How common is Freiberg's disease?

It is rare, affecting roughly 1 in 2,800 people. It is most common in adolescents and young adults, more frequent in females, usually affects one foot, and involves the second toe joint in most cases.

What is recovery like after surgery?

Usually protected weight-bearing in a boot at first, a gradual return to normal shoes, and physiotherapy to restore movement and strength. Full recovery can take several months, and most patients have significant pain relief and better function.

Freiberg's Disease: Causes, Symptoms and Treatment

What is Freiberg’s disease?

Freiberg’s disease (or Freiberg’s infraction) affects the metatarsal head, the rounded end of the long bone just before the toe, most often at the second toe joint. The bone and cartilage of the joint surface become damaged, causing pain, stiffness and difficulty walking. It is a form of osteochondrosis or avascular necrosis: the bone temporarily loses its normal blood supply and strength, and may collapse.

How does it occur?

It usually comes from repeated stress over time rather than a single injury. Contributing factors include:

Repetitive overload of the metatarsal head
A long second metatarsal, which takes more weight
Altered forefoot mechanics, such as a hypermobile first ray
Reduced blood supply to the metatarsal head
Medical factors such as diabetes or cholesterol disorders
Occasionally a genetic or congenital predisposition

What are the symptoms?

Pain in the ball of the foot, usually under the second toe, worse walking, standing, running or pushing off. It may settle with rest early on and become more persistent later.
Swelling and tenderness around the toe joint; shoes feel tight over the ball of the foot.
Stiffness, especially in the morning, with increasingly limited movement.
Catching, grinding or clicking in the joint.
Changes in the toe, with swelling, slight misalignment or callus under the ball of the foot.

Symptoms usually progress gradually, from pain only with activity to daily pain and, in advanced stages, arthritis.

How is it diagnosed?

X-rays are the key first test. They show flattening, irregularity or collapse of the metatarsal head, joint narrowing and arthritis, and are used to grade the disease (Smillie stages I to V).
MRI shows early bone changes and swelling before collapse is visible on X-ray, and helps with surgical planning.

Treatment without surgery

Recommended for early disease (Smillie stages I to II) and milder symptoms, to off-load the joint while the bone recovers:

Activity modification, limiting running, jumping, prolonged standing and high-impact sport
Footwear with a cushioned, stiff or rocker sole and a wide forefoot
Insoles with metatarsal pads or bars to shift pressure away from the toe
Pain relief for flare-ups
Physiotherapy for foot mechanics, calf tightness and gait
A protective boot for a short period in more painful early cases

Many people with early disease improve, gradually over months. Non-surgical treatment is less effective once the joint has collapsed.

Surgery

The best-studied operations preserve the joint:

Dorsal closing wedge metatarsal osteotomy. A small wedge of bone is removed so healthier cartilage rotates into the weight-bearing area. A long-established technique with good pain relief, though it slightly shortens the metatarsal.
Autologous osteochondral transplantation. A small plug of healthy cartilage and bone, usually from the knee, is transferred to the damaged area. It restores the surface without shortening the bone, and comparative studies show better movement, faster return to activity and fewer complications, with a small risk of donor-site problems.

Other options in selected cases include modified Weil osteotomy, microfracture and joint resurfacing or interposition procedures.