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You are in the right place. Dr. Tom Biernacki, DPM, FACFAS — board-certified foot & ankle surgeon with 3,000+ surgeries — explains exactly what Freiberg’s disease means and what actually works. Call (810) 206-1402 for a same-day appointment at our Howell or Bloomfield Hills office.
Medically Reviewed by Dr. Tom Biernacki, DPM, FACFAS
Board-Certified Podiatrist & Foot Surgeon · Howell & Bloomfield Hills, MI · Last updated: May 2026
Freiberg’s disease (Freiberg infraction) is avascular necrosis of the metatarsal head — most commonly the second, causing the metatarsal head to lose its blood supply, flatten, and fragment. It most often affects active adolescent females during growth spurts. Early stages are managed with offloading orthotics, a CAM boot, and activity restriction. Advanced cases with significant joint collapse may require surgery to restore the metatarsal head contour.
⚠️ See a podiatrist promptly if you have:
- Progressive ball-of-foot pain that worsens over weeks
- Swelling at the base of the second or third toe
- Pain that significantly limits walking or sport activity
- A sensation of grinding or clicking in the forefoot
- Symptoms that don’t improve with rest and anti-inflammatories after 2 weeks
Dr. Scholl’s Metatarsal Cushioning Pads
⭐ DPM’s First-Line Treatment for Freiberg Disease
Offloading the affected metatarsal head is the single most important conservative intervention for Freiberg disease. Metatarsal pads placed just behind the painful joint reduce peak plantar pressure by up to 50%, relieving pain and protecting the fragile avascular bone from further collapse during the revascularization process. Our clinic prescribes these immediately at first visit.
PowerStep Pinnacle Arch Support Insole
⭐ Best Insole for Metatarsal Head Offloading
PowerStep insoles provide a rigid base that transfers load from the forefoot to the midfoot arch, reducing the compressive and shear forces on the diseased metatarsal head during gait. For Freiberg disease, the combination of a metatarsal pad placed on top of the PowerStep insole creates the most effective conservative offloading system available without a custom orthotic.
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The most important clinical decision with Freiberg Disease isn’t which treatment to start with — it’s identifying the correct subtype. That changes everything. Call (810) 206-1402.
The most important clinical decision with Freiberg Disease isn’t which treatment to start with — it’s identifying the correct subtype. That changes everything. Call (810) 206-1402.
Related Conditions
Medically reviewed by Dr. Tom Biernacki, DPM
Board-certified podiatric surgeon | Balance Foot & Ankle
Last reviewed: May 2026
In This Article
Freiberg’s Disease Stages: Smillie Classification
Freiberg’s disease is staged on X-ray using the Smillie classification. Stage determines treatment aggressiveness — early stages caught in adolescents have the best chance of healing without permanent joint damage. Late-stage disease with metatarsal head collapse requires surgical intervention to restore a functioning joint surface.
| Smillie Stage | X-ray Finding | Pain Level | Treatment |
|---|---|---|---|
| Stage 1–2 | Sclerosis, early flattening | Moderate | CAM boot 6–8 weeks, offloading orthotic |
| Stage 3 | Central collapse, intact margins | Moderate–severe | Extended offloading or surgical debridement |
| Stage 4–5 | Head fragmentation, loose bodies | Severe, arthritic | Surgical joint reconstruction or metatarsal osteotomy |
Freiberg’s Disease Treatment
The cornerstone of conservative treatment is complete offloading of the affected metatarsal head. A stiff-soled shoe or rocker-bottom shoe prevents the metatarsal from bending under load. For active adolescents or adults with early-stage disease, a CAM boot for 6–8 weeks allows the avascular bone to stabilize and potentially revascularize. Custom orthotics with a metatarsal pad placed just proximal to the metatarsal heads provide ongoing protection after the acute phase. NSAIDs reduce joint inflammation, and a single corticosteroid injection can calm severe acute flare-ups without accelerating bone loss when used judiciously.
The most damaging mistake with Freiberg’s disease is continuing high-impact activity — running, sports, or prolonged standing — while the metatarsal head is avascular. Every compression cycle on the affected metatarsal head accelerates fragmentation and collapse. An athlete who “plays through” Freiberg’s disease can turn a Stage 2 lesion (conservatively manageable) into a Stage 4 requiring surgical joint reconstruction. Temporary activity restriction is a small price to pay to preserve a healthy joint for life.
Frequently Asked Questions About Freiberg’s Disease
Who gets Freiberg’s disease?
Freiberg’s disease most commonly affects active adolescent females between ages 11–17 — likely related to the vulnerability of the growth plate combined with repetitive loading during sports. It can also occur in adults, particularly those with a relatively long second metatarsal, hypermobile first ray, or a history of direct trauma to the metatarsal head. The second metatarsal is affected in approximately 68% of cases.
Does Freiberg’s disease go away on its own?
In early stages (Smillie 1–2), appropriate offloading allows the avascular bone to stabilize and the joint to remodel into a functional shape — some patients achieve complete symptomatic resolution. Later stages (3–5) with significant collapse do not self-correct, and the resulting joint incongruency leads to progressive arthritis without surgical treatment.
Can I still exercise with Freiberg’s disease?
Low-impact activities — swimming, cycling, upper body strength training — are generally tolerated and recommended to maintain fitness during treatment. High-impact activities (running, jumping, court sports) must be avoided during the acute phase. Your return-to-sport timeline depends on your stage of disease and response to offloading — typically 8–16 weeks for early-stage cases.
When should I see a podiatrist for Freiberg’s disease?
See a podiatrist if a child or teenager has persistent ball-of-foot pain under the second or third toe, especially if active in sports. Early detection at Stage 1–2 dramatically changes the outcome. Same-day appointments at Balance Foot & Ankle — (810) 206-1402 — Howell and Bloomfield Hills, MI.
Does insurance cover Freiberg’s disease treatment?
Yes — office visits, weight-bearing X-rays, MRI, custom orthotics, CAM boot, and surgical treatment for Freiberg’s disease are covered by most PPO plans and Medicare when medically documented. Call (810) 206-1402 to verify your specific benefits before your visit.
Ball of Foot Pain That Won’t Resolve?
Dr. Tom Biernacki evaluates Freiberg’s disease with weight-bearing X-rays and MRI at Balance Foot & Ankle. Same-day appointments in Howell and Bloomfield Hills, MI.
Related: Toe Capsulitis · Metatarsalgia · Stress Fracture · Custom Orthotics Michigan
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In-Office Treatment at Balance Foot & Ankle
If home treatment isn’t providing relief for your foot and ankle conditions, our podiatry team at Balance Foot & Ankle can help with same-day evaluations and advanced in-office care.
Same-day appointments available. (810) 206-1402
Frequently Asked Questions
When should I see a podiatrist?
See a podiatrist if: foot or ankle pain has lasted more than 2–4 weeks without improvement, you’re changing your gait to avoid pain, you have an open wound or sore that isn’t healing, you notice nail discoloration or thickening, you have diabetes and any foot concern, or pain is severe enough to wake you at night. Most foot conditions are easier and cheaper to treat early — what starts as a minor issue can become a surgical problem with months of delay.
What is the difference between a podiatrist and an orthopedic surgeon?
Podiatrists (DPM — Doctor of Podiatric Medicine) specialize exclusively in the foot, ankle, and lower leg. Orthopedic surgeons (MD/DO) have broader musculoskeletal training but variable foot/ankle subspecialization. For foot and ankle-specific problems, a podiatrist often has more focused training and experience. For injuries involving the leg above the ankle, complex pediatric cases, or multi-level reconstruction, orthopedic consultation may be appropriate. We frequently co-manage patients with orthopedic colleagues.
How do I know if my foot pain is serious?
Signs that warrant same-day or next-day evaluation: severe pain that appeared suddenly without clear cause, swelling, redness, and warmth that appeared suddenly (possible gout, infection, or Charcot fracture), an open wound that looks infected (redness spreading, pus, warmth), inability to bear weight, or any foot problem in a diabetic patient. Pain that’s been present for weeks and is stable is important but not an emergency — schedule within 1–2 weeks.
Can foot problems cause back and knee pain?
Yes — this is a kinetic chain effect. Abnormal foot mechanics (overpronation, supination, leg length discrepancy) cause compensatory changes in knee, hip, and lumbar alignment. Roughly 30% of patients presenting to our clinic with knee pain have a treatable foot-level biomechanical cause. Correcting foot mechanics with orthotics or appropriate footwear often provides significant knee and back relief. If you have chronic knee or back pain and haven’t had your foot mechanics evaluated, it’s worth a consult.
Are orthotics worth it?
For the right conditions, yes — custom orthotics are among the most cost-effective interventions in podiatry. They’re most effective for: plantar fasciitis, flat feet with secondary knee/back pain, leg length discrepancy, metatarsalgia, posterior tibial tendon dysfunction, and diabetic foot pressure management. Quality OTC orthotics ($35–60) resolve symptoms for 60% of patients with mild-to-moderate conditions. Custom orthotics are appropriate when OTC options have failed or when the biomechanical problem is complex. We cast custom orthotics in-office.
How do I choose the right running shoes?
Start with your foot type (flat, neutral, high arch) and running pattern (overpronator, neutral, supinator). Flat feet and overpronators do best in stability or motion-control shoes. Neutral feet do well in neutral-cushioned shoes. High arches need maximum cushioning with flexible soles. Always buy running shoes at the end of the day (foot swelling peaks then), get properly fitted by a specialist, and replace every 300–500 miles. If you’ve been injured repeatedly, a gait analysis can identify the mechanical flaw driving your injury pattern.
What is the difference between a sprain and a fracture?
A sprain is a ligament injury (the tissue connecting bones); a fracture is a break in the bone itself. Both can occur with the same trauma (ankle roll, fall). The old test — ‘if you can walk, it’s not broken’ — is wrong; many fractures are initially weight-bearable. Key differences: a fracture typically produces localized bone tenderness along the bone itself, while a sprain is tender over the ligament. X-ray is the standard to differentiate. High-grade sprains without proper treatment can be as disabling as fractures.
How do I prevent foot and ankle injuries?
The four most impactful prevention strategies: (1) Supportive, appropriately fitted footwear for your foot type and activity. (2) Gradual activity progression — the 10% rule (never increase weekly mileage or intensity by more than 10%). (3) Regular calf and ankle mobility work. (4) Strengthening the posterior tibial tendon, peroneals, and intrinsic foot muscles. Most overuse injuries are preventable; most acute injuries are not — but ankle sprain recurrence (60–70% without rehab) is prevented by balance and proprioception training.
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.