Alfred H Freiberg, in 1914 first described the painful condition of the foot due to partial collapse of the joint surface of the second metatarsal head.[1] He believed that trauma caused the condition, hence used the term infarction. He thought that the excessive length of the 2nd ray in combination with the insufficient first ray complex results into an overload of the 2nd ray and subsequently articular collapse of the 2nd joint surface.

Alfred H Freiberg, in 1914 first described the painful condition of the foot due to partial collapse of the joint surface of the second metatarsal head.[1] He believed that trauma caused the condition, hence used the term infarction. He thought that the excessive length of the 2nd ray in combination with the insufficient first ray complex results into an overload of the 2nd ray and subsequently articular collapse of the 2nd joint surface.[1] Since then various theories are postulated but still today the exact cause and appropriate management of the condition is controversial.

We had a middle-aged lady, teacher by profession, reported in our OPD with complains of vague foot pain. The pain was insidious in onset and dull aching in nature, gradually increasing in intensity, not associated with any history of trauma, aggravated with activity and partially relieved with rest.

Pain was localized to the dorsal surface of the left foot near the 2nd toe base and 2nd meta tarso phalangeal (MTP) joint. There were no local signs of inflammation. There was localized tenderness at the 2nd MTP joint. The range of motion of the 2nd MTP joint was reduced compared to the right  foot.

There was no associated systemic disease like diabetes, hypertension, thyroid disorder etc. No other joint was involved.

We examined the patient with x rays of both the foot, which revealed sclerosis of the left 2nd metatarsal head with flattening of the articular surface of the 2nd metatarsal.

MRI was done to confirm our diagnoses which showed sclerosis of the 2nd metatarsal head with incongruity of the 2nd metatarsal joint surface with sub chondral collapse (Freiberg disease stage 2)

We discussed the disease with the patient explaining the various management options. As she was a teacher by profession so we decided to give her a shoe modification with metatarsal bars, along with non-steroidal anti-inflammatory drugs to give her relief from pain.

We are having a follow up for 1 year and the patient is pain free and pursuing her profession actively.

Flattened sclerotic 2nd metatarsal head

Footwear modification using a soft rubber metatarsal bar to relieve pressure from metatarsal head by local cobbler shop

Etiology

Although Freiberg himself favored a traumatic etiology for the condition, he admitted that trauma cannot always explain the causation with certainty.[2] In adolescents the disease is thought to belong to a group of diseases involving the growth disturbances of the epiphysis or the apophysis, i.e., osteochondrosis. [3] The adult-onset form of the disease however is different from the juvenile form although they behave almost similarly radiologically. Unlike other osteochondrosis it is not associated with smoking, steroid use or alcoholism. Most authors today believe that Freiberg disease is probably multifactorial in origin where the initial insult is traumatic or vascular. [3] Infection is almost certainly ruled out to be an etiological factor. [4] 

Epidemiology

Freiberg disease is an uncommon medical condition. The male to female ratio is 1:5. Again, this female preponderance is very uncommon in other osteochondrosis where males are more affected.[5] In almost 95