Freiberg disease

Dr Henry Knipe and Dr Jeremy Jones et al.

Freiberg disease, also known as Freiberg infraction, is osteochondrosis of metatarsal heads. It typically affects the 2nd metatarsal head (the 3rd and  4th may also be affected). It can be bilateral in up to 10% of cases.

It is most common in women aged 10-18 years (male to female ratio of 1:3). 

Clinically they present with pain that is increased by weight-bearing, plus swelling and tenderness.

The cause of Freiberg infraction is controversial and is probably multifactorial.

A traumatic insult in the form of either acute or repetitive injury and vascular compromise, perhaps due to an elongated 2nd metatarsal, are the most popular theories, and as it is more commonly seen in women, particularly during adolescence, high-heeled shoes have been postulated as a possible causative factor.

Histologically, Freiberg infraction is characterised by the collapse of the subchondral bone, osteonecrosis, and cartilaginous fissures 1

Plain radiograph

These can be split into early and late features:

Early
  • flattening and cystic lesions of the affected metatarsal head
  • widening of the metatarsophalangeal (MTP) joint
Late
  • osteochondral fragments
  • sclerosis and flattening of the bone
  • increased cortical thickening

Some publications advocate use of the Bragard staging classification 10, which requires two views/planes of the forefoot:

  • I - metatarsal head flattening and decreased subchondral bone density
  • II - metatarsal head sclerosis, fragmentation and deformation, with cortical thickening
  • III - metatarsophalangeal (MTP) osteoarthrosis with intra-articular loose bodies
MRI

Early MR imaging findings include low-signal-intensity changes in the metatarsal head on T1-weighted images with increased signal intensity on corresponding T2-weighted and STIR images.

With disease progression, flattening of the metatarsal head occurs, and low-signal-intensity changes develop on T2-weighted images as the bone becomes sclerotic.

Albert H Freiberg first described it in 1914 8,9.

On imaging consider

  • normal variant, as a flat metatarsal head is described in ~10% of asymptomatic population
  • fracture of metatarsal head or neck
  • unstable metacarpus (only identified on MRI)
    • torn metacarpophalangeal collateral ligaments 
  • adolescent or young women
  • pain and swelling at 2nd metatarsophalangeal (MTP) joint
  • flattening and cystic lesions of the affected metatarsal head
  • widening of the MTP joint
Share article

Article information

rID: 8906
Synonyms or Alternate Spellings:
  • Freiberg infraction
  • Freiberg's disease
  • Freiberg's infraction
  • Freiberg–Köhler disease
  • Köhler-Freiberg disease
  • Köhler disease type II

Support Radiopaedia and see fewer ads

Cases and figures

  • Drag
    Case 1
    Drag here to reorder.
  • Drag
    Freiberg's infrac...
    Case 2
    Drag here to reorder.
  • Drag
    Case 4
    Drag here to reorder.
  • Drag
    Case 5
    Drag here to reorder.
  • Drag
    Fourth metatarsal...
    Case 6: affecting 4th and 5th metatarsals
    Drag here to reorder.
  • Drag
    Case 7
    Drag here to reorder.
  • Drag
    Case 8
    Drag here to reorder.
  • Drag
    Case 9
    Drag here to reorder.
  • Drag
    Case 10
    Drag here to reorder.
  • Drag
    Case 11
    Drag here to reorder.
  • Drag
    Case 12
    Drag here to reorder.
  • Updating… Please wait.
    Loadinganimation

    Alert accept

    Error Unable to process the form. Check for errors and try again.

    Alert accept Thank you for updating your details.