Freiberg disease

Last revised by Yaïr Glick on 21 Dec 2023

Freiberg disease, also known as Freiberg infraction, is osteochondrosis of the metatarsal heads. It commonly affects the 2nd or 3rdmetatarsal head (in ~2/3 and ~1/4 of all cases, respectively) or rarely, the 4th or 5th metatarsal head 13. It can be bilateral in up to 10% of cases.

Freiberg disease is most common in adolescent athletic females (M:F = 1:5) and young women. It is the fourth most common osteochondrosis and is only osteochondrosis more common in females 13.

Patients typically present with localized forefoot plantar pain, especially on weight-bearing, with swelling and tenderness.

The cause of Freiberg disease 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. It is associated with As it is more commonly seen in women, particularly during adolescence, high-heeled shoes have been postulated as a possible causative factor.

Histologically, Freiberg disease is characterized by the collapse of the subchondral bone, osteonecrosis, and cartilaginous fissures 1

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

  • stage I: metatarsal head flattening and decreased subchondral bone density

  • stage II: metatarsal head sclerosis, fragmentation, and deformation, with cortical thickening

  • stage III: metatarsophalangeal osteoarthrosis with intra-articular loose bodies

These can be split into early and late features:

  • flattening and cystic lesions of the affected metatarsal head

  • widening of the metatarsophalangeal joint

  • osteochondral fragments

  • sclerosis and flattening of the bone

  • increased cortical thickening

Early MRI 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.

In early stages of the disease, it can be managed with lifestyle modifications, immobilization and NSAID therapy. In advanced stages, surgery can be considered. It is usually divided into joint preserving or reconstruction options 12.

Albert H Freiberg (1868-1940) was an American orthopedic surgeon who first described his eponymous condition in 1914 8,9,11.

On imaging consider

  • normal variant: metatarsal head flattening is described in ~10% of the asymptomatic population

  • fracture of metatarsal head or neck including subchondral insufficiency fracture

  • lesser metatarsal head instability (only identified on MRI) due to plantar plate tear

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Cases and figures

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