Freiberg’s Disease: How to Manage

What Causes Freiberg Disease?

The exact cause of Freiberg’s disease is unknown. However, we think the blood supply to growing bone is compromised by blood flow. This block of the blood flow can result in bone death, collapse of the joint surface, and eventual arthritis. Excessive bone stress plays a significant role, so runners, jumpers, or dancers are at greater risk. Other risk factors include a long second metatarsal or altered foot biomechanics, such as flat feet. Some athletes with poor bone health, such as osteopenia, are also at risk. 

Symptoms 

Typically, patients present with pain at the ball of the foot, especially beneath the second toe. The pain often worsens during weight-bearing activities such as running, walking, or jumping. The symptoms begin gradually in many cases, with no apparent injury or trauma.

Swelling over the second metatarsophalangeal (MTP) joint is a common finding. Some individuals report that pain may increase with push-off during walking or when wearing narrow or tight shoes.

A doctor’s examination finds that pressing over the affected metatarsal head reproduces the pain, and movement of the joint may be restricted or painful.

Several other conditions can mimic Freiberg disease, so it is essential to consider a range of possible diagnoses when evaluating forefoot pain.

• Morton’s neuroma 

• Second metatarsal stress fracture

• Second MTP joint capsulitis or synovitis 

• Inflammatory arthritis 

Imaging to help with Diagnosis

Diagnosis of Freiberg’s disease is confirmed through imaging.

In the early stages, X-rays may appear normal. However, X-rays typically show flattening, sclerosis, or fragmentation of the metatarsal head as the disease progresses. The joint space may narrow, and the articular surface may become irregular.

MRI can be beneficial if the X-ray is normal. MRI detects bone marrow and cartilage changes and is more sensitive to early signs of bone death. 

Treatment Options for Freiberg’s Disease

Treatment depends on the severity and stage of the disease.

In the early stages, conservative management is usually effective. This includes reducing activity levels to limit impact loading on the forefoot. Footwear modification, including cushioned insoles or metatarsal pads, can help redistribute pressure away from the affected joint. Stiff-soled shoes or carbon-fibre inserts may limit joint movement and reduce symptoms. Anti-inflammatory medication may provide short-term relief. About 60% of cases will improve with simple treatments if the pathology is mild or detected early. 

Rehabilitation is critical. A structured rehabilitation program led by a physiotherapist can improve foot mechanics. 

Some doctors use injections as an adjunct to rehab. Cortisone injections may be helpful in advanced arthritis cases, but should be avoided in the early stages. PRP injections may help with healing in the early stages, although we do not have evidence to suggest they are effective. 

In more advanced cases or when simple treatment fails, surgery may be required. Surgical options include joint debridement, osteotomy to redistribute pressure, or metatarsal head resection in severe cases. Surgery aims to preserve function and reduce pain. Most patients recover well with appropriate surgery. 

Final Word from Sportdoctorlondon about Freiberg Disease 

Freiberg’s disease is an uncommon cause of forefoot pain in active young individuals. It most often affects the second metatarsal head and is characterised by reduced blood supply, leading to bone swelling. With early detection, conservative measures are usually successful. Advanced stages may require surgery. A diagnosis must be made early so recovery is quicker without joint damage. 

Related conditions:

• Causes of second toe pain