Freiberg’s infraction is a condition where the rounded end (head) of a metatarsal bone in the foot loses its blood supply, causing the bone to gradually weaken, flatten, and collapse. The second metatarsal, the long bone behind your second toe, is the one most commonly affected. The term “infraction” refers to an incomplete fracture, and the condition is also called Freiberg disease.
What Happens Inside the Bone
The underlying problem is avascular necrosis, which means bone tissue dies because blood flow to the area is cut off. In Freiberg’s infraction, repeated microtrauma near the growth plate and the area just below the joint surface disrupts the tiny blood vessels feeding the metatarsal head. Without a steady blood supply, the bone can no longer repair itself or maintain its structure.
Over time, the metatarsal head starts to flatten. Healthy bone is gradually absorbed, and the cartilage covering the joint surface begins to sink inward. If the process continues unchecked, the joint surface collapses further, loose fragments of bone and cartilage can break off, and the joint develops arthritis. The condition progresses through five recognized stages, from a small stress fracture in otherwise normal-looking bone all the way to permanent joint deformity with degenerative changes.
Who Gets It and Why
Freiberg’s infraction most often appears in adolescents and young adults, particularly during periods of rapid growth when the growth plates are still open and vulnerable to repetitive stress. It occurs more frequently in females. Activities that put repeated force on the ball of the foot, such as running, jumping, or dancing, increase the risk. A second metatarsal that is longer than the first can also be a contributing factor, since it absorbs more impact during walking and push-off.
Symptoms to Recognize
The hallmark symptom is pain in the ball of the foot, centered around the base of the second toe. The pain typically worsens with weight-bearing activities, especially walking, running, or pushing off the ground. You may notice swelling and tenderness directly over the affected metatarsal head. Pressing on the area or bending the toe up and down often reproduces the pain. As the condition progresses, the toe joint can become stiff, and you may find yourself shifting your weight to the outer edge of your foot to avoid the discomfort.
In earlier stages, symptoms can be mild and intermittent, making it easy to dismiss as a bruise or general soreness in the forefoot. This is one reason the condition sometimes goes undiagnosed until significant damage has already occurred.
How It’s Diagnosed
X-rays are the first step and can show characteristic changes in the metatarsal head: increased bone density (sclerosis), flattening of the normally rounded joint surface, and in later stages, visible collapse or loose bone fragments. However, in the earliest stages, X-rays may look completely normal.
MRI is far more useful for catching Freiberg’s infraction early. It can detect bone marrow swelling, joint fluid, and subtle fracture lines before any structural changes show up on a standard X-ray. If your symptoms point toward this condition but X-rays appear unremarkable, an MRI can confirm what’s happening beneath the surface.
The Five Stages of Progression
The Smillie classification system describes how the condition advances:
- Stage 1: A small stress fracture appears in the bone just beneath the joint surface. The bone looks denser than normal on imaging because blood flow has been disrupted, but the overall shape of the metatarsal head is still intact.
- Stage 2: Bone begins to be absorbed, and the central part of the cartilage surface starts to sink. The edges of the joint and the underside of the metatarsal head remain undamaged, but the contour of the joint surface is changing.
- Stage 3: The central collapse deepens, creating bony projections on either side of the sunken area. The cartilage on the underside of the metatarsal head is still intact at this point.
- Stage 4: The collapse worsens enough that the remaining intact cartilage gives way. The bony projections on the edges fracture and fold inward. At this stage, restoring the original anatomy is no longer possible.
- Stage 5: The metatarsal head is permanently flattened and deformed, with degenerative arthritis in the joint. The bone shaft becomes thickened and dense. Only the very bottom of the metatarsal head retains any resemblance to its original shape.
Catching the condition in stages 1 through 3 gives the best chance of preserving joint function. By stage 4 or 5, treatment becomes more about managing symptoms and restoring as much mobility as possible.
Non-Surgical Treatment
For early-stage Freiberg’s infraction, conservative treatment is the first line of approach and is often effective. The primary goals are reducing pressure on the affected metatarsal head and giving the bone a chance to heal.
Activity modification is essential. This means cutting back on high-impact activities like running or jumping that drive force through the ball of the foot. Stiff-soled shoes or rocker-bottom shoes can limit how much the toe joint bends during walking, reducing stress on the damaged area. Custom orthotics with a metatarsal pad or a cutout beneath the affected metatarsal head can offload pressure. In some cases, a short period of immobilization in a walking boot or cast helps calm acute symptoms.
Anti-inflammatory medications and ice can help manage pain and swelling during flare-ups. Many people with early-stage disease find that a combination of footwear changes, orthotics, and activity adjustments is enough to control symptoms long-term.
When Surgery Is Needed
Surgery becomes an option when conservative measures fail or the condition has progressed to a stage where the joint surface is significantly damaged. Several surgical approaches exist, and the choice depends on how far the disease has advanced.
One of the most commonly used procedures is a dorsal closing wedge osteotomy. The surgeon removes a small wedge of bone from the top of the metatarsal neck and rotates the head so that healthier cartilage from the underside of the bone is repositioned into the weight-bearing surface of the joint. This essentially brings undamaged cartilage into play where the worn cartilage used to be. The wedge is typically angled at about 15 degrees, though this can be adjusted depending on how much rotation is needed. The bone is held in place with a small pin while it heals.
Other surgical options include joint debridement (cleaning out damaged cartilage and loose fragments), bone grafting, shortening the metatarsal to reduce pressure, and in advanced cases, replacing the joint surface or removing part of the metatarsal head entirely. A cartilage transplant technique has also been used in younger, active patients, with some returning to sports within three months.
Recovery and Long-Term Outlook
Outcomes after treatment are generally positive, especially when the condition is caught before the joint surface fully collapses. After joint debridement surgery, patients in published case series regained about 80% of their normal range of motion. Following osteotomy, 14 out of 15 feet in one study achieved pain relief within 12 months. Patients who underwent joint debridement through a small camera (arthroscopically) were symptom-free at two years in multiple reported cases.
Long-term follow-up data after interposition arthroplasty, where tissue is placed between the joint surfaces to act as a cushion, has shown improvements in both pain scores and range of motion that held up over an average of more than 11 years.
The main long-term concern is osteoarthritis in the affected joint, which becomes more likely the further the disease has progressed before treatment. Stage 5 disease involves permanent degenerative changes by definition. Even with successful surgery, some degree of joint stiffness or mild discomfort during high-impact activities can persist. Wearing supportive footwear and using orthotics after treatment can help protect the joint over time.