(Operative Lisfranc Fixation – ORIF / Ligamentous Repair)

This protocol provides general postoperative rehabilitation guidelines following surgical treatment of a Lisfranc (tarsometatarsal) injury. Progression is criteria-based and may vary depending on injury pattern, fixation type, sport demands, and individual healing response.

Important: This protocol is a guideline only. Rehabilitation should be individualized based on surgeon preference, fixation method, clinical exam, and imaging when appropriate.
 

• Protect surgical fixation and reduction
   
• Control pain and swelling
   
• Allow incision healing
   
• Maintain overall conditioning
   

• Non–weight bearing (NWB)
   
• Immobilized in splint (or cast/boot per surgeon preference)
   

• Strict elevation and edema control
   
• Gentle toe range of motion as tolerated
   
• Hip, core, and upper-extremity strengthening
   
• Straight-leg raises and non-involved limb conditioning
   

• No weight bearing
   
• No midfoot loading or twisting
   
• No forced forefoot motion
   

• Maintain ankle and subtalar joint mobility
   
• Prevent stiffness and deconditioning
   
• Protect Lisfranc complex during biologic healing
   

• Strict non–weight bearing for a total of 6 weeks
   
• Cast or CAM boot per surgeon preference
   

• Ankle range of motion (dorsiflexion, plantarflexion, inversion, eversion)
   
• Toe and first MTP joint mobility
   
• Gentle intrinsic foot activation without loading
   
• Stationary bike with minimal or no resistance (if cleared)
   
• Pool-based ROM once incisions are healed
   
• Continued proximal strengthening (hips, core)
   

• Healed incision
   
• Controlled swelling and pain
   
• Surgeon clearance
   

• Gradual reintroduction of load
   
• Restore protected gait mechanics
   
• Begin functional strengthening
   

• Week 6–7: Partial weight bearing (~25–50%) in CAM boot with assistive device
   
• Week 7–8: Progress to weight bearing as tolerated in boot
   
• Advance only if gait remains non-antalgic and swelling is controlled
   

• Weight-shifting and gait training in boot
   
• Closed-chain strengthening in protected range
   
• Seated calf raises
   
• Balance and proprioception (double-leg progressing to single-leg)
   
• Continued cardiovascular conditioning
   

• Increase in midfoot pain, swelling, or limping should prompt slowing progression
   

• Transition out of boot
   
• Normalize gait
   
• Improve strength and balance
   

• Transition to supportive athletic shoe
   
• Consider stiff insert, carbon fiber plate, or rocker-sole shoe
   

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

• Minimal pain with walking
   
• Near-normal gait without boot
   
• No activity-related swelling flare
   

• Restore running mechanics
   
• Introduce power, agility, and sport-specific tasks
   
• Achieve criteria-based clearance for sport
   

• Walk → walk/jog intervals → continuous running
   
• Linear running before cutting or pivoting
   
• Plyometrics: hopping, bounding, jump training
   
• Sport-specific drills introduced gradually
   

Clearance is based on function, not time alone:

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

• Weight bearing as tolerated in supportive shoe (surgeon dependent)
   
• Temporary reduction in impact activities (2–4 weeks)
   
• Gradual return to sport once incision healed and symptoms resolve
   

• Swelling can persist for several months and does not necessarily indicate a problem
   
• Lisfranc injuries vary widely; recovery timelines differ by injury severity and sport
   
• Return-to-sport decisions should be criteria-driven, not calendar-driven
   

1. American Academy of Orthopaedic Surgeons (AAOS).
   Lisfranc (Midfoot) Injury. OrthoInfo.
   https://orthoinfo.aaos.org/en/diseases--conditions/lisfranc-midfoot-injury/
    
2. 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.
    
3. 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.
    
4. Watson TS, Shurnas PS, Denker J.
   Treatment of Lisfranc joint injury: current concepts.
   J Am Acad Orthop Surg. 2010;18(12):718–728.
    
5. Panchbhavi VK, Vallurupalli S, Yang J.
   Suture button fixation for Lisfranc injuries.
   Foot Ankle Int. 2009;30(11):1041–1046.