Freiberg’s Disease
Freiberg's Disease
Christopher McGrew
Rodolfo R. Navarro
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Description
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Osteonecrosis of the superior portion of the metatarsal head of unknown etiology
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Freiberg 1st described this entity in 1914 in 6 patients as an infraction (incomplete fracture without displacement of the fragments).
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4th most common osteochondrosis
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Affects women more commonly than men
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Synonym(s): Freiberg's infraction; Eggshell fracture; Koehler's second disease; Peculiar metatarsal disease; Malakopathy
Epidemiology
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Incidence unknown
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Male: Female ratio is 1:5
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Peak onset around 11–17 yrs, but may happen up into 30s
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Most common involvement is the 2nd metatarsal head
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2nd most common involvement is the 3rd metatarsal head
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Usually affects the longest metatarsal
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Occasionally seen in sports requiring sprinting and jumping
Risk Factors
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No known risk factors
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May be related to repetitive microtrauma vs vascular deficiency or both
Genetics
Unknown
General Prevention
None
Etiology
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No single clear etiologic factor exists.
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The process is postulated to be a combination of traumatic and vascular factors:
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Traumatic factors include metatarsal stress during normal activity and/or abnormal biomechanics of the forefoot intrinsically or as a result of footwear, causing repetitive microtrauma upon the dorsal aspect of the distal metatarsal head.
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Vascular factors include abnormal metatarsal head vascular variations, as well as trauma-induced vessel damage, spasm, and eventual ischemia.
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Commonly Associated Conditions
None known
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History
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Slow development of significant, dull, aching pain over affected metatarsal head
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Patient may notice loss of motion.
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Pain increases with activity and motion.
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Pain worsens with weight bearing.
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Pain often relieved by rest, but pain may awaken patient from sleep.
Physical Exam
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Surrounding soft tissue swelling and warmth
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Tenderness over metatarsal head
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May be painful with motion
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As disease progresses, osteophytes may be palpable.
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May be limited motion of metatarsophalangeal (MTP) joint
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Palpable crepitus in advanced disease
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Other foot deformities may be present, such as hallux valgus.
Diagnostic Tests & Interpretation
Imaging
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Radiography normal in early stages
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As the disease progresses, osteonecrotic changes are seen on the superior/central head.
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Eventually the superior/central head collapses and flattens.
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Medial and lateral dorsal osteophytes develop.
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Osteophytes may break free, becoming loose bodies, best seen on the oblique.
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Cystic changes may be seen in the head.
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The inferior portion of the metatarsal head is usually not involved.
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Radiographic staging of disease, based on correlation with Smillie's classification:
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Stage I: MTP joint space widening, with increased subchondral bone density
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Stage II: MT head flattening (anteroposterior view)
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Stage III: Collapse of the central portion of the dorsal part of the distal MT head.
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Stage IV: Medial and lateral fractures of the projections of the remaining metatarsal head (multiple loose bodies in the joint).
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Stage V: Complete loss of joint anatomy and integrity.
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Hot spot over metatarsal head
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Classic osteonecrotic changes seen in MRI
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May be useful in early detection prior to radiographic changes (1) [B]
Differential Diagnosis
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Fracture: Acute or stress
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Septic joint
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Neuroma
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Gout
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Metatarsalgia
P.269
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Symptomatic relief for early stages of disease prior to collapse and loose body formation
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Goal is to restrict weight bearing a sufficient time to allow healing to take place.
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Immediate cessation of sports
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Use of crutches to restrict weight-bearing may be indicated in early stages when most painful
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As symptoms subside, may progressively bear weight with use of metatarsal pads, bars, and/or a custom orthosis
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Occasionally may need a walking boot or short leg walking cast with a toe plate
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By restricting weight bearing, the lesion may heal over a period of 6–12 wks.
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Return to sports when asymptomatic with custom foot orthosis
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Operative treatment indicated if nonoperative treatment fails or if disease is advanced
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Joint debridement with dorsal osteophyte excision, synovectomy, and loose body excision
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Other operative options include dorsiflexion osteotomy or metatarsal head excision in an older, less demanding patient
Medication
Symptomatic treatment with acetaminophen or NSAIDs as indicated (2)[C].
Additional Treatment
Referral
Orthopedic surgery referral indicated if nonoperative treatment fails or if disease is advanced.
Complementary and Alternative Medicine
None
Surgery/Other Procedures
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Surgery is reserved for those patients who fail conservative therapies, or those with late-stage and demonstrated degenerative joint progression.
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In general, surgical procedures that preserve the articular interaction of the MTP joint have shown the most benefit. Examples include metatarsal osteotomy and excisional and incisional arthroplasty (2[C],3[B]).
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Follow-Up Recommendations
No standard return to participation protocol has been established. Protocol should be individualized and based on radiographic confirmation of healing as well as symptom resolution (2)[C].
Patient Education
Patient education should focus on the need for activity modification and a functional symptom-based rehabilitation program.
Prognosis
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For most nondegenerative lesions, conservative therapy is likely to lead to healing and resolution of symptoms.
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Current surgical procedures are demonstrating satisfactory results, but continue to be an investigative topic.
Complications
Joint degeneration or destruction with resultant chronic pain and/or loss of function.
References
1. Torriani M, Thomas BJ, Bredella MA, et al. MRI of metatarsal head subchondral fractures in patients with forefoot pain. AJR Am J Roentgenol. 2008;190:570–575.
2. Carmont MR, Rees R, Blundell C. Current concepts review: Freiberg's disease. Foot & Ankle International. 2009;30(2):167–176.
3. Sproul J, Klaaren H, Mannarino F. Surgical treatment of Freiberg's infraction in athletes. Am J Sports Med. 1993;21:381–384.
Additional Reading
Manusov EG, Lillegard WA, Raspa RF. Pediatric foot problems. American Family Physician. 1996;54(2):592–606.
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ICD9
732.5 Juvenile osteochondrosis of foot
Clinical Pearls
Typical presentation is a teenage female in a growth spurt who presents with forefoot pain with walking or activity.