Freiberg’s Disease, also known as Freiberg Infraction, is a condition in which the head of a metatarsal bone — most commonly the second — loses its blood supply (avascular necrosis), leading to collapse of the bone and damage to the joint surface. It primarily affects adolescents and young adults, particularly females, and can cause significant pain in the forefoot. Over time, this disruption of blood flow can result in arthritis of the metatarsophalangeal (MTP) joint.
How Common It Is and Who Gets It? (Epidemiology)
Freiberg’s Disease is relatively uncommon but is seen most frequently in adolescent and young adult females. It often occurs in individuals with a long second metatarsal or those who participate in activities that place repetitive stress on the forefoot, such as dancing, running, or soccer. The second metatarsal is most often affected, followed by the third. Bilateral cases (in both feet) are rare.
Why It Happens – Causes (Etiology and Pathophysiology)
The exact cause of Freiberg’s Disease remains uncertain, but several contributing factors are recognized:
- Repetitive microtrauma from high-impact activities or tight shoes
- Vascular compromise (loss of blood flow) to the metatarsal head
- Anatomical predisposition, such as a long second metatarsal or high arch
- Mechanical overload during walking or sports
These factors lead to ischemic necrosis (bone death) of the metatarsal head, followed by collapse, cartilage damage, and eventual arthritis of the joint.
How the Body Part Normally Works? (Relevant Anatomy)
The metatarsal heads form the joints at the base of the toes (MTP joints), which help bear weight and provide balance during walking. The second metatarsal head is particularly prone to overload because it often receives the most pressure during gait. The bone is covered by cartilage, which relies on a healthy blood supply to maintain smooth joint motion. When this blood supply is compromised, the bone weakens, leading to collapse of the metatarsal head and deformity of the joint.
What You Might Feel – Symptoms (Clinical Presentation)
Symptoms usually develop gradually and may worsen over time.
Common findings include:
- Pain in the ball of the foot, often described as walking on a hard stone
- Swelling and stiffness around the affected joint
- Tenderness over the top (dorsum) of the foot
- Difficulty wearing high heels or narrow shoes
- Limited range of motion at the affected MTP joint
- In advanced cases, deformities such as hammertoe or crossover toe may appear.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is made through clinical evaluation and imaging studies.
- X-rays: In early stages, may show subtle joint space widening or sclerosis. Later, they reveal flattening, collapse, or fragmentation of the metatarsal head.
- MRI: Detects early changes in bone marrow before collapse occurs.
- Bone scan: May show decreased uptake in the necrotic area surrounded by increased activity.
Early detection is key to preventing permanent damage and deformity.
Classification
The Smillie Classification is commonly used to describe the stages of Freiberg’s Disease:
- Stage I: Small subchondral fissure fracture in the metatarsal head.
- Stage II: Absorption of cancellous bone, causing collapse of the overlying surface.
- Stage III: Sinking and flattening of the articular surface with prominent edges.
- Stage IV: Severe destruction with peripheral projections and joint incongruity.
- Stage V: Advanced arthrosis with flattening, fragmentation, and chronic joint degeneration.
Other Problems That Can Feel Similar (Differential Diagnosis)
- Metatarsalgia from overuse or improper footwear
- Stress fracture of the metatarsal
- Morton’s neuroma
- Gout or inflammatory arthritis
- Osteochondritis dissecans
Accurate imaging helps distinguish Freiberg’s Disease from these other causes of forefoot pain.
Treatment Options
Non-Surgical Care
In early stages (Smillie I–II), conservative management is usually effective and aims to reduce pressure and allow healing.
- Activity modification: Avoid high-impact activities or prolonged walking.
- Shoe modifications: Use stiff-soled or rocker-bottom shoes to decrease forefoot pressure.
- Orthotics: Metatarsal pads or bars to offload the affected area.
- Medication: Anti-inflammatory drugs for pain and swelling.
- Immobilization: A walking boot or cast may be used for short-term rest.
Nonoperative management is successful in up to 60% of cases when initiated early.
Surgical Care
Surgery is indicated when non-surgical measures fail or in advanced stages (Smillie III–V).
Common procedures include:
- Core decompression: Drilling into the bone to stimulate blood flow and healing.
- Debridement: Removal of loose cartilage, osteophytes, or debris from the joint.
- Osteotomy: Dorsiflexion or shortening osteotomy to realign and relieve pressure on the affected metatarsal head.
- Osteochondral grafting: Transplantation of healthy bone and cartilage for joint restoration.
- Arthroplasty or fusion: For end-stage cases with severe arthritis or deformity.
Recovery and What to Expect After Treatment
- Nonoperative recovery: Pain relief typically occurs within several weeks to months with proper footwear and activity modification.
- After surgery: Recovery depends on the procedure but generally includes:
- Immobilization in a boot or cast for 4–6 weeks
- Gradual weight-bearing under supervision
- Physical therapy to restore motion and strength
Most patients experience significant improvement in pain and function within 3–6 months.
Possible Risks or Side Effects (Complications)
Potential complications include:
- Persistent pain or stiffness
- Joint degeneration or arthritis
- Transfer metatarsalgia (pain in adjacent toes)
- Deformity recurrence
- Limited joint motion after surgery.
Long-Term Outlook (Prognosis)
The prognosis depends on the stage of the disease at diagnosis. Early recognition and conservative treatment yield the best results. Advanced cases may require surgery, which often provides lasting pain relief but can result in mild stiffness. Regular follow-up and proper footwear help maintain long-term function.
Out-of-Pocket Costs
Medicare
CPT Code 28020 – Core Decompression: $122.88
CPT Code 28122 – Debridement: $135.39
CPT Code 28308 – Osteotomy: $130.95
CPT Code 20932 – Osteochondral Grafting: $176.01
CPT Code 28288 – Arthroplasty or Fusion: $137.73
Under Medicare Part B, 80% of the approved cost is covered after you meet the annual deductible, leaving the remaining 20% as your potential responsibility. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield typically cover that 20%, ensuring that most patients pay little to nothing out of pocket for Medicare-approved procedures. These supplemental plans work together with Medicare, filling the financial gap that standard coverage leaves behind.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it can serve as a secondary payer after Medicare. These policies often cover the remaining coinsurance or deductible, which usually ranges from $100 to $300 depending on your plan’s structure and whether your provider is in-network.
Workers’ Compensation
If Freiberg disease developed as a result of repetitive stress or trauma from your occupation, Workers’ Compensation will cover all surgical and rehabilitative costs related to the condition. You will not have any out-of-pocket expenses, as payments are handled directly by your employer’s insurance carrier.
No-Fault Insurance
If your forefoot injury or Freiberg disease was caused by an automobile accident, No-Fault Insurance will generally cover the entire treatment cost, including surgery and follow-up care. The only potential expense may be a small deductible or co-payment depending on your policy terms.
Example
Olivia Bennett developed Freiberg disease in her second metatarsal after years of sports activity, resulting in persistent forefoot pain. She underwent osteochondral grafting (CPT 20932) with an estimated Medicare out-of-pocket cost of $176.01. Because Olivia had supplemental insurance through AARP Medigap, the remaining balance was covered, leaving her with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is Freiberg Disease?
A. Freiberg disease is a condition where the head of a metatarsal bone in the foot loses its blood supply, leading to bone death and joint collapse.
Q. Which metatarsal is most commonly affected in Freiberg Disease?
A. The second metatarsal is most commonly affected.
Q. What causes Freiberg Disease?
A. Freiberg disease may be caused by repetitive trauma, vascular compromise, or structural abnormalities of the foot.
Q. What are the symptoms of Freiberg Disease?
A. Symptoms include pain in the forefoot, swelling, stiffness, and difficulty walking.
Q. How is Freiberg Disease diagnosed?
A. Diagnosis is made through clinical examination and confirmed with imaging studies like X-rays, MRI, or CT scans.
Q. What are the non-surgical treatments for Freiberg Disease?
A. Non-surgical treatments include activity modification, shoe inserts, anti-inflammatory medications, and physical therapy.
Q. When is surgery considered for Freiberg Disease?
A. Surgery is considered when conservative treatments fail and symptoms persist or worsen.
Q. What surgical options are available for Freiberg Disease?
A. Surgical options include debridement, osteotomy, joint replacement, or arthrodesis.
Q. What is the goal of surgical treatment for Freiberg Disease?
A. The goal of surgery is to relieve pain, restore joint function, and prevent further joint degeneration.
Q. What is the prognosis for patients with Freiberg Disease?
A. The prognosis depends on the stage of the disease at diagnosis and the effectiveness of treatment, with earlier intervention leading to better outcomes.
Q. What causes Freiberg’s Disease?
A. It is caused by loss of blood supply to the metatarsal head, often due to repetitive trauma or abnormal foot mechanics.
Q. Which toe is most affected?
A. The second metatarsal is most commonly affected, followed by the third.
Q. How is Freiberg’s Disease diagnosed?
A. Diagnosis is made through clinical evaluation and imaging, including X-rays and MRI.
Q. Can Freiberg’s Disease heal without surgery?
A. Yes. Early stages often respond well to rest, footwear modifications, and orthotics.
Q. When is surgery needed?
A. Surgery is considered for persistent pain or advanced stages with collapse of the metatarsal head.
Q. What is the recovery time after surgery?
A. Most patients return to normal footwear and daily activity within 2–3 months, with full recovery in 6 months.
Summary and Takeaway
Freiberg’s Disease is a rare but significant cause of forefoot pain, typically affecting the second metatarsal head in young women. It results from loss of blood supply leading to collapse of the bone. Early diagnosis and conservative treatment often prevent progression, while surgical options such as osteotomy or arthroplasty provide effective pain relief and functional restoration in advanced cases.
Clinical Insight & Recent Findings
A 2024 review in Cartilage by Yoshimura et al. presents an evidence-based treatment algorithm for Freiberg’s disease, a form of osteonecrosis that most often affects the second metatarsal head in young women and athletes. The study emphasizes that nonoperative care—including activity modification, orthotics, and footwear adjustments—should be the first-line treatment, especially in early disease stages where success rates reach about 60%.
When symptoms persist beyond six months, surgical options are tailored to disease severity. For early to mid-stage disease, core decompression, debridement, or dorsiflexion osteotomy can relieve pain and preserve the joint. More advanced stages may require osteochondral autologous transplantation, which restores cartilage and supports quicker return to activity, especially in young athletes. In end-stage cases, interposition or implant arthroplasty can relieve pain but are generally reserved for patients with low activity levels.
The authors propose a stage-based algorithm (illustrated in Figure 2 of the study) that helps clinicians balance joint-preserving and reconstructive options based on patient age, lesion size, and functional demands. (“Study on modern treatment strategies for Freiberg’s Disease – see PubMed“.)
Who Performs This Treatment? (Specialists and Team Involved)
Treatment is typically provided by orthopedic foot and ankle surgeons or podiatric surgeons. Radiologists assist in imaging interpretation, and physical therapists guide postoperative rehabilitation.
When to See a Specialist?
Consult a foot and ankle specialist if you experience persistent pain in the ball of your foot, especially when walking or wearing tight shoes. Early evaluation is essential for preventing permanent damage.
When to Go to the Emergency Room?
While Freiberg’s Disease rarely requires emergency care, immediate evaluation is recommended for sudden severe pain, inability to bear weight, or swelling following trauma.
What Recovery Really Looks Like?
Recovery depends on disease stage and treatment method. Early-stage patients improve within weeks of conservative care. Post-surgical patients typically regain comfortable walking within 3–6 months, though some residual stiffness may remain.
What Happens If You Ignore It?
Ignoring symptoms can lead to progressive collapse of the metatarsal head, chronic pain, stiffness, and arthritis in the affected joint.
How to Prevent It?
- Wear properly fitted, supportive shoes
- Avoid high heels and shoes with narrow toe boxes
- Maintain a healthy weight to reduce forefoot stress
- Address early foot pain before it progresses.
Nutrition and Bone or Joint Health
A diet rich in vitamin D, calcium, and protein supports bone strength. Omega-3 fatty acids and antioxidants may reduce inflammation and improve healing.
Activity and Lifestyle Modifications
Engage in low-impact activities such as swimming or cycling to maintain fitness without stressing the forefoot. Use cushioned footwear and orthotics to offload pressure from the metatarsal head.
Dr. Mo Athar
