Freiberg’s Disease: A Unique Case Study of Forefoot Pain

Freiberg’s disease, also known as Freiberg infarction, was first described in 1914. It is a rare condition that primarily affects the second or third long bones of the foot (metatarsals).^1,2 The disease mishappens the head of the metatarsals causing it to lose its smooth contour. It is said to be caused by the loss of blood supply to the bones around puberty.³ This may be a result of constant strain on the bone, leading to damage at the end of the bone in the areas where the bone grows. This, therefore, leads to an abnormal growth shape of the bone which can become square at the end. 

Multiple cases of the disease are symptomatic, or some may resolve on their own without treatment. This affects estimating the prevalence of the disease and makes it more challenging. Hence, the lack of a quantitative estimate of Freiberg’s disease in the current literature.⁴ Furthermore, this explains why it is a rare phenomenon.⁴ 

In addition, the disease is more common in women than men and affects teens or individuals in their early adulthood. However, it can develop at any age and with any sex.⁴ In addition, the frequent occurrence of the disease in females was said to be due to dorsiflexion injuries afflicted by wearing high heels. The symptoms present as stiffness, swelling and pain on the affected toe. The symptoms often worsen upon wearing high heels, with the pain being under the ball of the foot. In addition, individuals mostly realise these symptoms as they age.³ 

Patients with the disease often complain of chronic discomfort of the foot as the disease progressively worsens. As a result of this, the swelling around the stiffness that occurs on the affected toe becomes more noticeable, and patients tend to develop a limp to take some of the weight off the affected foot. The disease is usually diagnosed by looking at the clinical features of the foot, for example, if there is swelling or if the second or third toe has changed shape.³ Secondly, X-ray imaging can further be used to confirm the diagnosis of Freiberg’s disease. Finally, it can be treated nnon-operatively which aims to alleviate symptoms of the disease. However, if this does not work, then an operation needs to be carried out, although the outcome of the surgery is not always predictable. The pain usually disappears; however, the affected toe usually remains stiff.³

Furthermore, the disease is usually unilateral⁵ in that it only affects a single metatarsal.⁴ There has only ever been one case whereby the disease affected two metatarsals in female patients aged 72 and 42.⁶ This case study conducted by Donaldson et el. 2020 describes the first male case of Freiberg’s disease on two adjacent metatarsals.⁴

The case study

The 63-year male patient came into the clinic with a history of 1-year bilateral forefoot pain on the second and third metatarsophalangeal joints.⁷ he did not report any other joint pains. The case study was carried out over a year between November 2015 to November 2016. The patient reported that the pain was worse on the left foot and indicated on the visual analogue scale (pain scale) that the severity was nine out of ten. The patient walked pain-free for only 5 minutes before the pain returned. In addition, the patient had been treated at a different hospital and was given antibiotics. However, this did not improve any of his symptoms. 

The patient had not reported any previous injuries or trauma; upon examination, there was redness and swelling that affected both metatarsals. He had pain when moving his left second metatarsophalangeal with tenderness on both the second and third metatarsophalangeal bilaterally. In addition, after conducting medical imaging (Magnetic Resonance imaging).⁸ It showed that the patient had sclerosis⁹ of the metatarsal shaft. There was also flattening of the toes on his second and third metatarsals. As a result, the patient was given orthotics¹⁰ to reduce the pressures on the affected metatarsal heads. However, this did not improve the bilateral forefoot pains. As this did not work, the patient underwent Weil’s osteotomy¹¹ of the left foot with the second and third toes. 

This procedure was done instead of simple debridement¹² as debridement does not address the root cause, which was the long second and third metatarsal. The patient was given post-operative instructions to wear DARCO MedSurg Shoe for six weeks to protect the foot and accommodate for the bandages. Two weeks after the operation, the wound had healed without further complications. In addition, at six weeks, the patient was doing very well and was not in any pain. Medical imaging further showed that the patient had good bone healing and was discharged one year after the first operation. 

In summary, Freiberg’s disease is a rare condition that can cause severe foot pains; it can be treated operatively or non-operatively. However, the first line of treatment if an individual is diagnosed with the disease is firstly providing pain medications, advising the patient to rest the affected foot and finally providing orthotics. These conservative measures can relieve metatarsal pain and prevent the condition from progressing to later stages where anatomical restoration can no longer be obtained. In the case where this does not work, an operative approach can be taken; the patient can undergo several surgical techniques, including Weil’s osteotomy, which was used in this case study. This case study was unique as it reported the first male case whereby both the second and third metatarsals were affected.