Freiberg disease, also called Freiberg infraction, is an osteonecrosis of a lesser metatarsal head that most commonly affects the second metatarsal in adolescent or young adult females, causing forefoot pain and stiffness at the metatarsophalangeal (MTP) joint. It represents a spectrum from subtle subchondral collapse to advanced arthrosis and deformity, with early stages often responding well to conservative off‑loading and later stages sometimes requiring joint‑preserving or joint‑sacrificing surgery.pmc.ncbi.nlm.nih+3
Definition and epidemiology
Freiberg disease is defined as a localized osteonecrosis/osteochondrosis of a lesser metatarsal head, characterized by collapse, fragmentation, and subsequent deformity of the articular surface. Pathologically it is a form of osteonecrosis rather than classic inflammatory arthritis, and it most frequently involves the second metatarsal head, with the third less often affected and the fourth or fifth rarely involved.
Epidemiologically, Freiberg disease predominates in females and typically presents in adolescence or early adulthood, although later presentations occur in both sexes. The female preponderance is often attributed to both biomechanical factors (a relatively long second metatarsal and forefoot loading patterns) and footwear factors such as high‑heeled or narrow toe box shoes that increase pressure under the lesser metatarsal heads.
Etiology and pathophysiology
The precise cause is multifactorial, with several overlapping theories. A traumatic theory proposes that repetitive microtrauma to the metatarsal head—seen in running, dancing, jumping sports, or high‑heel use—produces cumulative injury to the subchondral bone plate and vascular supply, leading to collapse. A vascular theory emphasises disruption or insufficiency of intraosseous blood flow to the metatarsal head, predisposing to osteonecrosis in structurally vulnerable metatarsals such as a long second ray.wikipedia+4
Biomechanical and systemic contributors also appear relevant. Altered forefoot loading from cavus or planus foot types, hallux valgus with transfer loading, or iatrogenic overload after first ray surgery can increase stress on the second metatarsal head. Systemic factors such as collagen disorders, endocrine abnormalities, or vascular compromise are occasionally reported, although strong causal links remain less clear.
Clinical presentation and staging
Clinically, patients usually report insidious forefoot pain localised to the affected lesser MTP joint, worsened by weight‑bearing, particularly push‑off and activities that load the forefoot. Swelling, joint tenderness dorsally over the metatarsal head, and difficulty with high‑heeled or fashion shoes are typical, and patients may develop a limp or lateralised gait to avoid painful loading. Stiffness and reduced range of motion at the affected MTP joint, plantar callus under the involved metatarsal, and sometimes mechanical catching or locking can also occur as the articular surface fragments.
Radiographically, Freiberg disease classically demonstrates flattening and sclerosis of the metatarsal head with varying degrees of fragmentation and joint space irregularity. MRI is useful in early disease, showing bone marrow oedema and subchondral changes in the metatarsal head before plain radiographs become diagnostic, which helps prompt off‑loading at a reversible stage. The Smillie classification describes five stages, from subchondral fissuring (stage 1) through dorsal collapse, fragmentation, and deformity (stages 2–4) to end‑stage arthrosis with a flattened, deformed head and secondary degenerative change (stage 5).
Management strategies
Treatment aims to relieve pain, preserve or restore joint congruity, and maintain functional gait, with strategies tailored to stage, symptoms, and patient demands. In early Smillie stages (1–3), nonoperative management is the mainstay, focusing on reducing load through the diseased metatarsal head so that bone remodelling and revascularisation can occur. Common measures include activity modification, temporary immobilisation or casting in more acute cases, metatarsal pads or bars, stiff‑soled or rocker‑soled footwear, and custom orthoses designed to off‑load the affected ray while redistributing pressure to adjacent metatarsals and the midfoot.
When conservative measures fail or in more advanced stages (typically Smillie 3–5), surgery is considered, balancing joint preservation against pain relief and long‑term function. Joint‑preserving options include dorsal closing‑wedge osteotomy of the metatarsal head to rotate a relatively preserved plantar cartilage segment dorsally into the weight‑bearing zone, osteochondral autologous transplantation (OAT) of cylindrical plugs from the knee to reconstruct the joint surface, and microfracture or drilling procedures for smaller focal lesions. For end‑stage deformity, interposition arthroplasty using soft‑tissue spacers, implant arthroplasty, or resection/shortening arthroplasty of the metatarsal head can relieve pain and restore shoe wear, though at the expense of some power at push‑off and with careful consideration of transfer metatarsalgia risk.
Prognosis and clinical implications
Prognosis is generally favourable when Freiberg disease is recognised early and appropriately off‑loaded, with many patients in early stages achieving pain relief and radiographic remodelling without surgery. Later‑stage disease can still be managed effectively, but may leave residual stiffness or mild deformity even with well‑executed reconstructive procedures, and return to high‑impact sport may be limited depending on the extent of osteonecrosis and the technique used.
From a clinical standpoint, Freiberg disease is an important differential diagnosis for chronic lesser MTP joint pain in adolescents and young adults, particularly active females or those with a long second metatarsal and a history of high‑heel or forefoot‑loading activities. Early detection using targeted imaging, meticulous assessment of forefoot biomechanics, and timely implementation of footwear and orthotic strategies can reduce progression to advanced collapse, while contemporary surgical algorithms—including dorsal osteotomy, OAT, and interposition arthroplasty—offer structured options for those who remain symptomatic despite conservative care.