What is Freiberg’s Disease?

Freiberg’s Disease—also called Freiberg infraction—is a rare condition that affects the metatarsal head (the rounded end of the long bones in the forefoot, most often the second metatarsal). It is a type of avascular necrosis, meaning the bone tissue loses its blood supply, leading to bone cell death, collapse of the joint surface, and pain in the ball of the foot.

It most commonly occurs in adolescent and young adult females, especially athletes or those with foot structures that place extra stress on the second metatarsal.

Causes

The exact cause is not fully understood, but Freiberg’s Disease is thought to result from a combination of:

  • Repetitive stress or microtrauma to the metatarsal head (running, dancing, jumping)

  • Vascular compromise – reduced blood flow leading to bone death

  • Foot structure abnormalities – a relatively long second metatarsal or short first metatarsal increases pressure on the joint

  • Hormonal influences – more common in adolescent girls, suggesting a possible hormonal component

  • Genetic predisposition – some evidence suggests inherited susceptibility

  • Poor footwear – high heels or narrow shoes that overload the forefoot

Symptoms

Patients with Freiberg’s Disease often experience:

  • Pain in the ball of the foot, especially under the second toe

  • Pain that worsens with weight‑bearing or wearing high‑heeled shoes

  • Swelling and stiffness around the affected joint

  • Limping or difficulty walking

  • A sensation of “walking on a stone” under the forefoot

  • In advanced cases: deformity, limited motion, or callus formation beneath the metatarsal head

Diagnosis

Diagnosis involves:

  • Physical exam – checking for localized pain, swelling, and stiffness at the second metatarsophalangeal (MTP) joint

  • X‑rays – may show flattening, sclerosis (hardening), or fragmentation of the metatarsal head

  • MRI – useful in early stages to detect bone changes before they appear on X‑ray

  • Classification – The Smillie classification (Stages I–V) describes progression from early microfracture to advanced joint collapse and arthritis

Nonsurgical Treatment

Early stages are usually managed without surgery:

  • Rest and activity modification – avoiding high‑impact activities

  • Immobilization – short leg cast or walking boot for 4–6 weeks if pain is severe

  • Supportive footwear – stiff‑soled shoes, rocker‑bottom soles, or metatarsal pads to offload pressure

  • Orthotics – custom inserts to redistribute weight

  • Medications – NSAIDs for pain and inflammation

  • Physical therapy – stretching and strengthening to reduce forefoot loading

When is Surgery Needed?

Surgery may be considered when:

  • Pain persists despite months of conservative care

  • The metatarsal head collapses, causing deformity or arthritis

  • Joint motion is severely limited

Surgical options include:

  • Debridement – removing loose bone or cartilage fragments

  • Osteotomy – realigning or shortening the metatarsal to reduce pressure

  • Arthroplasty – partial joint replacement or reconstruction in advanced cases

  • Interposition procedures – using soft tissue to cushion the joint

The choice depends on the stage of disease and the patient’s activity level.