Lisfranc ligaments !

The Lisfranc ligaments are strong bands joining the cuneiforms to the metatarsals; they are the key to a stable midfoot.

Official name: Cuneometatarsal interosseous ligaments

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What it is

Strong ligaments deep in the midfoot. The main one joins the inner cuneiform to the base of the second metatarsal.

What it does

Lock the bases of the metatarsals into the midfoot, keeping the arch stable when you push off.

Key facts

Attaches: Lisfranc ligament: medial cuneiform to base of 2nd metatarsal; plus dorsal and plantar tarsometatarsal ligaments
Function: Key stabilizer of tarsometatarsal joint; no ligament joins bases of 1st and 2nd metatarsals
Tight in: Forefoot abduction and plantarflexion under load

Relations

Superficial: Dorsalis pedis artery, which dives between the first and second metatarsal bases to the plantar arch, with the deep fibular nerve; both can be injured in a Lisfranc injury
Below: Fibularis longus tendon inserting on the plantar base of the first metatarsal and medial cuneiform; the plantar Lisfranc ligament
Medial: Tibialis anterior tendon inserting on the medial cuneiform and first metatarsal base
Lateral: Third to fifth tarsometatarsal joints, the more mobile lateral column

How to find it

The first tarsometatarsal joint is a groove felt on the medial border of the foot in front of the navicular tuberosity; the ligament itself lies deep between the medial cuneiform and the second metatarsal base, under the back of the first web space. Tenderness there, or bruising in the sole of the midfoot, points to an injury.

Examination

Piano key test: each metatarsal head is pushed up and down; pain at its tarsometatarsal joint suggests injury
Pronation–abduction stress: the forefoot is abducted and pronated with the hindfoot held; pain at the midfoot is positive
Single-limb heel rise: inability or midfoot pain suggests a Lisfranc injury

On imaging

Standing AP views of both feet: the medial edge of the second metatarsal base should line up with the medial edge of the intermediate cuneiform, and the gap between the first and second metatarsal bases should match the other side (a difference of about 2 mm is often cited). Oblique: fourth metatarsal lines up with the cuboid. CT shows small fractures; MRI the ligaments.

Common problems

Lisfranc injury: a sprain, tear or fracture-dislocation of the midfoot, from a twist on a pointed foot or a heavy weight landing on it.
Easy to miss: it can look like a simple sprain. Bruising on the bottom of the midfoot is a warning sign.
Untreated injuries can lead to a collapsed arch and midfoot arthritis.

How it is diagnosed

A physical exam; X-rays taken standing to compare both feet; CT or MRI to show small fractures and ligament tears.

Treatment

Stable sprains: a boot or cast with no weight on the foot for several weeks.
Unstable injuries: surgery to realign the bones and hold them with screws or plates.
Some severe injuries: fusion of the injured joints.

Clinical notes

Displacement patterns: homolateral (all metatarsals shift the same way), isolated, or divergent (first metatarsal medial, the rest lateral)
Plantar ligaments are stronger, so the metatarsal bases usually displace dorsally
Unstable injuries need anatomic reduction with fixation or primary fusion; post-traumatic midfoot arthritis is common if reduction is lost
High-energy injuries can cause compartment syndrome of the foot, partly from bleeding of the dorsalis pedis artery branches
Lisfranc (tarsometatarsal) disarticulation: the joint line runs obliquely from the base of the first metatarsal to the fifth metatarsal tuberosity; the Lisfranc ligament is the key that must be cut to open it

Memory aid

The second metatarsal is the keystone of the midfoot's 'Roman arch': lose its Lisfranc ligament and the arch falls.

Metatarsal fractures (including stress fractures)

Test yourself

Think of the answer, then tap the question to see it.

What do the Lisfranc ligament's main attachments bind together?

The medial cuneiform to the base of the second metatarsal, which sits recessed like a keystone; no ligament joins the first and second metatarsal bases.

What does the «fleck sign» on a foot X-ray indicate?

Avulsion of the Lisfranc ligament: a small bone fragment between the first and second metatarsal bases.

Which X-rays are key to diagnosing a Lisfranc injury, and why?

Weight-bearing views of both feet; non-standing films can look normal, and the side-to-side gap between the first and second metatarsal bases is compared.

In a Lisfranc injury, which way do the metatarsal bases usually displace, and why?

Dorsally, because the plantar ligaments are stronger than the dorsal ones.

Which artery and nerve lie over the Lisfranc ligaments and can be injured with them?

The dorsalis pedis artery, which dives between the first and second metatarsal bases, and the deep fibular nerve.

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Educational information, not medical advice. For any symptom, see a health professional.

Its names

Official Latin (TA2): ligamenta cuneometatarsea interossea; ligamenta tarsometatarsea dorsalia TA2 1958
Official Spanish (DeCS): Ligamentos cuneometatarsianos interóseos
English (TA2): Cuneometatarsal interosseous ligaments
Also called: Lisfranc's ligament medial

Sources: Terminologia Anatomica (TA2); Anatomy, Bony Pelvis and Lower Limb, Foot Joints; Anatomy of the Human Body (20th ed.): Surface Markings of the Lower Extremity (Lea & Febiger (Gray's Anatomy, 1918), 1918) · adapted, Public domain; Anatomy of the Human Body (20th ed.): Tarsometatarsal Articulations (Lea & Febiger (Gray's Anatomy, 1918), 1918) · adapted, Public domain; Anatomía humana (4.ª ed.), tomo 1, cap. 66: Pierna. Pie.

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Representative model, for educational purposes only.

Lisfranc ligaments highlighted on the Durgical 3D model