Freiberg's Disease

Lower Limb

Overview

Freiberg's disease is an osteochondrosis affecting the metatarsal head, most commonly the second metatarsal, characterized by avascular necrosis and fragmentation of the epiphysis. It typically presents in adolescents and young adults with insidious onset of forefoot pain and swelling. The condition results from disrupted blood supply to the metatarsal epiphysis, leading to bone necrosis, collapse, and subsequent degenerative changes.

Pathophysiology

Freiberg's disease involves avascular necrosis (osteochondrosis) of the metatarsal head epiphysis, most frequently affecting the second metatarsal. The exact etiology remains unclear but proposed mechanisms include trauma (stress fracture or acute injury), repetitive microtrauma, and vascular compromise. The condition progresses through stages: initial necrosis, fragmentation and collapse of the epiphysis, and eventual healing with potential residual deformity. Repeated loading on the affected metatarsal head during the healing phase can perpetuate symptoms and accelerate degenerative joint disease.

Patient Education

Freiberg's disease is a self-limiting condition in most cases, but early activity modification, appropriate footwear, and weight management can significantly reduce symptom duration and prevent long-term complications such as arthritis.

Typical Presentation

Site

Forefoot, most commonly over the second metatarsal head; pain is typically plantar and dorsal to the affected metatarsal head

Quality

Dull, aching pain with occasional sharp pain on weight-bearing; described as throbbing or pressure-like

Intensity

Mild to moderate pain (3-6/10) that increases with activity; may be worse after prolonged standing or high-impact activities

Aggravating

Weight-bearing activities, running, jumping, prolonged standing, walking on hard surfaces, tight or ill-fitting shoes, pressure directly over the metatarsal head

Relieving

Rest, elevation, ice application, reduced weight-bearing, soft shoe inserts or metatarsal pads, anti-inflammatory medication

Associated

Swelling over the metatarsal head, limp or antalgic gait, limited dorsiflexion of the affected metatarsal joint, tender metatarsal head on palpation, possible callus formation, stiffness after periods of rest

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

No accuracy study

Metatarsophalangeal (MTP) Joint Range of Motion Assessment

Procedure

Move the second MTP joint (occasionally the third) passively into flexion and extension and compare with the neighbouring toes and the other foot.

Positive Finding

Reduced, painful movement of the second MTP joint, often with swelling.

Interpretation

Painful stiffness of one lesser MTP joint, typically the second, in an adolescent or young adult (more often female) supports Freiberg's disease. X-rays confirm it; early changes may only show on MRI.

Sources

No accuracy study

Resisted Toe Flexion (Second MTP)

Procedure

Ask the patient to curl the second toe down against your finger.

Positive Finding

Pain at the second MTP joint.

Interpretation

Loads the painful joint and supports a local joint source. It does not separate Freiberg's disease from synovitis or a plantar plate injury.

Sources

No accuracy study

Passive MTP Joint Compression and Distraction Test

Procedure

Hold the second toe and push it gently into the joint (compression), then pull it gently away (distraction).

Positive Finding

Pain with compression that eases with distraction.

Interpretation

Suggests a joint surface problem such as Freiberg's disease or early arthritis. Not a validated test.

Further reading

No accuracy study

Second MTP Dorsiflexion Stress

Procedure

Passively extend (dorsiflex) the second MTP joint to end of range.

Positive Finding

Pain at the second MTP joint at end of range.

Interpretation

Suggests a second MTP joint source. Turf toe is an injury of the big toe joint and does not apply here.

Further reading

Not a diagnostic test

Single-Leg Stance and Gait Analysis (Functional Assessment)

Procedure

Watch the patient walk and rise onto the toes on the affected leg.

Positive Finding

Pain at push-off, or the patient avoids loading the forefoot.

Interpretation

Shows how much the condition limits function and guides offloading (stiff-soled shoes, metatarsal pad). Not a diagnostic test.

Further reading

No accuracy study

Palpation of Second Metatarsal Head and MTP Joint Line

Procedure

Palpate the second metatarsal head from above and below, and around the joint line.

Positive Finding

Tenderness and swelling around the second MTP joint.

Interpretation

Localised tenderness and swelling of the joint supports Freiberg's disease or synovitis. Tenderness between the heads suggests a neuroma instead; tenderness on the shaft suggests a stress fracture.

Sources

⚠ Red Flags

  • •Severe acute pain with trauma or sudden onset suggesting acute fracture
  • •Signs of compartment syndrome (severe swelling, pain out of proportion, neurovascular compromise)
  • •Fever, systemic illness, or signs of infection in affected area
  • •History of malignancy or immunosuppression with unexplained bone pain
  • •Bilateral metatarsal involvement without clear biomechanical explanation
  • •Progressive neurological symptoms in the foot

⚡ Yellow Flags

  • •High pain catastrophization or fear-avoidance behaviors limiting activity excessively
  • •Prolonged symptoms without appropriate medical investigation or imaging
  • •Social or sport-related pressure to return to activity too quickly
  • •Poor adherence to activity modification despite pain
  • •Disproportionate emotional response to diagnosis
  • •Multiple previous injuries with current overprotection

Osteopathic Techniques

Non-operative care comes first at every stage: activity modification, protected weight-bearing (stiff-soled shoe, boot or cast), footwear changes and orthoses with a metatarsal bar to offload the painful metatarsal head. Most patients in Smillie stages 1–3 do well long term; surgery is mainly for stages 4–5. No trials of osteopathic techniques were found.

Safety: Freiberg disease is an infraction of a metatarsal head, so it needs imaging and early offloading to let it heal and limit progression to arthritis. Keep techniques to the midfoot, ankle and calf rather than the affected joint, and refer for a surgical opinion if conservative care fails.

Region

Midfoot and ankle (not the affected MTP joint)

Technique

Articulation, ankle and footNo trials found

Rationale

Gentle glides of the toe, midfoot and ankle joints to restore foot mobility.

How it's done, cautions & evidence

How it's done

Passive, rhythmic, low-velocity glides of the ankle (talocrural), subtalar, midfoot and toe joints, within or up to the end of the available range, often aimed at restoring ankle dorsiflexion.

Cautions

Before mobilising an acute ankle injury, check for fracture with the Ottawa ankle rules (tenderness over either malleolus), and palpate the base of the 5th metatarsal, the navicular and the midfoot for a Lisfranc injury.

Evidence in Freiberg's Disease

Searched 25 Oct 2026: no trials of foot or ankle mobilisation in Freiberg disease.

Region

Plantar foot

Technique

Soft tissue, foot and ankleNo trials found

Rationale

Soft tissue to the plantar fascia, foot muscles and the tissues around the toe joints and ankle ligaments.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the plantar fascia, the small muscles of the foot and the tissues around the heel and the ankle ligaments.

Evidence in Freiberg's Disease

Searched 25 Oct 2026: no trials of plantar foot soft tissue in Freiberg disease.

Sources

Region

Gastrocnemius-soleus (calf)

Technique

Muscle energy, calf (gastrocnemius and soleus)No trials found

Rationale

Calf muscle energy technique to ease gastrocnemius-soleus tightness that limits ankle dorsiflexion.

How it's done, cautions & evidence

How it's done

The calf is taken to its barrier by dorsiflexing the ankle. The patient pushes the foot gently down, at about 10–20% effort, against resistance for 5–10 seconds, relaxes for 3–5 seconds, and the new barrier is taken up.

Cautions

Not used with an acute fracture, a joint infection or a bone malignancy; take care with severe osteoporosis or after surgery that limits muscle contraction. Use the least force needed: too much can tear a muscle or pull off a tendon, especially in older patients.

Evidence in Freiberg's Disease

Searched 25 Oct 2026: no trials of calf muscle energy technique in Freiberg disease.

Region

First ray and midfoot tender points

Technique

Counterstrain, foot and ankle tender pointsNo trials found

Rationale

Gentle indirect technique: tender points in the foot and ankle are eased by passive positioning.

How it's done, cautions & evidence

How it's done

Find a tender point in the foot, ankle or calf. Passively move the foot and ankle into the position where the tenderness and tissue tension ease most, and hold it for about 90 seconds while monitoring the point. Return slowly to neutral and re-check.

Cautions

Do not use over an acute fracture, or in a patient who cannot give feedback.

Evidence in Freiberg's Disease

Searched 25 Oct 2026: no trials of counterstrain in Freiberg disease.

Rehabilitation Exercises

Metatarsophalangeal Joint Mobilization with Towel

Range of MotionBeginner

Gastrocnemius and Soleus Stretch (Standing or Seated)

StretchingBeginner

Plantar Fascia Stretch (Manual or Tennis Ball)

StretchingBeginner

Intrinsic Foot Muscle Strengthening (Short Foot Exercise)

StrengtheningBeginner

Toe Flexion Resistance Band Exercise

StrengtheningIntermediate

Calf Raises (Modified or Double Leg)

StrengtheningIntermediate

Single Leg Stance (Weight on Unaffected Leg)

BalanceIntermediate

Gait Training with Metatarsal Pad Offloading

PosturalBeginner

Ankle Circles and Alphabet Tracing with Foot

Range of MotionBeginner

Hip Abduction Strengthening (Standing or Side Lying)

StrengtheningIntermediate

Swimming or Pool Walking (Non-Weight Bearing)

CardiovascularIntermediate

Proprioceptive Training on Foam Pad (Advanced Stage)

PosturalAdvanced

Referral Criteria

  • •Severe pain unresponsive to conservative management after 3-6 months
  • •Imaging evidence of significant metatarsal head collapse requiring surgical evaluation
  • •Progressive neurological symptoms or vascular compromise
  • •Persistent functional limitation affecting ability to walk or bear weight
  • •Concern for alternative diagnosis requiring specialist imaging or investigation
  • •Failed conservative management with consideration for orthopedic surgical intervention (arthroscopy, osteotomy, or arthroplasty)
  • •Symptoms suggesting infection, compartment syndrome, or other acute complications