Freiberg’s Disease—also known as Freiberg’s infraction—stands out as a relatively rare but impactful disorder. First described by Alfred H. Freiberg in 1914, this disease primarily affects adolescents and young adults, especially females, and can cause chronic pain in the forefoot. Understanding its causes, symptoms, diagnosis, and treatment options is crucial for both medical professionals and patients.

What is Freiberg’s Disease?

• Definition: Freiberg’s Disease is an osteochondrosis (a disorder of bone growth) involving the metatarsal head, most often the second metatarsal. It is essentially a localized form of avascular necrosis, meaning the bone tissue dies due to insufficient blood supply.
• Location: Most cases involve the second metatarsal head, though the third and fourth metatarsals can occasionally be affected
• Demographics: It is four to five times more common in females than males, with peak incidence between ages 13–18, often in physically active adolescents.

Causes and Risk Factors

The exact cause remains unclear, but several contributing factors have been identified:

• Repetitive trauma: Stress from activities like running, dancing, or sports can cause microfractures in the metatarsal head.
• Vascular insufficiency: Reduced blood flow leads to necrosis of bone tissue.
• Foot anatomy: A relatively long second metatarsal increases pressure on the joint, raising risk.
• Gender predisposition: Hormonal and biomechanical differences may explain higher prevalence in females.
• Footwear: High heels or poorly cushioned shoes can exacerbate forefoot stress.

Symptoms

Patients with Freiberg’s Disease typically present with:

• Pain in the ball of the foot, especially during weight-bearing activities.
• Stiffness and swelling around the metatarsophalangeal (MTP) joint.
• Restricted range of motion, particularly dorsiflexion of the toe.
• Tenderness when pressing on the affected metatarsal head.
• In advanced cases, joint deformity and arthritic changes may occur.

Diagnosis

Diagnosis involves a combination of clinical examination and imaging:

• X-rays: Reveal flattening of the metatarsal head, sclerosis (hardening), and joint space narrowing.
• MRI scans: Detect early changes in bone marrow and blood supply.
• Clinical history: Pain localized to the forefoot, worsened by activity, is a key indicator.

Staging of Freiberg’s Disease

The condition progresses through stages:

1. Early stage: Subtle pain, minimal radiographic changes.
2. Intermediate stage: Flattening of the metatarsal head, sclerosis visible.
3. Advanced stage: Collapse of the joint surface, arthritic degeneration, and deformity.

Treatment Options

Treatment depends on severity and stage:

Non-Surgical Management

• Activity modification: Reducing high-impact activities.
• Orthotics: Custom insoles to redistribute pressure.
• NSAIDs: To manage pain and inflammation.
• Immobilization: Short-term casting or stiff-soled shoes.

Surgical Management

Reserved for advanced cases:

• Debridement: Removal of necrotic tissue.
• Osteotomy: Surgical reshaping of the metatarsal head.
• Joint replacement or fusion: For severe arthritis.
• Bone grafting: Restores structure and blood supply.

Impact on Patients

• Quality of life: Chronic pain can limit sports, walking, and daily activities.
• Psychological effects: Adolescents may struggle with reduced mobility and social participation.
• Long-term risks: Untreated disease can lead to permanent deformity and arthritis

Freiberg’s Disease, though rare, is a serious orthopedic condition that primarily affects the second metatarsal head in young, active individuals. It results from a combination of repetitive trauma and vascular insufficiency, leading to bone necrosis and joint collapse. Early recognition is vital, as conservative treatments can prevent progression, while advanced cases may require surgery. With proper management, most patients can regain mobility and reduce pain, underscoring the importance of awareness among clinicians and patients alike.