athletes have an inability to weight-bear. Severe tenderness is felt over the medial aspect of the first tarsometatarsal joint where there is a diastasis greater than 5 mm and collapse of the medial arch.

Signs a Foot or Ankle Injury is Serious

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Due to the fundamental function of the feet during athletic or even everyday physical activity performance, injuries to the foot can greatly affect the lifestyle of whoever it targets, regardless of how minor or unusual these may be. Lisfranc injuries affect the middle area of the foot, creating issues and complications among the surrounding structures of the feet, such as the tendons and ligaments, among others. Athletes who repeatedly and constantly use their feet during sports, such as running and jumping, can be at higher risk of developing Lisfranc injuries, regardless of how rare these might be.
For more information, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez

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