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Basics ⬇

Author(s): ChristopherMcGrew, MD, FACSM, CAQSM and MargaretPusateri, MD

Description

  • Osteonecrosis of the superior portion of the metatarsal head of unknown etiology
  • Freiberg first described this entity in 1914, in six patients as an infraction (incomplete fracture without displacement of the fragments).
  • Fourth most common osteochondrosis
  • Affects women more commonly than men
  • Synonym(s): Freiberg infraction; eggshell fracture; Koehler second disease; metatarsal flat-head; metatarsal epiphysitis; osteochondritis deformans metatarsojuvenilis; peculiar metatarsal disease; malakopathie

Epidemiology

  • Incidence unknown
  • Male:female ratio is 1:5.
  • Peak onset around 11 to 17 yr, but reported age range of 10 to 77 yr
  • Has been hypothesized that the condition is progressive, beginning in adolescence and remaining asymptomatic until later in life when symptoms occurs secondary to joint arthrosis
  • Most common involvement is the 2nd metatarsal head, approximately 2/3 of cases
  • Second most common involvement is the 3rd metatarsal head, involved in 27% of cases
  • 4th and 5th metatarsal heads rarely involved
  • Bilateral involvement is seen in <10% of cases.
  • Usually affects the longest metatarsal
  • Occasionally seen in sports requiring sprinting and jumping

Etiology and Pathophysiology

  • No single clear etiologic factor exists.
  • Several theories have been postulated:
    • 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 on 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.
    • Mechanical factors include immobility of the 2nd metatarsal due to its “keystone” position at its articulation with the midfoot, a longer 2nd metatarsal, a short 1st metatarsal, a hypermobile 1st metatarsal, hallux abducto valgus, use of high-heeled shoes, and rapid weight gain.
    • Systemic factors are thought to be possible contributors including infection, endocrine disturbance, hormonal changes, osteopenia, steroid use, inflammatory diseases such as systemic lupus erythematous, and hypercoagulable states.

Genetics

Unknown

Risk-Factors

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

General Prevention

None

Commonly Associated Conditions

None known

Diagnosis ⬆ ⬇

History

  • Slow development of significant, dull, aching pain over affected metatarsal head
  • Patient may notice loss of range of motion.
  • Pain increases with activity and motion.
  • Pain worsens with weight bearing, especially barefoot or in high-heeled footwear.
  • Pain often relieved by rest, but pain may awaken patient from sleep

Physical Exam

  • Surrounding soft tissue swelling
  • Tenderness over affected metatarsal head
  • May be painful with motion
  • May be limited motion of metatarsophalangeal (MTP) joint
  • Palpable bony prominences and crepitus possible in advanced disease
  • Other foot deformities may be present such as hallux valgus.

Differential Diagnosis

Diagnostic Tests & Interpretation

ALERT

Radiography normal in early stages:

  • Asymmetric joint space widening may be seen 3 to 6 wk following symptom onset, differentiating it from other arthritides whose characteristic finding involves joint space narrowing.
  • 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 lateral oblique radiographs.
  • 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 classification:
    • Stage I: MTP joint space widening, with increased subchondral bone density
    • Stage II: metatarsal head flattening (anteroposterior view)
    • Stage III: collapse of the central portion of the dorsal part of the distal metatarsal 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
  • Three-phase bone scan in the early stages will reveal a photopenic area surrounded by a focal uptake. Later stages show generalized increased uptake of the entire affected metatarsal head (1)[C].
  • Magnetic resonance imaging (MRI) has been purported to be the gold standard in early diagnosis of Freiberg as radiographs are often normal in the early stages (2)[C].
  • Early stages of Freiberg will have a hypointense signal on T1-weighted images and heterogeneous increased on T2-weighted images.
  • In addition to MRI, 3D computed tomography (CT) scans have also been used to determine the exact Smillie stage and aid in preoperative planning.

Treatment ⬆ ⬇

General Measures

  • Nonoperative management should be the first line of treatment regardless of stage at time of presentation.
ALERT

Goal is to restrict weight-bearing for a sufficient time to allow healing to take place.

  • Immediate cessation of sports and high-impact activities
  • 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 to 12 wk.
  • Return to sports when asymptomatic with custom foot orthosis.
  • Operative treatment indicated if nonoperative treatment fails or if disease is advanced
  • Smillie stages I to III have a good chance of success with nonoperative, conservative management.
  • Smillie stages IV to V are more likely to require operative management.
  • There is a wide range of surgical procedures described in the literature for management of Freiberg.
  • Joint-preserving procedures are typically performed in the early stages of disease, whereas joint-destructive procedures are reserved for advanced stages.

Medication

Symptomatic treatment with acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) as indicated (3)[C]

Issues for Referral

Orthopedic surgery or podiatry referral indicated if nonoperative treatment fails or if disease is advanced

Surgery/Other Procedures

  • Surgery is reserved for those patients who fail conservative therapies or those with late stage and demonstrated degenerative joint progression.
  • Examples of joint-sparing procedures include core decompression, bone grafting, metatarsal osteotomies, joint débridement, and microfracture surgery.
  • Examples of joint-destructive procedures include arthroplasty, implant arthroplasty, interpositional arthroplasty, metatarsal head resection, and osteochondral distal metatarsal allograft replacement.

COMPLEMENTARY & ALTERNATIVE MEDICINE

None

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.

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

Additional Reading ⬆ ⬇

  • Ishimatsu T, Yoshimura I, Kanazawa K, et al. Return to sporting activity after osteochondral autograft transplantation for Freiberg disease in young athletes. Arch Orthop Trauma Surg. 2017;137(7):959–965.
  • Pereira B, Frada T, Freitas D, et al. Long-term follow-up of dorsal wedge osteotomy for pediatric Freiberg disease. Foot Ankle Int. 2016;37(1):90–95.
  • Shane A, Reeves C, Wobst G, et al. Second metatarsophalangeal joint pathology and Freiberg disease. Clin Podiatr Med Surg. 2013;30(3):313–325.

References ⬆ ⬇

  1. Talusan PG, Diaz-Collado PJ, Reach JS Jr. Freiberg’s infraction: diagnosis and treatment. Foot Ankle Spec. 2014;7(1):52–56.
  2. Schade VL. Surgical management of Freiberg’s infraction: a systematic review. Foot Ankle Spec. 2015;8(6):498–519.
  3. Seybold JD, ZideJR. Treatment of Freiberg disease. Foot Ankle Clin. 2018;23(1):157–169.

Clinical Pearls ⬆

Typical presentation is an adolescent female in a growth spurt who presents with forefoot pain with walking or activity.