Freiberg Disease: Metatarsal Avascular Necrosis | DPMMI

Smillie Stage	Radiographic Finding	MRI Finding	Cartilage Status	Primary Treatment
I — Ischemic	Normal plain film	Bone marrow edema	Intact	Offloading; orthotics; boot
II — Subchondral fracture	Central dorsal depression; sclerosis	Subchondral fracture line	Peripheral intact	Aggressive offloading; orthotics
III — Absorption	Deepening depression; peripheral shell preserved	Edema; partial collapse	Peripheral intact	Conservative; or debridement
IV — Collapse	Flattened head; loose bodies; shell fracture	Collapse; loose bodies	Plantar cartilage often preserved	Dorsal closing wedge osteotomy
V — Arthrosis	Pan-joint arthritis; osteophytes; complete deformity	Full-thickness cartilage loss	Destroyed	Resection / arthroplasty / fusion

Surgical Procedure	Stage Indication	Key Benefit	Success Rate
Arthroscopic debridement + synovectomy	II–III	Minimally invasive; preserves joint	60–75% symptom relief
Dorsal closing wedge osteotomy	III–IV	Rotates healthy plantar cartilage into articulation	70–80% good/excellent
Weil shortening osteotomy	II–III (long 2nd MT)	Reduces mechanical overload	70–80% satisfaction
Metatarsal head resection	IV–V	Reliable pain relief; simple	75–85% pain relief
MTP fusion	V (young active patient)	Durable; eliminates arthritis pain	85–90% satisfaction

Quick answer: Freibergs disease (Freibergs infraction) is osteonecrosis of the second metatarsal head, most common in adolescent girls. Treatment depends on stage: stage 1-2 (early) responds to non-weight-bearing in walking boot for 6-8 weeks plus physical therapy. Stage 3-4 (collapse) often needs joint preservation surgery (osteotomy) or arthroplasty. Caught early, surgery is usually avoidable. Call (810) 206-1402.

Freiberg’s disease is one of those diagnoses that surprises patients because most people have never heard of it — yet it causes very real, often significant forefoot pain that doesn’t respond to generic metatarsalgia treatments. At Balance Foot & Ankle, we see this condition more frequently than most practices because our sports medicine focus brings in active adolescents and adults with persistent ball-of-foot pain that others have failed to explain.

The critical issue with Freiberg’s disease is that early diagnosis and treatment can prevent progression to irreversible joint damage, while delayed treatment often means surgical intervention. If you or your child has had persistent forefoot pain for weeks or months — particularly around the second or third metatarsal — Freiberg’s disease deserves a place on the differential diagnosis list.

What Is Freiberg’s Disease?

Freiberg’s disease is an osteochondrosis — a condition in which bone and cartilage in a joint undergo avascular necrosis (death from loss of blood supply), followed by collapse and remodeling. It was first described by Alfred Freiberg in 1914, who noted a pattern of metatarsal head flattening in young patients presenting with forefoot pain.

The second metatarsal is affected in approximately 68% of cases, the third in about 27%, and the remaining cases involve the fourth or, rarely, the first metatarsal. The condition is significantly more common in females than males (approximately 4:1 ratio) and typically presents between ages 13 and 18 — though it can occur in adults, where it may be triggered by repetitive trauma or vascular compromise.

The pathological sequence is well understood: loss of blood supply → bone cell death (osteonecrosis) → structural weakening → microfractures (the “infraction”) → collapse of the metatarsal head → reactive new bone formation and joint incongruity. The Smillie classification system stages this progression from Stage I (early vascular disruption, minimal radiographic change) through Stage V (severe joint collapse with loose bodies and severe arthrosis).

Symptoms of Freiberg’s Disease

Freiberg’s disease symptoms center on the affected metatarsal head and worsen predictably with weight-bearing activities. The presentation often evolves — early stage symptoms are mild and easily dismissed as “growing pains” or general forefoot discomfort, while advanced stage disease produces significant functional limitation.

• Localized pain at a specific metatarsal head — point tenderness directly over the second (or third) metatarsal head at the ball of the foot
• Pain that worsens with weight-bearing — walking, running, and standing, with relief when sitting or non-weight-bearing
• Stiffness in the affected metatarsophalangeal (MTP) joint — reduced range of motion compared to adjacent toes
• Swelling at the MTP joint — often visible as puffiness around the base of the affected toe
• Antalgic gait — instinctively avoiding weight-bearing on the painful area, leading to altered walking patterns
• Callus formation under the affected metatarsal head
• Crepitus — a grinding or grating sensation in the joint during motion in advanced cases
• Joint locking or loose body sensation in Smillie Stage IV-V disease

What Causes Freiberg’s Disease?

The precise etiology of Freiberg’s disease remains debated, but the current consensus points to a combination of vascular compromise and repetitive mechanical stress acting on a metatarsal head during a vulnerable period of bone development.

• Repetitive microtrauma — high-impact sports, prolonged standing, and activities involving forced toe extension (running, jumping, ballet) generate repetitive compression and shear forces at the metatarsal head
• Long second metatarsal (Morton’s foot) — when the second metatarsal is disproportionately long, it bears a greater share of forefoot load, increasing mechanical stress on its head
• Vascular vulnerability — the distal metatarsal head has relatively limited blood supply through a small number of nutrient vessels; injury or compression of these vessels can trigger avascular necrosis
• High-heeled footwear — concentrates body weight on the metatarsal heads and increases dorsiflexion forces at the MTP joints
• Adolescent growth spurts — rapid bone growth may temporarily outpace the vascular supply to metatarsal heads, creating a window of vulnerability
• Female sex — likely multifactorial: higher rates of high-heel use, hormonal factors affecting bone vascularity, and different foot morphology
• Systemic vascular conditions — in adults, conditions affecting end-arteriolar blood flow (diabetes, collagen vascular disease, steroid use) can precipitate osteonecrosis

How Is Freiberg’s Disease Diagnosed?

Freiberg’s disease diagnosis requires imaging — it cannot be reliably confirmed on clinical examination alone, though the pattern of point tenderness and MTP joint stiffness should immediately raise suspicion. The staging diagnosis determines treatment.

Weight-bearing X-rays: The first-line imaging study. Early-stage Freiberg’s (Smillie I-II) may show subtle flattening or sclerosis of the metatarsal head that is easily missed on non-weight-bearing films. Later stages (III-V) show progressive flattening, joint space narrowing, loose bodies, and arthrosis visible on standard X-rays.

MRI: The gold standard for early diagnosis. MRI detects bone marrow edema and early avascular changes before they are visible on X-ray — critical for Stage I-II disease where intervention can prevent progression. In a young patient with the right clinical picture and normal X-rays, MRI is the essential next step. A 2024 review in the Journal of Foot and Ankle Surgery confirmed MRI sensitivity exceeds 90% for early Freiberg’s disease versus 60–70% for plain X-ray.

CT scan: Useful for surgical planning in advanced cases — provides precise detail about the degree of articular surface collapse and the size/location of any loose bodies.

Differential diagnosis: Metatarsalgia, Morton’s neuroma, second MTP joint capsulitis, metatarsal stress fracture, inflammatory arthropathy (particularly gout and rheumatoid arthritis), and synovial cyst. The imaging findings of Freiberg’s disease are sufficiently distinctive that the differential usually narrows quickly once imaging is obtained.

Freiberg’s Disease Treatment

Treatment is staged according to disease severity. The fundamental goals are: reduce mechanical stress on the affected metatarsal head, allow revascularization and healing where possible, and — in advanced disease — restore joint function through surgical intervention.

Conservative Treatment (Smillie Stages I–III)

Activity modification: Reducing or eliminating high-impact activities during the acute phase. Swimming and cycling maintain fitness without loading the forefoot. This is particularly important in adolescents — halting the mechanical injury cycle gives the bone the best chance to revascularize.

Immobilization: In more acute presentations or in younger patients with Stage I-II disease, a short period in a walking boot or cast can offload the metatarsal head and allow initial healing. Duration is typically 4–8 weeks.

Metatarsal offloading orthotics: Custom or semi-custom orthotics with metatarsal domes positioned proximal to the affected head transfer load away from the diseased bone. This is a long-term intervention that should be maintained even after symptoms resolve to prevent relapse:

Footwear modification: Wide toe box shoes with substantial forefoot cushioning and a rocker-bottom sole to reduce MTP joint dorsiflexion during push-off. Eliminating high heels entirely during treatment.

Physical therapy: MTP joint range of motion exercises, intrinsic foot strengthening, and gait retraining to normalize weight distribution across the forefoot.

Surgical Treatment (Smillie Stages III–V)

Surgery is indicated when conservative treatment fails to provide adequate relief, when disease has progressed beyond Stage III, or when loose bodies are present causing mechanical symptoms. Several surgical approaches are available, chosen based on the stage of disease:

• Joint debridement and loose body removal (arthroscopic or open) — appropriate for Stage III-IV; removes fragmented cartilage and loose bodies, smooths articular surfaces
• Dorsal closing-wedge osteotomy — the most widely used surgical technique; rotates the unaffected plantar cartilage into the weight-bearing position, effectively replacing the diseased dorsal surface with healthy tissue; consistently good outcomes in Stages III-IV
• Metatarsal shortening osteotomy (Weil osteotomy) — reduces load on the metatarsal head by shortening the metatarsal; useful when metatarsal length excess is a primary contributing factor
• Joint resection arthroplasty or implant arthroplasty — for Stage V disease with severe arthrosis; removes the damaged metatarsal head and either leaves a joint space or inserts an implant

Surgical outcomes for Freiberg’s disease are generally favorable, particularly for the dorsal closing-wedge osteotomy, which produces good-to-excellent results in 80–90% of appropriately selected patients. Recovery involves 6–8 weeks of protected weight-bearing followed by gradual return to activity over 3–6 months.

The Most Common Mistake We See

The most common mistake with Freiberg’s disease is treating it as generic metatarsalgia for months before obtaining the imaging that would reveal the diagnosis. Metatarsal padding and general orthotics provide some symptomatic relief — enough to keep patients going — but don’t halt the underlying bone necrosis. By the time imaging is finally obtained, what was once Stage II disease amenable to conservative treatment may have progressed to Stage IV requiring surgery.

The lesson: any patient with point tenderness over a single metatarsal head should have weight-bearing X-rays as a minimum, and MRI if X-rays are normal but symptoms persist beyond 4–6 weeks. The cost of early MRI is dramatically lower than the cost of surgical intervention for advanced disease — both financially and in terms of recovery time.

Frequently Asked Questions About Freiberg’s Disease

Is Freiberg’s disease serious?

Freiberg’s disease is a serious condition if untreated or treated inappropriately, because the underlying bone necrosis can progress to irreversible joint collapse. However, when diagnosed early (Stage I-II), it can often be managed conservatively with excellent outcomes and minimal long-term joint damage. The prognosis is directly related to the stage at diagnosis — which is why early evaluation matters significantly.

Can Freiberg’s disease heal on its own?

In very early stage disease (Stage I), with aggressive offloading and activity modification, some degree of spontaneous revascularization and healing can occur — particularly in adolescents whose bone has greater healing capacity. However, this requires significant load reduction that is difficult to achieve without a structured treatment program. Left completely untreated with continued mechanical loading, Freiberg’s disease does not resolve on its own and typically progresses.

Who gets Freiberg’s disease?

Freiberg’s disease predominantly affects adolescent females between ages 13 and 18, particularly those active in sports, dance, or activities requiring prolonged time on their feet. The female-to-male ratio is approximately 4:1. It also occurs in adults — particularly those with diabetes, systemic inflammatory conditions, or a history of corticosteroid use — though in adults, the vascular component is typically more prominent. The condition is underrecognized, and many affected individuals are misdiagnosed for months before receiving the correct diagnosis.

The Bottom Line

Freiberg’s disease is an avascular necrosis of a metatarsal head that can progress from minor bone edema to severe joint collapse if not recognized and treated at the appropriate stage. The key is early diagnosis — which requires clinical suspicion, weight-bearing X-rays, and MRI when X-rays are equivocal. Early-stage disease responds well to conservative offloading. Advanced disease requires surgical reconstruction. If you or your teenager has persistent point tenderness at the ball of the foot that hasn’t been explained after standard forefoot treatment, ask specifically about Freiberg’s disease.

Sources

• Freiberg AH. Infraction of the second metatarsal bone — a typical injury. Surg Gynecol Obstet. 1914;19:191-193.
• Smillie IS. Freiberg’s infraction (Kohler’s second disease). J Bone Joint Surg Br. 1957;39-B(3):580-584.
• Carmont MR, Rees RJ, Blundell CM. Current concepts review: Freiberg’s disease. Foot Ankle Int. 2009;30(2):167-176.
• Chao KH, Lee CH, Lin LC. Surgery for symptomatic Freiberg’s disease: extraarticular dorsal closing-wedge osteotomy in 13 patients followed for 2-4 years. Acta Orthop Scand. 1999;70(5):483-486.

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