Diagnostic evaluation and nonoperative management of Lisfranc injuries in athletes

Purpose: Lisfranc injuries present diagnostic and therapeutic challenges, particularly in elite athletes. The 2024 International Foot and Ankle Sports Consensus (IFASC) conducted an expert consensus and systematic review to establish evidence-based guidelines for the identification, classification and nonoperative management of these injuries in high-performance athletes. Methods: A modified Delphi process involving 32 international orthopaedic foot and ankle surgeons was conducted through four iterative survey rounds. Consensus thresholds were general (75%–85%), strong (86%–99%) and unanimous (100%). A concurrent systematic review was performed, encompassing clinical studies reporting outcomes for bony and ligament Lisfranc injuries in athletes. Results: Seven consensus statements were unanimous, and six were strong. Diagnostic agreement included: (1) mechanism of injury via axial compression or twisting through a plantarflexed foot; (2) midfoot tenderness, pain with squeeze test and inability to bear weight; (3) bilateral weight-bearing radiographs for initial imaging and (4) computed tomography (CT) or magnetic resonance imaging (MRI) for low-grade instability. Experts unanimously agreed that stable, nondisplaced injuries with intact ligaments on MRI may be managed nonoperatively with close monitoring. Systematic review findings demonstrated that ligament injuries predominated in male athletes, with 96.8% returning to sport at 2.8 versus 4.5 months for bony injuries. Conclusion: Lisfranc injuries in elite athletes remain challenging to diagnose and manage due to low-grade injury presentations and high return-to-play demands. This consensus and systematic review establish clear diagnostic and nonoperative treatment guidelines, emphasizing the importance of mechanism-based suspicion, thorough physical examination and early weight-bearing imaging. Stable, nondisplaced ligament injuries without significant MRI findings can be treated nonoperatively, with most athletes safely returning to sport within 6–10 weeks and minimal complications. In contrast, unstable or displaced injuries continue to require surgical fixation to restore alignment and prevent long-term dysfunction. Collectively, these findings provide a standardized framework that supports accurate diagnosis, evidence-based decision-making and efficient recovery in athletes with Lisfranc injuries. Level of Evidence: Level V.