Freiberg’s Infraction: Avascular Necrosis of the Metatarsal Head Causes and Treatment

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

What Is Freiberg’s Infraction?

Freiberg’s infraction (also called Freiberg’s disease) is avascular necrosis (death of bone tissue due to interrupted blood supply) affecting the head of a metatarsal bone—most commonly the second metatarsal, and occasionally the third or fourth. First described by Alfred Freiberg in 1914, the condition predominantly affects adolescent females and young adult women, with a female-to-male ratio of approximately 5:1. It presents as progressive forefoot pain, joint swelling, and stiffness at the affected metatarsophalangeal (MTP) joint.

Causes and Pathophysiology

The exact cause of Freiberg’s infraction remains debated, but the prevailing theory involves repetitive microtrauma to the metatarsal head during a period of rapid growth, which disrupts the tenuous blood supply to the metatarsal epiphysis. The second metatarsal—typically the longest—bears the highest compressive load per unit area during push-off, making it most vulnerable. Additional contributing factors include a long second metatarsal, high-heeled shoe wear, hypermobility of the first ray (which transfers excess load to the second metatarsal), and participation in high-impact sports during adolescence.

Once blood supply is disrupted, the metatarsal head undergoes a predictable sequence: initial ischemia, collapse of subchondral bone, fragmentation of the articular surface, and eventual remodeling. Cartilage destruction and joint deformity progress with continued weight-bearing stress during the vulnerable phase of bone remodeling.

Symptoms and Clinical Presentation

Freiberg’s infraction presents as localized pain at the second (or occasionally third) MTP joint that worsens with walking and forefoot loading activities. The joint is tender to palpation and may be swollen with limited range of motion. Patients often describe a feeling of walking on a stone under the ball of the foot. In advanced stages, a painful dorsal osteophyte (bone spur) may limit toe extension and produce mechanical clicking or catching within the joint.

Staging (Smillie Classification)

Freiberg’s infraction is staged radiographically using the Smillie classification from I to V. Early stages (I-II) show fissuring and early flattening of the metatarsal head; intermediate stages (III-IV) demonstrate progressive collapse, fragmentation, and loose body formation; late stage (V) shows severe joint destruction with complete loss of articular congruity. Early diagnosis at stages I-II offers the best opportunity for joint-preserving treatment.

Conservative Treatment

Early-stage Freiberg’s infraction is managed conservatively with relative rest and activity modification to reduce forefoot loading. Stiff-soled shoes or a metatarsal bar orthosis offloads the affected joint during the healing phase. A walking boot or short leg cast provides more complete unloading for 4–6 weeks in patients with significant pain. NSAIDs and ice manage acute inflammation. Many early cases heal with remodeling of the metatarsal head and restoration of a functional joint surface.

Surgical Options

Surgical intervention is considered when conservative care fails or for advanced-stage disease. Joint-preserving procedures include dorsal closing wedge osteotomy—rotating the intact plantar cartilage into the weight-bearing zone—which has shown excellent results in stages II-IV. Arthroscopic debridement removes loose bodies and inflamed synovium while assessing cartilage viability. In late-stage disease with severe cartilage destruction, joint-resecting procedures such as partial metatarsal head excision or silicone implant arthroplasty are considered. Early diagnosis and prompt treatment significantly improve the likelihood of a joint-preserving outcome.

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Clinical References

1. Thomas MJ, et al. “The population prevalence of foot and ankle pain.” Pain. 2011;152(12):2870-2880.
2. Hill CL, et al. “Prevalence and correlates of foot pain in a population-based study.” J Foot Ankle Res. 2008;1(1):2.
3. Riskowski JL, et al. “Measures of foot function, foot health, and foot pain.” Arthritis Care Res. 2011;63(S11):S229-S236.

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