Freiberg's disease

Last evidence check March 2011


Freiberg's disease of the second metatarsal head - the commonest site

Freiberg's disease is an "infraction" of the dorsal part of one of the lesser metatarsal heads. Gauthier and Elbaz (1979) recorded 2/3 of lesions in the second metatarsal, 1/4 in the third, 4% in the fourth and only one in the fifth. There is a partial collapse of the metatarsal head, with degenerative change in the joint. The lower part of the head, however, is normally well preserved. Gauthier and Elbaz described five stages (with the number of cases in their series):

Several papers attribute a similar classification to Smillie (1957) but this reference is an abstract which does not, in itself, contain a classification.

Freiberg's is a condition of young adults. Some series report about half have a clear history of trauma and others of repeated stress. Stanley (1990), however, found only a weak relationship with trauma, repeated stress and wearing high-heeled shoes, but found the affected metatarsal long in comparison with the adjacent rays in 85% of 31 feet.

A useful review of Freiberg's disease was produced by Carmont (2009).

Clinical features

Most patients complain of pain in the affected joint, usually quite clearly localised in the upper or lower part of the joint, but sometimes more generalised across the forefoot, and may simply be referred as "metatarsalgia". Some patients complain of stiffness in the joint, or of osteophytes rubbing on the shoe.

The foot is usually of neutral shape. The affected joint is usually thickened and there may be tender osteophytes. The joint is stiff and manipulation reproduces the patient's pain.


Many patients require only explanation of the condition and simple advice about pain control and shoe choice. Large osteophytes may make it difficult to find comfortable shoes, and pain under the affected metatarsal, or in transfer lesions, can be helped with a metatarsal dome insole; the orthotist's advice and help are valuable. The symptoms are often non-progressive, and the patient need not have any intervention simply to prevent future trouble. For more troublesome joints, an injection of steroid + local anaesthetic can help resolve symptoms.

Surgery can be offered for intractable pain or pressure symptoms. Options include: