Freiberg's disease

What is Freiberg's disease, and how common is it?

Freiberg's disease (also called Freiberg's infraction) is a rare condition¹. The blood supply to the end of one of the long bones behind your toes (a metatarsal) is disrupted, so that area of bone dies and crumbles². The clinical name is osteonecrosis (bone death) of the metatarsal head.

It most often affects the bone behind the second toe, then the third³. It mostly affects teenage girls and young women, but it can happen at any age⁴. Over time the bone end can flatten and collapse, and the joint at the base of the toe can develop arthritis later⁴.

What causes Freiberg's disease, and who gets it?

No one knows the exact cause². The leading idea is that repeated stress on the forefoot disrupts the blood supply to the end of the bone⁵. Blood vessel problems, genes and the way the foot works may also play a part³.

It's seen most in teenage girls who play sport, although it can occur across a wide age range⁶. Because the cause isn't fully understood, you haven't done anything wrong, and there's no known way to prevent it³. It can help to tell your podiatrist about activities that load the ball of your foot, and any family history.

What does it feel like, and how is it diagnosed?

The usual sign is pain near the ball of the foot, often behind the second toe, that's worse with activity⁷. There may also be swelling, tenderness, clicking or grating, and less movement in the toe joint⁷.

Many other problems can cause pain in the same place, including Morton's neuroma (a pinched nerve), a stress fracture (a small crack in the bone) and plantar plate injury (damage to the ligament under the toe joint)⁸. Their features overlap, so it isn't something to work out from symptoms alone⁹.

A podiatrist or doctor will ask how the pain began and what makes it worse, then examine your forefoot⁸. The diagnosis is made from this and confirmed with an X-ray³. Early on, the X-ray can look normal, so a bone scan or MRI may be used. Later X-rays show a flattened, broken-up bone end³.

What can I do first, and what will a podiatrist suggest?

Treatment without surgery is the first step⁴. The aim is to take pressure off the sore bone end³. You can start yourself: cut back on activities that flare the pain, wear comfortable, well-padded shoes with plenty of room for the toes, and avoid high heels².

A podiatrist or doctor can add shoe inserts (orthoses) or metatarsal pads, and sometimes a short time in a walking boot, cast or stiff-soled shoe⁷⁵. A pharmacist or doctor can advise on pain relief.

Early disease often settles with this kind of care, and may even settle by itself³. The research on treatments for Freiberg's disease is limited, and no one option has been shown to be best¹⁰. It's worth reviewing progress regularly; if you're not improving, your podiatrist can plan the next step.

What helps if that isn't enough?

Surgery is considered if care without surgery hasn't worked after about 6 months⁴. It's rarely needed². Which operation suits depends on your age, activity level and the condition of the joint, so it's a shared decision with an orthopaedic surgeon⁴. Your GP or podiatrist can refer you.

Operations that keep the joint tend to give better results than those that remove or destroy part of it¹⁰. Every type of operation carries a risk of a stiff or "floating" toe (one that no longer rests on the ground) and of pain moving to a neighbouring toe bone¹¹.

How long does recovery take, and can it come back?

The outlook is generally good, but no set recovery time can be promised. Early disease often settles with care that doesn't involve surgery⁶. Treating it early seems to matter: in children who had surgery, more advanced disease was linked to poorer results¹². Many people who have surgery report pain relief and a return to full activity¹⁰.

It isn't clear yet how often Freiberg's disease returns, what prevents it, or when it's safe to return to sport. Check with your podiatrist before going back to full sport. If pain returns or gets worse, have it reassessed rather than waiting.