Freiberg’s Infraction: Metatarsal Head Avascular Necrosis Explained

Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

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Freiberg’s infraction is avascular necrosis (AVN) of a metatarsal head — most commonly the second metatarsal head, less often the third or fourth. First described by Alfred Freiberg in 1914, it predominantly affects adolescent females (female-to-male ratio of approximately 5:1) and young active adults, though it can present at any age. Without appropriate management, it progresses to metatarsal head collapse and permanent second MTP joint arthritis.

Why the Metatarsal Head Loses Blood Supply

The exact pathogenesis of Freiberg’s infraction remains debated, but the prevailing theory involves repetitive mechanical stress to the second (or third) metatarsal head creating microvascular disruption and subchondral fatigue failure. Contributing factors include:

• Metatarsal length pattern: A long second metatarsal (Morton’s foot) concentrates increased load at the second MTP joint
• Elevated first ray: First metatarsal insufficiency transfers load to the second metatarsal
• High-heeled footwear: Increases forefoot loading pressure at the MTP joints
• Repetitive activity: Running, dancing, and athletic sports during adolescent skeletal development
• Vascular anatomy: The second metatarsal head has relatively tenuous blood supply at the subchondral level

Symptoms

The primary symptom is forefoot pain localized to the second (or third) MTP joint, worse with weight-bearing and activity. Early Freiberg’s presents as diffuse MTP joint pain and swelling; advanced disease produces stiffness, loss of MTP dorsiflexion, palpable MTP joint effusion, and pain throughout the range of motion.

Staging (Smillie Classification)

The Smillie classification (Stages I–V) guides treatment:

• Stage I: Ischemic necrosis — MRI shows bone marrow edema, X-ray normal
• Stage II: Central depression of the articular surface — subtle flattening visible on X-ray
• Stage III: Absorption of central bone, peripheral osteochondral fragments
• Stage IV: Loose bodies, articular surface collapse
• Stage V: Advanced arthrosis — joint space narrowing, osteophytes, flattened metatarsal head

Treatment

Conservative Management (Stages I–II)

Early-stage Freiberg’s infraction is treated with offloading to allow revascularization: a metatarsal pad or custom orthotic with a metatarsal bar redistributes pressure away from the affected metatarsal head. A walking boot for 4–8 weeks is recommended for acute painful presentations. Activity modification — particularly avoiding high-impact loading — during the revascularization period prevents progression.

Surgical Management (Stages III–V and failed conservative care)

Joint debridement and loose body removal (arthroscopic): Removes osteochondral fragments and smooths the articular surface — most appropriate for Stage III with preserved central joint space.

Dorsiflexion osteotomy: Rotates the metatarsal head so the healthier plantar cartilage becomes the weight-bearing surface — the most commonly performed procedure for Stage II–III Freiberg’s in active patients. Preserves joint motion and produces reliable pain relief.

Shortening osteotomy (Weil osteotomy): Decompresses the MTP joint and reduces loading at the affected metatarsal head.

MTP joint arthroplasty or fusion: For advanced Stage IV–V disease with irreparable joint destruction.

Freiberg’s Infraction — Metatarsal Avascular Necrosis

Freiberg’s infraction causes progressive forefoot pain from blood supply disruption to a metatarsal head. Our podiatrists diagnose it early with MRI and provide treatments from custom orthotics to joint-preserving surgery that protect the joint and relieve pain.

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Clinical References

1. Smillie IS. Freiberg’s infraction (Köhler’s second disease). Journal of Bone and Joint Surgery. 1957;39-B(3):580-588.
2. Gauthier G, Elbaz R. Freiberg’s infraction: a subchondral bone fatigue fracture. Clinical Orthopaedics and Related Research. 1979;(142):93-95.
3. Carmont MR, et al. Freiberg’s disease: a systematic review of clinical features and treatment options. Foot and Ankle Surgery. 2020;26(4):367-375.

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Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon 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 reached over one million views.