Freiberg’s disease is an uncommon condition affecting the metatarsal bones of the foot, characterized by avascular necrosis of the metatarsal head. This disorder, first described by Alfred H. Freiberg in 1914, primarily affects adolescents and young adults, causing significant pain and functional impairment in the forefoot. While relatively rare compared to other foot conditions, Freiberg’s disease represents an important differential diagnosis for anyone presenting with persistent metatarsalgia, particularly when conservative treatments fail to provide relief.
Pathophysiology and Affected Area
The condition most commonly affects the second metatarsal head, though it can occasionally involve the third or, more rarely, the fourth metatarsal. The second metatarsal is particularly vulnerable due to its anatomical characteristics: it is typically the longest metatarsal bone and bears significant weight-bearing forces during walking and running. The disease process involves disruption of the blood supply to the metatarsal head, leading to bone death, collapse, and eventual deformity if left untreated.
The exact mechanism triggering avascular necrosis in Freiberg’s disease remains debated among orthopedic specialists. Several theories have been proposed, including repetitive microtrauma from mechanical stress, vascular insufficiency, and acute traumatic injury. The condition may result from a combination of these factors, with biomechanical stress playing a particularly important role. Activities that place excessive pressure on the forefoot, such as ballet dancing, high-impact sports, or wearing high-heeled shoes, may contribute to development of the condition in susceptible individuals.
Clinical Presentation and Demographics
Freiberg’s disease demonstrates a notable female predominance, with women affected approximately four to five times more frequently than men. The typical age of onset is during adolescence, particularly between the ages of 11 and 17, though the condition can manifest in adults as well. This age distribution corresponds with periods of rapid skeletal growth and increased physical activity, supporting the role of mechanical stress in disease development.
Patients typically present with insidious onset of pain localized to the affected metatarsal head. The pain is characteristically aggravated by weight-bearing activities and pressure on the ball of the foot, while resting usually provides relief. Physical examination reveals point tenderness over the involved metatarsal head, often accompanied by swelling and limitation of motion at the metatarsophalangeal joint. As the disease progresses, patients may develop a stiff, painful joint with restricted dorsiflexion and plantarflexion. Some individuals adopt an antalgic gait, shifting weight away from the affected area to minimize discomfort.
Diagnosis and Staging
Diagnosis of Freiberg’s disease relies on a combination of clinical findings and imaging studies. Plain radiographs remain the initial imaging modality of choice and typically reveal characteristic changes, though early-stage disease may appear normal on X-rays. The radiographic progression includes flattening and sclerosis of the metatarsal head, followed by fragmentation, collapse, and eventual remodeling with degenerative changes.
Several staging systems have been developed to classify disease severity and guide treatment decisions. The most commonly used classification divides the disease into five stages, ranging from Stage I with minimal radiographic changes and possible fissuring, through Stage V with advanced degenerative arthritis and significant deformity. Advanced imaging modalities, including magnetic resonance imaging, can detect early changes before they become apparent on plain radiographs, revealing bone marrow edema and early structural abnormalities.
Treatment Approaches
Management of Freiberg’s disease follows a staged approach, beginning with conservative measures for early-stage disease and progressing to surgical intervention when necessary. Conservative treatment options include activity modification, orthotic devices with metatarsal pads or bars to offload pressure from the affected area, non-steroidal anti-inflammatory medications, and footwear modifications. Stiff-soled shoes or rocker-bottom shoes can reduce stress on the metatarsophalangeal joint during gait. These conservative measures prove effective in many cases, particularly when implemented early in the disease process.
When conservative management fails to provide adequate symptom relief, or when the disease has progressed to more advanced stages with significant structural damage, surgical intervention may become necessary. Multiple surgical procedures have been described, with selection depending on disease stage, patient age and activity level, and degree of joint involvement. Early-stage disease may benefit from core decompression or drilling procedures designed to stimulate revascularization. More advanced cases might require debridement of loose bodies, osteotomy to realign the joint surface, or metatarsal shortening procedures.
In cases with severe joint destruction and persistent symptoms despite other interventions, more extensive procedures such as metatarsal head resection, interpositional arthroplasty, or joint replacement may be considered. The goal of surgical treatment is to relieve pain, restore function, and prevent progressive degeneration while preserving as much normal anatomy as possible.
Prognosis and Long-term Outcomes
The prognosis for Freiberg’s disease varies considerably depending on the stage at diagnosis, promptness of treatment initiation, and individual patient factors. Early diagnosis and appropriate intervention generally result in favorable outcomes, with many patients achieving significant pain relief and functional improvement. However, advanced disease with substantial joint destruction may lead to chronic pain and permanent limitation of joint motion despite treatment.
Long-term follow-up studies suggest that some patients develop degenerative arthritis of the affected joint regardless of treatment, though appropriate management can slow progression and maintain function. Patient education about activity modification, proper footwear, and biomechanical principles plays a crucial role in optimizing outcomes and preventing recurrence or progression.
Freiberg’s disease represents a challenging but manageable condition requiring careful diagnosis and individualized treatment planning. Increased awareness among healthcare providers and patients can facilitate earlier recognition and intervention, ultimately improving outcomes for those affected by this uncommon but significant cause of forefoot pain.