Freiberg’s disease
or osteochondrosis of the metatarsal head
The disease of Freiberg is a benign condition that occurs more frequently in adolescents or young adults, more often in females. It involves avascular necrosis of the head of a metatarsal bone, most commonly the 2nd, less frequently the 3rd, and rarely the 4th toe.
It is a type of disorder affecting the growth of the articular cartilage at the head of the metatarsal bone, leading to a loss of roundness of the head which flattens and becomes “square.” This condition can progress to arthritis of the metatarsophalangeal (MTP) joint of the affected toe. It is equivalent to Koenig’s disease in the knee or Panner’s disease in the humeral condyle of the elbow.
Freiberg's disease:
Q & A
Palpation of the metatarsal head between the examiner’s thumb and index finger triggers pain. A general X-ray focused on the painful toe usually confirms the diagnosis.
MRI allows for a comprehensive study of the metatarsal head and the condition of the joint capsule, which often shows inflammation known as bursitis. In cases requiring surgical intervention, MRI helps plan the procedure and verify, often the case, that the entire head is not destroyed and that there is still a circular (and thus spherical towards the bottom of the head) portion remaining. This allows for excision of the affected part and/or (osteotomy) rotation of the head upwards.
CT scan (computed tomography densitometry study) assesses the joint’s condition, extent, and whether there is osteoarthritis of the MTP joint.
In the absence of pain: therapeutic abstention and monitoring.
Medical Treatment:
- NSAIDs, Painkillers, Sports rest, Proper footwear: i.e., comfortable,
- Otherwise, custom-made orthotic insoles: Orthopedic Insoles made to distribute pressure and unload the area around the diseased metatarsal head,
- In case of failure: Corticosteroid injections;
Surgical Treatment:
- Percutaneous approach: distal metatarsal metaphyseal osteotomy DMMO: when done in isolation on the diseased metatarsal, there is a risk of developing metatarsalgia transfer to neighboring lateral heads;
- Open surgery: Conservative and limited resection of the de-vascularized (=necrotic) part with rotational osteotomy, flipping upward of the head, this procedure is called Gauthier’s operation, resembling a Weil osteotomy;
- Prosthesis implant replacing the entire MTP joint if there is advanced osteoarthritis and the MTP joint is destroyed.
Generally, there are no signs in young individuals, and the condition often remains subclinical in adult patients. It may manifest during prolonged exertion (intense sports or dancing) as pain at the base of the toe. It progresses to difficulty walking and/or running. It can affect both feet.
There is a hereditary factor and intense sports, such as dancing.
Typically six weeks, including three weeks with offloading shoes, for healing, with a maximum of six to eight weeks before resuming sports, eight to twelve weeks afterward.
Freiberg disease : Terminology
Osteotomy: Cutting of bone to correct alignment, done with a surgical saw or by weakening the bone with perforations all around, like a postage stamp, allowing bone correction through manual tension. It is a type of therapeutic “fracture.”
DMMO: Distal metaphyseal metatarsal osteotomy: Distal and metaphyseal osteotomy on the metatarsal, often performed percutaneously to align metatarsal heads.
Koenig’s disease: Lesion of the femoral condyle.
Needle aponeurotomy: Mini-invasive technique using the bevel of a needle to sever the plantar fascia.
Dupuytren’s disease: Nodule and cords causing flexion of the 4th and/or 5th fingers towards the palm of the hand.
Peyronie’s disease: Fibrotic retraction of the cavernous bodies of the penis.
