Freiberg Disease (Infraction) Workup

Updated: May 28, 2021
  • Author: Shayne D Fehr, MD, FAAP; Chief Editor: Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS  more...
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Laboratory Studies

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, rheumatologic, and oncologic processes may cause pain and abnormal imaging of the metatarsal head.


Imaging Studies


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 for achieving a full appreciation of subtle changes early in the disease. One study advocated the use of radiographs to assess musculoskeletal foot conditions in women related to poorly fitting shoes. [22]

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.

Bone scintigraphy, MRI, and CT

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. [21]

Magnetic resonance imaging (MRI) is helpful in detecting early Freiberg disease not visualized on plain radiographs. [23] 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. [6]

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) computed tomography (CT) was useful in characterizing the extent of osteonecrosis in a lesion. [24]


Histologic Findings

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. [25]

Young et al described separation of the deeper layers of the hyaline cartilage in a 55-year-old man with Freiberg disease. [26] 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 [AVN]).



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. As is frequently the case with other musculoskeletal conditions, multiple classification systems exist, with varying levels of validation. [24] Nevertheless, the classification scheme developed by Smillie in 1967 [27] 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
Early stage I-II lesion of Freiberg disease, best Early stage I-II lesion of Freiberg disease, best seen on oblique radiograph.
Stage III Freiberg disease with advanced flattenin Stage III Freiberg disease with advanced flattening.
Stage IV Freiberg disease with articular collapse Stage IV Freiberg disease with articular collapse and loose body formation.
Stage V Freiberg disease with advanced degenerativ Stage V Freiberg disease with advanced degenerative changes involving metatarsal head and proximal phalanx.