Freiberg’s Infraction — Avascular Necrosis 2nd Metatarsal Head Michigan

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

What Is Freiberg’s Infraction?

Freiberg’s infraction — also called Freiberg’s disease or Freiberg’s osteochondrosis — is avascular necrosis (AVN) of the second metatarsal head, causing collapse of the articular cartilage and bone of the metatarsal head with subsequent forefoot pain, swelling, and progressive deformity. It occurs predominantly in adolescent females between ages 12–18 during the period of rapid growth when the blood supply to the metatarsal epiphysis is most vulnerable to disruption from repetitive microtrauma. Freiberg’s accounts for approximately 1% of all foot conditions seen in adolescent sports medicine, but is significantly underrecognized — it is frequently misdiagnosed as metatarsalgia, Morton’s neuroma, or a stress reaction. At Balance Foot & Ankle in Howell and Bloomfield Hills, Michigan, Dr. Tom Biernacki, DPM evaluates Freiberg’s infraction. Call (810) 206-1402.

Who Gets Freiberg’s — Risk Factors

Freiberg’s infraction occurs predominantly in: female athletes ages 12–18 (female-to-male ratio 5:1); high-impact sports with forefoot loading — gymnastics, ballet, running, basketball; patients with a long second metatarsal relative to the first (Morton’s toe anatomy) that concentrates loading at the second metatarsal head; and high-heeled shoe wear during adolescence that shifts body weight onto the forefoot. The combination of rapid growth (thin, vulnerable epiphyseal blood supply), high forefoot loading, and anatomic risk factors creates the ischemic insult that triggers metatarsal head AVN. The condition is occasionally bilateral (10% of cases) and rarely affects the third metatarsal.

Staging and Imaging

Freiberg’s infraction is staged on X-ray using the Smillie classification: Stage I — early ischemia (X-ray normal, MRI shows bone marrow edema); Stage II — central depression of the metatarsal head with intact peripheral cartilage; Stage III — resorption of bone proximal to the central depression; Stage IV — central collapse with loose osteochondral fragments; Stage V — metatarsal head flattening with pan-articular involvement and secondary MTP joint arthritis. MRI is essential for early diagnosis (Stage I) when X-rays are normal — bone marrow edema in the metatarsal head is the first finding. Early diagnosis allows conservative management that prevents progression to the irreversible collapse of Stage IV–V.

Conservative Management — Stages I–III

Stages I–III Freiberg’s infraction are managed conservatively to offload the metatarsal head during the healing phase: non-weight-bearing cam boot for 4–8 weeks for active Stage I–II; transition to a custom orthotic with a metatarsal bar or metatarsal dome placed proximal to the second metatarsal head — shifting weight-bearing contact proximal to the damaged articular surface; stiff-soled shoes or a carbon fiber insole plate to reduce MTP joint dorsiflexion during push-off; and activity modification reducing high-impact forefoot loading. Conservative management is most effective in Stage I–II before articular collapse — recovery time 3–6 months. Stage III with central depression but intact peripheral cartilage can be managed conservatively in lower-demand patients.

Surgical Management — Stages III–V

Surgical management is considered for Stage III–IV Freiberg’s failing conservative management, and for Stage V arthritis. Options: joint debridement and loose body removal for Stage III–IV with loose osteochondral fragments; dorsiflexion osteotomy of the distal second metatarsal — rotating the intact plantar cartilage into the weight-bearing position to restore a congruent articulating surface — the most commonly performed procedure for Stage II–IV with favorable results in adolescents; and silicone or biological MTP joint replacement for Stage V pan-articular arthritis in adults. Outcomes of dorsiflexion osteotomy are excellent in adolescents with good remaining cartilage — 85%+ good or excellent results at 10 years.

Freiberg’s Infraction Management in Howell & Bloomfield Hills Michigan

Dr. Tom Biernacki, DPM evaluates Freiberg’s infraction with clinical examination, weight-bearing X-rays, and MRI coordination at Balance Foot & Ankle. Early-stage metatarsal head offloading is initiated at the first visit. Serving Howell, Brighton, Bloomfield Hills, Royal Oak, Auburn Hills, and all Southeast Michigan. Book your evaluation or call (810) 206-1402.

Freiberg’s Disease Treatment in Michigan

Freiberg’s infraction (avascular necrosis of the metatarsal head) typically affects young athletes and can lead to permanent joint damage if not diagnosed early. Our podiatrists use X-ray and MRI to catch this condition early and prevent progression.

Explore Our Foot Treatment Options → | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Carmont MR, et al. Freiberg’s disease: a systematic review of clinical features and treatment options. Foot Ankle Surg. 2009;15(2):63-68.
2. Smillie IS. Freiberg’s infraction (Köhler’s second disease). J Bone Joint Surg Br. 1957;39-B(3):580-585.
3. Gauthier G, Elbaz R. Freiberg’s infraction: a subchondral bone fatigue fracture. Clin Orthop Relat Res. 1979;(142):93-95.

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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.