Freiberg’s Disease: Osteochondrosis of the Metatarsal Head

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 disease — avascular necrosis of a metatarsal head, most commonly the second — is an uncommon but important cause of forefoot pain that affects predominantly adolescent and young adult females and is frequently misdiagnosed as Morton’s neuroma or metatarsalgia. Unlike Morton’s neuroma, Freiberg’s disease produces bony changes visible on X-ray and MRI, and its natural history ranges from spontaneous healing with appropriate offloading in early stages to progressive joint destruction requiring surgical intervention in advanced cases.

Etiology, Staging, and Diagnosis

Etiology: repetitive microtrauma and increased mechanical stress at the metatarsal head (long second metatarsal, restricted first MTP mobility, high-heeled footwear) leads to subchondral stress fracture and compromise of the intraosseous blood supply, producing avascular necrosis. The second metatarsal head is most commonly affected (68%), followed by the third (27%). Smillie classification (X-ray staging): Stage I — subchondral fissure visible on MRI only; Stage II — early flattening of the metatarsal head on X-ray; Stage III — further flattening with central absorption; Stage IV — fracture through the central head with loose body formation; Stage V — complete joint destruction with flattened head and irregular joint surface. Presentation: pain at the second (or third) MTP joint aggravated by weight-bearing, specifically with push-off; swelling and limited MTP dorsiflexion; tenderness directly over the metatarsal head; the pain is at the joint (not between the metatarsal heads as in Morton’s neuroma). MRI: the gold standard for early diagnosis — subchondral bone marrow edema and low-signal T1 changes identify avascular necrosis before X-ray changes appear.

Treatment

Early stages (I–II): offloading with a metatarsal bar orthotic or rigid-soled shoe reducing MTP dorsiflexion stress; activity modification for 6–8 weeks; non-weight-bearing cast for acute severe cases; spontaneous healing occurs in most early-stage cases with adequate offloading. Advanced stages (III–V): surgical débridement of loose bodies; joint-preserving procedures (dorsiflexion osteotomy of the metatarsal neck to rotate intact plantar articular cartilage into the weight-bearing position — Gauthier procedure); metatarsal head resection for Stage V disease with acceptable forefoot function at the cost of transfer metatarsalgia risk. Dr. Biernacki at Balance Foot & Ankle evaluates forefoot pain with weight-bearing X-ray and MRI to identify Freiberg’s disease at early stages when joint-preserving treatment is possible. Call (810) 206-1402 at our Bloomfield Hills or Howell office.

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Frequently Asked Questions

When should I see a podiatrist?

See a podiatrist for any foot or ankle pain that persists more than 2 weeks, doesn’t improve with rest, limits your daily activities, or is accompanied by swelling, numbness, or skin changes. People with diabetes or circulation problems should see a podiatrist regularly even without symptoms.

What does a podiatrist treat?

Podiatrists diagnose and treat all conditions of the foot, ankle, and lower leg including plantar fasciitis, bunions, hammertoes, toenail problems, heel pain, nerve pain, diabetic foot care, sports injuries, fractures, and foot deformities — both surgically and non-surgically.

What can I expect at my first podiatry visit?

Your first visit includes a full medical history, physical examination of your feet and gait, and in-office diagnostic imaging if needed (X-rays, ultrasound). We’ll discuss your diagnosis and create a personalized treatment plan. Most visits take 30–45 minutes.

Need Treatment at Balance Foot & Ankle?

Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin see patients at our Howell and Bloomfield Township offices.

Book Online or call (810) 206-1402

Freiberg’s Disease Treatment in Howell & Bloomfield Hills

Freiberg’s disease causes pain and stiffness in the ball of the foot from metatarsal head osteochondrosis. Our podiatrists offer conservative management with orthotics and modifications, as well as surgical options for advanced cases that don’t respond to non-operative care.

Explore Forefoot Treatment Options | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Freiberg AH. Infraction of the second metatarsal bone, a typical injury. Surg Gynecol Obstet. 1914;19:191-193.
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. Carmont MR, Rees RJ, Blundell CM. Current concepts review: Freiberg’s disease. Foot Ankle Int. 2009;30(2):167-176.

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Dr. Tom Biernacki, DPM

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Dr. Carl Jay, DPM

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Dr. Daria Gutkin, DPM

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Dr. Tom Biernacki, DPM

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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.