Freiberg's Infarction (Freiberg's Disease)

Freiberg's disease is a loss of blood supply to the head of a metatarsal bone in the ball of the foot, usually the second. The bone can soften and collapse, damaging the toe joint and causing pain and stiffness. It is most often seen in adolescents and young adults, more commonly in females. Treatment ranges from footwear changes to surgery.

The metatarsals are the five long bones of the forefoot. Their rounded ends (the metatarsal heads) form the joints at the base of the toes. In Freiberg's disease, part of the metatarsal head loses its blood supply (avascular necrosis). The bone beneath the joint surface can then flatten and break up. The condition is also known as Freiberg's infraction. The second metatarsal head is most often affected; the third can also be involved.

What are the symptoms?

• Pain in the ball of the foot, especially under the second toe
• Swelling or tenderness over the forefoot
• Stiffness or limited movement at the toe joint
• A sensation of walking on a stone
• Pain that worsens with walking, sport or high heels

Pain can occur at night, which is typical of bone that has lost its blood supply. The affected toe may also sit raised off the ground and, in later stages, the joint can dislocate.

What causes Freiberg's disease?

The exact cause is unknown. The factors thought to contribute include:

• Repetitive stress or overload of the forefoot
• A second metatarsal that is longer than average
• Reduced blood supply to the metatarsal head
• Genetic predisposition
• Injury during adolescence, while the growth plates are still open

Theories fall into three groups: repeated small injuries, an impaired blood supply and general medical conditions such as lupus, diabetes and conditions that increase blood clotting. Some people may lack one of the small arteries that normally supplies the second metatarsal head.

How is it diagnosed?

Freiberg's disease is confirmed with X-rays showing flattening, fragmentation or collapse of the metatarsal head. In the early stages, an MRI scan may detect changes before they are visible on X-ray. A CT scan can help to define the shape of the metatarsal head when an operation to realign the bone is being planned.

Non-surgical treatment

Treatment usually starts without surgery and aims to reduce pressure on the painful joint:

• Activity modification, avoiding impact sports and prolonged standing
• Stiff-soled or rocker-bottom shoes to limit joint movement
• Custom orthotics to offload the affected metatarsal
• Anti-inflammatory medication
• Immobilisation in a boot in some cases

When is surgery recommended?

Surgery may be considered if symptoms persist or if imaging shows collapse of the joint. The options include:

• Debridement and bone grafting: removing loose fragments and damaged cartilage, and grafting bone to restore the shape of the metatarsal head
• Cartilage scaffold: applying a matrix to the prepared joint surface to encourage repair
• Osteotomy: cutting and repositioning the metatarsal to shorten or elevate it and reduce load on the joint
• Excision arthroplasty: removing part of the joint, reserved for very advanced cases

The choice depends on the stage of the disease and on how much healthy joint surface remains.

Early studies of debridement, bone graft and a collagen matrix have been described as promising. Removing the metatarsal head risks moving pain to the neighbouring metatarsals and leaving a short, unstable toe.

What does the research show?

The evidence for surgery in Freiberg's disease is limited. A systematic review of 50 articles in Foot and Ankle Surgery (Alhadhoud and colleagues) found only poor evidence (grade C) to support either joint-sparing or joint-sacrificing operations. It called for higher-quality trials.

A separate systematic review of 38 studies in Foot & Ankle Specialist (Schade) included 257 joint-sparing and 70 joint-destructive procedures. More than 90% resolution of pain and full return to activity was reported after joint-sparing procedures, and more than 70% after joint-destructive procedures. The review concluded that joint-sparing procedures are reported more often and appear to have a better outlook for symptom relief and return to activity. It was based only on Level IV studies, so it cannot show which operation is best.

What is recovery like?

• 0–2 weeks: rest with the foot elevated; post-operative shoe; limited weight-bearing
• 2–6 weeks: wound review; gradual walking and light physiotherapy
• 6–12 weeks: improved comfort; return to supportive shoes
• 3–6 months: continued recovery; custom orthotics in use
• 6–18 months: return to sport if healing is complete

How Mr Hester can help

Mr Hester is a dual fellowship-trained foot and ankle surgeon (FRCS Tr&Orth), trained at Guy's and St Thomas' and in Toronto and Calgary, and a member of BOFAS and EFAS. He sees patients privately at The London Clinic, Cromwell Hospital, King Edward VII's Hospital and HCA The Shard. His NHS practice is at King's College Hospital.

Insured patients need a GP referral and an authorisation code from their insurer. Self-pay patients are welcome. To book, call 020 7046 8004.

Frequently Asked Questions

Sources

1. Alhadhoud MA, Alsiri NF, Daniels TR, Glazebrook MA. Surgical interventions of Freiberg's disease: A systematic review. Foot Ankle Surg. 2021;27(6):606–614. PMID: 32917526. https://pubmed.ncbi.nlm.nih.gov/32917526/
2. Schade VL. Surgical Management of Freiberg's Infraction: A Systematic Review. Foot Ankle Spec. 2015;8(6):482–489. PMID: 25990579. https://pubmed.ncbi.nlm.nih.gov/25990579/
3. Pain in the ball of the foot. NHS. https://www.nhs.uk/symptoms/foot-pain/pain-in-the-ball-of-the-foot/