Insights Into Lisfranc Rehabilitation with Performe Sports Medicine

Performe Sports Medicine integrates podiatry, physiotherapy and strength and conditioning in one practice, aligned by a shared decision-making framework. As a performance clinic run by podiatrists and physiotherapists, foot and ankle injuries account for a large majority of their cases. Lachlan Fooks and Mitch Podhajski lead the rehabilitation team and work with athletes across a multitude of sports.

This article outlines Performe’s framework for integrating technology into Lisfranc injury rehabilitation. Lisfranc injury is often complex and traumatic, serving as an umbrella term for multi-ligamentous and osseous injuries of the midfoot. These may include tearing or rupture of the midfoot ligaments, with or without concomitant fractures of the midfoot bones, such as the metatarsals, cuneiforms and cuboid. Because many cases require postoperative rehabilitation, high-quality care is essential for a safe return to activity.

Anatomy of the midfoot bones, with labels indicating the region where the injury occurs.

The Need for Objective Testing in Lisfranc Rehabilitation

Lisfranc injuries present distinct rehabilitation challenges, including prolonged immobilization, which can lead to midfoot stiffness, calf atrophy and altered load tolerance. These deficits can present as reduced ankle strength, balance capabilities and lower-extremity power, qualities that are most accurately assessed and monitored with force plate technology.

Traditional milestones such as gait assessment, pain scores and time sit at the tip of the iceberg, visible and important, but only part of the picture. Beneath the surface, metrics such as force production, rate of force development (RFD) and asymmetry provide deeper insight into how the athlete is loading and moving and are critical for determining readiness to progress or return to sport.

For complex midfoot injuries, objective data is essential to guide progression and reduce postoperative uncertainty.

For complex midfoot injuries, objective data is essential to guide progression and reduce postoperative uncertainty. ForceDecks allows teams to track force production, asymmetry and RFD from early-phase rehabilitation through return to sport, supporting clearer decision-making and communication across practitioners and athletes.

The Performe Rehabilitation Method

ForceDecks testing occurs at key checkpoints throughout rehabilitation. Testing primarily focuses on unilateral performance to ensure capacities are adequately improving following prolonged immobilization and surgical fixation.

Phase 1: Early Loading and Re-Education

Following boot removal, primary rehabilitation objectives focus on restoring symmetrical weight acceptance and re-establishing neuromuscular control of the foot.

ForceDecks assessments begin with the quiet stand to evaluate load distribution and monitor asymmetry as walking exposure and daily loading increase. Often, asymmetries persist despite visually normal gait mechanics. Having objective tools such as ForceDecks allows the Performe team to identify deficits and determine loading strategies before serious complications or compensations arise.

Having…ForceDecks allows the Performe team to identify deficits and determine loading strategies before serious complications or compensations arise.

Phase 2: Unilateral Strength Development

Unilateral strength underpins walking, running and change of direction, making its restoration critical for performance and reinjury risk. Monitoring unilateral maximal strength through peak force and asymmetry measures provides valuable insight to guide progression and identify compensatory strategies.

The single leg isometric mid-thigh pull (SL IMTP) is a practical way to assess this capacity. Metrics such as peak force and RFD inform load prescription, exercise progression and decisions around returning to higher-demand activities like plyometrics and running.

The SL IMTP is a practical way to assess [unilateral force production]. Metrics such as peak force and RFD inform load prescription [and] exercise progression…

The following are examples of test findings and how they can inform decision-making:

The data from this testing battery helps the Performe team ensure their athletes are progressing and on track in rehabilitation. It also allows the team to compare their athletes with age- and sex-matched peers via Norms and identify which physical qualities require more specific loading interventions to provide a safe return-to-play environment.

Phase 3: Plyometric Exposure and Elastic Capacity

As rehabilitation advances, objectives shift toward restoring unilateral plyometric capacity, improving midfoot stability under dynamic, high-RFD loading and preparing the athlete to meet sport-specific demands.

As rehabilitation advances…[Performe measures] unilateral plyometric capacity [and] midfoot stability under dynamic, high-RFD loading…

The Performe team uses single leg jump (SLJ) and single leg range of stability testing to better understand power and balance in the lower extremity. The SLJ assesses takeoff and landing force characteristics, while single leg range of stability testing evaluates dynamic balance, postural control and load tolerance through the midfoot. The team analyzes various metrics for each.

Deficits identified at this stage help explain underlying physical performance limitations. For example, poor SLJ performance, as indicated by greater RSI-Mod asymmetry, may suggest that an athlete is not yet prepared for high-velocity deceleration tasks or more complex sporting movements. The SLJ also helps determine whether strength improvements identified in the SL IMTP are transferring effectively into faster, more dynamic actions.

The SLJ also helps determine whether strength improvements identified in the SL IMTP are transferring effectively into faster, more dynamic actions.

Similarly, markedly reduced CoP excursion during a range of stability assessment may indicate persistent neuromuscular control deficits or intrinsic foot weakness that should be addressed before progressing to higher-demand activities.

Single leg range of stability assessment being performed with key elements of the CoP trace identified.

Phase 4: Effective Return-to-Sport

ForceDecks provides an objective reference point throughout the return-to-sport process, helping guide decision-making across the rehabilitation team. Return-to-sport clearance is not based on healing timelines alone, but also on the integration of objective testing data, clinical findings and field-based performance assessments.

Return-to-sport clearance is not based on healing timelines alone, but also on the integration of objective testing data, clinical findings and field-based performance assessments.

To support this process, Performe uses a defined return-to-sport criteria framework that must be achieved before full clearance is granted.

Neuromuscular control targets include < 10% asymmetry in balance and single leg tasks and < 10% asymmetry in the key jump metrics outlined above. Asymmetries beyond this range are associated with increased injury risk, reinforcing the need for objective monitoring (Wang et al., 2025).

Athlete returning to sport after achieving Performe’s established benchmarks.

Expanding Applications Beyond Lisfranc Rehabilitation

While this approach was developed for Lisfranc rehabilitation, the framework also applies to other lower-extremity conditions managed by the Performe team that require prolonged protection and gradual loading progression. Conditions such as ankle fractures, midfoot arthrodesis and other foot injuries can benefit from the same interdisciplinary approach, objective monitoring strategies and aligned decision-making processes.

To learn more about how ForceDecks can enhance rehabilitation protocols and return-to-sport decision-making in your practice, get in touch with our team.

References

1. Wang, P., Qin, Z., & Zhang, M. (2025). Association between pre-season lower limb interlimb asymmetry and non-contact lower limb injuries in elite male volleyball players. Scientific Reports, 15, 14481. https://doi.org/10.1038/s41598-025-98158-x