Freiberg disease is avascular necrosis of the metatarsal head. Pain is most pronounced with weight bearing. Diagnosis is confirmed with x-rays and MRI. Treatment includes immobilization, orthotics, and sometimes surgery.
(See also Overview of Foot and Ankle Disorders.)
Freiberg disease is a common cause of metatarsalgia. Freiberg disease is caused by microtrauma at the metaphysis and growth plate. Avascular necrosis flattens the metatarsal head. The second metatarsal head is most often affected. Freiberg disease is thought to occur more frequently among pubertal females and among people who have a short first metatarsal bone or long second metatarsal bone, which increases stress on the second metatarsal head and joint. The metatarsal joint tends to collapse, and activities that repetitively stress this joint, such as dancing, jogging, or running, may accelerate this process.
Bones of the Foot
Symptoms and Signs of Freiberg Disease
In patients with Freiberg disease, the pain is most pronounced in the forefoot at the metatarsal head with weight bearing, particularly when pushing off or when wearing high-heeled footwear. The metatarsophalangeal joint may also be swollen and have limited and painful passive range of motion.
Diagnosis of Freiberg Disease
X-rays and MRI
The diagnosis of Freiberg disease is confirmed with x-rays. Typically, the head of the second metatarsal is widened and flattened, and the metatarsal joint is sclerotic and irregular. MRI findings show patchy marrow edema at the metatarsal head.
Treatment of Freiberg Disease
Immobilization and weight unloading if acute, then modification of footwear
Sometimes surgery
Immobilization may help alleviate pain. Long-term management of Freiberg disease may require orthoses with metatarsal bars and low-heeled footwear, possibly with rocker sole modifications, to help reduce stress on the second metatarsal head and joint.
Subchondral drilling and interpositional arthroplasty are early surgical considerations. Surgical osteotomy is indicated to reorient any remaining viable plantar articular cartilage. Surgical excision of the metatarsal head should be avoided due to the resultant transfer metatarsalgia on the adjacent digits (1).
Treatment reference
1. Carmont MR, Rees RJ, Blundell CM: Current concepts review: Freiberg's disease. Foot Ankle Int 30(2):167-176, 2009. doi:10.3113/FAI-2009-0167
