Freiberg Disease Workup
- Author: Shayne D Fehr, MD, FAAP; Chief Editor: Jason H Calhoun, MD, FACS more...
On the basis of the clinical presentation and imaging findings, laboratory studies and other investigations may be indicated to rule out other etiologies of pain or deformity. In particular, infectious and oncologic processes may cause pain and abnormal imaging of the metatarsal head.
Depending on the stage of the disease, radiographs may show only sclerosis and widening of the joint space (early), with complete collapse of the metatarsal head and fragmentation later. Osteochondral loose bodies may be seen late in the disease as well. Oblique views may be especially useful to fully appreciate subtle changes early in the disease. One study advocates the use of radiographs to assess musculoskeletal foot conditions in women related to poorly fitting shoes.
Occasionally, patients are completely asymptomatic, with changes noted on radiographs taken for other reasons. Whether these patients later develop symptomatic Freiberg disease is not known.
The use of bone scanning has been described with photopenia in the early stages of the disease, with intense uptake later as the head is reconstituted or revascularized. Although bone scintigraphy has been used in the study of Freiberg disease, its value as a diagnostic or prognostic tool is unknown.
magnetic resonance imaging (MRI) is helpful in detecting early Freiberg disease not visualized on plain radiographs. MRI may demonstrate hypointense signal in the epiphysis on T1 images and mixed hypointense and hyperintense signals on T2 images. Flattening of the metatarsal head may be identified as well.
MRI has been advocated by some physicians as helpful for preoperative evaluation, especially if an osteotomy is planned. One study demonstrated that three-dimensional (3D) CT scans were useful in characterizing the extent of osteonecrosis in a lesion.
Histologic examination of tissue from resected specimens has produced varied findings. Different studies have found bone resorption and new bone formation, depending on the stage of the disease.
Young et al described separation of the deeper layers of the hyaline cartilage in a 55-year-old man with Freiberg disease. The separation had occurred in close proximity to the zone of mineralization, and avascularity was not evident. The authors concluded that in this one case, a traumatic shear or compression-type injury was likely to have been responsible, as opposed to some type of vascular insult (avascular necrosis).
Several staging schemes have been described. Most are based on radiographic appearance, including the amount of collapse and the presence or absence of secondary degenerative changes. The classification scheme developed by Smillie in 1967 is the most often quoted system and divides the radiographic changes into the following five stages (see the images below):
Stage I - The earliest sign is fissuring of the epiphysis; radiographic changes at this stage may be so subtle that they are missed with routine radiographs
Stage II - Later central depression of the articular surface becomes evident as subchondral cancellous bone is resorbed; the articular cartilage hinges on an intact plantar bridge
Stage III - The central depression is seen to be resulting in medial and lateral projections at the margins; the plantar hinge remains intact at its plantar isthmus
Stage IV - This stage demonstrates that the central portion has sunk below the surface and is free of the plantar hinge, thus becoming a loose body; fractures of the medial and lateral projections are present, with folding of the projections over the central loose body
Stage V - This final stage shows marked flattening and deformity of the metatarsal head with secondary degenerative changes; the central loose body may have been resorbed at this stage; the shaft of the metatarsal becomes thickened and dense
Freiberg AH. Infraction of the second metatarsal bone, a typical injury. Surg Gyn Ob. 1914. 19:191.
Katcherian DA. Treatment of Freiberg's disease. Orthop Clin North Am. 1994 Jan. 25(1):69-81. [Medline].
Gauthier G, Elbaz R. Freiberg's infraction: a subchondral bone fatigue fracture. A new surgical treatment. Clin Orthop Relat Res. 1979 Jul-Aug. (142):93-5. [Medline].
Mandell GA, Harcke HT. Scintigraphic manifestations of infraction of the second metatarsal (Freiberg's disease). J Nucl Med. 1987 Feb. 28(2):249-51. [Medline].
Freiberg AH. The so-called infraction of the second metatarsal bone. J Bone Joint Surg. 1926. 8:257.
Omer GE Jr. Primary articular osteochondroses. Clin Orthop Relat Res. 1981 Jul-Aug. (158):33-40. [Medline].
Cerrato RA. Freiberg's disease. Foot Ankle Clin. 2011 Dec. 16(4):647-58. [Medline].
Huber JF. The arterial network supplying the dorsum of the foot. Anatomy Rec. 1941. 80:373.
Leung PC, Wong WL. The vessels of the first metatarsal web space. An operative and radiographic study. J Bone Joint Surg Am. 1983 Feb. 65(2):235-8. [Medline].
Wiley JJ, Thurston P. Freiberg’s disease. J Bone Joint Surg Br. 1981. 63:459.
Viladot A, Viladot A. Osteochondroses: aseptic necrosis of the foot. Jahss M. Disorders of the foot and ankle. 2nd edition. Philadelphia: Saunders; 1991. 617–38.
Bayliss NC, Klenerman L. Avascular necrosis of lesser metatarsal heads following forefoot surgery. Foot Ankle. 1989 Dec. 10(3):124-8. [Medline].
Stanley D, Betts RP, Rowley DI, Smith TW. Assessment of etiologic factors in the development of Freiberg's disease. J Foot Surg. 1990 Sep-Oct. 29(5):444-7. [Medline].
Donahue SW, Sharkey NA. Strains in the metatarsals during the stance phase of gait: implications for stress fractures. J Bone Joint Surg Am. 1999 Sep. 81(9):1236-44. [Medline].
Smillie IS. Freiberg's infraction (Kohler's second disease). J Bone Joint Surg Br. 1957. 39B:580.
McMaster MJ. The pathogenesis of hallux rigidus. J Bone Joint Surg Br. 1978 Feb. 60(1):82-7. [Medline].
Helal B, Gibb P. Freiberg's disease: a suggested pattern of management. Foot Ankle. 1987 Oct. 8(2):94-102. [Medline].
Braddock GT. Experimental epiphysial injury and Freiberg's disease. J Bone Joint Surg Br. 1959 Feb. 41-B(1):154-9. [Medline].
Hoskinson J. Freiberg's Disease: A Review of the Long-term Results. Proc R Soc Med. 1974 Feb. 67(2):106-7. [Medline].
Nguyen VD, Keh RA, Daehler RW. Freiberg's disease in diabetes mellitus. Skeletal Radiol. 1991. 20(6):425-8. [Medline].
Murphy GA. Lesser Toe Abnormalities. Canale ST, Beaty JH. Campbell's Operative Orthopaedics. 12th ed. Philadelphia: Elsevier Mosby; 2012. IV: 4018-20.
Goud A, Khurana B, Chiodo C, Weissman BN. Women's musculoskeletal foot conditions exacerbated by shoe wear: an imaging perspective. Am J Orthop (Belle Mead NJ). 2011 Apr. 40(4):183-91. [Medline].
Mifune Y, Matsumoto T, Mizuno T, Ikuta S, Kurosaka M, Kuroda R. Idiopathic osteonecrosis of the second metatarsal head. Clin Imaging. 2007 Nov-Dec. 31(6):431-3. [Medline].
Chun KA, Oh HK, Wang KH, Suh JS. Freiberg's disease: quantitative assessment of osteonecrosis on three-dimensional CT. J Am Podiatr Med Assoc. 2011 Jul-Aug. 101(4):335-40. [Medline].
Freiberg AA, Freiberg RA. Core decompression as a novel treatment for early Freiberg's infraction of the second metatarsal head. Orthopedics. 1995 Dec. 18(12):1177-8. [Medline].
Young MC, Fornasier VL, Cameron HU. Osteochondral disruption of the second metatarsal: a variant of Freiberg's infraction?. Foot Ankle. 1987 Oct. 8(2):103-9. [Medline].
Smillie IS. Treatment of Freiberg's infraction. Proc R Soc Med. 1967 Jan. 60(1):29-31. [Medline].
Kidd LJ, Cowling NR, Wu AC, Kelly WL, Forwood MR. Selective and non-selective cyclooxygenase inhibitors delay stress fracture healing in the rat ulna. J Orthop Res. 2013 Feb. 31(2):235-42. [Medline].
Erdil M, Imren Y, Bilsel K, Erzincanli A, Bülbül M, Tuncay I. Joint debridement and metatarsal remodeling in Freiberg's infraction. J Am Podiatr Med Assoc. 2013 May-Jun. 103(3):185-90. [Medline].
Lee SK, Chung MS, Baek GH, Oh JH, Lee YH, Gong HS. Treatment of Freiberg disease with intra-articular dorsal wedge osteotomy and absorbable pin fixation. Foot Ankle Int. 2007 Jan. 28(1):43-8. [Medline].
Al-Ashhab ME, Kandel WA, Rizk AS. A simple surgical technique for treatment of Freiberg's disease. Foot (Edinb). 2013 Mar. 23(1):29-33. [Medline].
Chao KH, Lee CH, Lin LC. Surgery for symptomatic Freiberg's disease: extraarticular dorsal closing-wedge osteotomy in 13 patients followed for 2-4 years. Acta Orthop Scand. 1999 Oct. 70(5):483-6. [Medline].
Kinnard P, Lirette R. Freiberg's disease and dorsiflexion osteotomy. J Bone Joint Surg Br. 1991 Sep. 73(5):864-5. [Medline].
Smith TW, Stanley D, Rowley DI. Treatment of Freiberg's disease. A new operative technique. J Bone Joint Surg Br. 1991 Jan. 73(1):129-30. [Medline].
Lui TH. Arthroscopic interpositional arthroplasty for Freiberg's disease. Knee Surg Sports Traumatol Arthrosc. 2007 May. 15(5):555-9. [Medline].
Cracchiolo A 3rd, Kitaoka HB, Leventen EO. Silicone implant arthroplasty for second metatarsophalangeal joint disorders with and without hallux valgus deformities. Foot Ankle. 1988 Aug. 9(1):10-8. [Medline].
Shih AT, Quint RE, Armstrong DG, Nixon BP. Treatment of Freiberg's infraction with the titanium hemi-implant. J Am Podiatr Med Assoc. 2004 Nov-Dec. 94(6):590-3. [Medline].
Townshend DN, Greiss ME. Total ceramic arthroplasty for painful destructive disordersof the lesser metatarso-phalangeal joints. The Foot. 2006. 17:73.
Maresca G, Adriani E, Falez F, Mariani PP. Arthroscopic treatment of bilateral Freiberg's infraction. Arthroscopy. 1996 Feb. 12(1):103-8. [Medline].
Miyamoto W, Takao M, Uchio Y, Kono T, Ochi M. Late-stage Freiberg disease treated by osteochondral plug transplantation: a case series. Foot Ankle Int. 2008 Sep. 29(9):950-5. [Medline].