Freiberg’s Disease

By admin On Sep 18, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Freiberg's Disease

Christopher McGrew

Rodolfo R. Navarro

Basics

Description

Osteonecrosis of the superior portion of the metatarsal head of unknown etiology
Freiberg 1st described this entity in 1914 in 6 patients as an infraction (incomplete fracture without displacement of the fragments).
4th most common osteochondrosis
Affects women more commonly than men
Synonym(s): Freiberg's infraction; Eggshell fracture; Koehler's second disease; Peculiar metatarsal disease; Malakopathy

Epidemiology

Incidence unknown
Male: Female ratio is 1:5
Peak onset around 11–17 yrs, but may happen up into 30s
Most common involvement is the 2nd metatarsal head
2nd most common involvement is the 3rd metatarsal head
Usually affects the longest metatarsal
Occasionally seen in sports requiring sprinting and jumping

Risk Factors

No known risk factors
May be related to repetitive microtrauma vs vascular deficiency or both

Genetics

Unknown

General Prevention

None

Etiology

No single clear etiologic factor exists.
The process is postulated to be a combination of traumatic and vascular factors:
- 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.
- Vascular factors include abnormal metatarsal head vascular variations, as well as trauma-induced vessel damage, spasm, and eventual ischemia.

Commonly Associated Conditions

None known

Diagnosis

History

Slow development of significant, dull, aching pain over affected metatarsal head
Patient may notice loss of motion.
Pain increases with activity and motion.
Pain worsens with weight bearing.
Pain often relieved by rest, but pain may awaken patient from sleep.

Physical Exam

Surrounding soft tissue swelling and warmth
Tenderness over metatarsal head
May be painful with motion
As disease progresses, osteophytes may be palpable.
May be limited motion of metatarsophalangeal (MTP) joint
Palpable crepitus in advanced disease
Other foot deformities may be present, such as hallux valgus.

Diagnostic Tests & Interpretation

Imaging

Radiography normal in early stages
As the disease progresses, osteonecrotic changes are seen on the superior/central head.
Eventually the superior/central head collapses and flattens.
Medial and lateral dorsal osteophytes develop.
Osteophytes may break free, becoming loose bodies, best seen on the oblique.
Cystic changes may be seen in the head.
The inferior portion of the metatarsal head is usually not involved.
Radiographic staging of disease, based on correlation with Smillie's classification:
Stage I: MTP joint space widening, with increased subchondral bone density
Stage II: MT head flattening (anteroposterior view)
Stage III: Collapse of the central portion of the dorsal part of the distal MT head.
Stage IV: Medial and lateral fractures of the projections of the remaining metatarsal head (multiple loose bodies in the joint).
Stage V: Complete loss of joint anatomy and integrity.
Hot spot over metatarsal head
Classic osteonecrotic changes seen in MRI
May be useful in early detection prior to radiographic changes (1) [B]

Differential Diagnosis

Fracture: Acute or stress
Septic joint
Neuroma
Gout
Metatarsalgia

P.269

Treatment

Symptomatic relief for early stages of disease prior to collapse and loose body formation
Goal is to restrict weight bearing a sufficient time to allow healing to take place.
Immediate cessation of sports
Use of crutches to restrict weight-bearing may be indicated in early stages when most painful
As symptoms subside, may progressively bear weight with use of metatarsal pads, bars, and/or a custom orthosis
Occasionally may need a walking boot or short leg walking cast with a toe plate
By restricting weight bearing, the lesion may heal over a period of 6–12 wks.
Return to sports when asymptomatic with custom foot orthosis
Operative treatment indicated if nonoperative treatment fails or if disease is advanced
Joint debridement with dorsal osteophyte excision, synovectomy, and loose body excision
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

Surgery is reserved for those patients who fail conservative therapies, or those with late-stage and demonstrated degenerative joint progression.
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]).

Ongoing Care

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

For most nondegenerative lesions, conservative therapy is likely to lead to healing and resolution of symptoms.
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.

Codes

ICD9

732.5 Juvenile osteochondrosis of foot