LISFRANC (MidFoot ligament injury) ORIF Rehab Protocol

Lisfranc Injury Postoperative Rehabilitation Protocol

(Operative Lisfranc Fixation — ORIF / Ligamentous Repair)

This protocol outlines general rehabilitation guidelines following operative management of Lisfranc (tarsometatarsal) injuries. Progression should remain criteria-based rather than strictly time-based and individualized according to:

• Injury severity and pattern
• Fixation method and stability
• Sport/activity demands
• Patient healing response and      symptoms
• Surgeon preference and imaging      findings when indicated

Important: This protocol serves as a guideline only. Clinical judgment should always guide rehabilitation progression.

Phase 0 — Immediate Postoperative Protection (Weeks 0–2)

Goals

• Protect surgical fixation and      maintain reduction
• Control pain and swelling
• Promote incision healing
• Maintain general conditioning

Immobilization / Weight Bearing

• Strict non–weight bearing      (NWB)
• Splint, cast, or CAM boot per      surgeon preference

Therapy / Activity

• Aggressive elevation and edema      control
• Gentle active toe ROM as      tolerated
• Hip, core, and upper-extremity      strengthening
• Straight-leg raises and      contralateral limb conditioning

Restrictions

• No weight bearing
• No midfoot loading or rotational      stress
• No forced forefoot or midfoot      motion

Phase 1 — Protection With Early Mobility (Weeks 2–6)

Goals

• Maintain ankle and subtalar      mobility
• Prevent stiffness and proximal      deconditioning
• Protect biologic healing of      Lisfranc complex

Immobilization / Weight Bearing

• Continue strict NWB through      week 6
• Cast or CAM boot per surgeon      preference

Therapy / Activity

• Ankle ROM: dorsiflexion,      plantarflexion, inversion, eversion
• Toe and first MTP mobility      exercises
• Gentle intrinsic activation      without loading
• Stationary cycling with minimal      resistance (if cleared)
• Pool-based ROM once incisions      healed
• Ongoing hip/core strengthening

Criteria to Progress

• Incisions healed
• Controlled swelling and pain
• Radiographic and clinical surgeon      clearance

Phase 2 — Progressive Weight Bearing (Weeks 6–8)

Goals

• Gradual load introduction to      midfoot
• Normalize protected gait      mechanics
• Begin functional strengthening

Weight Bearing Progression

• Weeks 6–7: Partial WB (~25–50%) in CAM boot      with assistive device
• Weeks 7–8: Progress to WBAT in boot

Progress only if:

• Minimal midfoot pain
• Controlled swelling
• Non-antalgic gait pattern

Therapy Focus

• Gait training in boot
• Weight-shifting drills
• Closed-chain strengthening in      protected range
• Seated calf raises
• Early balance and proprioception      work
• Cardiovascular conditioning as      tolerated

Caution Signs

• Increased midfoot pain
• Swelling escalation
• Limping or altered gait

If present → slow progression.

Phase 3 — Boot Weaning and Functional Strengthening (Weeks 8–10)

Goals

• Transition out of immobilization
• Normalize gait mechanics
• Improve foot strength and      proprioception

Footwear Transition

• Supportive athletic shoe
• Consider:
  • Carbon fiber insert
  • Stiff-soled shoe
  • Rocker-bottom footwear

Therapy Focus

• Gait retraining
• Progressive calf strengthening      (eccentric emphasis)
• Intrinsic foot strengthening
• Step-ups, controlled single-leg      tasks
• Elliptical and treadmill walking      progression

Criteria to Progress

• Minimal pain with walking
• Near-normal gait without boot
• No reactive swelling after      activity

Phase 4 — Return-to-Sport Progression (Weeks 10–16+)

Goals

• Restore strength, endurance, and      mechanics
• Introduce power and agility      safely
• Prepare for sport-specific      demands

Activity Progression

1. Walking progression
2. Walk–jog intervals
3. Continuous running
4. Linear running before      cutting/pivoting
5. Plyometrics (hopping, bounding,      jump training)
6. Gradual sport-specific drills

Return-to-Sport Criteria (Typically ~3–4 Months)

Clearance should be functional rather than calendar-based:

• No midfoot tenderness
• Minimal swelling
• Full ankle and first MTP      functional motion
• Strength ≥90% of contralateral      side
• Pain-free hopping, cutting, and      sport-specific tasks
• Athlete confidence without      compensatory mechanics

Phase 5 — Hardware Removal (If Planned ~5–6 Months)

Post-Removal Considerations

• WBAT in supportive footwear      (surgeon dependent)
• Temporary reduction in impact      activity (≈2–4 weeks)
• Gradual return to sport once      incision healed and symptoms resolved

Patient Counseling Points

• Midfoot swelling can persist for      several months and does not necessarily indicate complications.
• Lisfranc injuries vary widely in      severity — recovery timelines differ substantially.
• Premature return to sport risks      fixation failure, chronic pain, and midfoot arthritis.
• Return-to-sport decisions should      always be criteria-driven, not time-driven.

Selected References

• American Academy of Orthopaedic      Surgeons (AAOS). Lisfranc (Midfoot) Injury. OrthoInfo.
• Nunley JA, Vertullo CJ.      Classification, investigation, and management of midfoot sprains: Lisfranc      injuries in the athlete. Am J Sports Med. 2002;30(6):871–878.
• Deol RS, Roche A, Calder JDF.      Return to training and playing after acute Lisfranc injuries in elite      professional soccer and rugby players. Am J Sports Med.     2016;44(1):166–170.
• Watson TS, Shurnas PS, Denker J.      Treatment of Lisfranc joint injury: current concepts. J Am Acad Orthop      Surg. 2010;18(12):718–728.
• Panchbhavi VK, Vallurupalli S,      Yang J. Suture button fixation for Lisfranc injuries. Foot Ankle Int.     2009;30(11):1041–1046.
• Jackson JB 3rd, Strasser NL,      Gonzalez T, Park J. Management and return to play of the elite athlete for common      sports-related injuries about the foot. J Am Acad Orthop Surg. 2024      Oct 17;33(16):e899-e908. doi:10.5435/JAAOS-D-23-00881. PMID: 39467272.