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Lisfranc ligament

The Lisfranc ligament complex is a key stabilizing structure of the tarsometatarsal (TMT) joint, connecting the medial cuneiform to the base of the second metatarsal. It serves as the major stabilizer of the midfoot arch, maintaining alignment between the medial and lateral columns of the foot during weight-bearing and locomotion.

The complex consists of multiple ligamentous components—dorsal, interosseous, and plantar—collectively preventing diastasis between the medial cuneiform and second metatarsal. Injury to this complex (the Lisfranc injury) may lead to severe midfoot instability, chronic pain, and post-traumatic arthritis if missed or untreated.

Synonyms

  • Lisfranc ligament

  • Tarsometatarsal ligament complex

  • Medial cuneiform–second metatarsal ligament

Lisfranc Ligament Parts

The Lisfranc ligament complex consists of three main parts — dorsal, interosseous (Lisfranc proper), and plantar — which work together to stabilize the Lisfranc joint (tarsometatarsal articulation).

1. Dorsal Lisfranc Ligament

  • Location: Lies on the dorsal surface of the foot, superficial to the tarsometatarsal joint capsule.

  • Attachments: Extends from the medial cuneiform to the base of the second metatarsal, sometimes with additional slips to the first and intermediate cuneiforms.

  • Structure: Thin, relatively weak fibrous band compared to the plantar and interosseous parts.

2. Interosseous Lisfranc Ligament (Lisfranc Proper Ligament)

  • Location: Deep within the first intermetatarsal space, forming the strongest and most important component of the complex.

  • Attachments: Runs obliquely from the lateral surface of the medial cuneiform to the medial base of the second metatarsal.

  • Structure: Dense, short, and thick fibrous band — the true Lisfranc ligament.

3. Plantar Lisfranc Ligament

  • Location: Deep on the plantar aspect of the tarsometatarsal joint complex.

  • Attachments: Extends from the plantar surface of the medial cuneiform to the base of the second metatarsal, sometimes giving slips to the first and intermediate cuneiforms.

  • Structure: Strong and broad, composed of oblique fibers oriented medially to laterally.

Relations

  • Superiorly: Dorsal tarsometatarsal joint capsule and tendons of the extensor hallucis longus and extensor digitorum longus

  • Inferiorly: Plantar fascia and plantar tarsometatarsal ligaments

  • Medially: Medial cuneiform

  • Laterally: Base of the second metatarsal and adjacent lateral cuneiform articulation

  • Posteriorly: Intermediate cuneiform and midfoot bones

Function

  • Midfoot stabilization: Prevents separation between medial cuneiform and second metatarsal

  • Arch integrity: Maintains the transverse and longitudinal arches of the foot

  • Force transmission: Distributes weight from hindfoot to forefoot during gait

  • Rotational restraint: Limits excessive torsion and shearing between metatarsals

  • Clinical importance: Essential for coordinated, pain-free walking and running

Clinical Significance

  • Lisfranc injury: Includes ligament tears, avulsions, or fracture-dislocations involving the tarsometatarsal joints

  • Mechanism: Usually due to twisting on a plantarflexed foot, crush injuries, or axial load

  • Classification: Can be purely ligamentous or associated with fractures (bony Lisfranc injury)

  • Symptoms: Midfoot pain, swelling, plantar ecchymosis, and inability to bear weight

  • Complications: Untreated injuries lead to midfoot collapse, chronic instability, and post-traumatic arthritis

  • Diagnosis: MRI is the most sensitive imaging modality; CT accurately demonstrates subtle diastasis and fractures

  • Surgical importance: Accurate recognition and fixation of the Lisfranc ligament complex are crucial for restoring normal foot alignment

MRI Appearance

  • T1-weighted images:

    • Normal ligament: low signal (dark linear band) between medial cuneiform and base of second metatarsal

    • Ligament tear: discontinuity or irregular high-signal gap

    • Surrounding fat planes: bright, helping delineate ligament margins

    • Chronic injury: thickened, poorly defined low-signal structure due to fibrosis

  • T2-weighted images:

    • Normal ligament: low signal (dark band) with smooth margins

    • Partial tear: focal or linear high signal within the ligament

    • Complete tear: bright high-signal fluid gap replacing the ligament

    • Associated findings: bone marrow edema in medial cuneiform or base of second metatarsal, joint effusion, and subtle diastasis

  • STIR:

    • Normal ligament: dark

    • Acute injury: bright hyperintense signal in ligament and surrounding soft tissue

    • Excellent for detecting bone marrow edema or soft-tissue contusion

  • Proton Density Fat-Saturated (PD FS):

    • Normal: uniformly dark, sharply defined structure

    • Ligament sprain or partial tear: bright signal infiltration along ligament fibers

    • Best for detecting low-grade ligamentous injuries and periligamentous edema

  • T1 Fat-Sat Post-Contrast:

    • Normal: minimal enhancement

    • Acute ligamentous injury: enhancement due to hyperemia or inflammation

    • Chronic scarring: variable, often peripheral enhancement

CT Appearance

Non-Contrast CT:

  • Lisfranc ligament itself is not directly visualized but inferred by bone alignment

  • Normal: no diastasis between medial cuneiform and second metatarsal

  • Acute injury:

    • Diastasis >2 mm between cuneiform and second metatarsal base

    • Small avulsion fragments (fleck sign) at ligament insertion

    • Step-off or rotation at the tarsometatarsal joints

  • Chronic injury: degenerative changes, sclerosis, and subluxation

Post-Contrast CT (standard):

  • Limited role; not routinely used for ligament evaluation

  • May highlight reactive soft tissue enhancement in acute injury

MRI images

Lisfranc ligament AXIAL cross sectional anatomy 3T MRI AI enhanced radiology image-img-00000-00000

MRI images

Lisfranc ligament CORONAL cross sectional anatomy 3T MRI AI enhanced radiology image-img-00000-00000

MRI images

Lisfranc ligament coronal cross sectional anatomy 3T MRI AI enhanced radiology image-img-00000-00000

MRI images

Lisfranc ligament coronal cross sectional anatomy 3T MRI AI enhanced radiology image-img-00000-00000_00001

MRI images

Lisfranc ligament coronal cross sectional anatomy 3T MRI AI enhanced radiology image-img-00000-00000_00002