What is Freiberg Infraction?
Freiberg disease is a rare medical condition that affects the head of the metatarsal bones in your foot. Metatarsals are long bones in the feet, and their “head” is the rounded end part of these bones. In Freiberg’s disease, this part of the bone can lose its blood supply and die, a process known as osteonecrosis.
The disease was named after Dr. Alfred Freiberg, who first described this situation in 1914, when he noticed that six patients all had the same type of damage to the second metatarsal bone in their foot. However, this problem can potentially happen to any of the five metatarsal bones.
A significant result of Freiberg disease is that the affected bone can become flat and start to collapse, which can lead to additional damage in the joint between the metatarsal and the toes. This damage can then develop into arthritis. Despite how unique it may seem, this condition, which causes the second metatarsal bone to lose its blood supply, is the fourth most common type of osteochondrosis, a family of disorders that affect bones and joints.
What Causes Freiberg Infraction?
Freiberg disease is a condition that affects the bones in the balls of the feet (known as the metatarsal heads). It falls under a group of disorders called osteochondroses, which occur when an injury to the end part of a long bone (epiphysis) changes the process of bone growth. This then results in an uneven joint surface.
The exact cause of Freiberg’s disease is still unclear, but some notable possibilities include repeated minor injuries (microtrauma), disrupted blood supply (vascular compromise), or certain systemic disorders, which are diseases affecting multiple parts of the body. Systemic conditions that may be linked with Freiberg disease are diabetes, systemic lupus erythematosus (an autoimmune disease), and hypercoagulability (a condition making you prone to blood clots). There’s also a chance that genetics could play a part, as this condition has been documented in identical twins.
In a notable study, Freiberg disease was reported as the first medical symptom in an 18-year-old woman diagnosed with Sneddon syndrome. Sneddon syndrome is a rare disease involving blood vessels, characterized by purplish, net-like skin discoloration (livedo racemosa) and frequent stroke-like events.
Risk Factors and Frequency for Freiberg Infraction
Freiberg disease is a condition that affects the bones and is more commonly found in females, with a 5:1 female-to-male ratio. It often impacts the dominant foot about 36% of the time. Only a small percentage (less than 10%) of cases involve both feet. The disease mostly targets the second, third, and fourth metatarsals (bones in the foot), with the second being affected 68% of the time, the third 27% of the time, and the fourth in about 3% of cases. It’s very rare for the fifth metatarsal to be affected.
The typical age at which Freiberg disease gets diagnosed is between 11 and 17 years. However, it can also affect women in their 70s.
Signs and Symptoms of Freiberg Infraction
People with Freiberg disease often feel pain and swelling in the front region of their foot, specifically around the head of the metatarsal bone – the long bones in the foot. It can feel like walking on a hard object, like a stone. The onset of these symptoms is usually gradual rather than sudden, and they tend to worsen when the person walks, especially if they are barefoot or wearing high-heeled shoes. Interestingly, taking steroids for a short period after foot injury can lead to an unusual presentation of this condition.
During a physical exam, the affected toe may look swollen, especially near the joint connecting the toe to the rest of the foot. The patient might have the affected toe raised slightly, and complex malalignments in the toe’s alignment, such as hammertoes or crossover deformities, could develop in long-term or advanced cases. The movement range at the toe joint is usually reduced and, when touched, a grinding noise or feel (crepitation) might be detected. Hard and thickened skin (callus) may also develop on the underside of the foot in reaction to the continuous pressure. A special test known as the “Digital Lachman testing” might be undertaken to check for joint instability, with abnormal results if the joint pops out of position and causes the same pain the patient has been feeling.
Testing for Freiberg Infraction
Freiberg disease, a condition that affects the foot, can be diagnosed through a clinical exam and through the use of x-rays. These x-rays, which are taken while the patient is bearing weight on their feet, can reveal changes that may occur early on in the disease. For instance, the area between the joints may appear larger due to a buildup of fluid. This early sign of the disease can sometimes be seen 3 to 6 weeks after the onset of symptoms.
As the condition worsens, you might see an increase in bone density in the region right below the cartilage and a flattening of the head of the metatarsal bone (bone in the foot). Oblique radiographs (x-rays taken at an angle) can be specifically helpful in evaluating the top portion of the metatarsal head. This helps to identify a flattened metatarsal head even in tricky cases. As the disease progresses further, other findings may include a central depression in the joint, loose bodies within the joint, and hardening of the metatarsal head. Eventually, you might also see a thickening of the shaft of the metatarsal bone, which is the body’s late response to the abnormal stress. The final stages include the narrowing of the space between the joints and the onset of an arthritic condition called arthrosis.
Apart from x-rays, an MRI can also be useful in diagnosing Freiberg disease, especially if the x-rays don’t show any abnormalities. An MRI can detect changes in the bone marrows and show signs similar to those seen in osteonecrosis (a condition caused by reduced blood supply to the bones). For example, you might notice a lower signal on T1-weighted images or a mix of lower and higher signals on T2-weighted images, along with a flattening of the affected metatarsal head.
Another tool doctors might use is a nuclear medicine bone scan. This exam can be especially useful in early stages of the disease or when x-rays don’t show changes. Early on, the scan might show an area of decreased activity surrounded by increased radiotracer uptake – a pattern typically seen in early cases of a condition called avascular necrosis (where the bone tissue starts to die due to a lack of blood supply). In later stages of Freiberg’s disease, the scans may show widespread increased activity due to new blood vessel formation, bone repair, and the onset of arthritic involvement of the metatarsophalangeal joint (joint at the base of the toe).
Treatment Options for Freiberg Infraction
If a patient is diagnosed with a condition known as Freiberg disease, the first step in managing the disease doesn’t involve surgery. Instead, doctors try to relieve symptoms and minimize changes to the affected bones in order to reduce the risk of arthritis (painful inflammation and stiffness of the joints). Regardless of how severe the disease is, this initial approach is most commonly preferred.
In this early phase of treatment, doctors advise patients to adjust their activities and limit pressure on the affected foot. They may recommend wearing a stiff-soled shoe, a protective boot, or a cast. It’s possible patients may benefit from changes in their footwear, such as insoles that redistribute pressure away from the painful areas of the foot. These modifications to shoe wear have been shown to help patients recover without long-term problems. Also, oral anti-inflammatory medications (pills that reduce swelling and pain) may be used.
A new treatment that’s showing promise involves the use of a drug class called bisphosphonates. A specific regimen consisting of an initial injection of a drug called zoledronic acid, followed by a year of weekly doses of another drug called alendronate, has been found to eliminate symptoms and slow down the progression of the disease in its early stages.
Most patients with mild to moderate stages of Freiberg disease respond well to these non-surgical treatments and can enjoy successful outcomes in the long term. However, when these conservative measures are not successful, particularly in more progressed stages of the disease, a variety of surgical procedures can be considered.
There’s no consensus among surgeons about which surgical procedure should be primarily performed. Some focus on altering the conditions leading to the disease and some aim to restore the normal shape and function of the joint. Depending on the specifics of the disease, doctors might consider processes that remove dead tissue, correct abnormalities, or replace damaged parts of the joints.
The Gauthier osteotomy is a commonly performed procedure that spares the joint. During this surgery, the damaged cartilage is removed, and the remaining healthy cartilage is repositioned. This procedure has been found to have high patient satisfaction rates and no complications with long-term follow-ups.
For advanced cases of the disease, a more complex surgery might be required, which could lead to significant shortening of the affected bone due to removal of dead tissue. One popular tactic is an interpositional arthroplasty. Here, tissue from the patient (or sometimes from a donor) is used to make up for the bone and tissue that’s been removed. This technique reduces the need for artificial implants and helps keep the toe its original length. It has a high success rate, with up to 90% of patients experiencing improvement.
What else can Freiberg Infraction be?
When diagnosing patients with certain symptoms, doctors consider various possibilities, such as:
- Stress fracture
- Neuroma
- Plantar plate tear
- Inflammatory arthritis like rheumatoid arthritis or gout
X-ray images help doctors rule out certain conditions. If there’s a classic sign of flat metatarsal bones on the x-ray, this confirms the doctor’s suspicion.
What to expect with Freiberg Infraction
Patients with Smillie stages 1 to 3, which is a system to classify the severity of certain conditions, usually find that conservative treatment methods work well for them in the long-term. Conservative treatment refers to non-invasive therapies, such as medications or physical therapy. However, patients with more advanced stages usually undergo surgery, aiming to restore the alignment and smooth function of their joints and to prevent the condition from developing into arthritis.
Possible Complications When Diagnosed with Freiberg Infraction
Some issues that may arise include the development of severe arthritis, causing pain and restricting movement.
Possible Complications:
- Advancement to severe arthritis
- Associated pain
- Limited range of motion
Recovery from Freiberg Infraction
After undergoing surgery, recovery methods tend to differ based on the specific type of surgery a patient has. For example, patients who have a specific type of joint surgery known as the Gauthier dorsiflexion wedge osteotomy, are generally permitted to put some weight on their heel or are given a special shoe to offload the weight from the forefoot for about 3 weeks after the surgery. However, after certain types of surgeries that are more destructive to the joint, patients might have to avoid bearing weight for a short while.
Once patients are able to fully bear weight again, physical therapy typically becomes a part of their recovery. A rehabilitation program that includes exercises to recover the movement in the metatarsal phalangeal joint (this is the joint at the base of the big toe) and training to re-learn walking patterns is recommended.
Preventing Freiberg Infraction
Freiberg disease is an uncommon condition that affects the bones in the part of your foot between the arch and the toes, known as metatarsal bones. This condition usually affects teenage girls who are growing. While the cause of Freiberg disease isn’t completely understood, it might be due to repeated minor injuries to the foot (microtrauma), difficulty with blood flow to the area (vascular compromise), or possibly due to other health conditions (systemic disorders).
People with this condition usually start by noticing swelling and discomfort in the area of their foot where the metatarsal bones are. They might also feel like they’re walking on something hard, such as a stone. Walking barefoot can be especially painful. These symptoms don’t usually start suddenly, but rather gradually, without a specific incident causing them.
If you notice these symptoms, it’s important to seek medical help. A doctor can discern if it’s Freiberg disease by looking at your medical history, performing a physical examination, and possibly ordering imaging studies of your foot.
Treatment for Freiberg disease depends on how advanced the condition is. If caught early, footwear adjustments and nonsteroidal anti-inflammatory drugs (NSAIDs), which are a type of medicine that help with pain and swelling, could be enough to manage the condition. However, if the condition is more advanced, surgery might be necessary.