Medically reviewed by Dr. Tom Biernacki, DPM
Board-certified podiatric surgeon | Balance Foot & Ankle, Howell & Bloomfield Hills, MI
Last reviewed: May 2026
The most important clinical decision with Freiberg Infraction: Causes, Symptoms, and Treatment isn’t which treatment to choose — it’s identifying which subtype you have first. Our podiatrists see patients treated for the wrong subtype for months before the correct diagnosis leads to full resolution. Call (810) 206-1402 — expert podiatric care across Michigan.
Freiberg infraction is an avascular necrosis of a metatarsal head — most commonly the second, occasionally the third — that occurs predominantly in adolescent females during rapid growth spurts. The vascular insult causes cartilage collapse and metatarsal head flattening that can permanently alter joint mechanics if not treated in the acute phase. Early diagnosis changes outcomes dramatically.
Freiberg Infraction: Key Clinical Features
| Feature | Detail |
|---|---|
| Most common metatarsal affected | 2nd (68%); 3rd (27%); others rare |
| Peak demographic | Adolescent females 13-18 years; female:male ratio 3-5:1 |
| Primary symptom | Forefoot pain at 2nd or 3rd MPJ; worsened by activity and forefoot loading |
| X-ray finding (early) | Normal (X-ray lags 4-6 weeks behind symptom onset) |
| X-ray finding (established) | Metatarsal head flattening; subchondral sclerosis; joint space changes |
| MRI finding (early) | Subchondral bone marrow edema before X-ray changes visible |
| Smillie classification | Stage I-V: I=fissure, II-III=subchondral collapse, IV-V=loose bodies and severe joint destruction |
Treatment by Stage
| Stage | Conservative Treatment | Surgical Option | Prognosis |
|---|---|---|---|
| Stage I-II (early) | Non-weight-bearing cast/boot 4-6 weeks; metatarsal pad; stiff-soled shoe | Rarely needed | Excellent if treated early — head revascularizes |
| Stage III (subchondral collapse) | Extended offloading; metatarsal pad; 3-6 month conservative trial | Dorsal closing wedge osteotomy (rotates damaged cartilage away from weight-bearing) | Good with surgical correction |
| Stage IV-V (late / loose bodies) | Palliative: metatarsal pad, rigid-soled shoe, joint injection | Joint debridement; metatarsal shortening; arthrodesis (salvage) | Fair — permanent joint changes |
The dorsal closing wedge osteotomy is the most effective surgical treatment for Stage III Freiberg — it rotates the intact plantar cartilage into the weight-bearing zone, converting a painful articular surface into a functional one. Results are excellent when performed before Stage IV joint destruction.
At Balance Foot & Ankle in Howell and Bloomfield Hills, we evaluate forefoot pain with weight-bearing X-rays and MRI when clinical suspicion is high and X-rays are normal. Early Freiberg diagnosis is critical for conservative success. Call (810) 206-1402.
American Academy of Orthopaedic Surgeons: Freiberg’s Disease
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Freiberg infraction: time matters more than people realize
Freiberg infraction is osteonecrosis of a metatarsal head, most commonly the second. Caught at stage 1 or 2, an unloading regimen (carbon plate, custom orthotic, NSAIDs) can preserve the joint surface. Caught at stage 4 or later, joint preservation gets much harder. Imaging confirms staging; treatment is staged accordingly. We see a number of these in adolescents and active women.
Balance Foot & Ankle — Howell & Bloomfield Hills, MI: board-certified podiatrists, same-week appointments, most insurance accepted.
Book a Forefoot Evaluation → or call (810) 206-1402
Related reading: plantar plate tear · metatarsalgia · hallux rigidus
Doctor Answer
What is Freiberg’s infraction and how is it treated?
Freiberg’s infraction is avascular necrosis of a metatarsal head — most commonly the second — where the blood supply is disrupted, causing the metatarsal head to flatten, collapse, and become arthritic. It is most common in adolescent girls and young women. Early stages respond to metatarsal pads, orthotics, and rest. Advanced collapse with significant pain and limited joint motion may require surgical procedures including debridement, core decompression, or joint resurfacing depending on the stage.
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.