Freiberg’s Disease

Named after the person who originally described it, Freiberg’s disease refers to pain in the ball of the foot due to damage to the front of the metatarsal bones. Any metatarsal may be affected, but in almost 95% of cases the second or third metatarsals are involved. The first or fifth metatarsals are rarely involved.

It occurs mainly in teenagers or adolescents going through a growth spurt (the period of rapid physical growth at puberty). Females are five times more prone to developing this condition.

What happens

The metatarsals are the bones of the mid foot, located between the bones of the ankle and toes. These are five long cylindrical bones, each having a long shaft called the diaphysis and two wider ends called the epiphysis.

In adolescents, these bones are still undergoing growth, like other bones of the body. Growth in the long bones occurs at the part of the bone between the end (epiphysis) and the shaft (diaphysis) and this growth area is called the epiphyseal plate (growth plate).

Diagram of the bones in the foot  Cross-section of a bone in the foot

Any damage (trauma, repeated stress or infection, etc.) to the epiphyseal plate, leads to formation of micro fractures (Freiberg’s Infarction), as a result of which the blood supply to the end of the bone is interrupted (the direction of blood flow in the bone is from the shaft to the ends). The lack of blood supply causes irreparable damage to the epiphysis, leading to the death of bone cells (avascular necrosis/infarction), for this reason, this condition is also called Freiberg’s Infarction.

The damage may increase, leading to degeneration of the joint between the affected metatarsal and toe bone. The damaged bone may fracture, leading to small, loose bone fragments in the joint area causing further pain.

Diagram of a bone with avascular necrosis Freibergs disease

What does it feel like?

Mostly the second metatarsal is involved, especially if it is longer than the first metatarsal, as this puts greater pressure on the head of the second metatarsal, making it more vulnerable to stress injuries.

- A dull pain in the ball of the foot behind the 2nd toe, which gets worse on walking, especially in high heels
- The affected area may become swollen
- The skin over the affected area may also become red
- The joint (metatarso-phalangeal joint) becomes stiff and there is pain on moving the joint (a limp during walking)
- A cracking or grinding sound when the joint is moved

How is it discovered?

The symptoms, along with X-ray findings, are helpful in confirming the diagnosis. However, in many patients, the condition produces no symptoms at all and is diagnosed accidentally, when the foot is examined for some other problem.

MRI (magnetic resonance imaging) is another helpful investigation method, and is preferred when surgical treatment is planned.

How is it treated?

Many cases are either asymptomatic (no pain or problem) or resolve spontaneously without any treatment. However, if any such problem arises it is better to seek early treatment.

In the early stages, the condition responds well to a conservative treatment approach. This involves:

- Rest, no stressful movements or weight-bearing activities. Take a break for 4 to 6 weeks until the symptoms improve.
- Use pain killers and anti-inflammatory medicines
- Support the foot during walking by using orthotics. Choose comfortable footwear; avoid high heels, use metatarsal pads to support the painful area.
- Intensive pain and swelling require applying a cast to completely immobilize the area for about a month.

If the symptoms get worse and a conservative approach fails to solve the problem, surgery is the final solution. It depends upon the extent of damage and may involve any of the following:

- Cleaning and removing the damaged bone
- Placing new bone at the site (bone grafting)
- Shortening the length of the metatarsal bone (osteotomy)
- Reconstructing/realigning the joint to eliminate pain and stiffness (arthroplasty)

Orthotics that will help to treat Freiberg’s Disease can be found below.

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