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Freiberg disease
Other names	Freiberg infraction
Freiberg disease as seen on plain film
Specialty	Orthopedics

Freiberg disease, also known as a Freiberg infraction, is a form of avascular necrosis in the metatarsal bone of the foot. It generally develops in the second metatarsal, but can occur in any metatarsal. Physical stress causes multiple tiny fractures where the middle of the metatarsal meets the growth plate. These fractures impair blood flow to the end of the metatarsal resulting in the death of bone cells (osteonecrosis). It is an uncommon condition, occurring most often in young women, athletes, and those with abnormally long metatarsals. Approximately 80% of those diagnosed are women.

Initial treatment is generally 4–6 weeks of limited activity, often with crutches or orthotics. In rare cases, surgery is necessary to reduce the bone mass of the metatarsal.

The condition was first described by Alfred H. Freiberg in 1914. He initially thought the condition was caused by acute physical trauma, which is why it was initially called an infraction.

External links

Category:Osteonecrosis

Freiberg disease

Abstract:

Freiberg's Disease, first described in 1914, is a rare condition affecting the second metatarsal head in the foot, causing avascular necrosis and pain. It typically affects teenagers and young adults, with most cases reported in females. The disease is often linked to repetitive stress or injury and can affect both feet or nearby metatarsals. A case report by Donaldson et al. highlights a male patient with bilateral Freiberg's Disease affecting adjacent metatarsals, emphasizing the need for early diagnosis. Key features include normal-looking X-rays and MRI for early diagnosis. Treatment varies from rest and pain relief to surgery depending on severity.[1]https://pmc.ncbi.nlm.nih.gov/articles/PMC10731624/

Signs and Symptoms of Freiberg's Disease:

Short-Term Signs and Symptoms: The most common symptom of Freiberg's Disease is pain, especially in the forefoot during activities like walking or running. Patients may also experience noticeable swelling around the affected metatarsal head, increased tenderness in the area, and stiffness that limits movement in the affected toe or foot. Additionally, the area may feel warm due to inflammation.

Long-Term Signs and Symptoms: If left untreated, Freiberg's Disease can lead to long-term issues. Patients may develop deformities in the affected metatarsal, chronic pain that persists even at rest, and joint instability that makes it difficult to maintain balance. Over time, there is also a risk of developing osteoarthritis in the affected joint due to long-term changes.

Areas of the Body Affected: Freiberg’s Disease primarily affects the second metatarsal head, but it can also involve the third metatarsal and nearby joints in the forefoot. Pain may radiate to adjacent joints, such as the toes or midfoot.

Presentation of the Disease: Patients typically present with a complaint of forefoot pain, particularly in the second and third metatarsophalangeal joints. They often describe the pain as sharp or aching, which worsens with movement and improves with rest. During a physical examination, visible swelling, tenderness, and limited movement in the affected area may be observed.

Gaps in Knowledge: There are still gaps in understanding Freiberg's Disease, including its exact prevalence, which is not well known. The mechanisms leading to avascular necrosis are not fully understood, and more research is needed to determine the long-term effects of the disease, including the effectiveness of treatments and the risk of complications like osteoarthritis.

Summary Table of Symptoms:

Symptom	Short-Term	Long-Term
Pain	Localized, worsens with activity	Chronic, persistent
Swelling	Noticeable around the metatarsal	Possible deformity
Tenderness	Increased sensitivity	Joint instability
Stiffness	Limited range of motion	Potential development of arthritis
Warmth	Area may feel warm

In summary, Freiberg’s Disease primarily affects the second metatarsal head and can lead to significant pain and discomfort. Early recognition of symptoms is crucial for effective management and to prevent long-term complications.

Overview of Freiberg Disease (Freiberg's Infraction)

Definition and Characteristics: Freiberg disease, also known as Freiberg's infraction, is a type of osteonecrosis that mainly affects the heads of the metatarsal bones, particularly the second metatarsal. It is non-infectious and results from the death of bone tissue due to inadequate blood supply.

Causes and Contributing Factors:

Pathophysiology: The development of Freiberg disease involves several factors:

• Trauma: Both minor and significant foot injuries can trigger the condition.
• Biomechanical Issues: Abnormal foot mechanics, causing excessive pressure on the metatarsal heads during physical activity, are major contributors.
• Systemic Conditions: Vascular or metabolic disorders that impair blood flow or bone health may increase the risk.
• Hormonal Influences: Hormonal changes, particularly in young females, are linked to the disease's higher prevalence in this group.

Prevention Strategies

• Appropriate Footwear: Wearing well-cushioned and supportive shoes can help reduce stress on the metatarsal heads.
• Activity Modification: Limiting high-impact activities, especially for those at risk, can prevent the condition.
• Early Medical Intervention: Prompt medical attention for foot pain can prevent the disease from progressing.

Risk Factors

• Demographics: More common in adolescents and young adults, with a higher prevalence in females, often associated with athletic activities.
• History of Foot Injury: Prior injuries can increase the likelihood of developing Freiberg disease.
• Genetic Predisposition: A genetic inclination to bone health issues may raise the risk.

Recommendations and Knowledge Gaps

General Guidelines: Although the CDC does not provide specific guidelines for Freiberg disease due to its non-infectious nature, general foot health advice includes:

• Regular Foot Care: Those with risk factors should monitor their foot health and seek medical advice for persistent pain.
• Education on Footwear: Raising awareness about proper footwear can help prevent foot problems.

Gaps in Knowledge:

• Understanding Pathogenesis: The exact mechanisms behind the development of osteonecrosis in Freiberg disease are not fully understood.
• Long-term Outcomes: Limited information on the long-term results of various treatments leads to uncertainty in clinical decisions.
• Standardized Treatment: A universally accepted treatment protocol is lacking, complicating the management of the condition, as noted by experts like Yoshimura et al.

In conclusion, while Freiberg disease is influenced by various factors, prevention through appropriate footwear and activity management is essential. Ongoing research is crucial to better understand its underlying causes and to establish standardized treatment protocols.

https://journals.sagepub.com/doi/10.1177/19476035231205676

Pathophysiology of Freiberg Disease:

Which Body Part is Affected? The main area affected is the metatarsal head, which is the rounded end of the metatarsal bone that connects to the toes. The second metatarsal is most commonly involved, but other metatarsals can also be affected.

Key Components of the Disease:

1. Bone Death (Osteonecrosis): The main problem in Freiberg Disease is the death of bone cells due to a lack of blood flow. This causes the bone to collapse, leading to pain and deformity.
2. Foot Mechanics: Abnormal foot movement can put too much pressure on the metatarsal heads, contributing to the disease. This is often seen in athletes or very active people.
3. Injury: Minor injuries or repeated stress on the foot can start the disease process, causing inflammation and reduced blood flow.
4. Hormonal and Blood Flow Issues: Some theories suggest that hormonal changes, especially in young females, and problems with blood flow may also play a role.

Symptoms and Their Connection:

• Pain: The main symptom is pain in the front of the foot, especially when walking or running. This pain comes from inflammation and dead bone tissue.
• Swelling and Tenderness: As the disease gets worse, swelling and tenderness around the affected area can occur due to the body's response to the dead tissue.
• Deformity: Over time, the collapse of the metatarsal head can change the shape of the foot, leading to flattening and misalignment of the toes.

What Happens in the Body: In Freiberg Disease, the process starts with an injury or stress on the foot:

1. Reduced Blood Flow: This leads to bone cells dying (osteonecrosis).
2. Inflammation: The body reacts to the dead tissue with inflammation, causing more pain and swelling.
3. Bone Changes: The body tries to heal the area, but the lack of blood flow prevents proper recovery, leading to further damage.

Gaps in Knowledge: There are still some things we do not fully understand:

• The exact cause of the reduced blood flow is unclear, and more research is needed to find specific risk factors.
• We do not know enough about the long-term results of non-surgical versus surgical treatments.
• The role of genetics in developing Freiberg Disease is still unknown.

Theories on How the Disease Develops: Several ideas explain how Freiberg Disease might develop:

1. Stress Theory: This theory suggests that too much pressure on the metatarsal heads during activities can cause small injuries and reduced blood flow.
2. Blood Flow Theory: This idea proposes that problems with blood supply due to blood vessel issues or other health conditions contribute to the disease.
3. Hormonal Theory: This theory indicates that hormonal changes, especially in young females, may affect bone health and blood flow, making them more likely to develop the disease.

https://journals.sagepub.com/doi/10.1177/19476035231205676

Diagnosis:

When diagnosing Freiberg disease, patients usually see a healthcare professional who specializes in foot and ankle issues, like an orthopedic surgeon or a podiatrist. The diagnosis involves a mix of clinical evaluation and imaging tests, with X-rays being the main tool used to look for specific changes in the metatarsal head, such as flattening or sclerosis. Sometimes, an MRI is also used to check how much bone necrosis has occurred and to rule out other possible conditions. The diagnosis is primarily based on symptoms like localized pain in the forefoot, especially during activities that put weight on the foot, along with certain findings from the X-rays. However, diagnosing Freiberg disease can be tricky because it shares similarities with other conditions, such as metatarsalgia or stress fractures, which can lead to delays in getting the right treatment. Additionally, in the early stages of Freiberg disease, there may not be clear changes visible on X-rays, making it even harder to diagnose in a timely manner and increasing the chances of misdiagnosis.

Treatment:

Treatment for Freiberg disease varies depending on the stage of the disease and the severity of symptoms. Options include:

Nonoperative Management

• Rest and Activity Modification: Reducing activities that exacerbate pain can help alleviate symptoms.
• Pain Relief: Over-the-counter pain medications, such as ibuprofen or acetaminophen, can be used to manage discomfort.
• Orthotics: Custom shoe inserts may help redistribute pressure on the foot and improve alignment.
• Physical Therapy: Exercises to strengthen the foot and improve flexibility can be beneficial.
• Surgical Management :If nonoperative treatments are ineffective after several months, surgical options may be considered, including:
• Debridement: Removal of damaged tissue and bone to relieve pain and improve function.
• Osteotomy: Surgical realignment of the metatarsal to relieve pressure on the affected joint.
• Arthroplasty: Joint replacement or reconstruction may be necessary in advanced cases.

Epidemiology:

Freiberg disease is relatively rare, but it is more commonly diagnosed in young females, particularly those involved in sports or activities that place repetitive stress on the forefoot. The condition typically presents during adolescence or early adulthood, with a peak incidence in individuals aged 10 to 20 years. While the exact prevalence is not well-documented, it is recognized as a significant cause of forefoot pain in this demographic.

Prognosis:

The prognosis for individuals with Freiberg disease largely depends on the stage at which the disease is diagnosed and the effectiveness of treatment. Nonoperative management is generally successful in the early stages, with many patients experiencing significant relief from symptoms. However, if the disease progresses to more advanced stages, surgical intervention may be necessary, and the outcomes can vary. Early diagnosis and appropriate treatment are crucial for improving long-term outcomes and preventing complications such as arthritis in the affected joint.

Recent Research

Recent studies have focused on improving the understanding of Freiberg disease and optimizing treatment strategies. Research has highlighted the importance of early diagnosis and intervention, as nonoperative treatments are most effective in the early stages of the disease. Additionally, advancements in surgical techniques, such as arthroscopy, have shown promising results in reducing recovery time and improving outcomes for patients with more severe cases. Ongoing research aims to identify genetic and environmental factors that may contribute to the disease, which could lead to more targeted prevention and treatment strategies in the future.

Case studies:

1.In the case study presented in the document , a 63-year-old male patient experienced bilateral forefoot pain localized to the second and third metatarsophalangeal joints (MTPJs). He reported that the pain had persisted for one year and was particularly severe on the left foot, rating it as 9 out of 10 on a visual analogue scale. The patient noted that he could only walk pain-free for about five minutes.

Prior to this consultation, he had been treated at another hospital with a five-week course of oral antibiotics, which did not alleviate his symptoms. The case highlights the unusual presentation of Freiberg's Disease in a male patient, as the condition is more commonly reported in adolescent females and typically affects only one metatarsal. This case emphasizes the need for awareness of Freiberg's Disease as a potential cause of forefoot pain, even in older male patients, and illustrates the challenges in diagnosing and managing this condition effectively

2.The case study presented in the document describes a unique instance of Freiberg's Disease involving a 33-year-old Sudanese male who experienced bilateral forefoot pain and swelling localized in the first metatarsal bone. This presentation is atypical, as Freiberg's Disease predominantly affects the second and third metatarsal bones and is usually unilateral.

The patient had a five-year history of symptoms, which included pain during weight-bearing activities, swelling, and tenderness in the affected area. Radiological findings showed flattening and sclerosis at the distal end of the first metatarsal bones, consistent with Freiberg's Disease. The case highlights the challenges in diagnosing this condition due to its rarity and the potential for misdiagnosis with other metatarsalgia causes or connective tissue disorders.

The authors suggest that the unusual bilateral involvement and the absence of a trauma history may indicate a possible autoimmune component to the disease's pathophysiology, particularly given the higher incidence of Freiberg's Disease in females, who are more prone to autoimmune disorders. This case emphasizes the need for awareness of atypical presentations of Freiberg's Disease to improve early diagnosis and management strategies.

https://pmc.ncbi.nlm.nih.gov/articles/PMC10731624/

References

1. Yoshimura, I., Takao, M., Wagner, E., Stufkens, S., Dahmen, J., Kerkhoffs, G. M. M. J., & Glazebrook, M. (2023). Evidence-Based Treatment Algorithm for Freiberg Disease. Cartilage. doi:10.1177/19476035231205676.
2. Lee, S. K., Kim, K. J., Yang, D. S., & Choy, W. S. (2012). Metatarsophalangeal arthroscopic treatment for early stage IV of Freiberg’s disease: a case report. European Journal of Orthopaedic Surgery & Traumatology, 22(Suppl 1), 233-237. doi:10.1007/s00590-012-0959-2.
3. Smith, T. W., Stanley, D., & Rowley, D. I. (1991). Treatment of Freiberg’s disease: a new operative technique. Journal of Bone and Joint Surgery, 73(1), 129-130.
4. Hind El-Amin ¹, Ahmed Mahjoub Awad Ali ², Osama Khder O Elmansour ³, Randa Abbas ⁴, Elabbas Mohamed ⁵, Walialdeen H Biraima ³, Omer Kamal Ahmed ⁶, Abdallah Omer Mohamedali ⁶, Abdaljalil Arja ⁵, Ahmed O Ahmed Babikir ⁷
5. Schade VL. Surgical management of Freiberg’s infraction: a systematic review. Foot Ankle Spec. 2015;8(6):498-519.