Freiberg Disease Treatment Guide 2026 | DPM

Quick answer: Treatment for freiberg disease treatment follows a stepwise approach: 1) conservative care first (rest, ice, supportive footwear, OTC anti-inflammatories), 2) physical therapy and targeted exercises, 3) in-office treatments (injections, custom orthotics) if conservative fails at 4-6 weeks, 4) surgery for refractory cases. Most patients resolve at step 1 or 2. Call (810) 206-1402.

Freiberg’s disease (Freiberg’s infraction) is avascular necrosis of a metatarsal head — the blood supply to the bone is disrupted, causing the metatarsal head to die, collapse, and become painful. The 2nd metatarsal head is affected in 70-80% of cases; the 3rd is next most common. It primarily affects teenage girls and young adult women (female-to-male ratio 5:1), though it can occur in older adults. Cause: Not fully understood, but likely involves repetitive microtrauma to a long 2nd metatarsal combined with individual vascular susceptibility. High-heeled shoes, ballet, running, and adolescent growth spurts are associated risk factors. Symptoms: Pain under the ball of foot at the 2nd metatarsal head. Swelling and stiffness at the 2nd MTP joint. Pain with walking, worse in thin-soled shoes, and with toe dorsiflexion. X-ray shows metatarsal head flattening, widening of the joint space, and in later stages, loose bodies and fragmentation. Smillie classification (stages 1-5): Stage 1 — subchondral fracture, normal x-ray; Stage 2 — early resorption, slight flattening; Stage 3 — sinking of central metatarsal head; Stage 4 — loose bodies, significant flattening; Stage 5 — advanced arthrosis. Conservative treatment (Stages 1-3): Metatarsal pad to offload the affected metatarsal head. Custom orthotic with forefoot relief. Stiff-soled shoe to limit MTP joint motion during walking. Activity modification — reduce impact loading. Immobilization in a walking boot for 4-6 weeks in acute stages. Non-weight-bearing casting for young patients with severe pain. Surgical treatment (Stages 3-5): Dorsiflexion osteotomy (rotating the metatarsal head to expose fresh cartilage) for Stage 3-4; metatarsal head resection or interpositional arthroplasty for Stage 5. See our metatarsalgia guide for related forefoot conditions.

When Shoes Aren’t Enough — Dr. Tom’s Top 9 Orthotics

About 30% of patients I see for foot pain need MORE than a great shoe — they need a structured insole. Below: my complete 2026 orthotic ranking with pros, cons, and the specific patient I’d give each one to.

In-Office Treatment at Balance Foot & Ankle

If home treatment isn’t providing relief for your freiberg disease treatment, our podiatry team at Balance Foot & Ankle can help with same-day evaluations and advanced in-office care.