Freiberg's Disease: Symptoms, Diagnosis, and Functional Impact

What does Freiberg's disease look like?

Freiberg's disease, also known as Freiberg's infraction or osteochondrosis of the metatarsal head, primarily presents as pain and stiffness in the forefoot, often accompanied by swelling and tenderness over the affected metatarsophalangeal joint, with diagnostic imaging revealing characteristic changes to the metatarsal head.

Understanding Freiberg's Disease: A Brief Overview

Freiberg's disease is a condition characterized by osteonecrosis (death of bone tissue due to lack of blood supply) of the metatarsal head, most commonly affecting the second metatarsal, though the third or fourth can also be involved. While its exact cause is debated, it is often linked to repetitive microtrauma, vascular compromise, and mechanical overload, leading to a collapse of the metatarsal head and subsequent degenerative changes in the joint. Understanding its nature helps to interpret its various clinical and radiological manifestations.

The Clinical Presentation: What You Feel (Subjective Symptoms)

The "look" of Freiberg's disease from a patient's perspective primarily involves their experience of symptoms. These often develop gradually and worsen over time.

• Forefoot Pain: This is the hallmark symptom.
  • Location: Typically localized to the ball of the foot, specifically under the base of the affected toe (most often the second toe).
  • Character: Described as an aching, throbbing, or sharp pain.
  • Aggravating Factors: The pain is usually exacerbated by weight-bearing activities, walking, running, jumping, and wearing high-heeled or tight shoes. Rest tends to relieve it.
  • Progression: Initially intermittent, the pain can become constant as the condition advances.
• Stiffness: A feeling of stiffness or limited movement in the affected toe joint, especially after periods of rest.
• Swelling: Noticeable swelling around the metatarsophalangeal (MTP) joint of the affected toe.
• Tenderness: The area directly over the metatarsal head feels tender to the touch.
• Difficulty Walking: Patients may develop an antalgic (pain-avoiding) gait, limping or shifting weight to the outer edge of the foot to reduce pressure on the painful area.
• Discomfort with Footwear: Shoes that put pressure on the forefoot can significantly worsen symptoms.

The Physical Examination: What a Professional Observes (Objective Signs)

During a physical examination, a healthcare professional will look for specific objective signs that "reveal" Freiberg's disease:

• Visual Inspection:
  • Swelling: Visible localized swelling over the dorsum (top) of the affected MTP joint.
  • Redness: While less common, some mild redness or warmth might be present due to inflammation.
  • Callus Formation: A callus may develop under the affected metatarsal head as the body attempts to protect the painful area from pressure.
  • Altered Gait: Observation of an antalgic gait during ambulation.
• Palpation:
  • Localized Tenderness: Exquisite tenderness directly over the involved metatarsal head when pressed.
• Range of Motion Assessment:
  • Restricted Motion: Painful and limited range of motion at the MTP joint, particularly during dorsiflexion (lifting the toe upwards). Plantarflexion (pointing the toe downwards) may be less affected.
  • Crepitus: A grinding or crackling sensation may be felt or heard during joint movement, indicating cartilage damage.
• Deformity: In advanced stages, the affected toe may appear slightly shorter or deviated due to the collapse of the metatarsal head.

Diagnostic Imaging: What X-rays and Other Scans Reveal

The definitive "look" of Freiberg's disease is often confirmed through imaging studies, which show the structural changes within the bone and joint.

• Plain Radiographs (X-rays): These are usually the first line of imaging.
  • Early Stages: X-rays may appear normal or show only subtle changes like slight flattening or widening of the metatarsal head.
  • Progressive Stages: As the disease advances, characteristic changes become evident:
    • Flattening of the Metatarsal Head: The normal rounded contour of the metatarsal head becomes flattened or depressed.
    • Sclerosis: Increased bone density (whiteness on X-ray) within the metatarsal head due to attempted bone repair.
    • Joint Space Narrowing: Reduction in the space between the metatarsal head and the proximal phalanx, indicating cartilage loss.
    • Subchondral Cysts: Small, dark, fluid-filled areas visible beneath the joint surface.
    • Osteophytes (Bone Spurs): New bone formations around the joint margins as a result of degenerative changes.
    • Loose Bodies: Fragments of bone or cartilage may break off and become visible within the joint capsule.
    • "Mushrooming" or Widening: The affected metatarsal head may appear wider than normal.
• Magnetic Resonance Imaging (MRI): More sensitive than X-rays, especially in early stages.
  • Early Changes: Can detect bone marrow edema (swelling), avascular necrosis, and cartilage damage before they are visible on X-rays.
  • Soft Tissue Involvement: Provides detailed views of surrounding soft tissues, ligaments, and tendons, helping to rule out other conditions.
• Bone Scans: May show increased metabolic activity in the affected area, indicating bone remodeling or inflammation.

Functional Impact: How it Affects Movement

The physical and radiological changes of Freiberg's disease directly translate into functional limitations, impacting a person's daily activities and participation in physical endeavors.

• Impaired Ambulation: Difficulty walking, especially on uneven surfaces or for prolonged periods.
• Activity Restriction: Pain prevents participation in high-impact activities like running, jumping, and certain sports.
• Footwear Limitations: Inability to wear certain types of shoes, particularly those with a narrow toe box or high heels, due to increased pressure on the forefoot.
• Gait Deviations: Compensatory movements to offload the painful area, which can lead to secondary issues in the ankle, knee, or hip over time.

When to Seek Professional Help

If you experience persistent forefoot pain, swelling, or stiffness that interferes with your daily activities, it is crucial to consult a healthcare professional, such as an orthopedic surgeon or podiatrist. Early diagnosis and intervention can help manage symptoms, slow the progression of the disease, and prevent further joint degeneration.