Quick answer: Freiberg Disease Avascular Necrosis Metatarsal Head is a clinical condition that responds to evidence-based treatment when caught early. Symptoms include pain, swelling, and altered function. Diagnosis requires clinical exam, often imaging. Treatment ladder: conservative care first (4-6 weeks), then targeted interventions if needed. Call (810) 206-1402.
★ DR. TOM BIERNACKI, DPM, FACFAS · BOARD-CERTIFIED PODIATRIST
The most important clinical decision with Freiberg Disease Avascular Necrosis Metatarsal Head isn’t which treatment to start with — it’s which subtype or underlying cause you actually have. That distinction changes everything. Call us: (810) 206-1402
Freiberg Disease: Quick Answer
Freiberg disease (also called Freiberg infraction) is avascular necrosis (death) of the second (occasionally third) metatarsal head — most commonly affects adolescent girls aged 13-18, often with a history of high heels or activity-related stress. The metatarsal head loses blood supply, the bone collapses, and the joint surface becomes irregular — causing chronic pain at the ball of the foot.
Treatment by Smillie staging: Stage 1-2 (early) — activity modification, metatarsal pad, custom orthotic with relief over the affected joint. Stage 3-4 (moderate) — CAM walking boot for 4-6 weeks to allow revascularization, then orthotic management. Stage 5 (end-stage with severe arthritis) — surgical options include osteotomy (Gauthier procedure to redirect joint surface), interpositional arthroplasty, or in severe cases joint replacement or fusion. Most patients diagnosed early have good outcomes; late-stage cases have residual stiffness.
Medically reviewed by Dr. Tom Biernacki, DPM
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Board-certified podiatric surgeon | Balance Foot & Ankle
Last reviewed: April 2, 2026
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What Is Freiberg Disease?
Freiberg disease is avascular necrosis (osteonecrosis) of the metatarsal head — most commonly the second, occasionally the third — caused by disruption of the blood supply to the metatarsal head that leads to bone death, collapse, and joint deformity. The condition was described by American surgeon Alfred Freiberg in 1914 and is also known as Freiberg infraction. It primarily affects adolescent females during rapid growth, though it can occur in adults. Without treatment, progressive metatarsal head collapse leads to painful forefoot arthritis at a young age. At Balance Foot & Ankle, we diagnose and treat Freiberg disease in patients throughout Southeast Michigan.
Causes and Risk Factors
The precise etiology of Freiberg disease involves a combination of vascular, mechanical, and genetic factors. Repetitive microtrauma to the metatarsal head from activities loading the forefoot in a growing adolescent with an inherently tenuous blood supply to the metatarsal head is the most accepted mechanism. Adolescent females who are active in dance, sports, or prolonged standing are disproportionately affected. A long second metatarsal relative to the first is a commonly observed associated finding, as it concentrates forefoot loading on the second metatarsal head. Thin or poorly cushioned footwear that allows direct impact loading of the metatarsal head may contribute to vascular compromise.
Symptoms and Staging
Forefoot pain beneath the second metatarsal head, worsening with weight bearing and forefoot loading activities, is the presenting complaint. Dorsal swelling at the second MTP joint and tenderness on palpation of the metatarsal head are characteristic. In advanced stages, restricted second MTP joint motion and visible joint deformity are present. The Smillie classification stages Freiberg disease from Stage I (early ischemia without radiographic changes) through Stage V (severe metatarsal head collapse with loose bodies and joint destruction). X-rays are initially normal; MRI detects early bone marrow changes before radiographic progression.
Conservative Treatment for Early-Stage Disease
Early-stage Freiberg disease — detected before significant metatarsal head collapse — responds to conservative management that offloads the affected metatarsal head and allows vascular recovery. A metatarsal bar proximal to the metatarsal heads, custom orthotics with second metatarsal head relief, and activity modification to reduce forefoot impact loading are the primary interventions. A CAM boot or short leg cast provides more complete offloading for acute, severe symptoms. Early detection and offloading in Stage I and II disease can prevent progression to collapse.
When to see a podiatrist:
- Persistent forefoot pain under the second or third toe lasting more than 2 weeks
- Visible swelling or stiffness at the ball of the foot
- Pain that worsens with walking, running, or wearing heels
- Decreased range of motion in the toe joint
Surgical Treatment
Advanced Freiberg disease with metatarsal head collapse, joint deformity, and failed conservative management is treated surgically. dorsiflexion osteotomy — rotating the metatarsal head to bring the less damaged plantar surface into the weight-bearing position — is effective for Stages II through IV. Joint debridement with loose body removal and metatarsal head reshaping improves joint congruity in less severe collapse. Metatarsal head excision or joint replacement is considered for advanced Stage V disease with severe collapse and arthritis.
If you have persistent forefoot pain at the second MTP joint, particularly as an adolescent or young adult, contact Balance Foot & Ankle for evaluation. Early diagnosis of Freiberg disease significantly improves outcomes. We serve Southeast Michigan with same-week appointments.
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When to See a Podiatrist
If foot or ankle pain has been bothering you for more than a few weeks, home care alone may not be enough. Balance Foot & Ankle offers same-week appointments at our Howell and Bloomfield Hills clinics — no referral needed in most cases. Bring your current shoes and a short list of symptoms and we’ll build you a treatment plan in one visit.
Call Balance Foot & Ankle: (810) 206-1402 · Book online · Offices in Howell & Bloomfield Hills
Frequently Asked Questions About Freiberg Disease
Can Freiberg disease heal on its own?
In early stages (Smillie Stage I-II), Freiberg disease can stabilize with conservative treatment including offloading and activity modification. However, it does not reverse on its own — the damaged bone will not regenerate without intervention. Early treatment prevents progression to joint collapse.
How is Freiberg disease diagnosed?
Diagnosis begins with a clinical exam assessing forefoot tenderness and joint range of motion. X-rays reveal flattening or fragmentation of the metatarsal head. MRI can detect early-stage changes before they appear on X-ray, making it valuable for early diagnosis and treatment planning.
What shoes should I wear with Freiberg disease?
Stiff-soled shoes with a rocker bottom reduce bending forces at the metatarsal head. Avoid high heels and flexible shoes that increase forefoot pressure. A metatarsal pad placed just behind the affected joint helps redistribute weight. In our clinic, we often recommend custom orthotics with a metatarsal bar for optimal offloading.
Is Freiberg disease the same as a stress fracture?
No. A stress fracture is a crack in the bone from repetitive loading, while Freiberg disease is death of bone tissue from disrupted blood supply (avascular necrosis). Both cause forefoot pain, but they require different treatment approaches. Your podiatrist can distinguish them with imaging.
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Book Your AppointmentFrequently Asked Questions
What causes this condition?
Causes include mechanical stress, biomechanical imbalance, age-related changes, and sometimes systemic disease. Our clinical exam plus imaging identifies the specific driver.
Can it go away on its own?
Mild cases sometimes resolve with rest and supportive footwear. Persistent symptoms past 4-6 weeks rarely resolve without active treatment.
Is surgery required?
Most patients resolve with non-surgical care. Surgery is reserved for refractory cases or structural deformity.
What is Metatarsalgia?
Metatarsalgia is a common foot/ankle condition that affects mobility and quality of life. Understanding the underlying cause is the first step in successful treatment. Our podiatrists at Balance Foot & Ankle perform a hands-on biomechanical exam, review your activity history, and use diagnostic imaging when appropriate to identify the root cause—not just treat the symptom. Many patients have been told to “rest and ice” without a deeper diagnostic workup; our approach is different.
Symptoms and warning signs
Common signs of metatarsalgia include pain that worsens with activity, morning stiffness, swelling, tenderness when palpated, and difficulty bearing weight. If you experience sudden severe pain, inability to walk, visible deformity, numbness or color change, contact our office the same day or visit urgent care—these can signal a more serious injury such as a fracture, tendon rupture, or vascular compromise. Diabetics with any foot wound should seek same-day care.
Conservative treatment options
Most cases of metatarsalgia respond to non-surgical care: structured rest, supportive footwear changes, custom orthotics, targeted stretching and strengthening protocols, anti-inflammatory medications when medically appropriate, and in-office procedures such as ultrasound-guided injections. We also offer advanced therapies including MLS laser therapy, EPAT/shockwave, regenerative injections, and image-guided procedures. Treatment is sequenced from least invasive to most invasive, and we explain the rationale at every step.
When is surgery considered?
Surgery is reserved for cases that fail 3-6 months of well-structured conservative care, when there is structural pathology (severe deformity, complete tear, advanced arthritis), or when imaging shows damage that will not heal without intervention. Our surgeons have performed 3,000+ foot and ankle procedures and prioritize minimally-invasive techniques whenever appropriate. We discuss recovery timelines, return-to-activity milestones, and realistic outcome expectations before any procedure is scheduled.
PubMed: Freiberg Disease — Metatarsal Head Necrosis
Recovery timeline and prevention
Recovery from metatarsalgia varies based on severity and chosen treatment path. Conservative cases often improve within 4-8 weeks with consistent adherence to the protocol. Post-procedural recovery may range from a few days (in-office procedures) to several months (reconstructive surgery). Long-term prevention involves footwear assessment, activity modification, structured strengthening, and regular check-ins with your podiatrist if you have a history of recurrence. We provide written home-exercise plans and digital follow-up support.
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Same-week appointments at our Howell and Bloomfield Hills offices. Board-certified podiatric surgeons. Most insurance accepted.
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Dr. Tom Biernacki, DPM is a board-certified foot & ankle surgeon (ABFAS & ABPM) at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has made him one of the most-followed foot & ankle educators on YouTube.