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Freiberg's disease

Other Names for this Disease
  • Freiberg's infraction
  • Freiberg-Kohler syndrome
  • Kohler's second disease
  • Osteochondrosis of the metatarsal head, usually the second
  • Second metatarsal osteochondrosis
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Your Question

My son has been diagnosed with Freiberg's disease. Is this condition easy to diagnose? Can an individual with this condition continue to play sports and participate in physical activities? How is it treated?

Our Answer

We have identified the following information that we hope you find helpful. If you still have questions, please contact us.

Can a young athlete with Freiberg's disease return to sports?

Although specific times depend upon the individual and his/her resolution of symptoms, the following  general guide may assist you in determining the appropriate time needed before resumption of activities. The young athlete treated conservatively can usually resume athletic activity after resolution of symptoms. If surgical removal of a loose body is required in older athletes, return to full competition may be possible in 4 to 6 weeks. After joint débridement and remodeling of the metatarsal head, competitive activity may be allowed after 8 to 12 weeks. If arthroplasty or osteotomy is performed, resumption of activity may not be possible for 12 weeks or longer.[1]
Last updated: 3/10/2009

What is Freiberg's disease?

Freiberg's disease is an osteochondrosis of the metatarsal head, most commonly occurring in young athletes older than 12 years who perform on their toes in either sprinting or jumping activities.[1][2] The primary complaint is often a vague forefoot pain, worsened by activity and weight-bearing and relieved with rest.[1] While some cases may resolve spontaneously, patients who do not respond to conservative measures may require surgery.[2][3] The exact cause remains unknown [2]  
Last updated: 3/10/2009

What causes Freiberg's disease?

The exact cause of Freiberg's disease remains uncertain.[2] Although some cases can be attributed to traumatic injury, not all cases can be explained by this cause. Freiberg disease in adolescents is thought to belong to a group of related diseases involving growth disturbances of the epiphysis (the area at the end of a bone) or apophysis (the bone's growth plate), collectively termed the osteochondroses. Radiographic changes among the osteochondroses are similar, regardless of location; they show subchondral collapse and fragmentation of the joint surface. Although considered to represent an interruption of normal growth processes, the specific events or factors that incite the cascade leading to articular collapse are unclear.[3] 

Although considering Freiberg disease to be a form of osteochondrosis makes sense, it does not fully explain the adult onset form of the disease, which may represent a different process altogether, albeit one with a similar radiographic appearance. While some authors consider the cause to be multifactorial, with no single etiology responsible for all cases, current theories are centered on whether the initial insult is predominantly traumatic (injury-related) or vascular (consistent with avascular necrosis - an injury to the blood supply to the metatarsal head). Infection, once thought to play a role, has essentially been eliminated as a significant factor.[3]

Last updated: 3/10/2009

What symptoms have been associated with Freiberg's disease?

Patients typically present with pain, stiffness, and a limp. History of trauma may or may not exist. The pain is often vague, related to activity, and poorly localized to the forefoot. Patients may describe a chronic history of forefoot pain with episodic exacerbation or a sudden onset of pain related to a specific injury.[3] If a synovitis (inflammation of the synovial membrane which lines the inside of the joint) is present, swelling becomes apparent.[2]

Physical examination typically reveals a limited range of motion, swelling, and tenderness with direct palpation of the metatarsophalangeal joint. A small effusion (pocket of fluid) may be present. A callus may be seen underneath the affected metatarsal head. Occasionally, patients are completely asymptomatic, with changes noted only on radiographs taken for other purposes. Whether these patients later develop symptomatic Freiberg disease is not known.[3]

Last updated: 3/10/2009

Is Freiberg's disease easy to diagnose?

The diagnosis of Freiberg disease is relatively straightforward when patients present with the typical complaints of activity-related forefoot pain with passive motion of the metatarsophalangeal joint and pain with palpation over the metatarsal head. Radiographs (X-rays), bone scans, and MRIs can help to confirm the diagnosis.[1][3] The differential diagnoses may include metatarsalgia, Morton neuroma, stress fracture of the metatarsal, and synovitis (inflammation of the synovial membrane which lines the inside of the joint).[3]
Last updated: 3/10/2009

How might Freiberg's disease be treated?

The teatment strategy depends on the severity of the symptoms, the age of the patient, and the presence of loose bodies.[1][3] Regardless of the treatment method chosen, the goal of therapy is to rest the joint to allow inflammation and mechanical irritation to resolve.[3]

Most patients with Freiberg's disease can be treated conservatively with modification of activities, semirigid orthoses, and metatarsal bars. In patients presenting with severe pain of an acute nature, a non – weight-bearing cast may provide sufficient relief during the acute phase.[3] On occasion, a short-leg walking cast with a toe extension may be used for 6 to 12 weeks to resolve acute symptoms.[1][2][3] Occasionally, crutches are needed to rest the painful foot completely.[2]

Surgical treatment is indicated if conservative measures do not relieve the symptoms.[1][2] Surgical options may include: (1) resection of the metatarsal head (Giannestras), (2) elevation of the depressed fragment of the metatarsal head and bone grafting of the defect (Smillie), (3) resection of the base of the proximal phalanx with syndactylization of the second and third toes (Trott), (4) dorsal closing wedge osteotomy of the metatarsal head (Gauthier and Elbay), and (5) joint débridement and metatarsal head remodeling (Freiberg and Mann).[2]
No consensus exists as to which surgical procedure is the most appropriate for patients with symptomatic Freiberg's disease.[3]

Last updated: 3/10/2009

Can a young athlete with Freiberg's disease continue to play sports or should his/her foot be immobilized?

The need for immobilization depends on the symptoms experienced and extent of the damage, if any. Regardless of the type of therapy undertaken, modification of activities should be considered, including cessation of all running and jumping activity until acute symptoms have subsided, as activity modification during  exacerbations  may  help  to  prevent the  aggravating  symptoms  of  pain  and  swelling.[1][3]  The decision regarding the best course of treatment should be shared by a physician familiar with the specific case and the patient and his/her family.
Last updated: 3/10/2009

If immobilization is recommended, how long does treatment generally take?

The length of time the foot is immobilized depends on the technique utilized. For example, with dorsal closing wedge osteotomy, the foot is immobilized in a short leg walking cast for 4 weeks. Pins are removed at 4 weeks, and weight bearing is allowed as tolerated. Patients are typically not allowed to run or engage in any strenuous physical activity for 8 weeks after surgery. With joint debridement and metatarsal head remodeling, continuous elevation of the foot for 48 hours is recommended, followed by walking in a wooden-soled shoe. At 2 weeks, the skin sutures are removed, and the forefoot is redressed, holding the toe in the desired position. At 4 weeks, a wide toe box shoe is allowed, and active and gentle active-assisted range of motion of the second metatarsophalangeal joint is encouraged.[2]  
Last updated: 3/10/2009

  • DeeLee JC, Drez D. Freiberg's Disease. DeeLee and Drez's Orthopaedic Sports Medicine, 2nd ed.. Philadelphia, PA: Saunders, An Imprint of Elsevier; 2003;
  • Canale ST, Beaty JH. Freiberg Infraction. Campbell's Operative Orthopaedics, 11th ed.. Philadelphia, PA: Mosby, An Imprint of Elsevier; 2007;
  • Boyer M, DeOrio JK. Freiberg Infraction. eMedicine. September 25, 2007; Accessed 3/10/2009.