Freiberg Disease (Freiberg Infraction)

Freiberg disease (also called Freiberg infraction) is an osteochondrosis affecting the metatarsal head, most commonly the second. It involves osteonecrosis with subsequent collapse and articular damage.

Epidemiology

Predominantly affects adolescent females (4:1 ratio). Peak age 13-18 years. Most common in second metatarsal (68%), followed by third (27%). Bilateral in approximately 10% of cases.

The exact cause is debated but likely multifactorial, combining vascular insufficiency, repetitive microtrauma/subchondral stress fracture, and a biomechanical/genetic predisposition.

• Vascular: the developing metatarsal head epiphysis has a relatively tenuous blood supply, vulnerable to ischaemia during adolescent growth.
• Mechanical loading: a long second metatarsal (Morton foot) increases peak pressure on the second head; high heels and tight footwear concentrate forefoot load.
• Final common pathway: subchondral insufficiency fracture leads to osteonecrosis, collapse and progressive articular destruction (the Smillie sequence).

Stage 1: Ischemia with epiphyseal fissure fracture. Earliest change. May not be visible on plain X-ray.

Stage 2: Resorption of subchondral bone. Altered density on X-ray.

Stage 3: Central depression of the metatarsal head. Dorsal rim projects dorsally. "Rim sign."

Stage 4: Central fragment becomes loose body. Peripheral rim may fragment.

Stage 5: Flattening and widening of metatarsal head. Secondary osteoarthritis. End-stage.

This classification guides treatment decisions.

History

Adolescent female with forefoot pain at the affected metatarsal head. Pain worse with activity and weight-bearing. May have insidious onset. Sometimes minimal symptoms initially.

Examination

Inspection: May see swelling over affected MTP joint.

Palpation: Tenderness at metatarsal head (dorsal and plantar).

Range of Motion: Reduced MTP motion, especially dorsiflexion which loads the damaged articular surface.

Gait: Modified gait to offload forefoot.

Plain Radiographs: Anteroposterior, oblique, and lateral views. Early: May appear normal or show subtle flattening. Progressive: Sclerosis, flattening, central collapse, loose bodies.

MRI: Sensitive for early disease before radiographic changes. Shows bone marrow edema, subchondral changes.

CT: Detail of collapse pattern for surgical planning.

Imaging Examples

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Differential Diagnosis of Forefoot Pain

The topic's own best comparative study (Mutlu 2022) and the "OPEN" treatment mnemonic both name metatarsal head restoration, but the technique itself is never described.

• What it is. A joint-preserving alternative to the dorsal wedge osteotomy for a collapsed-but-not-arthritic head (Smillie 3-4). Rather than removing the damaged dorsal surface, the surgeon elevates the depressed subchondral fragment back to its normal spherical contour and supports it, restoring the shape of the metatarsal head beneath the (often still-intact) cartilage cap.
• The technique. Through a dorsal approach the collapsed segment is reduced/elevated (an osteoarticular "tamp"), the resulting subchondral void is filled with bone graft (autograft or substitute) to buttress the elevated surface, and the head is stabilised. The aim is to regenerate the avascular subchondral bone under a preserved cartilage surface rather than excise part of the head.
• Evidence. In the topic's own Mutlu 2022 comparison (stages 3-4), head restoration gave better AOFAS (89 vs 78), VAS (1.3 vs 2.7) and range of motion (56 vs 48 degrees) than the dorsal closing-wedge osteotomy - but the data are single-centre and retrospective. It is reserved for a salvageable head where the cartilage is worth preserving; an end-stage (Smillie 5) head is not restorable.

The Talusan review (an EvidenceCard in this topic) lists "osteochondral transplant" as an operative option, but the body never explains it.

• What it is. An emerging joint-resurfacing technique for a focal, contained osteochondral defect of the metatarsal head (Smillie 3-4). A cylindrical osteochondral plug (or several small plugs, mosaicplasty) is harvested from a non-weight-bearing donor site - most often the ipsilateral knee (lateral trochlear margin/intercondylar notch) - and press-fit into a matched recipient socket drilled in the damaged dorsal weight-bearing surface, resurfacing it with living hyaline cartilage and viable subchondral bone.
• Rationale and caveats. Unlike the osteotomy (which reorients the patient's own cartilage) or head restoration (which elevates the patient's own bone), OATS brings in new cartilage and bone, so it can address a defect with no salvageable cartilage of its own. It carries knee donor-site morbidity, needs a contained defect small enough to fill, and is supported only by small series/case reports, so it remains a niche joint-preserving option before salvage in the young, high-demand patient.

Disease-related (untreated/progressive)

• Progressive collapse and secondary osteoarthritis of the MTP joint (Smillie 5).
• Loose bodies and mechanical locking.
• Stiffness and dorsal impingement limiting push-off.
• Transfer metatarsalgia to adjacent rays from altered loading.

Treatment-related

• After osteotomy: shortening, transfer metatarsalgia, stiffness, nonunion/malunion, recurrence.
• After head resection: floating/dorsiflexed toe, instability, marked shortening, transfer metatarsalgia.
• After arthrodesis: nonunion (10–15 percent), malunion, hardware irritation, loss of MTP motion.
• After silicone implant: implant fracture/migration and silicone synovitis (high mid-term failure, especially in the young).

Freiberg disease is too uncommon to feature in formal national arthroplasty registries or major society guidelines; management is driven by case series and consensus rather than guideline statements. The principles below are consistent across FRCS, FRACS, EBOT, ABOS and DNB/MS practice worldwide.

Global Epidemiology

• Fourth most common osteochondrosis (after Köhler, Panner and Sever disease).
• Strong female predominance and adolescent onset, though adults present later; second metatarsal head is most often affected, then the third.
• Long second metatarsal (Morton foot) and high-impact forefoot loading (dance, running) are recurrent risk factors across populations.

Consensus Practice (Side by Side)

High- vs Limited-Resource Variation

• Well-resourced settings: early MRI, arthroscopic debridement and head-restoration/osteochondral techniques are increasingly used.
• Limited-resource settings: diagnosis relies more on plain radiographs and clinical staging; prolonged conservative care and simpler open procedures (debridement, dorsal wedge osteotomy, head resection) predominate. Outcomes for these established operations remain good, which is reassuring where advanced techniques are unavailable.

The entire surgical literature for Freiberg disease is Level III–IV (small retrospective series, one small randomised trial): there are no large randomised comparisons, so most "best operation" claims rest on low-grade evidence and surgeon preference.

Freiberg disease is an osteonecrosis of the metatarsal head, most commonly affecting the second metatarsal (68%) in adolescent females (4:1 ratio). The Smillie classification (Stages I-V) guides treatment from conservative management with offloading for early stages to dorsal closing wedge osteotomy or debridement for advanced disease. Risk factors include long second metatarsal (Morton's foot), high heels, and repetitive microtrauma. X-ray findings progress from subtle sclerosis to flattening, fragmentation, and eventual osteoarthritis.