Freiberg disease (also called Freiberg infraction) is a chronic injury of the cartilage and subchondral bone of a metatarsal head, most commonly the second. It is classified as an osteochondrosis — a condition in which disrupted blood supply leads to bone death and eventual collapse of the joint surface.
Freiberg disease causes forefoot pain that can overlap with other conditions affecting the ball of the foot, including Morton's neuroma and plantar plate tear. MRI is essential for distinguishing between these diagnoses.
Pathophysiology
Stress on the metatarsal head
Although the etiology is unclear, it is thought to be related to repetitive microtrauma or a prior traumatic insult resulting in subchondral vascular compromise and bone death (osteochondrosis) of a metatarsal head. Freiberg disease most often affects the 2nd metatarsal head but can also involve the 3rd and 4th heads.
Patients who have a 2nd metatarsal head that is longer than the first are at increased risk to develop Freiberg disease.
It is most often seen in younger females from 10–18 years of age. The male to female ratio is 1:3.
Symptoms
Patients typically present with pain, swelling, and tenderness localized to the affected metatarsal head, worsened by weight-bearing and activity. There may be a palpable fullness or thickening around the joint, and range of motion at the metatarsophalangeal (MTP) joint is often reduced. In advanced cases, joint collapse and deformity can cause a persistent limp.
Diagnosis
X-rays may show flattening, sclerosis, or fragmentation of the metatarsal head in later stages, but early disease is frequently missed on plain films. MRI is the most sensitive imaging tool for Freiberg disease, detecting subchondral bone marrow edema, early cartilage loss, and joint effusion before structural collapse occurs — allowing for earlier intervention and better outcomes.
The Smillie classification is used to grade the severity of Freiberg disease on imaging:
- Stage I: Subchondral stress fracture with ischemia; no visible deformity on X-ray. MRI shows early bone marrow edema.
- Stage II: Central absorption of bone with early flattening of the metatarsal head.
- Stage III: Further absorption with a central depression, intact peripheral margins.
- Stage IV: Fracture of the peripheral margins with loose body formation.
- Stage V: Flattening and arthritic degeneration of the entire joint surface.
Treatments
Early stage (I–II) — conservative management:
Activity modification, offloading with metatarsal pads or a stiff-soled shoe, and in some cases a short period of immobilization in a boot or cast. NSAIDs help manage pain and swelling. The goal is to protect the metatarsal head while revascularization occurs.
Intermediate stage (III–IV) — continued conservative care or minimally invasive treatment:
Custom orthotics with metatarsal offloading, continued activity restriction, and physical therapy. Corticosteroid injections may provide symptomatic relief. Some patients at this stage are candidates for joint debridement or loose body removal.
Advanced stage (V) or failed conservative treatment:
Surgical options include dorsiflexion osteotomy of the metatarsal (rotating healthy cartilage into the weight-bearing zone), joint debridement with synovectomy, or in severe cases, joint resection or implant arthroplasty. Surgical outcomes are generally good when performed before complete joint destruction.
Get an MRI to Confirm Your Diagnosis
Before surgical planning or starting treatment, a clear MRI diagnosis ensures the right path forward. First Look MRI offers self-pay Foot and Ankle MRI scans — no doctor's order or insurance required — at our locations in Georgia, Texas, and Colorado.