Research Article| Volume 62, ISSUE 2, P382-387, March 2023

Defining Reference Values for the Normal Adult Lisfranc Joint Using Weightbearing Computed Tomography

Published:October 06, 2022DOI:


      The uninjured contralateral feet of consecutive patients undergoing cone-beam weightbearing computed tomography for acute Lisfranc injury between July 2017 and October 2019 were retrospectively analyzed. Of these, any cases with history or radiological evidence of trauma to the Lisfranc interval were excluded. The area of the non-weightbearing (NWBA) and weightbearing (WBA) Lisfranc joint was calculated (in mm2) using a novel technique. Area difference (AD) was calculated as WBA-NWBA. Area ratio (AR) was calculated as WBA/NWBA. A subset of cases was double-measured by 2 technologists to evaluate inter- and intraobserver variability. A total of 91 patients aged 15 to 74 years were included in the study. The measurement technique was reproducible with excellent intraobserver correlation (intraclass correlation coefficient [ICC]: 0.998, 95% confidence interval [CI]: 0.996-0.999) and high interobserver correlation (ICC: 0.964, CI: 0.939-0.979). The median NWBA was 83 (range 52-171) and median WBA was 86 (range 52-171). Median AD was 1 mm2 (range -3 to 10) and median AR was 1.01 (range 0.96-1.11). No significant difference was identified in AD or AR when adjusted for age, gender, patient-weight or weight put through the foot. Both AD and AR distributions were highly skewed toward 0 and 1, respectively. Based on 95% CI, normal reference range for AD is -1 to 7 mm2 and for AR is 0.98 to 1.09. Absolute area of the Lisfranc joint is highly variable between individuals. The Lisfranc joint is rigid with little to no physiologic widening in most subjects. The normal upper limit of widening of the Lisfranc area on weightbearing was 9%. Differences in age, sex, patient-weight or weight put through the foot were not significantly associated with the extent of joint widening.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Stødle AH
        • Hvaal KH
        • Enger M
        • Brøgger H
        • Madsen JE
        • Ellingsen Husebye E.
        Lisfranc injuries: incidence, mechanisms of injury and predictors of instability.
        Foot Ankle Surg. 2019; 26: 535-540
        • Rosenbaum A
        • Dellenbaugh S
        • Dipreta J
        • Uhl R.
        Subtle injuries to the Lisfranc joint.
        Orthopedics. 2011; 34: 882-887
        • Llopis E
        • Carrascoso J
        • Iriarte I
        • Serrano MdP
        • Cerezal L
        Lisfranc injury imaging and surgical management.
        Semin Musculoskelet Radiol. 2016; 20: 139-153
        • Rettedal DD
        • Graves NC
        • Marshall JJ
        • Frush K
        • Vardaxis V.
        Reliability of ultrasound imaging in the assessment of the dorsal Lisfranc ligament.
        J Foot Ankle Res. 2013; 6: 7
        • Kennelly H
        • Klaassen K
        • Heitman D
        • Youngberg R
        • Platt SR.
        Utility of weight-bearing radiographs compared to computed tomography scan for the diagnosis of subtle Lisfranc injuries in the emergency setting.
        Emerg Med Australas. 2019; 31: 741-744
        • C W.J.
        Practical Nonparametric Statistics.
        3rd ed. Wiley, New York1999
        • Malhotra G
        • Cameron J
        • Toolan BC.
        Diagnosing chronic diastasis of the syndesmosis: a novel measurement using computed tomography.
        Foot Ankle Int. 2014; 35: 483-488
        • Hamard M
        • Neroladaki A
        • Bagetakos I
        • Dubois-Ferrière V
        • Montet X
        • Boudabbous S.
        Accuracy of cone-beam computed tomography for syndesmosis injury diagnosis compared to conventional computed tomography.
        Foot Ankle Surg. 2020; 26: 265-272
        • Patel S
        • Malhotra K
        • Cullen NP
        • Singh D
        • Goldberg AJ
        • Welck MJ.
        Defining reference values for the normal tibiofibular syndesmosis in adults using weight-bearing CT.
        Bone Joint J. 2019; 101: 348-352
        • Shakoor D
        • Osgood GM
        • Brehler M
        • Zbijewski WB
        • de Cesar Netto C
        • Shafiq B
        • Orapin J
        • Thawait GK
        • Shon LC
        • Demehri S
        Cone-beam CT measurements of distal tibio-fibular syndesmosis in asymptomatic uninjured ankles: does weight-bearing matter?.
        Skelet Radiol. 2019; 48: 583-594
        • del Rio A
        • Bewsher SM
        • Roshan-Zamir S
        • Tate J
        • Eden M
        • Gotmaker R
        • Wang O
        • Bedi HS
        • Rotstein AH
        Weightbearing cone-beam computed tomography of acute ankle syndesmosis injuries.
        J Foot Ankle Surg. 2020; 59: 258-263