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Osteonecrosis of the lesser metatarsal heads

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

  • Freiberg's infraction is a condition of cartilage degeneration (osteonecrosis) of the lesser metatarsal heads -
    • first described in 1914 by Alfred H. Freiberg
    • adolescent females are the "textbook" patients - however both males and females may present with this condition later in life
    • second and third metatarsals are the most commonly affected, while involvement of the fourth and fifth is rare
      • more common in patients whose first metatarsal is shorter than the second metatarsal, which increases the weight on the second metatarsal head
    • incidence is higher in females than in males

  • pathophysiology is unknown, but studies suggest a combination of vascular compromise, genetic predisposition, and altered biomechanics

  • diagnosis is made clinically and imaging is used to confirm
    • clinical presentation
      • forefoot pain - generally affecting head of the second metatarsal
      • there is irritation of the joint
      • generally associated with physical activity
      • the head of the metatarsal is palpable and tender
      • may be localised swelling and stiffness in the metatarsophalangeal joint
      • patient may have an antalgic gait
      • conditions in the differential include stress fracture, synovitis, Morton's neuroma and osteosarcoma
    • early in the process, radiographs are normal however bone scans may demonstrate a photopenic center with a hyperactive collar
      • as Freiberg's infraction progresses, radiographs show a flattened and fragmented metatarsal head
    • magnetic resonance imaging can reveal hypointensity of the metatarsal head

  • management
    • nonoperative treatment is based on decreasing foot pressure and unloading the affected metatarsal. Spontaneous healing with remodeling may occur in early stages of the disease
    • operative options are dorsal closing wedge osteotomies, osteochondral transplant, and resection arthroplasty

  • outcomes of nonoperative and operative management are good to excellent and most patients are able to return to previous activity (1)


  • Talusan PG et al. Freiberg's infraction: diagnosis and treatment. Foot Ankle Spec. 2014 Feb;7(1):52-6.
  • Freiberg AH; Infraction of the second metatarsal bone, a typical injury, Surg Gyn Ob, 1914, 19:191.

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