Freiberg disease: Throw the kitchen sink at it

Freiberg disease is not a disease but a somewhat rare disorder of the metatarsal head in the foot. It also gets called Freiberg’s infarction, as an infarct is a lack of blood supply and that is part of the pathophysiology of the disorder. It was first described by Alfred H. Freiberg in 1914, hence the name of Freiberg or Freiberg’s disease.

What is Freiberg Disease?

Freiberg’s diseases most commonly affects the second metatarsal bone in the foot, but it can occasionally occur in other metatarsals as well. It is a type of avascular necrosis, which means that the blood supply to a portion of the bone is disrupted, leading to bone cell death and potential damage. It is thought that small fractures in and around the metatarsal head disrupt the blood supply. It is more common in females than males and is most common in the ages 13-18 years.

What Causes Freiberg Disease?

The exact cause of Freiberg’s diseases is not clear. It is mostly likely an overuse type problem leading to repeated trauma to the metatarsal head that somehow disrupts the blood supply. This leads to the avascular necrosis and further small fractures of the bone in the metatarsal head.

Playing a lot of sport, wearing high heel shoes and a longer second metatarsals bone are considered risk factors for Freiberg disease.

What are the symptoms for Freiberg Disease?

The most common symptom is pain around the 2nd metatarsal head that is worse on activity. There is also generally some swelling and stiffness of the joint. The swelling tends to be worse on the top of the foot. The onset of symptoms is usually gradual and there is usually not one incident or trauma that is related to the onset.

The diagnosis can generally initially be made on the physical examination and symptoms and can be confirmed by x-ray. These changes on x-ray are initially a subchondral sclerosis and then a flattening of involved metatarsal head. Later there is a obvious joint destruction.

The differential diagnosis for this includes a stress fracture, Morton’s neuroma, plantar plate tear, or an inflammatory arthritis such as rheumatoid arthritis.

What is the treatment for Freiberg Disease?

The initial management is a restriction of activity levels down to a level that can be tolerated. A walking cast or brace may be needed for 4 to 6 weeks to achieve this properly. A stiff soled shoe or a carbon fiber plate in the shoe can also restrict movement of the joint. Pain relief with NSAID’s and ice after activity may also be helpful.

How long for Freiberg’s disease to heal? If things go well, after the 4-6 weeks of limited activity, there can then be a gradual and slow return to physical activity. It is better if more rigid shoes, perhaps with a carbon plate a to stiffen the forefoot and the use of foot orthotics to spread out weightbearing be used. If things do not go well, then surgery may be indicated.

Surgical options include the removal of the loose fragments from inside the joint; a wedge osteotomy to elevate the metatarsal to reduce weightbearing on it; or a partial resection of the metatarsal head.

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