A foot sprain is common in sport, but it can be more serious than it looks. The midfoot connects the front of the ankle to the forefoot, and an injury here — a midfoot sprain — can damage the joints, ligaments, and tendons. One injury in particular, the Lisfranc injury, is potentially serious and easy to miss. So how do we grade midfoot injuries, and how do we avoid missing the important ones?
What is a midfoot sprain?
The midfoot is the middle part of the foot — a cluster of small bones forming the arch on the top of the foot, held together by strong ligaments. A midfoot sprain covers a spectrum of injury, from a mild ligament sprain to a bone fracture or a joint dislocation.
Injuries range from low-energy — a twist or a fall in sport — to high-energy — such as a fall from a height or a car accident. Importantly, low-energy injuries are most often missed because they look like a simple sprain.
What is a Lisfranc injury?
The Lisfranc joint is where the midfoot bones meet the long bones of the forefoot (the tarsometatarsal joints), stabilised by the strong Lisfranc ligament. A Lisfranc injury is damage to this complex — ranging from a ligament sprain to a fracture to a dislocation.
It matters because a Lisfranc injury is commonly mistaken for a simple sprain — around 1 in 5 are missed at first — yet it is not an injury to “walk off”. If missed or poorly treated, it can lead to arch collapse, midfoot instability, and early midfoot arthritis, resulting in lasting pain and disability. A classic mechanism is an athlete stumbling forward over a flexed foot, or being landed on.
Symptoms: when to suspect a Lisfranc injury
Suspect a Lisfranc injury — rather than a simple sprain — with any of these:
- Midfoot pain that worsens on standing, walking, or pushing off
- Significant swelling across the top of the midfoot
- Bruising on the sole of the foot — this plantar bruising is highly suggestive of a Lisfranc injury.
- Difficulty or inability to bear weight
- Pain that fails to settle after 1–2 weeks of rest, ice, and anti-inflammatories
The key safety message. If your midfoot pain hasn’t settled after 1–2 weeks of rest, ice, and ibuprofen — or if you can’t bear weight, or have bruising on the sole of your foot — see a doctor. A Lisfranc injury must not be missed, because the long-term consequences of missing it can be severe.
How is a Lisfranc injury diagnosed?
Diagnosis combines a careful clinical assessment with imaging.
On examination, the midfoot is tender, and pain is reproduced by moving or twisting the forefoot while holding the heel still. A useful test is the single-leg heel raise — coming up onto the toes on one foot loads the midfoot and can reveal a subtle injury.
Imaging confirms it — and here the details matter:
- Weight-bearing X-rays are essential. A non-weight-bearing X-ray can look normal even when there’s an injury, because the joint only separates under load. We sometimes X-ray the other foot for comparison. Changes we look for are separation of the first and second toe bones, malalignment of the mid-foot or collapse of the medial arch with weight-bearing views.
- A normal X-ray doesn’t fully exclude a mild sprain. Where suspicion remains, an MRI (or CT) shows the ligaments and any subtle injury, and guides treatment. MRI can often visualise the Lisfranc ligament and determine whether it is sprained or torn.
The guiding principle: be led by the clinical picture, even if the X-ray looks normal — because Lisfranc injuries are so easily missed.
How is a midfoot sprain treated?
Treatment depends on the severity and, crucially, on whether the midfoot is stable.
- Stable, low-grade sprains — treated non-operatively, with a period in a walking boot and protected weight-bearing, then a graded return once the pain settles. The transition from boot to shoe is done gradually.
- Unstable injuries, fractures, or dislocations — need surgery to realign and fix the joint, because restoring the normal alignment of the Lisfranc joint is the key to a good outcome and to preventing later arthritis.
Because the line between “stable” and “unstable” determines everything, an accurate diagnosis by someone experienced in these injuries is essential.
Frequently asked questions about a midfoot sprain and Lisfranc injury
How do I know if my midfoot sprain is serious?
Warning signs include being unable to bear weight, significant swelling, bruising on the sole of the foot, and pain that doesn’t settle after 1–2 weeks of rest, ice, and anti-inflammatories. Any of these should prompt a review, because they can indicate a Lisfranc injury rather than a simple sprain.
Why are Lisfranc injuries so often missed?
Because a low-energy Lisfranc injury looks just like an ordinary sprain, and a standard (non-weight-bearing) X-ray can appear normal. Around 1 in 5 are missed initially. This is why weight-bearing X-rays and a high index of suspicion matter — and why persistent midfoot pain should always be reviewed.
Can a Lisfranc injury heal without surgery?
Yes — a stable, low-grade sprain often heals in a walking boot with protected weight-bearing and a graded return. But an unstable injury, fracture, or dislocation needs surgery to realign the joint. Telling the two apart is the whole point of an accurate assessment.
How long does a midfoot sprain take to heal?
Even a mild midfoot sprain can take many weeks to months, and it’s slower than a typical ankle sprain. More severe or surgically treated injuries take longer, with a graded return to sport. Rushing back risks instability and long-term problems.
What happens if a Lisfranc injury is left untreated?
It can lead to arch collapse, ongoing midfoot instability, and early post-traumatic midfoot arthritis — causing chronic pain and stiffness that are much harder to treat than the original injury. This is exactly why the priority is not to miss it.
Final word from Sport Doctor London about a midfoot sprain and Lisfranc injury
A foot sprain is common, but a midfoot sprain can hide a more serious Lisfranc injury. If your midfoot pain fails to settle after 1–2 weeks of rest, ice, and ibuprofen, see your doctor. A Lisfranc injury must not be missed — the consequences, such as early midfoot arthritis, can be devastating, and getting the diagnosis right early makes all the difference.
If you have midfoot pain after an injury, Dr Masci can assess you in London and arrange the appropriate imaging. Contact the team here or call +44 (0) 203 488 0350.
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