My Patient Was Told She Has Freiberg's Disease

Dr Domenico Nicoletti rID: 44376 Radiopaedia

A patient came in last week asking for a second opinion for her toe pain. She had seen a doctor at her local polyclinic, gone for an x-ray and was told she might have early signs of Freiberg's disease.

She was subsequently asked to see a foot surgeon by the doctor. Her friends also suggested she see a podiatrist.

Freiberg's infarction or Freiberg's disease as it is commonly known is actually not a disease but microtrauma causing pain in usually the second toe of the foot at the metatarsal head. It can occur in other toes too. 

It is most common among teenage girls during puberty and more common in the second toe. This is especially if the second toe is longer than the big toe as this increases stress on the 2nd metatarsal head while walking, running and during sports. 

The physical stress causes multiple tiny small fractures where the metatarsal meets the growth plate. Pain is commonly felt in the forefoot while pushing off. The affected joint may sometimes be swollen and range of motion is limited there. Due to avascular necrosis (bone tissue dying due to lack of blood supply), the metatarsal head flattens (see picture below). This is usually confirmed by x-ray. 

There is no definitive treatment for Freiberg's, as it is also thought to be related to a stress fracture. Doctors will often get the patient to be non weight bearing to immobilize the foot. Corticosteroid injections may sometimes be given. In less severe cases, a rocker boot may be prescribed. Podiatrists may also prescribe orthotics with metatarsal pads and/ or low heel footwear. Severe cases may require surgery.

As you can see from the x-ray report above, my patient is clearly not an adolescent (although people of all ages can be affected by it). Even the reporting radiologist said it could be a normal variant. She also had been inactive for the past 3 years. 

What did I do? I treated her foot and plantar fascia along her Superficial Back Line and taught her to modify her gait for the time being. She was happy to be pain free after that and even asked if she could run. If she really had Freiberg's disease/ infarction, I would not, in my humble opinion, be able to change her symptoms that much in just one session.

References

Carter KR, Chambers AR and Dryer MA. Freiberg Infarction. (updated Mar 17, 2021). In: StatPearls (Interbet). Treasure Island (FL): StatPearls Publishing; 2021 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK537308.

Lin H and Liu AL (2013). Freiberg's Infarction. BMJ. Case Reports: 2013010121. DOI: 10.1136/bcr-2013-010121.