What is Freiberg’s disease?
Freiberg’s disease is a rare condition characterised by infarction and fracture of the metatarsal head. The most common age of onset of symptoms is in the second decade of life. Patients usually present with pain localized to the affected metatarsophalangeal joint. Most often a history of injury to the foot is reported, but in some cases the pain may not be due to an obvious injury. Walking without shoes or in high heels often exacerbates symptoms as pressure on the metatarsal heads increases.
What are the symptoms of Freiberg’s disease?
The symptoms of Freiberg’s disease usually involve a single metatarsal and bilateral location is found in less than 10% of cases. The second metatarsal is most commonly affected, comprising about two-thirds of all cases, while the third metatarsal is involved in about 27%.
What does the clinical examination reveal?
Clinical examination of the affected metatarsophalangeal joint generally reveals fluid collection and swelling around the joint. This swelling is often visualised as a loss of the normal contour of the extensor tendons of the fingers. The metatarsophalangeal joint is sensitive to palpation and the range of motion is often reduced. Pain generally decreases rapidly as palpation is performed away from the joint. There may be palpable cramping with passive joint movement depending on the severity of the degenerative lesions. As the disease progresses, a deformity resembling a ganglion-like deformity may develop.
What is the diagnostic process for Freiberg’s disease?
Standard radiographic evaluation is deemed necessary and is performed with anterior, lateral and oblique radiography of the foot. In the early stages of the disease, usually within 3 to 6 weeks of the onset of symptoms, the joints and bony structures may appear normal except for mild enlargement of the medial joint space. As the disease progresses, there is flattening of the metatarsal head and increased density of the subchondral bone. Anteroposterior radiographs may not show noticeable lesions in the early stages of the disease, but flattening of the metatarsal head may be seen on oblique views. Over time, additional findings include free bodies in the joint, progressive narrowing of the interarticular space, and hardening of the metatarsal head. In milder or equivocal cases, MRI may be useful to confirm the diagnosis.
How is Freiberg’s disease treated?
The expert orthopaedic surgeon advocates that conservative management should be the first line of treatment regardless of the severity of the disease at the time of presentation. Strategies for conservative treatment include:
The use of oral anti-inflammatory drugs
Avoidance of high-energy activity (such as running and jumping)
Modification of shoes. The use of a hard-soled shoe may be helpful to relieve metatarsal strain when walking.
Alternatively, metatarsal unloading guards can be used to relieve pressure under the metatarsal heads. In acute presentations with more severe pain, immobilisation with a boot or splint for up to 6 weeks is indicated.
Surgical techniques are divided into:
Maintenance surgery; – Replacement surgery.
Although many studies describe good results with many techniques, there are currently no defined guidelines for treatment. In general, surgical clearance with metatarsal osteotomy is preferred for earlier stages of the disease and surgical clearance with arthroplasty for more advanced stages of the disease.
The orthopaedic surgeon, Dr. Antonios Pettas, was responsible for the foot and ankle surgeries at Norrtälje Hospital in Stockholm. He has many years of experience, with a high success rate of operations. Contact him for an early diagnosis and treatment.