✅ Medically reviewed by Dr. Thomas Biernacki, DPM — Board-Certified Podiatrist · Last updated April 6, 2026

Freiberg’s Disease: Causes, Symptoms & Treatment Options

If you’re experiencing a deep, aching pain in the ball of your foot — especially behind your second toe — you may be dealing with Freiberg’s disease. This condition can be frustrating because it often gets misdiagnosed as a simple metatarsalgia or stress fracture. Understanding what’s actually happening inside the bone is the first step toward getting proper treatment and preventing permanent joint damage.

At Balance Foot & Ankle, we regularly diagnose and treat Freiberg’s infraction at our Howell and Bloomfield Hills offices using a combination of advanced imaging, custom orthotics, and when necessary, surgical intervention to restore the metatarsal head.

What Is Freiberg’s Disease?

Freiberg’s disease is a type of osteochondrosis — a condition where bone tissue dies due to loss of blood supply (avascular necrosis). It specifically affects the metatarsal heads in the ball of the foot. The second metatarsal head is involved in approximately 68% of cases, followed by the third metatarsal (27%) and rarely the fourth or fifth.

First described by Dr. Alfred Freiberg in 1914, the condition involves a predictable pattern of bone death, flattening, and eventual joint collapse if left untreated. The term “infraction” refers to an incomplete fracture — the bone weakens and micro-fractures before visibly collapsing on X-ray.

Why the Second Metatarsal?

The second metatarsal bears the most force during push-off in the gait cycle. It’s also typically the longest metatarsal in most foot types, creating a biomechanical lever arm that concentrates stress at the metatarsal head. Combined with a relatively precarious blood supply to the epiphysis (growth plate area), this makes the second metatarsal head uniquely vulnerable to avascular necrosis.

Freiberg’s Disease vs. Similar Conditions

Ball of the foot pain has many possible causes. This comparison table helps distinguish Freiberg’s disease from conditions that may present similarly.

Condition	Location	Key Feature	Age Group	Imaging
Freiberg’s Disease	2nd metatarsal head	Deep ache, worse with push-off, joint stiffness	Teens & young adults (F > M)	Metatarsal head flattening on X-ray/MRI
Morton’s Neuroma	3rd/4th interspace	Burning, shooting pain between toes, numbness	30-60 years (F > M)	Mulder’s click positive; ultrasound shows neuroma
Stress Fracture	Metatarsal shaft	Sharp pain, worse with activity, point tender	Athletes, any age	Fracture line on MRI/bone scan; X-ray may be normal early
Metatarsalgia	Ball of foot (general)	Burning, aching under metatarsal heads	Any age	Normal X-ray; biomechanical cause
Capsulitis (2nd toe)	2nd MTP joint	Swelling, toe drifting, “walking on a marble”	Adults 30-60	Joint space widening; plantar plate tear on MRI
Sesamoiditis	Under 1st metatarsal	Pain under big toe joint, worse with push-off	Runners, dancers	Sesamoid inflammation/fracture on imaging

What Causes Freiberg’s Disease?

The exact cause is considered multifactorial, but the primary mechanism involves disruption of blood flow to the metatarsal head. Several factors contribute to this vascular compromise.

Primary Causes & Risk Factors

Repetitive microtrauma is the most widely accepted contributing factor. Activities that load the forefoot — running, jumping, dancing, high-impact sports — create repeated compression of the metatarsal head against the proximal phalanx. Over time, this can damage the delicate blood vessels supplying the bone’s growth center.

Vascular vulnerability during growth plays a critical role. The epiphysis of the metatarsal head has a tenuous blood supply during adolescence, especially during periods of rapid growth. This is why Freiberg’s most commonly presents between ages 11–17, with a strong female predominance (roughly 5:1 female-to-male ratio), likely related to earlier skeletal maturation and the use of narrow, heeled shoes.

Structural biomechanics also contribute significantly. A longer second metatarsal (Morton’s foot type), hypermobile first ray, equinus (tight calf muscles), or high-arched foot type all increase load on the second metatarsal head. Patients with these foot structures are at higher risk because the second metatarsal absorbs disproportionate ground reaction force.

Acute trauma can trigger the condition in some cases — a single forceful impact to the forefoot (such as a missed step or landing hard on the ball of the foot) can damage the blood supply acutely rather than through gradual repetitive stress.

Systemic factors may contribute in certain patients, including conditions affecting vascular health (diabetes, lupus, hypercoagulability) or long-term corticosteroid use, which can weaken bone structure and blood supply.

Smillie Classification: Stages of Freiberg’s Disease

The Smillie classification system describes five progressive stages of Freiberg’s disease, which guide treatment decisions. Understanding which stage you’re in helps determine whether conservative treatment is likely to succeed or if surgical intervention is warranted.

Stage	Pathology	X-ray Findings	Treatment Approach
Stage I	Initial ischemia (fissure fracture)	Often normal; MRI shows early edema	Offloading, orthotics, activity modification
Stage II	Absorption of bone centrally	Subtle flattening, central sclerosis	Stiff-soled shoes, orthotics with metatarsal pad
Stage III	Further collapse with projection of plantar cartilage	Obvious metatarsal head flattening	Extended offloading; may need surgery
Stage IV	Loose body formation, articular destruction	Loose fragments visible, joint narrowing	Surgical intervention usually required
Stage V	Secondary degenerative arthritis	Flattened head, osteophytes, arthritis changes	Surgical reconstruction or joint salvage

Symptoms of Freiberg’s Disease

Freiberg’s disease typically develops gradually, though some patients report a specific event that triggered their symptoms. The hallmark presentation includes several characteristic features.

Pain in the ball of the foot is the primary symptom, localized to the affected metatarsal head (usually behind the second toe). The pain is typically described as a deep ache that worsens with weight-bearing activities, especially during push-off when walking or running. High heels and thin-soled shoes dramatically increase symptoms.

Swelling and stiffness develop around the MTP joint as the condition progresses. The joint capsule becomes inflamed, and patients often notice difficulty bending the affected toe. Range of motion testing reveals limited and painful dorsiflexion (upward bending) of the toe.

Limping or altered gait occurs as patients unconsciously shift weight away from the painful area. Many patients walk on the outside of the foot or shorten their stride to avoid push-off pressure on the forefoot.

A palpable prominence or grinding sensation may develop in later stages as the metatarsal head flattens and loose bodies form within the joint. Some patients describe a “clicking” or “catching” sensation when moving the toe.

How Is Freiberg’s Disease Diagnosed?

Accurate diagnosis requires a combination of clinical examination and imaging, since early-stage Freiberg’s can look identical to other forefoot conditions on physical exam alone.

Physical examination reveals point tenderness directly over the affected metatarsal head. Your podiatrist will assess for swelling, reduced range of motion at the MTP joint, and pain with axial loading (pushing up on the toe). A positive “squeeze test” — compressing the metatarsal head between thumb and finger — is often diagnostic.

X-rays are the first-line imaging study and may show characteristic flattening of the metatarsal head, sclerosis (increased bone density), fragmentation, or joint space widening. However, early Stage I disease often appears normal on X-ray, which is why many early cases get missed.

MRI is the gold standard for early detection. It can identify bone marrow edema and early avascular changes weeks to months before X-ray changes appear. MRI is particularly valuable for staging the disease and planning treatment.

CT scan may be ordered in advanced cases to better visualize the extent of bone collapse, loose body formation, and to assist with surgical planning.

Conservative Treatment Options

The goal of conservative treatment is to reduce mechanical stress on the affected metatarsal head, allowing the bone to heal (in early stages) or preventing further collapse (in moderate stages). Success rates for conservative treatment are highest in Smillie Stages I–III.

Phase 1: Acute Offloading (Weeks 1–6)

The immediate priority is removing pressure from the damaged metatarsal head. This may involve a short walking boot or stiff-soled postoperative shoe to immobilize the forefoot. Activity modification is essential — this means stopping running, jumping, and any high-impact exercise. Crutches or a knee scooter may be recommended for severe cases to achieve non-weight-bearing status. Ice application for 15–20 minutes several times daily helps manage inflammation, and NSAIDs like ibuprofen or naproxen can provide pain relief.

Phase 2: Supported Weight-Bearing (Weeks 6–12)

Once acute symptoms subside, the transition to protected weight-bearing begins with custom orthotics. A metatarsal pad positioned just proximal (behind) the affected metatarsal head is the single most important orthotic modification — it redistributes pressure away from the damaged bone. Custom foot orthotics with a metatarsal pad accommodation provide the most precise offloading.

Stiff-soled or rocker-bottom shoes reduce the bending forces at the MTP joint during push-off. Carbon fiber inserts can be added to existing shoes to create the same effect. Physical therapy during this phase focuses on maintaining joint mobility with gentle range-of-motion exercises and strengthening the intrinsic foot muscles.

Phase 3: Gradual Return to Activity (Months 3–6)

Return to full activity should be gradual and guided by symptoms and follow-up imaging. Low-impact activities (swimming, cycling) are reintroduced first, followed by walking progression, and finally sport-specific training. The orthotic with metatarsal pad support should be worn during all weight-bearing activities indefinitely. Follow-up X-rays at 3 and 6 months help monitor bone remodeling and ensure no progressive collapse.

Surgical Treatment Options

Surgery is considered when conservative treatment fails after 3–6 months, or when imaging shows progressive collapse (Smillie Stage III–V). Several surgical approaches are available depending on the severity of joint damage.

Joint debridement and drilling is appropriate for early-to-moderate disease. The surgeon cleans out the joint, removes loose bodies and damaged cartilage, and drills small holes into the metatarsal head to stimulate new blood vessel growth (revascularization). This technique works best in Stages II–III before significant articular surface collapse.

Dorsal closing wedge osteotomy is the most commonly performed procedure for Freiberg’s disease. The surgeon removes a wedge of bone from the dorsal (top) aspect of the metatarsal head, then rotates the remaining healthy plantar cartilage into the weight-bearing position. This effectively replaces the damaged articular surface with preserved cartilage from the non-weight-bearing portion. Studies report good to excellent outcomes in 85–90% of cases.

Metatarsal shortening osteotomy (Weil osteotomy) reduces pressure on the metatarsal head by shortening the bone. This can be performed alone or combined with debridement. It’s particularly useful when a long second metatarsal is a contributing factor.

Interpositional arthroplasty involves placing a tissue spacer (often from the joint capsule or a graft) between the metatarsal head and phalanx after removing damaged cartilage. This maintains joint space and motion while providing a new articulating surface.

Joint replacement or resection is reserved for severe Stage V disease with complete joint destruction. The metatarsal head may be partially resected, or in some cases a synthetic implant is placed. These are salvage procedures when other options have been exhausted.

Best Products for Freiberg’s Disease

Proper footwear and support devices are essential for managing Freiberg’s disease. These products help redistribute pressure away from the affected metatarsal head.

Prognosis & Long-Term Outlook

The prognosis for Freiberg’s disease depends heavily on the stage at diagnosis and how quickly treatment begins. Patients diagnosed in Stages I–II who comply with offloading protocols typically see good outcomes with conservative treatment alone, with most returning to full activity within 3–6 months.

Stage III patients have variable outcomes — roughly 50–60% respond to extended conservative care, while the remainder eventually require surgical intervention. Stages IV–V almost universally require surgery, but modern surgical techniques (particularly the dorsal closing wedge osteotomy) produce good to excellent results in the majority of patients.

Long-term, patients should continue wearing supportive shoes with metatarsal pad orthotics to prevent recurrence. Some patients develop mild secondary arthritis at the MTP joint even after successful treatment, which is generally manageable with ongoing orthotic support and activity modification.

Frequently Asked Questions

The Bottom Line

Freiberg’s disease is an uncommon but potentially serious condition that causes progressive damage to the metatarsal head in the ball of the foot. Early recognition and proper offloading are the keys to avoiding permanent joint damage. If you’ve been dealing with persistent pain behind your second toe that isn’t responding to typical metatarsalgia treatments, ask your podiatrist specifically about Freiberg’s disease — an MRI can catch it early when treatment is most effective.

Sources

• Smillie, I.S. “Freiberg’s infraction.” Journal of Bone and Joint Surgery. Classification system for avascular necrosis staging.
• Carmont, M.R., et al. “Freiberg’s disease: a systematic review of clinical features and treatment.” Foot and Ankle Surgery.
• Gauthier, G., Elbaz, R. “Freiberg’s infraction: a subchondral bone fatigue fracture.” Clinical Orthopaedics and Related Research.
• Katcherian, D.A. “Treatment of Freiberg’s Disease.” Orthopedic Clinics of North America. Review of conservative and surgical management.

Clinical References

1. Carmont MR, et al. Freiberg’s disease: a review of the long-term results of surgical treatment. J Foot Ankle Surg. 2009;48(5):588-592.
2. Gauthier G, Elbaz R. Freiberg’s infraction: a subchondral bone fatigue fracture. A new surgical treatment. Clin Orthop Relat Res. 1979;(142):93-95.
3. Katcherian DA. Treatment of Freiberg’s disease. Orthop Clin North Am. 1994;25(1):69-81.

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