What Is Freiberg’s Infraction?

Freiberg’s infraction is a form of osteochondrosis (avascular necrosis) affecting the head of one of the metatarsal bones — typically the second, though the third and fourth can also be involved. In this condition, the blood supply to the metatarsal head is disrupted, causing bone death, collapse, and eventual joint degeneration. The result is chronic ball-of-foot pain that can be debilitating without appropriate treatment.

At Balance Foot & Ankle in Howell and Bloomfield Township, Michigan, we have experience managing this relatively uncommon but serious condition across its various stages.

Who Is Affected?

Freiberg’s infraction most commonly affects adolescent and young adult females between ages 10 and 18, though it can occur in older adults. The female-to-male ratio is approximately 5:1. Active adolescents during growth spurts are particularly vulnerable. Adults who develop Freiberg’s are often middle-aged women with a long second metatarsal or a history of repetitive forefoot loading.

Causes

The exact cause of Freiberg’s infraction remains incompletely understood, but the prevailing theory involves repetitive microtrauma and overloading of the metatarsal head disrupting its blood supply. Risk factors include a longer second metatarsal relative to the first (Morton’s foot type), first-ray hypermobility that transfers excess load to the second metatarsal, high-heeled footwear, participation in repetitive impact sports, and possibly hormonal factors explaining the female predominance.

Stages and Symptoms

Freiberg’s infraction progresses through five stages from early ischemia without visible changes, through subchondral fracture and collapse, to advanced articular destruction with joint deformity and loose bodies. Symptoms include pain and tenderness directly over the affected metatarsal head in the ball of the foot, swelling and stiffness of the metatarsophalangeal (MTP) joint, limited range of motion in the involved toe, and pain that worsens with walking and wearing shoes with little forefoot cushioning. In advanced stages, a painful callus may form under the collapsed metatarsal head.

Diagnosis

X-rays show characteristic changes including metatarsal head flattening, increased bone density, joint space narrowing, and in late stages, loose bodies. MRI is the most sensitive tool for early diagnosis, detecting bone marrow edema before X-ray changes appear. Early detection allows intervention before irreversible joint collapse occurs.

Conservative Treatment

In the early stages, conservative treatment aims to offload the affected metatarsal head and allow bone remodeling. Strategies include metatarsal pads or bars placed proximal to the metatarsal head, stiff-soled footwear or a rocker-bottom shoe to reduce metatarsal head pressure, custom orthotics with metatarsal offloading, activity modification, anti-inflammatory medications, and in acute phases, a walking boot or short leg cast for several weeks.

Surgical Treatment

When conservative treatment fails or the condition is caught in an advanced stage with significant joint destruction, surgical options include dorsiflexion osteotomy (rotating the metatarsal head to present undamaged cartilage to the joint), joint debridement to remove loose bodies and damaged tissue, or in end-stage arthritis, joint resection arthroplasty. Surgical outcomes are generally good when appropriate patients are selected.

Foot or Ankle Pain? We Can Help.

Balance Foot & Ankle — Howell & Bloomfield Township, MI

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